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Sistem Neuromuskular. Tiga komponen utama Neuromuskular Nerve Nerve Neuromuscular junction Neuromuscular junction Muscle Muscle.

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Presentasi berjudul: "Sistem Neuromuskular. Tiga komponen utama Neuromuskular Nerve Nerve Neuromuscular junction Neuromuscular junction Muscle Muscle."— Transcript presentasi:

1 Sistem Neuromuskular

2 Tiga komponen utama Neuromuskular Nerve Nerve Neuromuscular junction Neuromuscular junction Muscle Muscle

3 Upper Motor Neuron Semua neuron yang menyalurkan impuls motorik secara langsung ke LMN atau melalui interneuronnya, tergolong dalam kelompok UMN. Neuron-neuron tersebut banyak terdapat di girus presentralis dinamakan juga korteks motorik. Melalui aksonnya neuron korteks motorik menghubungi motoneuron di kornu anterior medulla spinalis. Semua neuron yang menyalurkan impuls motorik secara langsung ke LMN atau melalui interneuronnya, tergolong dalam kelompok UMN. Neuron-neuron tersebut banyak terdapat di girus presentralis dinamakan juga korteks motorik. Melalui aksonnya neuron korteks motorik menghubungi motoneuron di kornu anterior medulla spinalis.

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5 Area Motorik

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7 Upper motorneuron Lower motorneuron

8 Lower Motor Neuron Merupakan neuron-neuron yang menyelurkan impuls motorik pada bagian perjalanan terakhir (kornu anterior medula spinalis) ke sel-sel otot skeletal. Merupakan neuron-neuron yang menyelurkan impuls motorik pada bagian perjalanan terakhir (kornu anterior medula spinalis) ke sel-sel otot skeletal.

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10 Motor end Plate Pada ujungnya setiap akson akan bercabang-cabang dan setiap cabang menghubungi membrane serabut otot. Serabut-serabut otot setiap unit motorik berkisar antara serabut otot. Tiap serabut otot memilki satu “motor end plate”. Pada ujungnya setiap akson akan bercabang-cabang dan setiap cabang menghubungi membrane serabut otot. Serabut-serabut otot setiap unit motorik berkisar antara serabut otot. Tiap serabut otot memilki satu “motor end plate”.

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12 Ujung-ujung terminal dari akson mengandung mitokondria dan ezim “cholin acertyltransferase”, yang diperlukan untuk sintesis “neurotransmitter” yang dinamakan “acetylcholine”. Ujung-ujung terminal dari akson mengandung mitokondria dan ezim “cholin acertyltransferase”, yang diperlukan untuk sintesis “neurotransmitter” yang dinamakan “acetylcholine”.

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14 Pelepasan Acetilkolin Nerves releasing Achetylcholine at the neuromuscular junction (=end plate) cause the contraction of skeletal muscle. The functional unit of a muscle organ is the muscle fiber (=muscle cell). Nerves releasing Achetylcholine at the neuromuscular junction (=end plate) cause the contraction of skeletal muscle. The functional unit of a muscle organ is the muscle fiber (=muscle cell).

15 The muscle fiber contracts in an "all-or- none" fashion when stimulated by an action potential. The action potential first causes intracellular Ca ++ release from the sarcoplasmic reticulum and the Ca ++ activates a cascade of events which results in the movement of actin over myosin (=sliding filament theory). The muscle fiber contracts in an "all-or- none" fashion when stimulated by an action potential. The action potential first causes intracellular Ca ++ release from the sarcoplasmic reticulum and the Ca ++ activates a cascade of events which results in the movement of actin over myosin (=sliding filament theory).

16 Tanda-tanda kelumpuhan UMN : Hiperrefleksia Terdapat refleks patologis Tonus otot meninggi atau hipertonia Terdapat Klonus Tidak terdapat atrofi otot yang lumpuh Refleks automatisme spinal (-) Tanda-tanda kelumpuhan LMN : Arefleksia (hilangnya refleks tendo) Tidak ada refleks patologis Hilangnya tonus otot (flacid) Tidak terdapat klonus Terdapat atrofi pada otot yang lumpuh

17 Gangguan yang menyebabkan kelemahan gerak (paralysis) Kelainan pada otot Periodik Paralysis Periodik Paralysis Inflamatory miopathy Inflamatory miopathy Miopati karena steroid Miopati karena steroid Rabdomyolisis Rabdomyolisis Neuromuscular junction Miastenia Gravis Miastenia Gravis Botulism Botulism Tick paralysis Tick paralysis Lambert Eaton Myastenic Syndrome Lambert Eaton Myastenic Syndrome

18 Gangguan yang menyebabkan kelemahan gerak (paralysis) Neuropati akut Paraneoplastik Paraneoplastik Vaskulitis (lupus, poliarteritis) Vaskulitis (lupus, poliarteritis) Neuropati motorik multifokal Neuropati motorik multifokal Poliradikulopati akut Guillain-Barre syndrome Guillain-Barre syndrome Lime Disease Lime Disease Sindrome Cauda Equina Sindrome Cauda Equina Penyakit Motor neuron Poliomyelitis Poliomyelitis Amyotropic Lateral Sclerosis (ALS) Amyotropic Lateral Sclerosis (ALS)

19 Gangguan yang menyebabkan kelemahan gerak (paralysis) Medula Spinalis Inflamasi (mielitis transversus) Inflamasi (mielitis transversus) Mielopati (spondilosis, hematom, infark) Mielopati (spondilosis, hematom, infark) Otak (Cerebrum, cerebellum) Lesi di Pons Lesi di Pons Lesi fokal/multifokal (infark, hematom) Lesi fokal/multifokal (infark, hematom)

20 Jenis Gangguan Saraf Polyneuropathy: motor, sensory, Polyneuropathy: motor, sensory, sensorimotor sensorimotor Radiculopathy Radiculopathy Polyradiculopathy Polyradiculopathy Plexopathy Plexopathy Mononeuropathy: isolated Mononeuropathy: isolated multiplex multiplex

21 Klasifikasi kausa Inherited Inherited HMSN and HLPP HMSN and HLPP Amyloid Amyloid Metabolic Metabolic Diabetes Diabetes Vitamins: B12, B1, E Vitamins: B12, B1, E Dialysis, Liver failure Dialysis, Liver failure Paraneoplastic Paraneoplastic sensory (anti-Hu) sensory (anti-Hu) Toxic Toxic Drugs, alcohol, organophosphates Inflammatory/Immune Inflammatory/Immune GBS, CIDP Vasculitis Infective Infective Leprosy, Lyme, HIV, Diphtheria Traumatic Traumatic

22 Klasifikasi tipe kerusakan Demyelinating Demyelinating Axonal Axonal Small fibre Small fibre Large fibre Large fibre Autonomic Autonomic

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24 Physical findings NerveNMJMuscle Reflexes Usually decr.NL or decr.NL or decr. Atrophy Can be severeMinimalVariable Fascic. SometimesNoneNone Sensory loss SometimesNoneNone

25 The Motor Unit Motor Neurone Disorders Myopathies Myasthenia etc Peripheral Neuropathy

26 Gangguan pada saraf: Variasi: Cell body, axon & myelin Cell body, axon & myelin Fiber size: large, small Fiber size: large, small Motor, sensory, autonomic Motor, sensory, autonomic Distribution: focal, multifocal, generalized Distribution: focal, multifocal, generalized Course: acute, subacute, chronic, lifelong Course: acute, subacute, chronic, lifelong Etiology: genetic, toxic, metabolic, autoimmune, traumatic, vascular, infectious Etiology: genetic, toxic, metabolic, autoimmune, traumatic, vascular, infectious

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28 Gangguan pada Saraf: berdasarkan Lokasi Radixradiculopathy Radixradiculopathy Plexusplexopathy Plexusplexopathy Single nervemononeuropathy Single nervemononeuropathy Several nervesmultiple mononeuropathy, mononeuritis multiplex Several nervesmultiple mononeuropathy, mononeuritis multiplex All nerves, polyneuropathy length-dependent All nerves, polyneuropathy length-dependent All nerves, polyradiculoneuropathy not length-dependent All nerves, polyradiculoneuropathy not length-dependent

29 Radix Segmental loss of Segmental loss of motor motor atrophy atrophy weakness weakness reflexes reflexes sensation sensation Signs usually minimal; symptoms can be severe (pain); Signs usually minimal; symptoms can be severe (pain); Usually only one limb. Usually only one limb.

30 Plexus Pain Pain Weakness, atrophy, variable, but usually more severe than radiculopathy Weakness, atrophy, variable, but usually more severe than radiculopathy Usually restricted to one limb Usually restricted to one limb Etiology: Etiology: Brachial: trauma, neoplasm, idiopathic Brachial: trauma, neoplasm, idiopathic Lumbosacral: diabetes, neoplasm Lumbosacral: diabetes, neoplasm

31 Single nerve (mononeuropathy) Restricted distribution Restricted distribution Pain, numbness or tingling, atrophy, weakness Pain, numbness or tingling, atrophy, weakness Etiology: Etiology: entrapment entrapment trauma trauma

32 Carpal tunnel syndrome N.Medianus N.Medianus Pain in hand, forearm, arm Pain in hand, forearm, arm Numbness in median distribution Numbness in median distribution Symptoms aggravated by wrist flexion Symptoms aggravated by wrist flexion

33 Ulnar neuropathy Numbness Numbness Atrophy of first dorsal interosseous Atrophy of first dorsal interosseous Weakness Weakness Compression at elbow Compression at elbow Entrapment in cubital tunnel Entrapment in cubital tunnel Distal injury Distal injury

34 Radial nerve: Saturday night palsy Weakness of wrist & finger extensors, brachioradialis Weakness of wrist & finger extensors, brachioradialis Pressure palsy Pressure palsy Trauma (humerus fracture) Trauma (humerus fracture)

35 Peroneal palsy Crossing legs Crossing legs Weight loss Weight loss Hospitalization Hospitalization Surgery Surgery

36 Several nerves (mononeuritis multiplex) Often painful at onset Often painful at onset Often sudden Often sudden Deficits in the distribution of several peripheral nerves (one at a time) Deficits in the distribution of several peripheral nerves (one at a time) Etiology: vasculitis Etiology: vasculitis

37 All nerves: Length-dependent (polyneuropathy) Lower before upper extremity Lower before upper extremity Distal first (feet) Distal first (feet) Atrophy of intrinsic foot muscles Atrophy of intrinsic foot muscles Decreased ankle jerks Decreased ankle jerks Stocking, then glove sensory loss Stocking, then glove sensory loss Distal motor and sensory findings always much more severe than proximal Distal motor and sensory findings always much more severe than proximal

38 Polyneuropathy (cont’d)

39 Most common kind of neuropathy Most common kind of neuropathy Etiology Etiology metabolic (diabetes, renal failure) metabolic (diabetes, renal failure) nutritional (thiamine, B12 deficiency) nutritional (thiamine, B12 deficiency) toxic (heavy metals, organic solvents, some drugs) toxic (heavy metals, organic solvents, some drugs) familial (Charcot-Marie-Tooth) familial (Charcot-Marie-Tooth)

40 All nerves, not length-dependent (polyradiculoneuropathy) Both proximal and distal weakness Both proximal and distal weakness Variable sensory symptoms Variable sensory symptoms Autonomic symptoms (pulse, blood pressure, urination...) Autonomic symptoms (pulse, blood pressure, urination...) Can affect respiration, swallowing Can affect respiration, swallowing Autoimmune Autoimmune

41 Guillain-Barré Syndrome (GBS) Definisi GBS : Penyakit demyelinasi akut, yang terutama mengenai susunan saraf tepi. Penyakit inflamasi pada sistim saraf tepi mempunyai karakteristik adanya infiltrasi limfosit dan makrofag dengan destruksi myelin Penyakit demyelinasi akut, yang terutama mengenai susunan saraf tepi. Penyakit inflamasi pada sistim saraf tepi mempunyai karakteristik adanya infiltrasi limfosit dan makrofag dengan destruksi myelin Derajad dan lokasi kerusakan tergantung saraf yang bermyelin: Motorik Derajad dan lokasi kerusakan tergantung saraf yang bermyelin: Motorik Merupakan penyakit Autoimmun

42 Guillain-Barre syndrome Progresses over days to <4 weeks Progresses over days to <4 weeks Typically ascending weakness Typically ascending weakness Reflexes lost early Reflexes lost early Motor symptoms predominate, but can affect sensation and autonomic function Motor symptoms predominate, but can affect sensation and autonomic function Respiratory failure requires support Respiratory failure requires support

43 Guillain-Barre syndrome (cont’d) Penyebab : autoimmun Target Antigen biasanya tidak diketahui Target Antigen biasanya tidak diketahui Pada beberapa kasus: Target serangan imun gangliosida (GM1, GQ1b) Pada beberapa kasus: Target serangan imun gangliosida (GM1, GQ1b) Faktor presipitasi: Infeksi virus (HIV, CMV, varicella zoster) Infeksi virus (HIV, CMV, varicella zoster) Infeksi bakteri (campylobacter jenjuni, typhoid, paratyphoid) Infeksi bakteri (campylobacter jenjuni, typhoid, paratyphoid) Immunisasi Immunisasi Sistemik (Hodgkins disease, leukemia, hipertiroidisme, sarkoidosis) Sistemik (Hodgkins disease, leukemia, hipertiroidisme, sarkoidosis) Transplantasi organ, operasi, kehamilan Transplantasi organ, operasi, kehamilan

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45 Latar belakang GBS Epidemiologi GBS Epidemiologi GBS 1- 4 kasus/ kasus/ Paling banyak pada pria Paling banyak pada pria Meningkat sesuai usia Meningkat sesuai usia Insidennya bervariasi sesuai musim Insidennya bervariasi sesuai musim

46 Gambaran klinis GBS - Gangguan Motorik: paralisis yang progressif, simetris pada extremitas bawah dan atas, bersifat asendern paralisis yang progressif, simetris pada extremitas bawah dan atas, bersifat asendern dimulai dari distal ke proksimal dimulai dari distal ke proksimal - Gangguan sensibilitas: Stocking, dan glove sensory loss (dysesthesia) - Gangguan otonom: penyebab kematian penyebab kematian

47 Clinical Picture of Polyneuropahty (Valenstein, 2000)

48 Gambaran klinis GBS Atypical presentations Atypical presentations Miller-Fisher Syndrome Miller-Fisher Syndrome Areflexia Areflexia Ophthalmoplegia Ophthalmoplegia Ataxia Ataxia

49 diagnosis GBS Riwayat penyakit sebelumnya atau vaksinasi Riwayat penyakit sebelumnya atau vaksinasi Dari pemeriksaan fisik (Physical Exam) Dari pemeriksaan fisik (Physical Exam) Laboratoratorium: Laboratoratorium: Peningkatan kadar protein pada pemeriksaan LCS dan rendahnya jumlah sel di LCS (disosiasi sitoalbumin) Peningkatan kadar protein pada pemeriksaan LCS dan rendahnya jumlah sel di LCS (disosiasi sitoalbumin) Electromyography – adanya blok konduksi saraf Electromyography – adanya blok konduksi saraf

50 1.Paralisis flasid simetris, difus 2.Gejala sensoris subyektif 3.Penyembuhan sempurna dalam 6 bulan 4.Disosiasi citoalbumin 5.Tanpa atau sedikit demam saat muncul paralysis 6.AL normal atau lymphositosis dengan sedikit atau tanpa kenaikan KED. Harus memenuhi 5 kriteria dari 6 kriteria KRITERIA GBS MENURUT GILROY DAN MEYER (1979)

51 Pengobatan GBS Fase akut Supportive care : monitoring fungsi vital (perawatn ICU) Supportive care : monitoring fungsi vital (perawatn ICU) Pemberian IV imunoglobulin (ivIg) 400 mg/kg selama 5 hari, plasmapheresis ml/kg plasma exchange diberikan 4 kali seminggu Pemberian IV imunoglobulin (ivIg) 400 mg/kg selama 5 hari, plasmapheresis ml/kg plasma exchange diberikan 4 kali seminggu Kortikosteroid Kortikosteroid Artificial ventilation (if necessary)  paralysis diafragma Artificial ventilation (if necessary)  paralysis diafragma Setelah fese akut Program rehabilitasi, bladder training, perbaikan ADL (activity daily living) Program rehabilitasi, bladder training, perbaikan ADL (activity daily living)

52 Summary of nerve disorders RootDisk, Herpes zoster RootDisk, Herpes zoster PlexusAutoimmune, trauma, neoplasm PlexusAutoimmune, trauma, neoplasm MononeuropathyTrauma, entrapment MononeuropathyTrauma, entrapment Multiple mononeuropathyVasculitis... Multiple mononeuropathyVasculitis... PolyneuropathyToxic, metabolic, nutritional PolyneuropathyToxic, metabolic, nutritional Polyradiculo- neuropathyAutoimmune Polyradiculo- neuropathyAutoimmune

53 Neuromuscular junction

54 Disorders of the neuromusuclar junction Release of acetyl choline: Release of acetyl choline: Botulism (toxin = endopeptidase targeting various proteins mediating exocytosis) Botulism (toxin = endopeptidase targeting various proteins mediating exocytosis) Lambert-Eaton myasthenic syndrome (antibodies to voltage-gated calcium channel) Lambert-Eaton myasthenic syndrome (antibodies to voltage-gated calcium channel) Acetylcholine receptor blockade: Acetylcholine receptor blockade: Myasthenia gravis (antibodies to ACh receptor) Myasthenia gravis (antibodies to ACh receptor)

55 Myasthenia Gravis Kelemahan yang berfluktuasi Kelemahan yang berfluktuasi Mata: ptosis, diplopia Mata: ptosis, diplopia Bulbar weakness: dysarthria, dysphagia Bulbar weakness: dysarthria, dysphagia Kelemahan otot proksimal Kelemahan otot proksimal Kelemahan respirasi Kelemahan respirasi Normal reflexes Normal reflexes Normal sensation Normal sensation Berkaitan dg thymoma Berkaitan dg thymoma Berkaitan dg penyakit autoimun Berkaitan dg penyakit autoimun Penyakit autoimun pada transmisi neuromuskular junction yang diakibatkan oleh antibodi yang menyerang reseptor asetilkolin atau melawan muscle spesific receptor tyrosine kinase

56 Myasthenia gravis is a neuromuscular disease leading to fluctuating muscle weakness and fatiguability. Myasthenia gravis is a neuromuscular disease leading to fluctuating muscle weakness and fatiguability. It is an autoimmune disorder, in which weakness is caused by circulating antibodies that block acetylcholine receptors at the post-synaptic neuromuscular junction, inhibiting the stimulative effect of the neurotransmitter acetylcholine. It is an autoimmune disorder, in which weakness is caused by circulating antibodies that block acetylcholine receptors at the post-synaptic neuromuscular junction, inhibiting the stimulative effect of the neurotransmitter acetylcholine. Myasthenia is treated medically with cholinesterase inhibitors or immunosuppressants, and, in selected cases, thymectomy. Myasthenia is treated medically with cholinesterase inhibitors or immunosuppressants, and, in selected cases, thymectomy. At 200–400 cases per million it is one of the less common autoimmune disorders. At 200–400 cases per million it is one of the less common autoimmune disorders.

57 Muscles become progressively weaker during periods of activity and improve after periods of rest. Muscles that control eye and eyelid movement, Muscles become progressively weaker during periods of activity and improve after periods of rest. Muscles that control eye and eyelid movement, facial expression, chewing, talking, and swallowing are especially susceptible. The muscles that control breathing and neck and limb movements can also be affected facial expression, chewing, talking, and swallowing are especially susceptible. The muscles that control breathing and neck and limb movements can also be affected

58 Myasthenia Gravis Terapi: Terapi: Acetyl cholinesterase inhibitors : pyridostigmin bromida 3x 60 mg Acetyl cholinesterase inhibitors : pyridostigmin bromida 3x 60 mg Plasmapharesis : plasma exchange Plasmapharesis : plasma exchange Imunoglobulin IV Imunoglobulin IV Immunosupresan (kontroversi) Immunosupresan (kontroversi) Steroid : mulai mg Steroid : mulai mg Azathioprine : 50 mg/hari Azathioprine : 50 mg/hari Cyclosporine : awal 3-4 mg/kg/hari dalam dosis terbagi Cyclosporine : awal 3-4 mg/kg/hari dalam dosis terbagi Cyclophosphamide : dosis 1-2 mg/kg/ hari Cyclophosphamide : dosis 1-2 mg/kg/ hari Thymectomy, indikasi: Thymectomy, indikasi: Timoma Timoma Generalized myastenia yang tidak terkontrol dengan antikolinesterase (< 50 th, 6-12 bulan tidak ada remisi spontan) Generalized myastenia yang tidak terkontrol dengan antikolinesterase (< 50 th, 6-12 bulan tidak ada remisi spontan)

59 Krisis Mistenia Adalah keadaan eksaserbasi penyakit Mistenia gravis dimana kelumpuhan menyebabkan episode akut kegagalan pernafasan Adalah keadaan eksaserbasi penyakit Mistenia gravis dimana kelumpuhan menyebabkan episode akut kegagalan pernafasan Terjadi pada 74% setelah 2 tahun miastenia gravis Terjadi pada 74% setelah 2 tahun miastenia gravis

60 Krisis Mistenia Faktor pencetus : Infeksi, terutama infeksi saluran nafas Infeksi, terutama infeksi saluran nafas Pemakaian obat2an: aminoglikosid, ciprofloksasin, klindamisin, propanolol, fenitoin Pemakaian obat2an: aminoglikosid, ciprofloksasin, klindamisin, propanolol, fenitoin Tidak diketahui (30-40%) Tidak diketahui (30-40%)

61 Krisis Mistenia Terapi : Kontrol airways, dan perbaiki ventilasi (jika perlu menggunakan ventilator) Kontrol airways, dan perbaiki ventilasi (jika perlu menggunakan ventilator) Terapi antikolinesterase Terapi antikolinesterase Kortikosteroid Kortikosteroid Plasma axchange atau IV Ig Plasma axchange atau IV Ig

62 Penyakit otot (myopathy) Symmetrical proximal weakness Symmetrical proximal weakness Reflexes normal (sometimes depressed) Reflexes normal (sometimes depressed) No sensory loss No sensory loss

63 Myopathy (cont’d) Inherited Inherited Dystrophies Dystrophies Congenital myopathies Congenital myopathies Channelopathies Channelopathies Acquired Acquired endocrine endocrine inflammatory, including autoimmune inflammatory, including autoimmune toxic (drugs...) toxic (drugs...)

64 Inflammatory myopathies Polymyositis Polymyositis isolated isolated with collagen vascular disease with collagen vascular disease Dermatomyositis Dermatomyositis childhood childhood adult: association with cancer adult: association with cancer others others

65 Dystrophy Musculorum Muscular dystrophy is a genetic condition causing muscle weakness

66 KRITERIA DIAGNOSIS Kelemahan otot-otot proksimal simetris Rash tipikal pada dermatomyositis Peningkatan enzim otot / plasma muscle enzymes (CK, aldolase, AST), khususnya creatine kinase Terdapat korelasi antara beratnya kelemahan dengan peningkatan enzim Gambaran myopati pada pemeriksaan needle EMG Gambaran abnormalitas yang khas pada biopsi otot (nekrosis serabut otot dan degenerasi, dengan infiltrasi sel-sel inflamasi) Dermatomyositis - Polymyositis

67 Polymyositis Polymyositis is a disease of muscle featuring inflammation of the muscle fibers Polymyositis is a disease of muscle featuring inflammation of the muscle fibers The cause of the disease is not known The cause of the disease is not known Polymyositis is slightly more common in females. It affects all age groups, although its onset is most common in middle childhood and in the 20 s Polymyositis is slightly more common in females. It affects all age groups, although its onset is most common in middle childhood and in the 20 s Weakness of muscles is the most common symptom of polymyositis Weakness of muscles is the most common symptom of polymyositis

68 Amyotrophic lateral sclerosis Lou Gehrig's disease Lou Gehrig's disease Amyotrophic lateral sclerosis (ALS) is a nervous system disease that attacks nerve cells called neurons in your brain and spinal cord Amyotrophic lateral sclerosis (ALS) is a nervous system disease that attacks nerve cells called neurons in your brain and spinal cord The cause of ALS is not known The cause of ALS is not known

69 Amyotrophic lateral sclerosis The disease belongs to a group of disorders known as motor neuron diseases, which are characterized by the gradual degeneration and death of motor neurons. The disease belongs to a group of disorders known as motor neuron diseases, which are characterized by the gradual degeneration and death of motor neurons. In ALS, both the upper motor neurons and the lower motor neurons degenerate or die, ceasing to send messages to muscles In ALS, both the upper motor neurons and the lower motor neurons degenerate or die, ceasing to send messages to muscles At first, this causes mild muscle problems. Some people notice At first, this causes mild muscle problems. Some people notice Trouble walking or running Trouble walking or running Trouble writing Trouble writing Speech problems Speech problems

70 Multiple sclerosis Multiple sclerosis (MS) is a nervous system disease that affects your brain and spinal cord. It damages the myelin sheath Multiple sclerosis (MS) is a nervous system disease that affects your brain and spinal cord. It damages the myelin sheath No one knows what causes MS. However, viral and autoimmune etiologies have been hypothesized. It may be an autoimmune disease No one knows what causes MS. However, viral and autoimmune etiologies have been hypothesized. It may be an autoimmune disease The symptom can include : The symptom can include : Visual disturbances Visual disturbances Muscle weakness Muscle weakness Trouble with coordination and balance Trouble with coordination and balance Sensations such as numbness, prickling, or "pins and needles" Sensations such as numbness, prickling, or "pins and needles" Thinking and memory problems Thinking and memory problems

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72 Myopathy predilection for neck, limb girdle and proximal muscles occasional respiratory muscle involvement possible risk of myoglobulinuria no sensory loss normal tendon reflexes (early stage) Neuromuscular junction cranial, limb girdle and proximal muscles may affect respiratory muscles no sensory loss autonomic symptoms present if pre-synaptic fatigueability when post-synaptic, post-exercise increase in strength when pre-synaptic Neuropathy weakness and sensory signs may have associated autonomic signs may involve cranial nerves tendon reflexes decreased or absent Motor neuron predominantly motor signs occasional sensory symptoms often asymmetric tendon reflexes may be increased if amyotrophic lateral sclerosis Key clinical features used to localize a neuromuscular disorder

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