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Motor Neglect J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.46.2.152 on 1 February 1983. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry 1983;46:152-158 Motor neglect D LAPLANE,* JD DEGOSt From the H6pital de la Salp&riere, * Paris and the H6pital Henri Mondor, t Creteil, France SUMMARY Motor neglect is characterised by an underutilisation of one side, without defects of strength, reflexes or sensibility. Twenty cases of frontal, parietal and thalamic lesions causing motor neglect, but all without sensory neglect, are reported. It is proposed that the cerebral structures involved in motor neglect are the same as those for sensory neglect and for the preparation of movement. As in sensory neglect, the multiplicity of the structures concerned suggests that this interconnection is necessary to maintain a sufficient level of activity. Predomi- nance of left sided neglect by right sided lesions suggests that the left hemisphere is dominant for deliberate activity; hemispheric dominance could be applied to sensory neglect where conscious awareness would play the role of deliberate activity. The terms unilateral motor neglect or unilateral tasks that could be performed with the "healthy hemi-inattention are used nearly interchangeably in side" even when this was inconvenient (for example guest. Protected by copyright. the classic as well as in contemporary literature and when they required a change in position of the reviews. Neglect may either be global' or partial body); non participation or feeble participation in (dissociated), as is the case with a visual and spatial bimanual tasks (such as clapping, opening a bottle, neglect, a sensory neglect, a hemicorporeal neglect buttoning or unbuttoning a garment); under- or and even a olfactory neglect.2 Unilateral underutil- non-participation of the hand in gesturing when isation of the limbs is frequently reported as a speaking; lack of arm swing when walking. This phenomenon associated with the "Neglect Syn- spontaneous underutilisation contrasted with near drome". Its isolated appearance was mentioned in normal movement and strength, when the examiner the older literature2-4 under various names. With P actively encouraged the patient to use the arm. In Castaigne,56 we have drawn attention to a distur- some cases, the patient described the disturbance by bance of spontaneous movement involving one half saying that the hand was lazy or unreliable, although of the body and having the appearance of hemi- the required task finally was performed correctly. plegia, yet with normal strength and dexterity, which The patient had to "command" the hand to per- can be proven by prompting an extraordinary effort form, he had to think of using it. In other cases, on the part of the patient during the examination. when the right hand was affected, the patient would We have called this disorder Motor Neglect. say that he had become a left hander whereas he had The purpose of this communication is to present been right handed. The disturbance rarely affected 20 cases of motor neglect in which localisation of the the upper limb alone; it usually involved both lesion is sufficiently well defined to allow a discus- extremities but predominantly the upper. In the http://jnnp.bmj.com/ sion of the topography of the lesion and the possible lower extremity the disorder was manifested by a lag pathophysiological mechanisms involved. in movement and a reduced range of motion, and automatic movements were specially disturbed: the Patients affected leg lagged behind the good one when walk- ing, or the leg stayed on the bed when the patient Motor neglect was unilateral in each of the cases and attempted to get up, causing falls. Here, as in the included, on the affected side, the following charac- case of the arm, deliberate effort would compensate teristics: underutilisation of the upper extremity for for the disturbance. In order to avoid confusing motor neglect with on September 25, 2021 by classical hemiplegia we have reported in this series Address for reprint requests: Prof D Laplane, H6pital de la Salpet- only cases that did not have a marked reduction of rire, 47 Boulevard de l'Hopital, 75651 Paris Cedex 13, France. muscle strength or other motor or reflex distur- Received 26 June 1982 and in revised form 13 September 1982. bance. We have included cases with hypotonia and Accepted 30 September 1982 other disorders of movement that increased or 152 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.46.2.152 on 1 February 1983. Downloaded from Motor neglect 153 tended to make motor neglect more obvious, but In all of the cases in this report, the precise which were not constant; these were: (1) Lack of anatomical localisation of the lesion has been asses- spontaneous "placing reaction". This was almost sed by the associated findings on neurological constant. When the patient was sitting, he let his examination, surgical intervention and/or hand rest along his body or between his legs rather anatomopathological verification. (Cases of motor than putting it "normally" on his thigh or on the arm neglect associated with subdural hematoma have of a chair. The leg could also be left in an uncom- been eliminated from the study as they do not lead fortable position such as behind the body, or beside to anatomical conclusions.) the chair, sometimes "lying on the back of the toes". In some cases, it tended to upset the equilibrium. Results When the subject moved from one place to another, no attempt was made by the hand to avoid hitting Twenty cases of pure motor neglect have been objects (for instance, the back of a chair); and such observed; 15 had frontal lesions, four parietal incidents did not produce change in the patient's lesions and one a thalamic lesion. All the patients posture. At times, the hand could be left to drag considered themselves to be right handed. The low passively on the surface of a bed or table. As the number of cases of motor neglect or parietal origin is patient got into bed, the arm or leg would be left due to the fact that we excluded patients presenting hanging out of bed. In other instances, the arm sensory neglect syndromes or other sensory distur- might be caught up under the body or the leg be bances that may represent elements of sensory neg- crossed under the healthy leg in an uncomfortable lect. The findings of the motor neglect syndrome position which the patient did not seem to notice. were always on the opposite side to the lesion, and However, in all cases, a comment from the examiner are summarised in table 1 for 12 patients with or a mere exhortation to assume a better position lesions in the right hemisphere and in table 2 for guest. Protected by copyright. without specification, caused the patient to rectify eight patients with left hemispheric lesions. his posture. (2) The insufficient or delayed reaction The retro-Rolandic lesions were all large glioblas- to assume correct posture could be so severe as to be tomas that did not easily lend themselves to absent; in this case the patient, losing his balance, anatomo-clinical correlations. Two were essentially fell to the affected side. There was no attempt to parietal, one parietotemporal, and one temporal but avoid the fall, or to minimise the shock. (3) There with "laminating" of the parietal area which showed was a lack of automatic withdrawal reaction to pain- multiple neuronal changes and gliosis. ful stimulation, which could be striking: the patient, The frontal lesions were in three groups: who appreciated pain normally, did not move the (A) Six small lesions (five metastases-cases 2, 3, 6, limb away although he protested and attempted to 13 and 14-and one glioblastoma-case 5) located use the healthy limb to retrieve the affected one or in the white substance of the posterior part of Fl fence away the painful stimulus. This sign, at times, overlapping F2 in front of the pre-Rolandic sulcus. was difficult to interpret as some patients believed (B) Lesions larger in size and/or involving less well that they must stoically sustain painful stimulation. defined anatomical landmarks and comprising three (4) In some cases voluntary gesture was faulty and it cases of corticectomy of the medial aspect of the appeared as if there was an error in the appreciation frontal lobe including the supplementary motor area of the necessary energy to reach a point in the cor- and the adjacent cingulate area7 performed for poreal or extracorporeal space; the movement intractable epilepsy (cases 7, 8 and 16); a case of always fell short of the target (hypometria). For ischaemia localised only by gamma scintilography in http://jnnp.bmj.com/ instance, when the patient is asked to put his finger the pre-Rolantic area (case 1); a parasagittal menin- to his nose, he bent his head forward to compensate gioma under coronal suture (case 4); and a left fron- for the inadequate movement of the arm while, in tal glioblastoma (case 15). other circumstances, he was able to raise the elbow (C) Flat lesions ("en plaque") involving the external much higher, as, for instance, when pointing at the cortex of the frontal lobe (meningioma "en plaque" ceiling. case 10, and frontal lobectomy indenting and cutting To prevent confusion with the syndrome of sen- through the back of the posterior part of F1-F2, case sory neglect, we have excluded from our study, all 9). on September 25, 2021 by patients presenting sensory disturbances including The thalamic lesion consisted of a nucleus of those with asomato-agnosia or denial. Some of our confluent lacunae in the ventro-lateral region of the patients presented some degree of visual neglect thalamus, but overlapping the internal capsule and from the beginning; in two cases this neglect the subthalamic region.
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