Dysmetria () is a lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye. It is a type of

ataxia Ataxia (from Greek α- negative prefix+ -τάξις rder= "lack of order") is a neurological sign consisting of lack of voluntary coordination of muscle movements that can include gait abnormality, speech changes, and abnormalities in e ...

. It can also include an inability to judge distance or scale. Hypermetria and hypometria are, respectively, overshooting and undershooting the intended position.

Presentation

Associated diseases

Dysmetria is often found in individuals with

multiple sclerosis Multiple sclerosis (MS) is an autoimmune disease resulting in damage to myelinthe insulating covers of nerve cellsin the brain and spinal cord. As a demyelinating disease, MS disrupts the nervous system's ability to Action potential, transmit ...

(MS),

amyotrophic lateral sclerosis Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND) or—in the United States—Lou Gehrig's disease (LGD), is a rare, Terminal illness, terminal neurodegenerative disease, neurodegenerative disorder that results i ...

(ALS), and persons who have had

tumors A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

stroke Stroke is a medical condition in which poor cerebral circulation, blood flow to a part of the brain causes cell death. There are two main types of stroke: brain ischemia, ischemic, due to lack of blood flow, and intracranial hemorrhage, hemor ...

s. Persons who have been diagnosed with

autosomal An autosome is any chromosome that is not a sex chromosome. The members of an autosome pair in a diploid cell have the same morphology, unlike those in allosomal (sex chromosome) pairs, which may have different structures. The DNA in autosome ...

dominant

spinocerebellar ataxia Spinocerebellar ataxia (SCA) is a progressive, degenerative, genetic disease with multiple types, each of which could be considered a neurological condition in its own right. An estimated 150,000 people in the United States have a diagnosis of ...

(SCAs) also exhibit dysmetria. There are many types of SCAs and though many exhibit similar symptoms (one being dysmetria), they are considered to be heterogeneous.

Friedreich's ataxia Friedreich's ataxia (FRDA) is a rare, inherited, autosomal recessive neurodegenerative disorder that primarily affects the nervous system, causing progressive damage to the spinal cord, peripheral nerves, and cerebellum, leading to impaired ...

is a relatively common cause of dysmetria. Cerebellar malformations extending to the

brainstem The brainstem (or brain stem) is the posterior stalk-like part of the brain that connects the cerebrum with the spinal cord. In the human brain the brainstem is composed of the midbrain, the pons, and the medulla oblongata. The midbrain is conti ...

can also present with dysmetria.

Causes

The actual cause of dysmetria is thought to be caused by lesions in the cerebellum or by lesions in the proprioceptive nerves that lead to the cerebellum that coordinate visual, spatial and other sensory information with motor control. Damage to the

proprioceptive Proprioception ( ) is the sense of self-movement, force, and body position. Proprioception is mediated by proprioceptors, a type of sensory receptor, located within muscles, tendons, and joints. Most animals possess multiple subtypes of propri ...

nerves does not allow the cerebellum to accurately judge where the hand, arm, leg, or eye should move. These lesions are often caused by

(MS),

(ALS), or

. According to the research article cited above, motor control is a learning process that utilizes APPGs. Disruption of APPGs is possibly the cause of ataxia and dysmetria and upon identification of the motor primitives, clinicians may be able to isolate the specific areas responsible for the cerebellar problems. There are two types of cerebellar disorders that produce dysmetria, specifically midline cerebellar syndromes and hemispheric cerebellar syndromes. Midline cerebellar syndromes can cause ocular dysmetria, a condition in which the eyes can not track an object properly and either overshoot (ahead of the object )or undershoot (lagging behind the object). Ocular dysmetria also makes it difficult to maintain fixation on a stationary object. Hemispheric cerebellar syndromes cause dysmetria in the typical motor sense that many think of when hearing the term dysmetria. A common motor syndrome that causes dysmetria is cerebellar motor syndrome, which also marked by impairments in

gait Gait is the pattern of Motion (physics), movement of the limb (anatomy), limbs of animals, including Gait (human), humans, during Animal locomotion, locomotion over a solid substrate. Most animals use a variety of gaits, selecting gait based on s ...

(also known as

), disordered eye movements,

tremor A tremor is an involuntary, somewhat rhythmic muscle contraction and relaxation involving neural oscillations, oscillations or twitching movements of one or more body parts. It is the most common of all involuntary movements and can affect the h ...

, difficulty

swallowing Swallowing, also called deglutition or inglutition in scientific and medical contexts, is a physical process of an animal's digestive tract (e.g. that of a human body) that allows for an ingested substance (typically food) to pass from the mou ...

and poor articulation. As stated above, cerebellar cognitive affective syndrome (CCAS) also causes dysmetria.

Anatomy

The

cerebellum The cerebellum (: cerebella or cerebellums; Latin for 'little brain') is a major feature of the hindbrain of all vertebrates. Although usually smaller than the cerebrum, in some animals such as the mormyrid fishes it may be as large as it or eve ...

is the area of the brain that contributes to coordination and motor processes and is anatomically inferior to the

cerebrum The cerebrum (: cerebra), telencephalon or endbrain is the largest part of the brain, containing the cerebral cortex (of the two cerebral hemispheres) as well as several subcortical structures, including the hippocampus, basal ganglia, and olfac ...

. Sensorimotor integration is the brain's way of integrating the information received from the sensory (or proprioceptive) neurons from the body, including any visual information. To be more specific, information needed to perform a motor task comes from

retinal Retinal (also known as retinaldehyde) is a polyene chromophore. Retinal, bound to proteins called opsins, is the chemical basis of visual phototransduction, the light-detection stage of visual perception (vision). Some microorganisms use ret ...

information pertaining to the eyes' position and has to be translated into spatial information. Sensorimotor integration is crucial for performing any motor task and takes place in the post parietal cortex. After the visual information has been translated into spatial information, the cerebellum must use this information to perform the motor task. If there is damage to any pathways that connect the pathways, dysmetria may result.

Motor

Motor dysmetria is the customary term used when a person refers to dysmetria. Dysmetria of the extremities caused by hemispheric syndromes is manifested in multiple ways: dysrhythmic tapping of hands and feet and dysdiadochokinesis, which is the impairment of alternating movements. Damage to the cerebellum makes a person slow to orient their extremities in space. Motor control as a learning process Recent research has also shed light upon a specific process that if interrupted, may be the cause of

and dysmetria. According to sources cited in this article,

motor control Motor control is the regulation of movements in organisms that possess a nervous system. Motor control includes conscious voluntary movements, subconscious muscle memory and involuntary reflexes, as well as instinctual taxes. To control ...

is a learning process that occurs in the

synapse In the nervous system, a synapse is a structure that allows a neuron (or nerve cell) to pass an electrical or chemical signal to another neuron or a target effector cell. Synapses can be classified as either chemical or electrical, depending o ...

s of Purkinje

dendrite A dendrite (from Ancient Greek language, Greek δένδρον ''déndron'', "tree") or dendron is a branched cytoplasmic process that extends from a nerve cell that propagates the neurotransmission, electrochemical stimulation received from oth ...

s. There have been varying theories as to the makeup of the cerebellum, which controls this process. Some predicted that the cerebellum was an array of adjustable pattern generators (APGs), each of which generate a "burst command" with varying intensity and duration. Other models, which apply mostly in

robotic Robotics is the interdisciplinary study and practice of the design, construction, operation, and use of robots. Within mechanical engineering, robotics is the design and construction of the physical structures of robots, while in computer s ...

applications, propose that the cerebellum acquires an "inverse model of the motor apparatus". More recent research in

electrophysiology Electrophysiology (from ee the Electron#Etymology, etymology of "electron" ; and ) is the branch of physiology that studies the electrical properties of biological cell (biology), cells and tissues. It involves measurements of voltage change ...

has shown modular structures in the

spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue that extends from the medulla oblongata in the lower brainstem to the lumbar region of the vertebral column (backbone) of vertebrate animals. The center of the spinal c ...

known as "motor primitives". Based on the APG model, modules of APG are the features that control

motor learning Motor learning refers broadly to changes in an organism's movements that reflect changes in the structure and function of the nervous system. Motor learning occurs over varying timescales and degrees of complexity: humans learn to walk or talk over ...

. The entire process is a

positive feedback loop Positive feedback (exacerbating feedback, self-reinforcing feedback) is a process that occurs in a feedback loop where the outcome of a process reinforces the inciting process to build momentum. As such, these forces can exacerbate the effects ...

. Inhibitory input is transmitted and received from various components of the

cortex Cortex or cortical may refer to: Biology * Cortex (anatomy), the outermost layer of an organ ** Cerebral cortex, the outer layer of the vertebrate cerebrum, part of which is the ''forebrain'' *** Motor cortex, the regions of the cerebral cortex i ...

, including the cerebellar nucleus, a motor cortical cell and

Purkinje cell Purkinje cells or Purkinje neurons, named for Czech physiologist Jan Evangelista Purkyně who identified them in 1837, are a unique type of prominent, large neuron located in the Cerebellum, cerebellar Cortex (anatomy), cortex of the brain. Wi ...

s. Purkinje cells send the inhibitive information by obtaining learning information from parallel fibers of

granule cells The name granule cell has been used for a number of different types of neurons whose only common feature is that they all have very small cell bodies. Granule cells are found within the granular layer of the cerebellum, the dentate gyrus of t ...

. This model of APGs is useful in that it effectively describes the motor learning process. Motor primitives are another proposed module of motor learning. This information was found by electrical stimulation of the lumbar spinal cord in rats and frogs. Upon the stimulation, researchers found that motor primitives are found in the

and use patterns of

muscle Muscle is a soft tissue, one of the four basic types of animal tissue. There are three types of muscle tissue in vertebrates: skeletal muscle, cardiac muscle, and smooth muscle. Muscle tissue gives skeletal muscles the ability to muscle contra ...

activation to generate a specific motor output. Different movements are learned from different levels of activation. These findings led researchers to believe that these same motor primitives could be found in the cerebellum. These two different models combined show that it is possible that motor primitives are in the cerebellum, because, "a set of parallel arrays of APG can drive each motor primitive module in the spinal cord." The authors have generated a model of adjustable primitive pattern generator (APPG), which is basically a group of parallel APGs summed together. The APPG model is a vector sum of all the inputs of the APG, which are units of position, velocity and time.

Granule cells The name granule cell has been used for a number of different types of neurons whose only common feature is that they all have very small cell bodies. Granule cells are found within the granular layer of the cerebellum, the dentate gyrus of t ...

send information from the spinal cord and the

motor cortex The motor cortex is the region of the cerebral cortex involved in the planning, motor control, control, and execution of voluntary movements. The motor cortex is an area of the frontal lobe located in the posterior precentral gyrus immediately ...

which in turn translates the information in a process called state mapping. The final model of the APPG becomes linear upon the vector summation of the information from the

neuron A neuron (American English), neurone (British English), or nerve cell, is an membrane potential#Cell excitability, excitable cell (biology), cell that fires electric signals called action potentials across a neural network (biology), neural net ...

s and muscles. This model is consistent with the "virtual trajectory hypothesis" which states that the desired trajectory is sent to the spinal cord as a motor command.

Saccadic

Saccades In vision science, a saccade ( ; ; ) is a quick, simultaneous movement of both eyes between two or more phases of focal points in the same direction. In contrast, in smooth-pursuit movements, the eyes move smoothly instead of in jumps. Control ...

are the very quick, simultaneous movements made by the eye to receive visual information and shift the line of vision from one position to another. A person depends profoundly on the ability of the accuracy of these movements. The information is received from the retina, is translated into spatial information and is then transferred to motor centers for motor response. A person with saccadic dysmetria will constantly produce abnormal eye movements including microsaccades, ocular flutter, and square wave jerks even when the eye is at rest. During eye movements hypometric and

hypermetric In poetry, metre (British English, Commonwealth spelling) or meter (American English, American spelling; see American and British English spelling differences#-re, -er, spelling differences) is the basic rhythm, rhythmic structure of a verse (poe ...

saccades will occur and interruption and slowing of normal saccadic movement is common.

Diagnosis

Diagnosis of any cerebellar disorder or syndrome should be made by a qualified

neurologist Neurology (from , "string, nerve" and the suffix -logia, "study of") is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the nervous system, which comprises the brain, the ...

. Prior to referring a patient to a neurologist, a general practitioner or MS nurse will perform a finger-to-nose test. The clinician will raise a finger in front of the patient and ask him to touch it with his finger and then touch his nose with his forefinger several times. This shows a patient's ability to judge the position of a target. Other tests that could be performed are similar in nature and include a heel to shin test in which

proximal Standard anatomical terms of location are used to describe unambiguously the anatomy of humans and other animals. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position prov ...

overshoot characterizes dysmetria and an inability to draw an imaginary circle with the arms or legs without any decomposition of movement. After a positive result in the finger-to-nose test, a neurologist will do a magnetic resonance image (MRI) to determine any damage to the cerebellum. Cerebellar patients encounter difficulties to adapt to unexpected changes of the inertia of the limbs. This can be used to increase dysmetria and confirm a diagnosis of cerebellar dysfunction. Patients also show an abnormal response to changes in damping. These findings confirm a role of the cerebellum in predictions.

Treatments

Currently there is no cure for dysmetria itself as it is actually a symptom of an underlying disorder. However,

isoniazid Isoniazid, also known as isonicotinic acid hydrazide (INH), is an antibiotic used for the treatment of tuberculosis. For active tuberculosis, it is often used together with rifampicin, pyrazinamide, and either streptomycin or ethambutol. F ...

and

clonazepam Clonazepam, sold under the brand name Klonopin among others, is a benzodiazepine medication used to prevent and treat anxiety disorders, seizures, bipolar mania, agitation associated with psychosis, obsessive–compulsive disorder (OCD), and ...

have been used to treat dysmetria.

Frenkel exercises Frenkel exercises are a set of exercises developed by Professor Heinrich Sebastian Frenkel to treat ataxia Ataxia (from Greek α- negative prefix+ -τάξις rder= "lack of order") is a neurological sign consisting of lack of voluntary ...

treat dysmetria.

Research

Researchers now are testing different possibilities for treating dysmetria and

. One opportunity for treatment is called rehearsal by eye movement. It is believed that visually guided movements require both lower- and higher-order visual functioning by first identifying a target location and then moving to acquire what is sought after. In one study, researchers used visually guided stepping which is parallel to visually guided arm movements to test this treatment. The patients had saccadic dysmetria which in turn caused them to overshoot their movements 3. The patients first walked normally and were then told to twice review the area that was to be walked through 3. After rehearsal with eye movements, the patients improved their motor performance. Researchers believe that prior rehearsal with the eyes might be enough for a patient with motor dysmetria as a result of saccadic dysmetria to complete a motor task with enhanced

spatial awareness Spatial contextual awareness consociates contextual information such as an individual's or sensor's location, activity, the time of day, and proximity to other people or objects and devices.Chen, Guanling, and David Kotz. 2000. A Survey of Context ...

. Research has also been done for those patients with MS. Deep brain stimulation (DBS) remains a viable possibility for some MS patients though the long-term effects of this treatment are currently under review. The subjects who have undergone this treatment had no major relapse for six months and disabling motor function problems. Most subjects benefited from the implantation of the

electrodes An electrode is an electrical conductor used to make contact with a nonmetallic part of a circuit (e.g. a semiconductor, an electrolyte, a vacuum or a gas). In electrochemical cells, electrodes are essential parts that can consist of a variety ...

and some reported that their movement disorder was gone after surgery. However, these results are limiting at this time because of the small range of subjects who were used for the experiment and it is unknown whether this is a viable option for all MS patients with motor control problems.

References

External links

{{Nervous and musculoskeletal system symptoms and signs Symptoms and signs: Nervous system