Journal of Neurology, Neurosurgery, and Psychiatry 1983;46:1052-1054

Short report

Non-paralytic motor disturbances and speech
disorders: the role of the supplementary motor area
HJ GELM_ERS
From the Department ofNeurology, Pr Irene Ziekenhuis, Almelo, The Netherlands

SUMMARY A right-handed patient with a lesion demonstrated by CT to involve the right medial
frontal cortex is described. He exhibited a strong contralateral grasp reflex, motor perseveration
and the presence of purposeful movements that appeared to be dissociated from conscious
volition. In addition, there was a disorder of speech consisting of a lack of spontanteous speech
production, with preserved ability to imitate. It is suggested that these disorders are due to
damage to the supplementary motor area.
Experimental studies in man' indicate that there are
a number of cortical fields involved in motor control,
among which is the supplementary motor area.

Although its functional distinctiveness has been
demonstrated, there are few descriptions of the
results of supplementary motor area damage.351213
The purpose of this case history is to describe the
clinical symptoms caused by a lesion involving the
right medial frontal cortex and to outline the "supplementary motor area-syndrome".
Case history
A 69-year-old right-handed man had sudden onset of
difficulty in speaking, together with weakness of the left
leg. Examination on admission showed him to be awake,
alert and oriented. He had a mild left-sided lower facial
weakness at rest and on volition, with a striking weakness
after laughing. There was total paralysis of the left leg.
Although the left arm showed a global inertia and no spontaneous movements, there was no paresis. The patient
found it an immense effort to move. When he moved, the
movements were correct but slow and deliberate. A strong
grasp reflex was noted in the left hand. Tendon reflexes
were exaggerated on the left and plantar responses were
extensor on the left and equivocal on the right. Visual
fields and ocular movements were full. Pinprick and vibratory sensation was normal as were detection of passive

movements and identification of palpated objects. The
patient did not initiate conversation. He spoke very haltingly in reply to questions. The responses were characterised by a great deal of difficulty in initiation. Comprehension of speech was good, as was the ability to imitate complex phrases sentences. There were no localising
phenomena indicating parietal lobe damage; the interpretation of body-perception was normal. Computed tomograms demonstrated an area of increased density involving
the right medial frontal cortex (2nd day after onset of
symptoms) (fig). Ten days after onset there was still a
strong grasp reflex in the left arm. The left leg had
improved in strength, but remained weak. The patient was
observed to reach out spontaneously with the left arm and
then would not be able to release his grip voluntarily. He
began to perseverate with his left arm when using a knife
and fork during meals, or when handling a haircomb or an
electrical razor. This motor perseveration was inhibited to
some extent by concentrated effort. After five weeks the
patient began to walk unaided, but he still displayed motor
perseveration of the left arm. This phenomenon was
indeed perseveration and not tonic innervation or an inability to release objects on account of the grasp reflex.

Discussion

This patient displayed a strong grasp reflex of the
left hand initially preceded by a global inertia. He
was observed to have motor perseveration (inappropriate repetition of a simple movement) of the
Address for reprint requests: Dr HJ Gelmers, Department of left hand. Later it was noted that apparently purNeurology, Pr Irene Ziekenhuis, 7607 PW Almelo, The Nether- poseful movements appeared to be occurring indelands.
pendent of conscious volitional control. AdditionReceived 15 December 1982 and in revised form 22 May 1983. ally, the patient exhibited a speech disorder, consisting of a lack of spontaneous speech with preserved
Accepted 2 June 1983
1052

Non-paralytic motor disturbances and speech disorders

Fig Selection of slices from a complete set of CT-scans.
The infraventricular (not depicted) and low ventricular (A)
slices were normal. The high ventricular slice (B)
demonstrated an area of increased density involving the
medial frontal area of the right hemisphere. In the
supraventricular slices (C, D) the extension of the
increased area is shown (the lesion is for reasons ofclarity
outlined in black ink).

ability to repeat. CT showed a lesion involving the
right medial frontal cortex.
A patient with some similar features has been
published,2 who suffered an infarction of the medial
frontal cortex due to occlusion of the left pericallosal
artery. This patient had spontaneous grasping
together with motor perseveration of the right hand.
He too was unable to inhibit these movements,
although he was fully aware of them. The ability to
execute new movements was retained. Others3 have
described global akinesia of the right arm in patients
with lesions involving the left medial frontal cortex.
All these motor phenomena were observed in our
patient. More widespread dissociative psychomotor
phenomena, including the "alien hand sign" and
"intermanual conflict" as observed in patients the
first weeks following section of the corpus callosum
for intractable epilepsy,4 were not seen in our
patient. This is contrary to other observers5 who, in
patients with medial frontal cortex infarction, noted
that one of the hands behaved in a way which the
patient found "alien" or at least uncooperative.
Two functional zones on the medial surface of the
frontal lobes, damage to which may be implicated in
the appearance of motor disturbance, as well as the

1053
speech disorder, are the supplementary motor area
and the cingulate cortex. Penfield and Jasper'
reported that stimulation of the supplementary
motor area produced vocalisation, speech arrest,
complex coordinated or repetitive movements usually appearing in the contralateral arm and arrest or
slowing of voluntary action following which it was
noted that the patient was "usually puzzled by his
inability to execute" the action he had intended.
Continuous electrical stimulation of anterior cingulate cortex in epileptic patients is followed by complex, highly. integated forms of motor behaviour
most often in the contralateral arm.6 Recently, regional blood flow studies in man have demonstrated
bilateral activation of supplementary motor area in
association with various complex movements of the
extremities,7 8 as well as with speech.9 10 From these
studies it has been suggested that the supplementary
motor area is involved in the assembly and execution of time-ordered sequences of motor instructions."I
Our patient also exhibited a speech disorder, consisting of a lack of spontaneous speech production,
with preserved ability to imitate. This type of speech
disturbance is often designed as transcortical motor
aphasia'2 and has been described in patients who
sustained damage to the left medial frontal cortex.5 1213 Although similar disturbances of speech of
patients have been recorded by others,3 no mention
was made of the site of the involving mediofrontal
lesion. Since the lesion in our patients was localised
in the right hemisphere, it is best not to describe this
speech disorder as an "aphasia". Moreover, it covers the recently proposed term "transcortical motor
aprosodia". 14
There seems now sufficient clinical and experimental evidence to conclude that lesions of the
medial frontal parts of the hemisphere, including the
supplementary motor area, gives rise to nonparalytic motor and speech disturbances.
The author is grateful to Professor Dr J Willemse,
Department of Child Neurology, Faculty of
Medicine, University of Utrecht, for support and
advice in this study.
References
'Penfield W, Jasper H. Epilepsy and the Functional
Anatomy of the Human Brain. Boston: Little Brown,
1954:88-108.
2 Shahani B, Burrows P, Whitty CWM. The grasp reflex
and perseveration. Brain 1970;93:181-92.
Damasio AR, Hoesen GW van. Structure and function
of the supplementary motor area. Neurology (Minneap) 1980;30:359.

1054
4Bogen JE. The callosal syndrome. In: Heilman KM,
Valenstein E, eds. Clinical Neuropsychology. New
York: New York University Press, 1979:308-59.
5Goldberg G, Mayer NH, Toglia JU. Medial frontal cortex infarction and the alien hand sign. Arch Neurol
1981 ;38:683-6.
6 Talairach J, Bancaud J. The supplementary motor area
in man: anatomo-functional findings by stereoelectroencephalography in epilepsy. Int J Neurol
1966;5:330-47.
7Roland PE, Skinh0j E, Lassen NA, et al. Supplementary
motor area and other cortical areas in organization of
voluntary movements in man. J Neurophysiol 1980;
43:118-36
8 Gelmers HJ. Cortical organization of voluntary motor
activity as revealed by measurements of regional cerebral blood flow. J Neurol Sci 1981 ;52:149-61.

Gelmers
9 Larsen B, Skinh0j E, Lassen NA. Variations in regional

cortical blood flow in the right and left hemispheres
during automatic speech. Brain 1978;101: 193-209.
10 Gelmers HJ. Regional cerebral blood flow correlates of
speech in the dominant and in the non-dominant
hemigphere. J Neurol Sci (In press).
" Orgogozo JM, Larsen B. Activation of the supplementary motor area during voluntary movement in man
suggests it works as a supra-motor area. Science
1979;206:847-50.
12 Masdeu JC, Schoene WC, Funkenstein H. Aphasia following infarction of the left supplementary motor
area. Neurology (Minneap) 1978;28:1220-3.
13 Alexander MP, Schmidt MA. The aphasia syndrome of
stroke in the left anterior cerebral artery territory.
Arch Neurol 1980;37:97-100.
4 Ross ED. The aprosodias. Arch Neurol 1981 ;38:561-9.