Motor Dysfunction In Patients Research Articles

Sympathetic Blockade Improved Motor Dysfunction in Patients with Posttraumatic Cervical Syndrome

Sympathetic Blockade Improved Motor Dysfunction in Patients with Posttraumatic Cervical Syndrome

Correlations Among Electrogastrogram, Gastric Dysmotility, and Duodenal Dysmotility in Patients With Functional Dyspepsia

The aim of this study was to assess gastric slow waves, antral and duodenal motility simultaneously, and determine the correlation among all these measures in patients with functional dyspepsia. Thirty-one patients with functional dyspepsia were assessed for severity of upper gastrointestinal symptoms with the electrogastrography (EGG) and antroduodenal manometry. The EGG and manometry were recorded for 3 to 4 hours in the fasting state and for 2 hours after a solid meal. Computerized spectral analysis methods were used to compute various EGG parameters. The EGG was abnormal in 71.0% of patients. The abnormalities included normal slow waves lower than 70% in the fasting state (51.6% of patients) and in the fed state (48.4% of patients), a decrease in dominant power in 28.9% of patients. Antral motility was abnormal in 80.6% of patients and duodenal motility was abnormal in 74.2% of patients. For the EGG and antral motility, 19 of 31 patients had both abnormal EGG and abnormal antral motility; 2 of 31 patients had both normal EGG and normal antral motility. For the EGG and duodenal motility, these values were 16/31 and 2/31, respectively. By both EGG and antroduodenal manometry, abnormal gastric motor function was found in 93.5% of patients. However, quantitative one-to-one correlation between any of the EGG parameters and the antroduodenal dysmotility was not noted. The patients showed high symptom scores particularly to upper abdominal pain, nausea, and belch. No one-to-one correlation was noted between the symptom scores and any of the EGG or motility parameters. More than two-thirds of patients with functional dyspepsia have abnormalities in the EGG and antral/duodenal motility. The sensitivity of these 2 different methods is essentially the same. EGG and antroduodenal manometry can complement each other in demonstrating gastric motor dysfunction in patients with functional dyspepsia.

Spiral analysis: a new technique for measuring tremor with a digitizing tablet.

A new computational method for quantification of tremor and other aspects of motor dysfunction is described. By using a digitizing tablet connected to a microcomputer, this analysis is derived from the handwritten Archimedean spiral. This technique extends the standard clinical neurologic test of spiral drawing into an objective and accurate measure that can automatically detect, characterize, and quantify motor dysfunction in patients with movement disorders. Further, it is safe, inexpensive, fast, portable, noninvasive, and can be administered to a large cohort of patients without the need for wires or other attachments. Spiral data are collected in the X, Y, and pressure axes, providing virtual "triaxial" recordings. Spiral analysis is shown to be capable of assessing subtle motor abnormalities potentially indicative of clinical problems in their earliest stages, and thus allow the most rational forms of genetic testing, treatment, or prevention. Spiral analysis may be useful as an initial marker of clinical involvement or serve as an objective gauge of change after therapeutic intervention.

Improvement of motor functions by noisy vestibular stimulation in central neurodegenerative disorders

Through the cerebellar vermis, the vestibular nerves are known to influence the basal ganglia and the limbic system. By means of noisy galvanic vestibular stimulation (GVS), it may be possible to ameliorate movement disorders, particularly akinesic symptoms, in patients with central neurodegenerative disorders. We evaluated the effect of 24-hour noisy GVS on a power-law temporal autocorrelation exponent of daytime wrist activity, separately for higher (local maxima) and lower (local minima) levels of activity, in 14 hospitalized patients. The power-law exponent for the local maxima was significantly (p < 0.002) lower with the noisy GVS than with sham stimulation, suggestive of more frequent switching behavior from low to high levels of activity or less severe akinesia. The noisy GVS may thus potentially improve certain motor dysfunctions in patients with distinct central neurodegenerative diseases.

Effects of Rivastigmine on Tremor and Other Motor Symptoms in Patients with Parkinson’s Disease Dementia

Rivastigmine is now widely approved for the treatment of mild to moderately severe dementia in Parkinson's disease (PDD). However, since anticholinergic drugs have a role in the management of tremor in patients with Parkinson's disease (PD), concerns have been raised that the use of cholinergic drugs might worsen PD. The current analyses were performed to examine the potential of rivastigmine to affect tremor and other motor symptoms in patients with PDD. The safety profile of rivastigmine was evaluated using a database from a 24-week, randomized, double-blind, placebo-controlled trial in 541 PDD patients (362 randomized to rivastigmine, 179 to placebo), and 334 PDD patients who subsequently entered an open-label 24-week extension on rivastigmine. During the double-blind trial, the adverse event (AE) of emerging or worsening tremor was reported in 10.2% of patients in the rivastigmine group, compared with 3.9% in the placebo group (p = 0.012). Tremor was most frequently reported during the titration phase of rivastigmine treatment, although this was not reflected in total motor Unified Parkinson's Disease Rating Scale (UPDRS) part III scores. Dose dependence of this AE was not observed. At the end of the double-blind phase, six (1.7%) rivastigmine-treated patients had discontinued the study because of tremor. In the open-label extension in which all patients received rivastigmine, tremor was reported by 6.9% of patients: 3.8% and 12.2% of whom had previously received double-blind rivastigmine and placebo, respectively (p = 0.006), suggesting that first exposure to rivastigmine leads to a transient increase in tremor. Three (0.9%) of the 334 patients who entered the open-label extension phase discontinued because of tremor. Incidences of worsening parkinsonism, bradykinesia and rigidity were all <5% in both treatment groups (all p-values not statistically significant, rivastigmine vs placebo). In the 48-week observation of rivastigmine treatment, there was no evidence of adverse long-term motor outcomes. Post-hoc analysis showed that similar improvements in the symptoms of dementia, including the ability to perform activities of daily living, were seen regardless of whether exacerbation of tremor was reported during the study. Rivastigmine did not induce clinically significant exacerbation of motor dysfunction in patients with PDD. Rest tremor incidence as an AE was a transient phenomenon during dose titration of rivastigmine. There was no indication that exposure to long-term rivastigmine was associated with a worsening of PD.

Diffusion Tensor Pyramidal Tractography in Patients With Anterior Choroidal Artery Infarcts

Anterior choroidal artery (AchoA) stroke often evolves into undulating hemipareses, which sometimes progress to high-grade hemiparesis or hemiplegia but may also completely regress. Spatial relationships of AchoA infarcts to corticospinal tracts (CSTs) and CST integrity were investigated with diffusion tensor imaging (DTI) to identify prognostic parameters related to diffusion anisotropy changes in AchoA stroke. Twenty-five AchoA stroke patients were prospectively examined with 3T DTI and diffusion tensor tractography (DTT) within a 3-day mean interval after onset. Analysis included the following: 1) stroke size on diffusion-weighted imaging; 2) fractional anisotropy (FA) and apparent diffusion coefficients at the largest stroke extents versus contralateral homologous structures; 3) lesion location related to CST ("involvement"); 4) amount of fiber trajectories of affected versus nonaffected CST ("fiber ratio"); and 5) presence of ipsilateral fiber disruption. Imaging findings were related to clinical status 3 months after symptom onset with respect to favorable, moderate, or unfavorable motor outcome. FA differences (due to FA reduction in the affected versus nonaffected hemisphere) were significantly higher for patients with unfavorable outcome (P=.03). Patients with favorable outcome had nearly symmetrical FA. CSTs were involved in ischemic lesions in all but 2 patients (complete involvement, n=3; partial, n=20). Two CSTs were completely disrupted, and both patients were hemiplegic (no disruption, n=14; partial disruption, n=9). Fiber disruption and CST involvement correlated negatively with motor score after AchoA stroke (P < .01), whereas infarct size did not. DTT may explain resulting motor dysfunction in patients with AchoA infarcts with more notably decreased FA being an indicator for unfavorable outcome.

Segmental and total oesophageal transit time in patients with corrosive-induced oesophageal stricture

The mainstay of treatment of corrosive oesophageal strictures is endoscopic dilatation. However, even after adequate dilatation, some patients may continue to have dysphagia. An associated oesophageal motor dysfunction in such patients may contribute to the persistence of dysphagia. To assess oesophageal motor dysfunction in patients with corrosive strictures using segmental and total oesophageal transit time by radionuclide scintigraphy. Thirty-five patients with corrosive-induced oesophageal strictures were evaluated after having achieved a dilatation of 15 mm. All patients underwent barium swallow and upper endoscopy for assessment of stricture(s). Oesophageal motility was assessed by radionuclide scintigraphy using Tc sulfur colloid. Total oesophageal transit time (ETT) and segmental (upper, middle and lower third of oesophagus) ETT were determined. Thirty-five patients (age 18-53 years) were evaluated. Twenty-eight (80%) patients had a single stricture while seven (20%) had either two or three strictures. Eighteen patients had no dysphagia, 13 patients had grade 1 dysphagia and four patients grade 2 dysphagia. Total ETT was prolonged in 12 patients. Upper, middle and lower third ETT was prolonged in four, seven and six patients, respectively. Length of the stricture correlated with prolongation of ETT as 6.66% patients with length < or = 5 cm, and 53.84% of patients with length >5 cm had prolonged total ETT (P=0.019). Patients with tortuous stricture had more prolongation of ETT as compared to those with straight strictures though it did not reach statistical significance. No significant correlation was observed between number of strictures and prolongation of total ETT. The severity of dysphagia correlated with prolongation of total ETT (P=0.011). Oesophageal transit time as assessed by scintigraphy is prolonged in one-third of patients with corrosive-induced oesophageal strictures despite having achieved adequate dilatation. Prolongation of ETT correlates with length of the stricture and severity of dysphagia correlates with prolongation of total ETT. These observations suggest impairment of oesophageal motility in these patients.

Motor dysfunction in patients with liver cirrhosis: impairment of handwriting

Motor dysfunction is an important clinical finding in patients with liver cirrhosis and mild forms of hepatic encephalopathy. The mechanisms and clinical appearance of motor impairment in patients with liver cirrhosis are not completely understood. We studied fine motor control in forty four patients with advanced liver cirrhosis (excluding those with hepatic encephalopathy grade II) and 48 healthy controls using a kinematic analysis of standardized handwriting tests. We analysed parameters of velocity, the ability to coordinate and the level of automatisation of handwriting movements. Furthermore, we studied the association between impairment of handwriting and clinical neuro-psychiatric symptoms. As compared with control subjects, patients showed a statistically significant reduction of movement peak velocity in all handwriting tasks as well as a substantial increase of number of velocity inversions per stroke. Using a z-score based assessment we found impairment of handwriting in fourteen out of forty four patients (31.8 %). The deterioration of handwriting was associated with clinical symptoms of motor dysfunction, such as bradykinesia, adiadochokinesia, dysmetria of upper extremities and gait ataxia. This is the first study that quantitatively investigates impairment of handwriting in patients with liver cirrhosis. Our findings suggest the application of kinematic analysis of handwriting for diagnostics of motor dysfunction in patients with mild forms of hepatic encephalopathy.

Acupuncture for Acute Stroke

Section Editors: Graeme J. Hankey MD, FRCP Acupuncture is widely used in the treatment of stroke in China and it is increasingly requested by patients in some Western countries. Experimental data indicate that acupuncture-like sensory stimulation activates multiple efferent (nerve) pathways leading to altered activity in numerous neural systems. The objectives of this study were to assess the effectiveness and safety of acupuncture in patients with acute stroke. We searched the Cochrane Stroke Group Trials Register (last searched August 2003), the Chinese Stroke Trials Register (August 2003), and the Chinese Acupuncture Trials Register (August 2003). Electronic searches were performed in the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2003), MEDLINE (1966 to 2003), EMBASE (1980 to 2003), …

Diagnostic value of fine motor deficits in patients with low-grade hepatic encephalopathy

The role of motor dysfunction in early diagnosis of low-grade hepatic encephalopathy remains uncertain. We performed a pilot study to comparatively investigate the kinematic characteristics of small and large rapid alternating movements in patients with liver cirrhosis and low-grade hepatic encephalopathy. A kinematic analysis of alternating handwriting (7.5 mm) and large drawing movements (DM, 175 mm) was performed in 30 patients with liver cirrhosis (no hepatic encephalopathy: n = 10; minimal hepatic encephalopathy: n = 9; grade I hepatic encephalopathy: n = 11; healthy controls: n = 12). The correlation between kinematic parameters, clinical neuro-psychiatric symptoms of cerebral dysfunction and the grade of encephalopathy was investigated. Both movement types, handwriting and drawing, were significantly slower in cirrhotic patients. In contrast to large DM, the deterioration of handwriting movements significantly correlated with the increase of symptoms of motor dysfunction and differentiated significantly within the group of cirrhosis patients corresponding to the degree of hepatic encephalopathy. The deterioration of fine motor control is an important symptom of low-grade hepatic encephalopathy. The kinematic analysis of handwriting allows the quantitative analysis of alterations of motor function and is a possible tool for diagnostics and monitoring of motor dysfunction in patients with low-grade hepatic encephalopathy.

Clarification of Findings

To the Editor: In the June 2002 issue of Physical Therapy , Martin et al (“Gait Initiation in Community-Dwelling Adults With Parkinson Disease: Comparison With Older and Younger Adults Without the Disease”) reported on a method that might be useful for detecting subtle signs of motor dysfunction in patients with Parkinson disease. The following 4 inconsistencies in their article, however, appear to be enough to prompt a request for clarification of their findings. In both Table 1 and the text of the article, the authors indicate that 12 people with Parkinson disease participated in the study. When describing the Hoehn and Yahr stages of these people, the authors state, “1 participant was in stage 1.5, 2 participants were in stage 2, 7 participants were in stage 2.5, and 6 participants were in stage 3.” How can these numbers be reconciled, unless a given participant can be in more than one stage simultaneously? In Table 2, the mean values for event B are considerably smaller than the mean values for event A, even though the 2 events happened at almost the same time, as implied in the corresponding values for % gait initiation cycle in Table 3. No units are specified for the values in Table 2, although the reader can guess that the units …

Influence of Helicobacter pylori infection on the prevalence of reflux esophagitis in Japanese patients.

Reflux esophagitis is caused by esophageal motor dysfunction in patients with sufficient gastric acid secretion. Helicobacter pylori causes atrophic gastritis and influences gastric acid secretion. Hiatus hernia (HH) of the esophagus causes motor dysfunction in the lower esophagus. Therefore, this study aimed to test whether H. pylori infection, gastric mucosal atrophy and HH are predictive factors for reflux esophagitis. Helicobacter pylori infection was examined in 781 patients by the measurement of serum immunoglobulin (Ig)G antibody, bacteriological culture and histological examination of biopsy specimens. The prevalence of HH, endoscopically identified gastric mucosal atrophy (closed- or open-type) and reflux esophagitis were investigated by reviewing endoscopic films. Investigated patients were divided into three age groups, under 49, 50-69, and over 70 years. The prevalence of esophagitis, H. pylori infection, gastric mucosal atrophy, and HH were compared to identify the possible predictive factors for reflux esophagitis by using logistic regression analysis. Sixty-nine patients with reflux esophagitis were found among the 781 investigated cases. The odds ratios of negative H. pylori infection, endoscopically identified closed-type gastric mucosal atrophy, and HH for the prevalence of reflux esophagitis were 1.342, 1.751 and 5.527, respectively. These results indicated that the presence of H. pylori infection was only a weak negative risk factor, and that HH was the most reliable endoscopic predictive factor for reflux esophagitis. Helicobacter pylori infection is a weak negative risk factor for the prevalence of reflux esophagitis, while HH is the most reliable predictive factor.

The motor dysfunction of patients with knee osteoarthritis in a Chinese population

Objective To determine the extent of motor dysfunction in people with knee osteoarthritis (OA), as compared with similarly aged subjects without knee OA, in a Chinese population. Methods Seventy-six subjects participated in this study. Isometric peak torque of the knee muscles, range of knee motion at rest and during walking, gait velocity, cadence, and stride length were compared. Results The isometric peak torque of both the quadriceps and the hamstrings of the affected leg of patients with knee OA were weaker than those of the controls (most P < 0.05). The gait velocity was 23.4% slower (P = 0.001), the cadence 33.3% less (P < 0.001), and the stride length 13.4% shorter (P = 0.010) in the patients with OA. The range of knee motion in the patients was reduced by 11.2% at rest (P = 0.003) and by 14.7% during walking (P = 0.001). Conclusion Patients with knee OA exhibited statistically significant deficiencies in the physical performance tested, as compared with similarly aged subjects without knee OA (by 9.6% to 33.3%), in a Chinese population. The indication that this study group seems less severely limited than those reported in Western literature warrants further investigation. Arthritis Care Res 45:62–68, 2001. © 2001 by the American College of Rheumatology.

Spatial functional distribution in the corticospinal tract at the corona radiata: a three-dimensional anisotropy contrast study.

The spatial functional distribution of the nerve fibers was investigated in the corticospinal tract at the level of the corona radiata. Thirteen patients with corona radiata infarction underwent axial single-shot echo planar diffusion-weighted magnetic resonance imaging using a 1.5 Tesla scanner. Image analysis used the three-dimensional anisotropy contrast (3DAC) method to demarcate the nerve fibers in the corticospinal tract. Axial 3DAC images demonstrated the corticospinal tract as a distinct area indicating nerve fiber integrity in all normal hemispheres and infarction as a dark or black area in affected hemispheres. Seven patients with upper extremity-dominant motor dysfunction had infarction located in the middle one third of the corticospinal tract. A patient with lower extremity-dominant motor dysfunction had infarction in the posterior one third. Five patients with equal motor dysfunction in the upper and lower extremities had infarction in both the middle and posterior one thirds of the corticospinal tract. The recovery of motor dysfunction at one month follow up correlated with the location of the corticospinal tract injury on the initial 3DAC images. The findings of the 3DAC images provide an indicator of the pattern and the recovery from acute and chronic motor dysfunction in patients with corona radiata infarction.

The motor dysfunction of patients with knee osteoarthritis in a Chinese population.

To determine the extent of motor dysfunction in people with knee osteoarthritis (OA), as compared with similarly aged subjects without knee OA, in a Chinese population. Seventy-six subjects participated in this study. Isometric peak torque of the knee muscles, range of knee motion at rest and during walking, gait velocity, cadence, and stride length were compared. The isometric peak torque of both the quadriceps and the hamstrings of the affected leg of patients with knee OA were weaker than those of the controls (most P < 0.05). The gait velocity was 23.4% slower (P = 0.001), the cadence 33.3% less (P < 0.001), and the stride length 13.4% shorter (P = 0.010) in the patients with OA. The range of knee motion in the patients was reduced by 11.2% at rest (P = 0.003) and by 14.7% during walking (P = 0.001). Patients with knee OA exhibited statistically significant deficiencies in the physical performance tested, as compared with similarly aged subjects without knee OA (by 9.6% to 33.3%), in a Chinese population. The indication that this study group seems less severely limited than those reported in Western literature warrants further investigation.

Reduced anterior cingulate gyrus volume correlates with executive dysfunction in men with first-episode schizophrenia

Although frontal lobe structural and functional abnormalities have been identified in schizophrenia, their relationship remains elusive. Because the frontal lobes are both structurally and functionally heterogeneous, it is possible that some measures of frontal lobe structure may not have accurately identified relevant frontal lobe subregions. The authors hypothesized that the volumes of two dorsal, ‘archicortical’ subregions (i.e. superior frontal gyrus and anterior cingulate gyrus), but not a ventral, ‘paleocortical’ subregion (i.e. orbital frontal region) would be significantly and selectively correlated with executive and motor dysfunction in patients with schizophrenia as previously reported for the anterior hippocampal region. Volumes of these frontal lobe subregions were measured from magnetic resonance images based on sulcal anatomy in 20 men and 15 women with first-episode schizophrenia. All patients completed a comprehensive neuropsychological test battery while clinically stabilized that encompassed six domains of functioning: attention, executive, motor, visuospatial, memory and language. Findings indicated that reduced anterior cingulate gyrus volume was significantly correlated with worse executive functioning in men; among women, there were no significant correlations. Among men, anterior cingulate gyrus volume was significantly more strongly correlated with executive functioning than with attention, visuospatial, memory, language and general intellectual functioning. Neither executive nor motor functioning was significantly more strongly correlated with the dorsal ‘archicortical’ volumes than with orbital frontal volume. These findings suggest a link between executive deficits and dysfunction of the dorsal ‘archicortical’ system and implicate sex differences in their relationship in first-episode schizophrenia.

Motility, heartburn and dyspepsia

SUMMARYDisordered motility has been considered fundamental to the pathophysiology of gastro‐oesophageal reflux disease and a number of dyspeptic syndromes. Motor activity is certainly essential for the homeostasis of the oesophagus and stomach ‐ in the oesophagus, the lower oesophageal sphincter and peristalsis are fundamental components of the ‘normal’ anti‐reflux defence mechanism, whereas, in the stomach, contractile activity regulates the orderly emptying of the various components of a meal.Recent studies have clarified considerably the role of the lower oesophageal sphincter in permitting reflux to occur under both physiological and pathological situations, and transient relaxation of the lower oesophageal sphincter is now regarded as the most important mechanism of reflux.Interest has also been renewed in the role of hiatus hernia in the pathogenesis of reflux disease. By moving the lower oesophageal sphincter into the thorax, a hiatus hernia deprives this sphincter of the beneficial effects of intra‐abdominal pressure and crural augmentation. Altered anatomical relationships also predispose the patient with a non‐reducing hiatus hernia to impaired clearance of acid, thus exacerbating reflux.Relationships between disordered peristalsis and reflux are complex. Primary disorders of peristalsis, such as scleroderma, are associated with severe and often complicated reflux disease. It is also evident that reflux may itself result in impaired peristalsis, particularly in the distal oesophagus. Whether aggressive treatment of reflux disease by either medical or surgical means can restore peristaltic function remains uncertain.The importance of co‐ordinated function of the antrum, pylorus and duodenum in the regulation of gastric emptying is being increasingly recognized. Foregut motor dysfunction is implicated in dyspepsia. Abnormalities in patients with dyspepsia include gastroparesis, antral hypomotility, gastric dysrhythmias, duodenal dysmotility, and duodeno‐gastric reflux. The true prevalence of these disorders is uncertain, and the reported relationship between these abnormalities and symptoms has often been inconsistent. The specificity of the abnormalities for dyspepsia is also open to question. In many instances, it remains unclear whether the motor abnormality is truly primary or rather an epi‐phenomenon. It seems reasonable to conclude that while considerable advances have been made in our understanding of both foregut motor physiology and the role of motor dysfunction in patients with reflux disease, the role of dysmotility in dyspeptic patients remains uncertain.

Modulation of electromyographic activity of wrist flexor and extensor muscles in patients with writer's cramp.

Patients with writer's cramp have two well-recognized neurophysiological abnormalities: reduced reciprocal inhibition of the wrist flexor motoneurons at rest, and increased cocontraction of antagonist muscles of the forearm during voluntary activity. In this article we present evidence for an impaired integration of sensory inputs into the voluntary motor activity during performance of a force-related task in patients with writer's cramp. Normal (control) subjects and patients activated wrist flexor and extensor muscles to maintain a predetermined level of force. Electrical stimuli were applied to median and radial nerve afferents and the modulatory effects induced in the electromyographic (EMG) activity were measured. For each muscle studied and nerve stimulated, we defined a characteristic sequence of excitatory (E) and inhibitory (I) phases of modulation of the averaged rectified EMG activity in control subjects. E and I phases were thought to represent excitation and inhibition, respectively, of the corresponding motoneuronal pool to homonymous or reciprocal afferent inputs. There were no differences between control subjects and patients regarding the level of background EMG activity in the agonist muscles during wrist flexion or wrist extension. In the agonist wrist flexors, patients had reduced homonymous and reciprocal inhibition. In the agonist wrist extensors, patients had reduced reciprocal excitation and reciprocal inhibition. These results are compatible with an abnormal CNS processing of the inputs generated by external stimuli during voluntary contraction of wrist flexor and extensor muscles. Defective integration of inputs from peripheral nerve afferents into the command for voluntary movement may partly underlie the pathophysiology of the motor dysfunction in patients with writer's cramp.

Malabsorption and motor dysfunction in patients with small bowel amyloidosis.

Malabsorption and motor dysfunction in patients with small bowel amyloidosis.

Oesophageal motor dysfunction in patients with diverticula of the mid-thoracic oesophagus.

Kaye, M. D. (1974). Thorax , 29 , 666-672. Oesophageal motor dysfunction in patients with diverticula of the mid-thoracic oesophagus. Oesophageal motor function was assessed by a perfused catheter manometric system in a consecutive series of 12 patients with diverticula located in the mid-thoracic oesophagus. In only one of the 12 patients was there radiographic evidence of prior tuberculous infection. Manometry revealed diffuse oesophageal spasm in five patients and vigorous achalasia in one. In the other six patients there was a definite but unclassifiable abnormality of motility, of moderate degree in four and mild in two. `Traction' is of less importance in the pathogenesis of mid-oesophageal diverticula than is generally supposed. An underlying disorder of oesophageal motor function should be suspected in patients with this type of lesion.