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PassPMR - 05 Neurology > 2- Hypokinetic Movement Disorder > Flashcards

2- Hypokinetic Movement Disorder Flashcards

1
Q

Pyramidal vs ExtraPyramidal Tracts: components and clinical manifestations

A

PYRAMIDAL

Tracts

  1. Corticospinal Tracts
  2. Corticobulbar Tracts

Pathology

  • Paralysis, paresis, hyperreflexia, and spasticity.

EXTRAPYRAMIDAL

Made up from

  1. Nuclie in basal ganglia
  2. Cerebellum
  3. Brainstem.

Tracts

  1. Reticulospinal tract
  2. Vestibulospinal tract
  3. Rubrospinal tract
  4. Tectospinal tract

Pathology

  • Akathisia, athetosis, ballismus, chorea, dystonia, myoclonus, stereotypy, tic, and tremor.
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2
Q

What is Parkinson’s Disease? What are the four parts of basal ganglia 🔑🔑

A

Parkinson Disease

Neuronal loss in the Substantia nigra (SN) with consequent dopamine depletion in the striatum is the neurochemical–pathologic hallmark of PD

  1. Hypoactivity of the striatonigral (direct) pathway → Hypokinesia
  2. Hyperactivity of striatopallidal (indirect) pathways → Hyerkinesia

Basal Ganglia Components

Function: movement modulation

  1. Substantia nigra (SN): reticular (SNr) compact (SNc)
  2. Striatum (Str)
  3. Subthalamic nucleus (STN)
  4. Globus pallidus (GP): internal (GPi) and external (GPe)

Clinical presentation

  1. Hypokinetic Hypertonic
    • Regidity
    • Bradykinesia - Akinesia
    • Parkinson Disease
  2. Hyperkinetic Hypotonic
    • Tremor - Chorea - Hemiballismus - Tics - Dystonia - Myoclonus
    • Huntington’s disease

Basal Ganglia Pathways

  1. The nigrostriatal pathway
    • From Substantia nigra pars compacta to the striatum
    • Neurotransmitter dopamine
    • Excites the direct pathway (Dopamine 1 receptors)
    • Inhibits the indirect pathway (Dopamine 2 receptors)
  2. The thalamostriatal pathway
    • From the intralaminar nuclei of the thalamus and terminate primarily in the striatum.

Direct Excitatory Pathway (D1 Receptors)

Movement initiation: excite the motor cortex to increase the motor activity.

Neurotransmitter: Dopamine

Indirect (D2 Receptors) & Hyperdirect Inhibitory Pathways

Movement termination: decreased activity of the cortical motor neurons and suppression of the spontaneous movement

Neurotransmitter: GABA and Glutamate

Neurology Secrets 6th Edition Chapter 11 pg138

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3
Q

What are the two systems that affect our motor co-ordination? 🔑🔑

A
  1. Basal ganglia, influence direction, amplitude, and course of movement
  2. Cerebellar function, for rapid corrections and coordination of movements.

Cuccurollo 4th Edition Chapter 12 PD pg867

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4
Q

List 5 causes of Parkinsonism other than Parkinson’s disease. 🔑🔑

A
  1. Cerebrovascular accidents/multiple lacunar strokes
  2. Brain tumors
  3. Posttraumatic parkinsonism
  4. Drug induced parkinsonism
  5. Toxins induced parkinsonism
  6. Normal Pressure Hydrocephalus
  7. Progressive supranuclear palsy (PSP)
  8. Multisystem atrophy (MSA)
  9. Corticobasal degeneration (CBD)

Cuccurollo 4th Edition Chapter 12 Movement Disorder pg873

PMR Secrets 3rd Edition Chapter 56 Movement Disorders pg466

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5
Q

What differentiates Parkinson Disease from other causes of parkinsonism?

List 5 symptoms in favor or parkinson-plus syndromes (parkinsonism). 🔑🔑

A

Progressive Supranuclear Palsy (PSP)

  1. Ocular signs (Supranuclear gaze palsy, nystagmus, blepharospasm, apraxia eyelid, blinking/saccadic abnormalities).
  2. Dominance of truncal symptoms.

Multiple System Atrophy (MSA)

  1. Early onset postural instability and autonomic dysfunction

Dementia with Lewy bodies (DLB)

  1. Early onset visual hallucinations, psychosis.

Parkinson Plus

  1. Low response to oral levodopa or dopamine agonists

Ref: chaudhuri – movement disorders in clinical practice textbook pg 34.

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6
Q

What are the drugs that can cause PD type features?

A
  1. Anti-Psychotics (Typical > atypical).
  2. Anti-Emetic (Dopamine antagonists)
  3. Lithium.
  4. Amiodarone
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7
Q

What are positive & negative prognostic factors of parkinsons disease? 🔑

A

POSITIVE

  1. Positive family history
  2. Early tremor
  3. Early rigidity

NEGATIVE

  1. Older age of onset.
  2. Associated co-morbidities.
  3. Decreased dopamine responsiveness
  4. Presentation with rigidity and bradykinesia.

Ref: 2005 – AAN – practice parameter diagnosis and prognosis of new onset PD.

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8
Q

What are the cardinal signs of Parkinson Disease? 🔑🔑 MOCK

A

TRAPGH

Resting tremor (pin rolling, bursts in agonist and antagonist muscles)

Rigidity (cogwheel or leadpipe) + Bradykinesia (slowness of movements)

Stooped posture and postural instability (lose of postural reflexes, high risk of fall)

Shuffling gait ( small steps , turning “ en bloc “ , freezing )

Decreased arm swing, short steps, marked flexion of the trunk during ambulation and standing (known as camptocormia), narrow base of support

Hypophonia

Extra

  1. Masked facies (hypomimia = expressionless face)
  2. Dysarthria
  3. Micrographia
  4. Difficulties cutting food, feeding, dressing
  5. Hypometria

Early PD

  • Most common initial symptom is resting tremor
  • Patients may feel clumsy or weak, as well as slow and stiff.
  • Activities such as dressing (particularly buttoning), shaving, cutting food, and writing are more difficult.

Advanced PD

  1. Apraxia (limb kinetic & gait)
  2. Akinesea or freezing
  3. Dyskinesea (medication side effects)
  4. Kyphosis

Cuccurollo 4th Edition Chapter 12 Movement Disorder pg870 Table 12-3

DeLisa 5th Edition Chapter 26 Movement Disorder pg646 Table 26.1

PMR Secrets 3rd Edition Chapter 56 Movement Disorders pg467

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9
Q

List 6 gait changes/abnormalities in Parkinson’s 🔑🔑

A

Gait Abnormalities in PD

  1. Freezing gait: Hesitation to initiate gait, person stops and cannot initiate movement while walking, turning around, or stepping around objects.
  2. Festinating gait: small steps increasing in speed, frequency with a forward trunk posture
  3. Shuffling gait: Decreased step and stride length, decreased cadence and velocity
  4. Narrow base of support.
  5. Stooped “flexion” posture
  6. Decreased arm swing
  7. Turn in-block
  8. Reduced hip, knee, and ankle flexion angles
  9. Diminished postural reflexes (proprioceptive deficits): difficulty adapting postural responses and stability during gait, especially on uneven surfaces

Gait patterns in parkinson

  1. Freezing
  2. Festinating
  3. Shuffling

Secondary impairments

  • Muscle weakness (disuse atrophy and contractures)

Cuccurollo 4th Edition Chapter 12 Movement Disorder pg890 Table 12-3

DeLisa 5th Edition Chapter 26 Movement Disorder pg649

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10
Q

List 5 risk factors of falls in parkinson disease 🔑🔑

A

Primary impairments

  1. Postural imbalance and decreased postural reflexes
  2. Loss of proprioceptive feedback
  3. Narrow base of support.

Secondary impairments

  1. Muscle weakness due to disuse atrophy
  2. Joint contractures due to rigidity
  3. Orthostatic hypotension & lightheadedness
  4. Polypharmacy
  5. Dystonia & dyskinesia

DeLisa 5th Edition Chapter 26 Movement Disorder pg649

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11
Q

What are non-pharmacological treatments of PD that improve gait? 🔑🔑 List five non-pharmacological ways to treat “freezing” during gait in Parkinson’s patients. Single most beneficial non-pharm therapeutic intervention to improve gait.

A

Most beneficial

  • Treadmill training combined with auditory and visual cues

Others

  1. Walking to the beat of music or clapping hands “auditory cues”
  2. Walking on an alternate coloured tiled floor “visual cues”
  3. Lower extremity stretching and ROM exercises
  4. Strength training especially trunk musculature
  5. Postural training
  6. Improved CV fitness.
  7. Balance training.
  8. Treadmill training
  9. Mental Rehearsal of movement that is going to be performed
  10. Walking aids.
  11. Parallel bar and lines

Delisa -pg 655; Movement Disorders Vol. 19, No. 8, 2004, pp. 871–884.

💡 Remember in GYM we have:

  • Strength machines, pulley, suspension
  • Gait: treadmill, assistive devices, parallel bars
  • Balance: board
  • Endurance: cycling
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12
Q

Ataxic Gait. Name 2 treatment modalities for immediate improvement in gait. 🔑🔑

A

💡 Immediate improvement = devices for immediate adjustment of gait

  1. Ankle weights or heavy footwear.
  2. Gait aid (4 wheeled walker or U walker).
  3. Shoe modification: Heel flare

Ref: first principles.

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13
Q

List two modalities for managing motor symptoms in patient with PD.

A
  1. Repetitive transcranial magnetic stimulation (rTMS)
  2. Transcranial direct current stimulation (tDCS)

Cuccurollo 4th Edition Chapter 12 Movement Disorder pg872 Table 12-3

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14
Q

Lewy body dementia (LBD) vs Parkinson disease dementia (PDD)

A

LBD might have hallucinations and delusions at times.

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15
Q

Non-motor signs & symptoms of PD 🔑🔑 OSCE

A

💡 PD SAS = Psychiatric, Dementia, Sensory, Autonomic & Sleep

1. Psychiatric Symptoms

Depression, anhedonia, anxiety and social isolation

2. Dementia

Executive functions (daily tasks), working memory, retrieval deficits, dementia

Tested by Mini-Mental State Examination & Clock-drawing test

3. Sensory impairments

Anosmia, impaired visual acuity, impaired visual contrast perception, impaired depth perception

4. Autonomic Dysfunction “BBSSH”

Bowel: Dysphagia, Sialorrhea (Drooling), Constipation, Fecal incontinence

Bladder: Urinary frequency and urgency

Sex: Erectile dysfunction and vaginal tightness.

Skin: Dry with dandruff.

Heart: Orthostatic hypotension

5. Sleep Disturbances

Before Sleeping: Poor sleep hygiene, Restless leg syndrome, Periodic limb paralysis, Insomnia (stimulant effects of PD medications), anxiety

During Sleep: Frequent nocturia, vivid dreams, nightmares

Cuccurollo 4th Edition Chapter 12 Movement Disorder pg870 Table 12-3

DeLisa 5th Edition Chapter 26 Movement Disorder pg647 Table 26.2

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16
Q

Antidepressant for PD

A

Selective serotonin reuptake inhibitors (SSRIs): Fluoxetine (Prozac)

17
Q

Risk factors for anxiety in PD patients include

A
  1. Female
  2. Younger age
  3. History of anxiety disorders
  4. Presence of motor fluctuations
18
Q

Causes of limb pain in PD

A
  1. Restless leg syndrome
  2. Rigidity
  3. CRPS
  4. Painful limb dystonia
  5. “Pseudo-rheumatic disorders” limb and joint deformities, and mechanically derived pain
19
Q

Sleep Disturbances in PD. List 4 causes. 🔑🔑

A
  1. Poor sleep hygiene
  2. Insomnia
  3. Stimulant effects of PD medications
  4. Anxiety
  5. RLS
  6. Frequent nocturia
  7. Vivid dreams
  8. Nightmares
  9. Excessive daytime sleepiness
  10. Nocturnal disorientation caused by cognitive impairment

Braddom 6th Edition Chapter 45 Movement Disorder pg976

20
Q

Define orthostatic hypotension (OH). List 4 symptoms and 4 treatments 🔑🔑

A

Definition

  • Decrease of 20 mm Hg in systolic and/or 10 mm Hg in diastolic blood pressure
  • Within 3 minutes in an upright position
  • With or without postural symptoms.

Symptoms

  1. Dizziness
  2. Light-headedness
  3. Blurred vision
  4. Syncope
  5. Postural instability

Treatment

  1. Avoid excessive straining (Valsalva) → high-fiber diets and stool softeners
  2. Avoid large meals: splanchnic vasodilatation and “steal” blood volume
  3. Avoid hot weather “vasodilation”
  4. Compression leg stockings and abdominal binders.
  5. Eliminating unnecessary antihypertensive drugs
  6. Fludrocortisone: Sodium and fluids retention
  7. Vasopressor: Midodrine (avoid in periphral vascular disease)

DeLisa 5th Edition Chapter 26 Movement Disorder pg650

Braddom 6th Edition Chapter 45 Movement Disorder pg976

21
Q

Feeding dysfunction in PD List 4 adaptive equipment to improve feeding in PD patient 🔑🔑

A

Gastrointestinal Problems in PD

  1. Swallowing Dysfunction
    • Dysphagia due to loss of lingual control and inability to propel the bolus due to delay in the contraction of pharyngeal muscles.
    • Assessment → Modified barium swallows
    • Treatment → oral-motor exercises and providing compensatory strategies
    • Malnutrition → gastrostomy feeding tube
  2. Delayed Gastric Emptying
    • Nausea and vomiting, GERD, “heartburn” or indigestion
    • Metoclopramide may worsen dyskinesias (extrapyramidal s/e)
  3. Constipation
    • Causes: autonomic dysfunction, medications, limited mobility, impaired hydration
    • Tx: Hydration, increased physical activity, and high-fiber diets.

Feeding Equipment

  1. Plate-guards
  2. Swivel fork and spoons
  3. Weighted utensils
  4. Large-handled cups with straw

Cuccurollo 4th Edition Chapter 12

Movement Disorder pg872 Table 12-3

DeLisa 5th Edition Chapter 26 Movement Disorder pg650-651

22
Q

Bladder dysfunction in Parkinson Disease 🔑🔑

A

Symptoms

  • Detrusor hyperreflexia → Urgency, frequency and urge incontinence
  • Detrusor hyporeflexia → Retention, difficulty voiding and incomplete emptying.

Treatment

  1. Behavioural and Lifestyle
    • Timed voiding
    • Redistribution of fluid intake: bulk of fluid ingestion occurs earlier in the day to avoid nocturia.
  2. Urine Collecting Device
    • Intermittent catheterization
  3. Pharmacological
    • Anticholinergics

Braddom 4th Edition Chapter 20 Bladder pg441

DeLisa 5th Edition Chapter 26 Movement Disorder pg651

23
Q

Parkinson patient rehab plan. (PT, OT, SLP & Psychologist)

A
  1. Physiotherapy
    • Aerobic: Arm and leg cycling, treadmill and hydrotherapy to improve reciprocal limb motions and increase gait efficiency
    • ROM exercises and joint mobility: pectoralis - hips - iliopsoas -
    • Stretching: passive or active +/- boomstick
    • Strength exercise to prevent deconditioning: pulley exercises
    • Gait training: hip extension, quadriceps and frenkel exercises
    • Postural training and cues: back extension exercises
    • Wheeled walkers are preferred to standard walkers with visual light beams and/or sound features serving as cues (e.g., the U-Step Walker).
  2. Occupational Therapy
    • Improving cognitive function
    • Balance (static and dynamic) and postural reflex improvement: Wobble board or balance-feedback training
    • Trunk stabilization exercises
    • Improving hand dexterity and writing skills
      • Built up pens
      • Electronic keyboard - computerized scanning - pointing devices
    • Fall prevention
    • Transfer training
    • Home assessment & modification: remove small mats and rugs to reduce tripping
    • Adaptive devices
      • Feeding: Plate guards - weighted plates - large handle cups - weighted utensils
      • Dressing: Velcro or zipper closure instead of buttons
  3. Speech Therapy
    • Dysarthria and dysphonia
      • Breathing and articulation exercises
    • Swallowing evaluation
      • Oropharyngeal dysphagia: bolus formation and loss of coordination
    • Food modification
      • Small frequent meals
      • Alter food texture
    • Postural & compensatory strategies
  4. Psychosocial Therapy
    • Depression & Social isolation
    • CBT Programs

Cuccurollo 4th Edition Chapter 12 Movement Disorder pg872 Table 12-3

PMR Secrets 3rd Edition Chapter 56 Movement Disorders pg469-471

24
Q

Ambulation aids in parkinson disease. 🔑🔑

A

💡 Patient eventually will need wheelchair or scooter

  • Effort should be made to keep it ambulatory as long as possible to minimize the development - of contracture, stiffness and deconditioning following immobilization.
  • Wheeled walker to prevent backward instability with added handbreak to ensure control

PMR Secrets 3rd Edition Chapter 56 Movement Disorders pg470

25
Q

List 5 Pharmacological Treatment for PD 🔑🔑 EXAM 2021

A

💡 Aman → Car to Promo → COMT, MAO

1. L Dopa:

Carbidopa / Levodopa (XR for extended release)

S/E: dyskinesias, orthostatic hypotension, nausea, confusion, and hallucinations.

2. Dopamine receptor agonists

Bromocriptine

3. NMDA Receptor Antagonist:

Amantadine

Release of endogenous dopamine, Mild anticholinergic

4. MAO-B Inhibitors

Rasagiline

5. COMT Inhibitors

Entacapone

6. Anticholinergic agents

Orphenadrine (Disipal)

Cuccurollo 4th Edition Chapter 12 Movement Disorder pg871 Table 12-3

Braddom 6th Edition Chapter 45 Movement Disorder pg977 Box 45.4

PMR Secrets 3rd Edition Chapter 56 Movement Disorders pg468 Box 56-2

26
Q

What are the common side effects of PD medications?

A

We are increasing the arousal:

  1. Confusion
  2. Hallucination
  3. Psychosis
  4. Nausea
  5. Abdominal cramping
  6. Diarrhea
  7. Postural hypotension → a agonist or mineralocoricoids
  8. Impulse disorders → gambling and increased sexual behaviors

PMR Secrets 3rd Edition Chapter 56 Movement Disorders pg468

27
Q

Risk factors for development of Levodopa-Induced Dyskinesias & Tx

A

Levodopa-Induced Dyskinesias

  1. Younger age at PD onset
  2. Greater disease severity
  3. Higher levodopa dose
  4. Longer disease duration, 7-8 years on Tx

Treatment

  1. Decreasing the dose of levodopa
  2. Decreasing the frequency with which levodopa is taken
  3. Adding amantadine to the medication regimen.
28
Q

Surgical Treatment

A

Indication

Antiparkinsonian meds are ineffective or poorly tolerated

Contraindication

Dementia or significant psychiatric/behavioral symptoms

Types

  1. Destructive / Ablative surgery → Thalamotomy & Pallidotomy (preferred)
  2. Deep brain stimulator (DBS)
  3. Chemoneurolysis with botulinum toxin (tremor and rigidity)

Cuccurollo 4th Edition Chapter 12 Movement Disorder pg874 Table 12-3

29
Q

Progressive Supranuclear Palsy (PSP) vs PD 🔑🔑 EXAM 2021

A
  1. Supranuclear vertical gaze palsy: lesion to supra nuclear pathway (dorsal midbrain) affecting midbrain and posterior commissure which is located in the superior cerebral aqueduct
  2. Early development of freezing
  3. Greater rigidity seen in the neck as compared with the limbs
  4. Lack of tremor
  5. Marked micrographia
  6. Relative sparing of limb movement (except writing)
  7. Tendency to fall backward with hand in extension

Braddom 6th Edition Chapter 45 Movement Disorder pg979

30
Q

Hallmark sign & Clinical Presentation of PSP 🔑🔑

A

💡 Supranuclear ophthalmoparesis manifested with a paralysis of vertical gaze.

Symptoms

  1. Supranuclear ophthalmoparesis
    • Paralysis of vertical gaze.
    • Difficulty with either opening or closing the eyes due to inhibition of levator palpebrae or orbicularis oculi muscles
  2. Gait and balance impairments
    • Stiff broad-based gait
    • Knees and trunk extended
    • Arms abducted
    • Postural instability with falls
  3. Marked change in personalities
    • Apathetic, depressed & monotonous speech.
  4. Pseudobulbar palsy (Dysarthria and dysphagia)
  5. Frontal lobe signs & Cognitive deficits.

Prognosis

  • Currently, no drug provides sustained relief in patients with PSP.
  • Patients usually become bedridden, unable to swallow and talk.
  • Gastrostomy is necessary in advanced stages.
  • Death, usually related to respiratory complications

Cuccurollo 4th Edition Chapter 12 Movement Disorder pg873

Neurology Secrets 6th Edition Chapter 11 pg145

31
Q

Multiple System Atrophy (MSA) vs PD 🔑🔑 EXAM 2020-2019

A

Pathophysiology

Damage to the oligodendrocytes by accumulation of the protein alpha-synuclein.

Triad

  1. Parkinsonism (MSA-P)
  2. Cerebellar dysfunction (MSA-C) → Ataxia and dysarthria
  3. Autonomic dysfunction.

MSA: more ataxia and cerebellar manifestations

PD: more extrapyramidal signs

Cuccurollo 4th Edition Chapter 12 Movement Disorder pg873

32
Q

Corticobasal Ganglionic Degeneration Clinical Presentation & Diagnosis

A

Motor manifestations

  1. Dystonia (usually fixed and often causing pronounced and/or painful deformities)
  2. Postural instability
  3. Athetosis
  4. Orofacial dyskinesias.

Cerebrocortical dysfunction

  1. Apraxia
  2. Cortical sensory loss
  3. Alien limb phenomenon
  4. Dementia
  5. Frontal lobe reflexes

Diagnosis “Corticobasal”

MRI shows asymmetric atrophy of the cerebral cortex

PassPMR - 05 Neurology (6 decks)

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