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Neuro Behavioral Med I > 7 - Management of Hypertonic States > Flashcards

7 - Management of Hypertonic States Flashcards

1
Q

Describe the motor organization in the body

A
  • Input from Temporal lobe to Parietal Command Center
  • Movement initiated in motor / pre-motor cortex
  • Extra-pyramidal system moderates movement (Basal Ganglia, Cerebellum)
  • Pyramidal fibers cross (decussate) in brainstem (contralateral effect)
  • α motor neuron transmits electrical impulse to muscle
  • corticospinal tract is predominately inhibitory to the α motor neuron (inhibits primitive reflexes so you don’t jerk your foot back from every stimulus)
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2
Q

Describe the function of the corticospinal tract

A
  • corticospinal tract is predominately inhibitory to the α motor neuron
  • inhibits primitive reflexes so you don’t jerk your foot back from every stimulus
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3
Q

What is rigidity?

A
  • An Increased resistance to passive range of motion
  • “lead pipe” phenomenon
  • You will see overactive agonist & antagonist muscles
  • Most often seen with basal ganglia dysfunction***
  • When you stretch your patient’s arm (passive range of motion), it is a little tense or rigid
  • Will often have a tremor superimposed on the rigidity
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4
Q

What is “cog wheeling”?

A
  • May relate to superimposed tremor
  • Will often have a tremor superimposed on the rigidity
  • If you find this, you will have diagnosed a basal ganglia dysfunction
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5
Q

Describe spasticity

A
  • Upper motor neuron syndrome
  • Exaggeration of flexion / extension skeletal muscle reflexes
  • resulting from cortico-spinal tract dysfunction
  • “Clasp knife” phenomenon / Clonus
  • Always pathologic –Measured on passive range of motion
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6
Q

What are the clinical manifestations of spasticity?

A
  • Abnormal posturing
  • Flexor / extensor spasms
  • Abnormal synergistic movements
  • Babinski sign / exaggerated cutaneous reflexes
  • Decreased postural / trunk stability
  • Decreased range of motion (contractures and joint stiffness)
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7
Q

What is cerebral palsy?

A
  • Non-progressive disorder of posture / motor control (Cerebral or Cerebellar)
  • Most often present at birth, may not be diagnosed right away
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8
Q

What are the clinical types of cerebral palsy

A

Clinical types

  • Spastic hemiparesis
  • Spastic diplegia
  • Spastic quadriplegia
  • Hypotonic
  • Dyskinetic – Choreo-athetosis
  • Ataxic
  • Mixed
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9
Q

What are the co-morbidities of patients with cerebral palsy?

A
  • Visual impairments
  • Hearing loss
  • Speech / language delay
  • Epilepsy
  • Mental retardation
  • Learning / behavioral problems
  • Depression
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10
Q

How do you manage your patients with cerebral palsy?

A
  • Evaluate for treatable disease (MRI, labs)
  • Physical / Occupational therapy (bracing)
  • Surgical release of tendons / grafting
  • Botox
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11
Q

What are the goals of treatment for cerebral palsy patients?

A
  • Mobility – Get them moving! (with or without assist devices)
  • Physical fitness (for health, mobility and independence)
  • Education (patients, parents and family, teachers)
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12
Q

What medciations can you use for spasticity?

A

Oral agents

  • Baclofen
  • Dantrolene
  • Tizanidine
  • Benzodiazepines (i.e.: Diazepam)
  • The problem with these is that they cause drowsiness

Intrathecal
- Baclofen

Injectable
- Botulinum toxin

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13
Q

What are the surgical treatments for spasticity?

A
  • Rhizotomy (dorsal / ventral root section)
  • Tendon release / transfer
  • Spinal stimulator
  • Baclofen intrathecal pump
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14
Q

What are other abnormal movements?

A
  • Tremor
  • Tic
  • Dystonia
  • Athetosis
  • Chorea
  • Hemi-Ballismus
  • Tardive Dyskinesia
  • Ataxia
  • Asterixis
  • Myoclonus
  • Restless legs
  • Psychogenic
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15
Q

What is a tremor?

A
  • Rhythmic oscillations about a joint

- Amplitude / Velocity similar in both directions

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16
Q

What are the tree types of tremors?

A

Three types

  • Resting
  • Postural
  • Intention
17
Q

Describe a resting tremor

A
  • Associated with basal ganglia pathology
  • Most prominent at rest (may have postural component)
  • “Pill Rolling” character
  • 3-5 Hz
  • Little functional impairment
18
Q

Describe a postural tremor

A
  • Often seen without identifiable pathology
  • Distal in limbs
  • Head / neck / lips / tongue involvement
  • Worse with stress / fatigue / stimulants
  • Better with rest
  • Gone during sleep
  • May be disabling
19
Q

Describe an intention tremor

A
  • Kinetic tremor - Brought out with movement
  • “Scanning” at end point of movement
  • Associated with disease of Cerebellum and its connections
  • Associated with Ataxia
20
Q

What is one treatment option for tremors?

A

Deep Brain Stimulation

Can abolish the tremor completely, but it is a brain surgery with a lump on the head, wires and it is expensive

21
Q

What is a tic?

A
  • Involuntary/Stereotyped/Quick movements
  • Irregular intervals
  • Simple/Complex
  • Buildup of “Psychic Tension”
  • Vocal/Guttural tics (noises, rarely actual words)
22
Q

What are simple tics?

A

Motor

  • Eye blinking
  • Eye rolling
  • Grimacing
  • Head / neck movement
  • Fist clenching
  • Toe curling
  • Truncal / Abdominal

Sonic/vocal

  • Throat clearing
  • Grunting
  • Sniffing
  • Snorting
  • Barking
  • Clicking
23
Q

What are complex tics?

A

Motor

  • Jumping
  • Touching
  • Smelling
  • Rubbing
  • Copropraxia
  • Echopraxia

Vocal

  • Coprolalia
  • Echolalia
  • Singing
  • Whistling
  • Humming
24
Q

What is Tourette syndrome?

A

Diagnostic criteria

  • Multiple motor tics
  • At least 1 vocal / sonic tic

Clinical presentation

  • Onset 1 year
  • Affect daily function / cause distress
  • ½ with obsessive / compulsive symptoms
  • Also see: ADD, Behavior disorders, Dyslexia
25
Q

What is dystonia?

A
  • Abnormal posturing
  • May be (focal/multi-focal, generalized, segmental, task specific – Writer’s Cramp, Yips)
  • It can come and go
26
Q

How do you treat dystonia?

A
  • Trial of L-dopa (there is a subunit that will be treatable with L-dopa)
  • Botox treatment
27
Q

What is athetosis?

A
  • Writhing / snake-like involuntary movements

- What it really is = the movement between two dystonic postures

28
Q

What is chorea?

A
  • Involuntary random movements sufficient to move a body part
  • Patients may finish with voluntary movement (because they are embarrassed and they try to cover it up)
  • Progressive in Huntington disease
  • “Dance” like movements
29
Q

Describe Huntington disease

A
  • Personality disorder (paranoia)
  • Dementia
  • Movement disorder (chorea)
  • Autosomal dominant
  • Onset – 3rd to 4th decade
  • Genetic testing is very diagnostic
  • You can test an asymptomatic family member to see if they have the Huntington gene
30
Q

What is hemi-ballismus?

A
  • Large amplitude motions
  • Violent form of Chorea
  • Typically one sided
  • Associated with lesions in the contralateral subthalamic nucleus
31
Q

What is tardive dyskinesia

A
  • Tardive = non-fixed
  • Abnormal movements brought on by medications/neuroleptics
  • Can occur secondary to dopa blockade - if you’re on it long enough it can be permanent
  • Oral, facial, lingual - most common involved areas
  • Also limb and trunk involvemet
32
Q

What is ataxia?

A
  • Decomposition of voluntary movement
  • You will see decreased movement speed, decreased coordination, halting or imprecise movement
  • Affects limbs, speech, eyes, trunk
  • Resulting from disease in Cerebellum & its connections
33
Q

What is asterixis?

A
  • Intermittent loss of postural tone
  • Affects limbs and trunk
  • Seen with metabolic or toxic encephalopathies (i.e. hepatic or renal disease)
  • “Negative” myoclonus
34
Q

What is myoclonus?

A
  • Involuntary jerks / “shock like” movements of muscle groups
  • Focal / multifocal / generalized
  • Cortical (Epilepsy / Degenerative disorders and Metabolic encephalopathies (Anoxia))
  • Subcortical / Spinal / Peripheral (Hemifacial spasm)
  • Physiologic – hypnic jerks
35
Q

What are restless legs?

A
  • Uncomfortable urge to move legs / body parts
  • Worse at rest
  • Associated sleep disorder
  • Associated Iron deficiency
  • Treated with reassurance, dopa agonists, sedatives, opiates
36
Q

What are the psychogenic issues?

A
  • Difficult diagnostic problem
  • Inconsistent findings / Incongruent with known pathologic entities
  • Improvement when distracted
  • May see other false neuro signs / symptoms
  • 2 – 5% movement disorders clinic patients
  • Psychiatric patients often have abnormal movements

Neuro Behavioral Med I (15 decks)

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