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)
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
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
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
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
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)
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
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
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
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
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)
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
13
Q
What are the surgical treatments for spasticity?
A
- Rhizotomy (dorsal / ventral root section)
- Tendon release / transfer
- Spinal stimulator
- Baclofen intrathecal pump
14
Q
What are other abnormal movements?
A
- Tremor
- Tic
- Dystonia
- Athetosis
- Chorea
- Hemi-Ballismus
- Tardive Dyskinesia
- Ataxia
- Asterixis
- Myoclonus
- Restless legs
- Psychogenic
15
Q
What is a tremor?
A
- Rhythmic oscillations about a joint
- Amplitude / Velocity similar in both directions
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
