L5 Movement Disorders Flashcards
Movement Disorders
neurological conditions characterized by an excess of movement or paucity of voluntary movement unrelated weakness or spasticity
fall into hyperkinetic and hypokinetic
Dyskinesia
uncontrolled, involuntary movement that occur in pts with movement disorders
Types of dyskinesia
dystonia
athetosis
chorea
ballismus
tic
myoclonus
tremor
Hypokinetic movement disorders
- movement are difficult to initiate
- slow and rigid
- ex: parkinson’s disease
Hyperkinetic Movement Disorders
- movements are dancelike and involuntary
- includes huntington’s disease, hemiballismus
Athetosis
- writhing, twisting movements of limbs, face, trunk
- caused by basal ganglia diseases and stroke
Chorea
- nearly continuous involuntary movements that are fluid or jerky
- can be small or large amplitude
- caused by huntington’s disease, side effect of levodopa
Choreoathetosis
blend of athetosis and chorea
Ballismus
- large amplitude, more rotatory, or flinging quality than chorea
- most common type is hemballismus/unilateral
- caused by infarct of subthalamic nucleus/basal ganglia
Tic
- sudden brief action that is usually preceded by an urge to perform it and is followed by sense of relief
- includes motor and vocal tics
- example: tourette’s syndrome
Myoclonus
- sudden, rapid, muscular jerk
- can be focal, unilateral, bilateral
- caused by anoxic brain injury, encephalitis, toxic or metabolic encephalopathies in severely ill patients
- common in end stage renal or liver disease
Tremor
- rhythmic or semirhythmic oscillating movements
- both agonist and antagonist muscles are activated resulting in bidirectional movements
- can be slow or fast
Types of tremors
- resting tremor (PD)
- postural tremor (PD, cerebellar, metabolic)
- intention tremor (cerebellar)
Dystonia
- co-contraction of agonist and antagonist muscles causing distorted positions of the affected body part during voluntary movement
- can be generalized, unilateral, focal
- exact pahtophys is unknown, current hypothesis is disorder of brain networks
- multiple causes, adult onset
- examples includes torticollis, writer’s cramp, musician’s cramp
Types of dystonia
- cervical (most common)
- blepharospasm (eye twitch)
- limb
- musician’s
Medical treatment for dystonia
- focal dystonia treated with botox
- general dystonia treated with anticholinergic medications
- DBS
Outcome measures for Dystonia
- unified dystonia rating scale
- global dystonia scale
Huntington’s Disease prevalence
- inherited autosomal dominant neurodegenerative disease
- caused by huntington gene mutation
- 4-5 cases/100,000
- average onset is 30-50 yo
- no cure, medial survival is 15 years
Huntington’s overview
- gradual onset of defects in behavior, cognition, movement beginning in 4th to 5th decade
- presents as alteration in mood or change in personality like impulsive behavior, irritability, suspiciousness
- hallmark is movement disorder consisting of rapid, jerky, no clear purpose
Huntington’s Disease Pathophys
- selective atrophy in caudate and putamen, atrophy in frontal and temporal cortex
- degeneration of spiny neurons
- decreased inhibition to GPe leads to greater inhibition of GPe on STN
- inhibition on STN makes it less able to excite GPi, resulting in less tonic inhibition from GPi
CP of Huntington’s
Abnormalities of
* motor s/s
* oculomotor s/s
* mood dysfunction
* cognition
Motor s/s of HD
- early in disease clumsiness, mild jerking, fidgety movements
- as disease progresses, movements become more dance-like
- no weakness, ataxia, or deficit of sensory function
Oculomotor S/S of HD
slow saccades
impaired smooth pursuit
Mood dysfunction S/S of HD
depression
irritability or aggression
Cognition S/S of HD
depression and anxiety
OCD
impulsive, manic behavior
late stage severe dementia
Presymptomatic/early stage of HD
- presents with chorea, impaired balance, fine motor problems, unsteady gait
- PTs should do exercise, balance training, environmental mods
- main goal of PT is to delay onset of mobility problems
Middle Stage of HD
- presents as chorea, joint ROM limitations, weak stabilizers, falls
- PTs should do strengthening, ROM, functional training, fall prevention
- main goal of PT is maintain function and delay decline
Late Stage of HD
- presents as postural changes, respiratory limitations, risk for pneumonia
- PTs should do exercises for ROM, postural alignment, chest PT, seating systems
- main goal of PT is limit impact of complications
Functional Neurologic Disorder
- involuntary but learnt habitual movement pattern driven by abnormal self-directed attention
- triggered by physical or pyscho events
- brain prioritizes excessively strong predictions based on what the brain expects to see or be able to do over the actual incoming sensory input
Pathophys and etiology of FND
not only the occurrence of stressful events and elevation of biological stress markers, but addition of greater perceived stress and/or lack of awareness of this stress that appears to contribute to and result from the underlying pathophys
5 constructs affected in FND
- emotion processing, such as salience
- agency
- attention
- interoception
- predictive processing/interference
Emotion Processing in FND
- one of the core features
- evidence supports increased emotional reactivity, heightened arousal and avoidance, impaired top-down emotion regulation, deficits in emotional awareness, errant activation of learned/innate defensive responses
Agency
- two events must occur for agency : person must have the sense of willing the movement, movement has to happen
- feedforward has to meet feedback
- this matching of signals occurs in the right TPJ.
- TPJ becomes activated when tehre is a mistmatch between wiling and movement
Attention
- impairment in attention has been characterized in FND
- manifests as attentional perservation, which is tendency to focus on a partciular physiological system to neglect of other systems and impaired ability to adaptively, volitionally shift attentionIn
Interoception
- process by which nervous system senses, interprets, integrates internal bodily signals, providing a moment by moment mapping of body’s internal landscape across conscious and unconscious levels
- FND may preferentially influence the weighting of top-down or bottom-up information streams in the CNS
- leads to abnormally enhanced or diminished sensory perceptions or movements
Perceptual Inference and Predictive Processing
- the process by which a person generates beliefs or explanations about the causes and effects of events occurring within and outside the body
- potential overutilization of the prediction rather than reliance on sensory information to update predictive model
How is FND diagnosed?
Hoover’s sign
Hip abductor sign
distraction or entrainment of a tremor
Hoover’s sign
weakness of hip extension which returns to normal with contralateral hip flexion against resistance
Hip abductor sign
weakness of hip abduction which returns to normal with contralateral hip abduction against resistance
Distraction or entrainment of a tremor
abolishing tremor by asking the patient to copy rhythmical movements or generate ballistic movements with contralateral limb
Subjective exam for FND
- ask to know full range of symptoms
- describe a typical day
- ask about onset and disease course
- ask about triggers
- patient’s understanding of disease
- functional outcome measure
Treatment for FND
- neurologist
- OT
- PT
- SLP
- psychiatry
PT for FND
PT has an important role in normalizing illness beliefs reducing abnormal self-directed attention and breaking down learnt patterns of abnormal movement. use:
- education
- demonstration that normal movement can occur
- retraining movement with diverted attention
- changing maladaptive behaviors related to s/s
Critical outcomes of explanation which appear to facilitate PT for FND patients…
- an understanding by pt that their treating health professionals accept that they have genuine problem
- understanding by pt that they have a problem which has potential for reversibility and thus PT can help
Who can benefit from PT with FND
- unambiguous diagnosis of FMD
- pt has confidence or openness to diagnosis of FMD
- pt desires improvement and can identify treatment goals
Treatment for FND in PT
- retraining movement w/diverted attention
- minimize self-focused attention through distraction
- non-specific and graded exercise
- visualization or external focus of attention, mirrors
- graded sensory stimulation
- introducing role of PT in retraining in nervous system
- explanation that wide variety of factors may be involved in triggering s/s
- explanation of diagnosis
- explanation of possible improvement
- acknowledging s/s are real, build trust
Best to do PT in…
- optimum setting
- treatment duration and parameters are unknown, will vary on intensity on pts s/s and ability to limit environmental triggers
