Module E-06

Question 1

Hallmark features of disordered movement include:

Answer 1

1) Impaired postural reflexes that would normally contribute to balance (either during movement or while stationary).
2) Diminished or slowed movements (hypokinesia/bradykinesia).
3) Excessive involuntary movements (hyperkinesia).
4) Uncoordinated or unsteady movements (ataxia).

Question 2

4 types of involuntary movements

Answer 2

1) Tremor
2) Chorea
3) Athetosis
4) Ballismus

Question 3

What are tremors?

Answer 3

• Alternating contraction of opposing muscles
• Forms of tremor are varied and hence have differing causes. Some tremors are effectively benign, whereas others reflect significant pathology

Question 4

What is chorea?

Answer 4

• involves brief, purposeless, irregular jerky movements of body parts
• Voluntary behaviors (e.g., walking) may be affected, as choreatic movements become disruptive. The expression of successive choreatic movements resembles dancing – hence the term “chorea”

Question 5

Most common reason for Chorea

Answer 5

often stemming from basal gangliar disease

Question 6

Describe Athetosis

Answer 6

comprises continuous slow writhing of body parts

Question 7

Most common reason for Athetosis

Answer 7

often related to basal gangliar pathology

Question 8

Describe Ballismus

Answer 8

“Flinging” and rotatory movements involving the limbs are characteristic.

Question 9

Most common reason for Ballismus

Answer 9

Causal lesions often affect the subthalamus, which contributes to basal gangliar function

Question 10

What differentiates Hypokinesia in Lower vs Upper motor lesions

Answer 10

• Lower motor neurons or the neuromuscular junction can be implicated, with hypokenesis presenting as flaccid
  paralysis.
• Lesions of upper motor neurons, which often yield elevated muscular tone and hence hyperreflexia.

Question 11

What causes hypokinesia in Parkinson’s?

Answer 11

• Dysfunction involves modulatory/regulatory circuits
• The basal ganglia are not regulated normally by the mesencephalic substantia nigra.
• correlates with impaired initiation of movement, rigidity, poor postural reflexes and slowing of movement (i.e., bradykinesia).
• Perhaps paradoxically, patients expressing Parkinson disease and hence hypokinesia/bradykinesia often exhibit resting tremor

Question 12

What type of interactions between Sensory and motor systems cooperate to maintain equilibrium?

Answer 12

o Some sensory-motor interactions are largely reactive.

o Other such interactions involve predictive or anticipatory circuitry.

Question 13

Decorticate posture

Answer 13

• a cerebral lesion affecting the corticospinal and corticobulbar systems with sparing of motor centers of the brainstem.
• In such cases, the disinhibited red nucleus of the midbrain increases tone of the flexor muscles of the upper limbs, while pontine and medullary motor centers (in the absence of cerebral influence) independently promote extension
  of the legs.
• The posture, if not tonically expressed, may be elicited by noxious stimuli.

Question 14

Decerebrate posture

Answer 14

• the muscle tone of the arms favors extension (resulting from the loss of red nuclear output).
• Remaining disinhibited brainstem motor centers continue promoting extension of the legs.
• The posture, if not tonically expressed, may be elicited by noxious stimuli.

Question 15

What is Station?

Answer 15

The ability of the patient to stand steadily with the feet together

Question 16

How is Gait assessed?

Answer 16

• The patient attempts to walk in a straight path (usually in the absence of special visual cues such as lines on the floor).
  -The task may be repeated while the patient walks in tandem (heel-to-toe) or preferentially on either the heels or the toes.
• The ability of the patient to turn smoothly while
  reversing direction should be assessed.

Question 17

Categories of tremors

Answer 17

1) Resting tremor- typically becomes more apparent when the patient is otherwise motionless (i.e., at rest).
2) Intention (kinetic) tremor becomes apparent with purposeful movement (e.g., reaching for a glass).

3) Essential tremor (benign familial tremor) commonly prompts misdiagnoses of cerebellar or Parkinson disease, as it can resemble intention or resting tremor.
4) Postural tremor may arise only when a particular posture is assumed (e.g., when the arms are outstretched with the palms up.

Question 18

In what syndrome is a resting tremor seen?

Answer 18

• Parkinson disease, although not all patients will exhibit the phenomenon
• The resting tremor may diminish at later stages of the disease.

Question 19

What causes intention(kinetic ) tremor?

Answer 19

Cerebellar lesions

Question 20

Describe intention tremor

Answer 20

• Tremor becomes apparent with purposeful movement (e.g., reaching for a glass).
• The amplitude of the intention tremor tends to increase as the affected body part approaches the target in space.

Question 21

Hallmark motoric manifestations of Parkinson’s disease

Answer 21

• resting tremor
• bradykinesia
• Facial Masking
• Rigidity
• Loss of Postural Reflexes
• Parkinsonian Gait
• Loss of Habituation to Glabellar Stimulation
• Speech

Question 22

What are the Prodromal manifestations of Parkinson’s?

Answer 22

o Hyposmia
o Autonomic dysfunction - Erectile, Cardiac and GI
o Rapid eye movement sleep disorder- Maintenance or breakthrough of muscular rigor during dream
sleep

Question 23

What does Hyposomia indicate?

Answer 23

Indicates degeneration of olfactory bulbs

Question 24

What does the Rapid eye movement sleep disorder indicate?

Answer 24

Reflects pontine degeneration

Question 25

What is Akinesia?

Answer 25

reflects the absence of movement (or limited movement – as in hypokinesia)

Question 26

What is Bradykinesia

Answer 26

refers to movements that are

pathologically slower than normal. In Parkinson disease, initiation of movement may be particularly difficult

Question 27

What is Facial Masking?

Answer 27

Facial expression commonly diminishes, resulting in a masked appearance

Question 28

Describe the Rigidity in Parkinsonism

Answer 28

muscular rigidity (stiffness) of differing forms, as revealed during assessment of passive movement.
o Cogwheel rigidity refers to the recurrent stepwise release and return of resistance to passive movement.
o Lead-pipe rigidity refers to resistance that is sustained
throughout a range of passive movement.

Question 29

Describe the Loss of Postural Reflexes in Parkinsonism

Answer 29

disruptions of station do not provoke corrective postural adjustment, and patients fall.

Question 30

Describe the Parkinsonian Gait in Parkinsonism

Answer 30

• Patients taking short shuffling steps.
• Turning is difficult, and many small steps replace smooth pivoting.
• Unintentional acceleration may arise (festination).
• A slight push from the back may yield propulsive steps, whereas a push from the front may trigger retropulsion.
• Gait may normalize with sensory cues (parallel lines on floors or rhythmic acoustic stimuli)

Question 31

Describe the Speech in Parkinsonism

Answer 31

speech tends to be quiet, hoarse, and monotonous but

occasionally with accelerative bursts (festination of speech)

Question 32

What is the glabellar reflex?

Answer 32

The glabellar reflex involves noxious stimulation (firm tapping) between the eyes to elicit bilateral blinking. The ophthalmic branch of cranial nerve V serves as the sensory limb of the reflex, whereas the temporal branches of cranial nerve VII constitute the motor limb.
In neurologically intact persons, blinks weaken with repeated stimulation.

Question 33

Describe the Loss of Habituation to Glabellar Stimulation in Parkinsonism

Answer 33

In neurologically intact persons, blinks weaken with repeated stimulation. Such habituation does not readily occur in Parkinson disease.

Question 34

Traditional Stages of Parkinson Disease (with the exclusion of prodromal manifestations)

Answer 34

1. Unilateral
2. Bilateral but with preserved postural reflexes
3. Bilateral with loss of postural reflexes (falls becoming more likely)
4. Severe disability but with some movement
5. Akinesia

Question 35

Differential Diagnosis for resting tremor of Parkinson Disease

Answer 35

o Essential (postural) tremor differs in that it may only be expressed when a particular posture is maintained
o Intention tremor often indicates cerebellar disease rather than Parkinson disease

Question 36

Conditions that mimic Parkinson’s disease

Answer 36

o Iatrogenic
o Postencephalitic
o Stroke-induced
o Drug-induced
o Neoplast

Question 37

5 types of HYPERkinetic disorders

Answer 37

1) Chorea
2) Athetosis
3) Dystonia
4) Ballismus
5) Tic Syndromes

Question 38

2 Diseases that manifest in Choretic movements

Answer 38

1) Huntington disease - autosomal dominant condition.
2) Sydenham disease - a transient disorder that bears autoimmune characteristics with a link to childhood rheumatic fever.

Question 39

Condition where Athetoid movements are seen

Answer 39

athetoid cerebral palsy

Question 40

Athetosis accompanies __________

Answer 40

hemiplegia, with a hemiplegic gait therefore

being superimposed

Question 41

What is Hemiballismus?

Answer 41

the condition is unilateral with manifestations expressed contralateral to the injury

Question 42

What are Dystonias?

Answer 42

Involve muscle spasms or sustained abnormal postures

Question 43

What are Generalized Dystonias?

Answer 43

Abnormal postures involving the trunk and limbs.

Question 44

What are Spasmodic torticollis?

Answer 44

a specific dystonia involving the neck. In this

condition, neck muscles (e.g., sternocleidomastoid) contract involuntarily and may become hypertrophic

Question 45

Most dystonias are ________ or _________

Answer 45

Partial;segmental

Question 46

What are Tics?

Answer 46

irregularly occurring stereotyped movements that are usually transient and coordinated. They range from simple (e.g. eye blinking, arm jerks) to more complex (head shaking, spitting, floor-licking).

Question 47

What is Tourette’s Syndrome

Answer 47

A genetic disorder with an onset about seven years of age, is a specific form of tic disorder.

Question 48

Symptoms of Tourette’s Syndrome?

Answer 48

o Multifocal tics are common and often accompany attention deficit hyperactivity disorder.
o Key to the diagnosis of Tourette syndrome is a vocal tic (e.g., barking, grunting).

Question 49

3 Drug induced Movement disorders

Answer 49

1) Tardive dyskinesia
2) Dopa-induced dyskinesia
3) Drug-induced Parkinsonism

Question 50

What drug causes Tardive Dyskinesia?

Answer 50

some antipsychotic drugs (dopamine receptor antagonists)

Question 51

Manifestations of Tardive Dyskinesia

Answer 51

• The condition commonly features stereotypic oral movements.
• Advanced age of patients predicts greater vulnerability.
• Dyskinesia does not necessarily abate with drug withdrawal, perhaps becoming permanent.

Question 52

What drug causes Dopa Induced Dyskinesia?

Answer 52

often arises during treatment of Parkinson disease with the precursor to dopamine.

Question 53

Manifestations of Dopa Induced Dyskenesia

Answer 53

Choreatic movements predominate, but facial dystonias (e.g., grimacing or eye closure) are not uncommon.

Question 54

What drugs cause Drug induced Parkinsonism?

Answer 54

Can arise with agents that suppress dopaminergic transmission. The symptoms dissipate within weeks of
withdrawal of these agents.