Movement disorders Flashcards
1
Q
Tremor
A
contraction of antagonistic muscles
most common movement disorder
2
Q
Types of tremor
A
resting-
come and go depending on pt’s stress level
better during movement
action-
- postural- body part held against gravity
- kinetic- voluntary movement of limb
- intention- worst with goal-directed movement
- isometric- occur during muscle contraction against stationary objects
3
Q
Action tremor types
A
- postural- body part held against gravity
- kinetic- voluntary movement of limb
- intention- worst with goal-directed movement
- isometric- occur during muscle contraction against stationary objects
4
Q
Benign essential tremor (familial tremor)
A
increase with age
inherited- autosomal dominant disorder
5
Q
Essential tremor is usually ____ tremor
A
postural- action tremor
with “essential” action (ex writing)
6
Q
Essential tremor affect what limbs?
A
hands, forearms, head, voice- “essential” body parts
7
Q
Essential tremor- exacerbating and relieving ?
A
stress exacerbates
alcohol relieves
8
Q
Essential tremor workup
A
not needed- maybe TSH
clinical dx
9
Q
Essential tremor tx- intermittent
A
propranol (BP med- a beta blocker)
s/e- hypotension, dizziness, light headedness
alcohol
10
Q
Essential tremor tx- persistent
A
1. propranol (BP med- a beta blocker) s/e- hypotension, dizziness, light headedness 2. primidone 3. second line choice: - gabapentin, topirimate, nimodipine
11
Q
Essential tremor- prognosis
A
slow, gradual progression
12
Q
Physiological tremor characteristics
A
occurs in all people- not neurological disease
in all voluntary muscle groups
not visible to eye
13
Q
Physiological tremors are heightened by
A
fear/anxiety hypoglycemia exhaustion hyperthyroidism caffeine alcohol benzodiazepine withdrawal stimulants fever
14
Q
Parkinsonism tremor characteristics
A
rest tremor
pill-rolling
starts in 1 hand
15
Q
Parkinsonism tremor is associated with
A
bradykinesia and rigidity
16
Q
Cerebellar tremor characteristics
A
uni or bi
manifests as intention tremor
finger to nose test, heel to shin
worsens approaching target
17
Q
Cerebellar tremor causes
A
MS
CVA
Brainstem tumor
18
Q
Drug induced tremors
A
long list- epinephrine prozac caffeine thyroid hormone
19
Q
Orthostatic tremors
A
legs and or trunk after standing
unsteadiness
not visible
responds to klonopin (sedative)
20
Q
Psychogenic tremor (functional tremor)
A
not neurological looks like others sudden onset and remission stops with distraction increases with stress
21
Q
Primary writing tremor
A
action
limited to one hand
22
Q
Restless leg syndrome (RLS) aka
Willis-ekbom disease (Wed)
A
uncomfortable urge to move legs when relaxed
“tingling”, creeping/crawling sensation, cramping, electric
relieved with movement
during sleep= PLMS (periodic limb movements of sleep)
23
Q
Restless leg syndrome risk factors
A
Diabetes IDA ESRD (end stage renal disease) RA PD neuropathy myelopathy
24
Q
RLS pathophysiology
A
iron deficiency anemia most common treatable cause (have decreased iron stores)
secondary to peripheral neuropathy, uremia, pregnancy
25
RLS tx
- iron replacement
| - avoid antidepressants, sedating antihistamines- makes you relax
26
RLS- intermittent symptoms tx
- levodopa- "on demand"
s/e: nausea, dizziness, somnolence
- benzodiazepines (klonopin)
27
Dopamine agonists- RLS
mirapex
s/e: ortho hypotension, nausea, dizziness
requip
s/e: hypotension, drowsiness, dizziness, nausea, fatigue
neupro- patch
s/e: hypotension, edema, drowsiness, dizziness, dyskinesia
28
Alpha-2 delta calcium channel ligands- RLS
gabapentin
s/e: dizziness, drowsiness, fatigue
lyrica
s/e: somnolence, ataxia, edema
29
Huntington disease
inherited (autosomal dominant) and fatal progressive neurodegenerative disorder characterized by chorea, psychiatric disturbances and dementia
30
Huntington disease- clinical representation
chorea- "choreography= dance" rapid involuntary movements
- can cause dysarthria, dysphagia, and involuntary vocalization
- common cause of death= dysphagia and aspiration
weight loss/cachexia
dementia
psychiatric symptoms
- increased risk of suicide
abnormal eye movements
31
Huntington disease dx
clinical, family hx
| genetic testing- confirm
32
Huntington disease tx
no cure, can't halt
33
Huntington disease meds- help with chorea
xenazine
= dopamine-depleting agent
s/e: drowsiness, sedation, depression, etc.
34
Huntington disease meds- neuroleptics (depresses nerve functions- tranquilizer)
```
- chorea and psych
= antipsychotic
zyprexa
haldol
clozapine
```
-psych
TCAs (tricyclic antidepressants) and SSRIs (selective serotonin reuptake inhibitor)
35
Parkinson disease
progressive neurodegenerative disorder characterized by bradykinesia, tremor, rigidity, & postural instability
36
Parkinson disease- epidemiology
family hx- increased risk
| genetic contribution
37
Parkinson disease- pathophysiology
degeneration of dopaminergic neurons in the substantia nigra
imbalance of dopamine & acetylcholine
- dopamine decreased, excess acetylcholine relative to dopamine
note- acetylcholine activates skeletal muscles- tremors
38
Parkinson disease classic triad
resting tremor
- "pill rolling"
- stress exacerbates
bradykinesia
- slowness of voluntary movement- have trouble getting up from chair
- slow shuffling gait (=festinating gait)
- reduced blinking and masked facies (hypomimia)
rigidity
- resistance to passive movement of a joint
- decreased arm swing
- stooped posture
39
Parkinson disease- types of rigidity
- cogwheel- able, rigid, able, rigid, etc.
| - lead pipe- entire ROM
40
Parkinson disease motor clinical features
```
dysarthria
dysphagia
sialorrhea
blurred vision
micrographia
freezing gait
```
41
Parkinson disease non motor clinical features
```
depression
anxiety
dementia
constipation
olfactory dysfunction
cognitive dysfunction
```
42
Parkinson disease dx
clinical- must have bradykinesia and tremor or rigidity
beneficial response to dopaminergic therapy
43
Parkinson disease tx
amantadine
- antiviral med
- mild, early disease
- se: orthostatic hypotension, hallucinations
anticholinergic meds
- tremor and drooling
- cogentin- most common
- se- dry mouth, confusion, hyperthermia, etc.
levodopa (a precursor of dopamine)
- most reliable- drug of choice
- for bradykinesia
- combined w carbidopa to decrease se of nausea, light-headedness, and postural hypotension
- carbidopa/levodopa (Sinemet)
- patients >65
dopamine agonists
- directly stimulate dopamine receptors
- mirapex, nuepro, cycloset
- cause dopamine behaviors "fun things"
- patients <65-70
MAO B inhibitors
COMT inhibitors
- extender for sinemet, not alone
- tasmar (needs LFT monitoring), comtan
44
Tardive dyskinesia (TD)
hyperkinetic movement disorder with a delayed onset that appears after prolonged use of dopamine receptor blocking agents (antipsychotics (neuroleptics) and antiemetics (anti-nausea))
45
Antipsychotics first gen
haldol
| chlorpromazine
46
Antipsychotics second gen
clozapine
zyprexa
seroquel
risperdal
47
Antiemetics
reglan (metoclopramide)
| compazine
48
Tardive dyskinesia clinical features
insidious onset
| after a dose reduction, discontinuation or switch to a less potent antipsychotic
49
Tardive dyskinesia- orofacial manifestations
```
protruding, twisting tongue
smacking lips
retraction of corners of mouth
puffing cheeks
chewing movements
puckering lips
```
50
Tardive dyskinesia- limb movements
```
twisting finger
piano playing
finger spreading
tapping foot
extending toes
```
51
Tardive dyskinesia- neck and trunk
```
retrocollis
shoulder shrugging
rocking or swaying
rotating hip movements
thrusting hip
```
52
Tardive dyskinesia- respiratory
tachypnea
irregular breathing rhythms
grunting noises
53
Tardive dyskinesia- dx
clinical
must have:
1. dyskinetic or dystonic involuntary movements
2. 1 month use of drug tx
3. excluded other causes of abnormal movements
54
Tardive dyskinesia- tx
discontinue meds if possible
| switch from typical to atypical antipsychotic (second gen- clozapine, seroquel)
55
Tardive dyskinesia- prognosis
can achieve remission if early detection
56
Amyotrophic lateral sclerosis (ALS)
Also known as Lou Gehrig's disease or Motor Neuron Disease (MND)
progressive neurodegenerative disorder of motor neurons that cause muscle weakness, disability, and death
57
Amyotrophic lateral sclerosis (ALS)- epidemiology
sporadic
| smoking likely a risk factor
58
Amyotrophic lateral sclerosis (ALS)- pathophysiology
degeneration of MOTOR neurons at ALL level of the CNS
onset- only UMN involvement or LMN but progressive loss of both
59
Amyotrophic lateral sclerosis (ALS)- clinical features- LMN
```
weakness
atrophy
fasiculations
difficulty rising from chair
foot drop
cramps
difficulty writing
```
60
Amyotrophic lateral sclerosis (ALS)- clinical features- UMN
```
hyperreflexia
spasticity
slowed rapid alternating movements
spastic gait
poor balance/falling
incoordination of movement
stiffness/slowness
```
61
Amyotrophic lateral sclerosis (ALS)- clinical features- bulbar
head, face, neck areas
```
Jaw spasticity
Slow tongue movement
Facial diparesis
Dysphagia
Dysarthria
Laryngospasm
Pseudobulbar affect
Sialorrhea
Poor lip closure/seal
Difficulty managing pharyngeal secretions
Muscle atrophy and fasiculations
Hoarseness
Increased facial reflexes
```
62
Amyotrophic lateral sclerosis (ALS)- clinical features- axial
```
absent abdominal reflexes
difficulty holding up head
difficulty maintaining an erect body posture
lumbar lordosis
cramps
```
63
Amyotrophic lateral sclerosis (ALS)- clinical features- respiratory
```
Tachypnea
Reduced vocal volume
Shorter sentences & frequent pauses for breath
Use of accessory respiratory muscles
Dyspnea
Weak cough
Sleep disordered breathing
Confusion
```
64
Amyotrophic lateral sclerosis (ALS)- dx summary
LMN degeneration by clinical, electrophysiological, or neuropathological examination
UMN degeneration by clinical examination
Progressive spread of s/sx to other regions
65
Amyotrophic lateral sclerosis (ALS)- tx
Riluzole (rilutek)- extend tracheostomy-free survival by 2-3 months
- se: nausea, weakness, hepatic impairment, neutropenia, dizziness
nutrition
respiratory management
- pulmonary function tests
- ventilation
pseudobulbar affect- (ex- laughing then crying)
- neudexta, elavil
spasicity
- baclofen, zanaflex
sialorrhea
- atropine, hyoscyamine, glycopyrrolate
66
Amyotrophic lateral sclerosis (ALS)- prognosis
3-5y survival
67
Myasthenia gravis
autoimmune disorder characterized by dysfunction at the neuromuscular junction, causing weakness and fatigability of skeletal muscles
68
Myasthenia gravis- pathophysiology
autoantibodies against acetylcholine receptor in postsynaptic neurotransmitter junction --> weakness & fatigue of muscles
have thymic abnormalities
69
Myasthenia gravis- clinical features
symptoms fluctuate throughout day
improve after rest
ocular symptoms
- ptosis, diplopia
bulbar symptoms
- dysarthria (speaking)
- dysphagia (swallowing)
- fatigable chewing
expressionless- "she lost her smile"
dropped head syndrome
respiratory insufficiency and failure "myasthenic crisis"
limb weakness
no reflex changes
70
Myasthenia gravis- dx
ice pack test- improves
edrophonium test- improves
serum AChR antibiodies- (+)
- (-) then (+) for MuSK (muscle specific receptor tyrosine kinase)
single-fiber electromyography=most sensitive test for MG
repetitive nerve stimulation
71
Myasthenia gravis- tx
1st line: acetylcholinesterase inhibitors (mestinon)
immunotherapy added to above
- corticosteroids
- azathioprine
- mycophenolate mofetil
- cyclosporine
exacerbation?
- Plasmapheresis and IVIG
72
Tourette syndrome
neurological disorder manifested by multiple motor and phonic tics
73
Tourette syndrome- epidemiology
kids, teens
74
Tourette syndrome- pathophysiology
bilineal transmission (innervated by both social & environmental factors and genetic abnormalities)
disinhibition of motor and limbic system
75
Tourette syndrome- types of tics
tics- sudden, brief movements or utterances
involuntary but can be suppressed
motor
phonic
76
Tourette syndrome motor tics
motor tics:
simple- blinking, head thrusting
complex- gesturing
involve face, neck, shoulders
Echopraxia= imitation of movement of others
self-mutilating- hair pulling, biting nails, lips, tongue
77
Tourette syndrome phonic tics
grunts, hisses, coughing, utterances, barks
Coprolalia- involuntary obscene speech
echolalia- repetition of others' speech
palilalia- rep. of words of phrases
78
Tourette syndrome- comorbidities
ADHA
OCD
Learning disorders
Conduct disorders
79
Tourette syndrome- dx
multiple motor ticks and >1 phonic tic present
occur many times during day or intermittently for 1 year
tics grow and change location overtime
80
Tourette syndrome- tx general
Cognitive behavior therapy- Habit reversal training
81
Tourette syndrome- antidopaminergic meds
haldol (1st gen antipsychotic)
pimozide
fluphenazine
etc.
82
Tourette syndrome tx for those with ADHD
alpha adrenergic agonists
clonidine (catapres)- BP med
guanfacine (intuniv)
83
Tourette syndrome- tx for focal tics
botulinum toxin
84
Tourette syndrome tx for disabling tics
deep brain stimulation of globus pallidus, thalamus, or other subcortical targets
85
Tourette syndrome tx for those with OCD
behavior therapy + SSRI
prozac
if no response, 2nd gen antipsychotic
