Movement Disorders Flashcards
What is the clinical syndrome of Parkinsonism?
1) Bradykinesia *** (must have)
2) Lead pipe rigidity
3) Tremors
How are UMN lesion rigidity and Parkinsonism rigidity different and why?
UMN: Clasp knife
- some agonists > antagonists → resistance varies depending on position of joint
Parkinsonism/Extrapyramidal: Lead pipe
- both agonist and antagonistic muscles rigid → joint is tight/rigid regardless of position
What is “cogwheel rigidity”?
Lead pipe rigidity + tremor
How does bradykinesia present in parkinsonism?
1) Hypomimia
- mask-like faces + paucity of blinking
2) Hypophonia
3) Decremental bradykinesia
- reduced arm swing walking
- micrographia
- progressive reduction in amplitude of movements
4) Festinant gait
- reduced stride + paradoxically exaggerated tremor
What is a festinant gait?
Rapid, small steps, done in an attempt to keep the center of gravity (COG) in between the feet while the trunk leans forward involuntarily and shift the COG forward
In which condition are intention tremors seen?
Cerebellar lesions
In which condition are resting tremors seen?
Parkinsonism
- better with movement
What type of tremor is a postural tremor?
Benign essential
What are 5 causes of Parkinsonism?
1) Idiopathic
2) Neuroleptic medication (anti-dopaminergics)
3) Parkinson plus syndromes
4) Wilson’s disease
5) Infective encephalitis
6) Vascular Parkinsonism
Why should metoclopramide be avoided in a patient with Parkinson disease?
Blocks dopamine receptors → exacerbate parkinsonism symptoms
Must use peripherally active anti-emetics (Eg. domperidone/odansetron)
How does Wilson’s disease cause Parkinsonism?
Defect in biliary Copper excretion → Copper deposited in basal ganglia of the brain
How is Wilson’s disease diagnosed?
1) Low levels of caeruoloplasmin (copper transporter)
2) High urine copper levels
3) Kayer Fleishcher rings in eyes
4) Parkinsonism and Liver issues
How is Wilson’s disease treated?
Penicillamine
- sequestered copper
How is progressive supranuclear palsy different from lewy body dementia and multiple systems atrophy?
Progressive Supranuclear Palsy:
- Parkinsonism + eye movement abnormalities
Lewy body dementia:
- Parkinsonism + lilliputian hallucination + cognitive deficits
Multiple systems atrophy:
- Parkinsonism + autonomic failure/cerebellar disease
Which infection is associated with parkinsonism?
Japanese encephalitis
What is Parkinson Disease?
Neurodegenerative condition characterised by asymmetric parkinsonism and apoptosis of dopaminergic nigro-striatal neurons
What are the clinical manifestations of Parkinson’s disease?
Motor:
1) Decremental bradykinesia
2) Hypophonia
3) Hypomimia
4) Micrographia
5) Festinant gait
6) Pill-rolling tremor
7) Lead pipe/cogwheel rigidity
Non-motor:
1) Depression
2) Psychiatric
3) Dementia
4) Mild cognitive impairment
5) Sleep/fatigue/REM sleep disorder
6) Dysautonomia
7) Constipation
8) Sialorrhoea
9) Pain
10) Anosmia
What are 3 brain areas implicated in Parkinson’s disease?
1) Meso-cortical dopaminergic pathways
- mood/motivation
2) Nigro-strial pathways
- movements
3) Locus coerulus
- noradrenergic
- mood
4) Dorsal raphe nuclei
- serotonergic
- mood
- sleep
How is Parkinson’s disease treated?
1) Conservative:
- OT/PT/Support groups
2) Surgical:
- deep brain stimulation
3) Pharmacological
a) Motor symptoms:
- L-dopa
- MOAi/COMTi
- Dopamine agonist
b) Non-motor symptoms
- Citalopram → depression
- Rivastigmine → dementia
- Quetiapine → psychosis
- Botulinum toxin → sialorrhoea
- Amantadine → dyskinesia
What are 4 neural pathways that involve dopamine and their associated diseases?
1) Mesocortical → schizophrenia
2) Mesolimbic → schizophrenia
3) Nigro-striatal → parkinson disease
4) Tubero-infundibular → hyperprolactinemia
Why should dopamine not be given in patients with parkinson’s disease?
1) Cannot cross BBB
2) Stays in peripheral ciculation → AEs eg.HBP/↑HR
Why give carbidopa with L-dopa when it inhibits the conversion of levodopa to dopamine?
Carbidopa cannot cross BBB → prevent peripheral conversion of L-DOPA to Dopamine
→ limits peripheral side effects
What are 4 AEs of L-dopa?
ST:
1) Nausea
2) ↑daytime sleepiness
3) Dyskinesia
4) Impulse control disorders
5) Psychosis/hallucinations
LT:
6) On-off phenomenon
7) “freezing”
8) Dyskinesia
What are 4 forms of hyperkinesia?
1) Myoclonus
- instantaneous muscle contraction
2) Tics
- worse during anxiety/suppressible to certain extent
- basal ganglia dysfunction
- Typified by Tourette syndrome
3) Tremor
- rhythmic sinusoidal oscillatory movements
4) Choreoathetosis
- irregular jerky/twisty movements
What are 4 forms of tremors?
1) Pharm (eg. ß-agonists)
2) Endocrine (eg. hyperthyroidism)
3) Essential
4) Cerebellar
5) Dystonia
6) Parkinsonism
What are 5 causes of choreoathetosis?
1) Pharm (eg. L-DOPA)
2) Genetic (eg. Huntington’s disease)
3) Post-infectious (ge. Sydenham’s)
4) Autoimmune (eg. Lupus)
5) Stroke
6) Pregnancy
What is Sydenham’s chorea?
Post-Strep pyogenes infection chorea