Movement disorders

Question 1

Parkinson’s
Sx, dx, ix, mx

Answer 1

Hypokinetic disorder

Sx:
- bradykinesia
- shuffling gait
- flexed trunk
- slow speech
- hypomimia
- reduced blinking
- micrographia
- rigidity
- lead pipe
- cogwheel
- festinant gait
- tremors
- resting, pill rolling
- improves with action
- postural instability
- falls
- autonomic disturbances
- hypersalivation
- constipation
- incontinence
- cognitive impairment
- olfactory abnormalities
- sleep disturbance

Dx:
Gradual onset that is progressive:
- Bradykinesia
- hypokinesia
And one of:
- stiffness/rigidity
- resting tremor
- balance problems

Ix:
- DAT scan
- neuro exam
- structural MRI
- CT
- serum caeruloplasmin (to exclude Wilson’s)

Mx:
- levodopa (co-careldopa)
- dopamine agonist (pramipexole)
- MAOI-B (rasagilene)
- dopamine releasers (amatadine)
- anticholinergics (benztropine)
- COMTi (entacapone)

Question 2

Polymyalgia rheumatica
Def, sx, ix, mx

Answer 2

Polymyalgia rheumatica (PMR) is an inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck. There is a strong association with giant cell arteritis, and the two conditions often occur together.

Sx:
• Shoulder/hip girdle stiffness (usually in the mornings) for >1 hour, with associated inflammatory pain
• Typically, these symptoms respond to treatment with corticosteroids within 72 hours and a therapeutic trial can be useful in the diagnosis
• Systemic symptoms include:
• Low-grade fever
• Reduced appetite
• Weight loss
• Malaise
• High spiking temperatures are unusual (unless coexistent giant cell arteritis is present)
• Up to 50% of patients develop peripheral joint manifestations, with the knees and wrists most commonly affected

Ix:
The first-line investigations for polymyalgia rheumatica are indicative of the differentials, which include malignancy, endocrinopathy and metabolic bone disease.
The most indicative investigations are ESR and CRP - the ESR can be markedly raised (>60 mm/hr).
The essential investigations are:
• FBC
• U&Es
• LFTs
• Bone profile
• Protein electrophoresis
• Thyroid function tests
• Creatinine kinase
• Rheumatoid factor
• Urinalysis

Mx:
- low dose corticosteroids eg. Prednisolone
DONT STOP:
Don’t – steroid dependence occurs after 3 weeks of treatment, and abruptly stopping risks adrenal crisis
S – Sick day rules (steroid doses may need to be increased if the patient becomes unwell)
T – Treatment card – patients should carry a steroid treatment card to alert others that they are steroid-dependent
O – Osteoporosis prevention may be required (e.g., bisphosphonates and calcium and vitamin D)
P – Proton pump inhibitors are considered for gastro-protection (e.g., omeprazole)