Movement Disorders Flashcards
What are the questions asked during the evaluation of a patient for a movement disorder?
• Are movements abnormal • Are movements infvoluntary or semi-involuntary • Is it a movement disorder • Cause of movements • Treatment ○ Specific (wilson disease) ○ Symptomatic § PT, ST § Pharm § Surgical? DBS?
What are the terms used when describing the body part affected in the movement disorder?
• Focal vs. segmental vs. generalized
What are the terms used when describing the pattern affected in the movement disorder?
- Repetitive
- Flowing
- random
What are the terms used when describing the duration affected in the movement disorder?
• Brief vs. sustained
• Constant vs. intermittent
• Episodic (paroxysmal, diurnal)
○ Dirunal is daytime, nocturnal is nighttime
What are the terms used when describing the rhythmicity affected in the movement disorder?
- Rhythmic vs. arrhythmic
* Fast or slow (Hz)
How can you describe the movements seen in a movement disorder?
• Timing ○ Continual, paroxysmal, diurnal • Induction ○ Stimuli-induced, action-induced, exercise-induced • Complexity ○ Complex vs. simple • Suppressibility ○ Volition, sensory tricks, positions • Other symptoms that accompany ○ Restlessness, urge to make a movement • Provoking factors ○ Sensory, physical, psychological • Onset ○ Insidious vs. sudden
D1 neurons are what pathway and do what? D2?
- D1 = direct pathway = facilitates movement
- D2 = indirect pathway = inhibits movement
- Dopamine normally activates direct and inhibits indirect overall (facilitating movement)
What are the six given examples of hyperkinesias?
• Tremor • Chorea • Tics • dystonia *restless legs *myoclonus
Parkinsonism is an example of what general type of movement disorder?
Hypokinesia
What is “tremor”
• Rhythmic oscillatory movement produced by alternating or synchronous contraction of antagonist muscles • Usually happens: ○ While resting ○ With intentional action ○ Sustained posture • Usually characterized by ○ Slow or fast frequency ○ 4-6 Hz or 16-18 Hz ○ Regular vs. jerky § Jerky - dystonia and myoclonus
What are the given types of tremor you need to think about?
• Essential • Parkinsonian • Psychogenic • Dystonic • Cerebellar • Brainstem • Orthostatic • Secondary ○ Meds, metabolic, physiologic
What drugs induce tremor?
- Theophylline
- Bronchodilators
- Amphetamines
- Tricyclic antidepressants
- Caffeine
- Cyclosporin
- Steroids
- Lithium
- Alcohol
- Amiodarone
- Valproate
- Neuroleptics
- Metaclopromide
- Reserpine
- Anti-nauseants
What are some pretty common drug causes of temor (drugs you will find more often than others)
alcohol, caffeine, steroids, neuroleptics, amphetamines, tricyclic antidepressants, bronchodilators
What’s up with essential tremor?
- Typically older patients
- Aka - benign, familial, senile
- Postural and kinetic tremor
- Hands, arms
- Head,
- Voice
- Classic archimedies spiral on writing (squiggly lines)
- Bimodal distribution of young and old
What is the pharm treatment for ET?
• ET - essential tremor • Beta blockers ○ propanolol • Primidone ○ Primidoneis an anti-epileptic drug, also called an anticonvulsant. ○ Barbituate anticonvulsant • Topiramate ○ Topiramateis a seizure medicine, also called an anticonvulsant. ○ Carbonic anhydrase inhibitor • Gabapentin ○ Gabapentinis an anti-epileptic medication, also called an anticonvulsant. ○ GABA agonist • Clonazepam ○ Benzodiazepene anticonvulsant
What are the non-pharm ET treatments?
• ET - essential tremor • Botulinum toxin ○ Head and hand tremor • Assisted devices ○ Weighted utensils ○ Non-cut gloves ○ Tremor-cancellation spoon
What are the surgical treatments for ET?
- Thalamotomy
* DBS (thalamus) - VM
What’s up with Tics?
- Not necessarily tourette syndrome
- Brief, intermittent movements or sounds
- Sudden, abrupt, transient
- Repetitive and coordinated
- Vary in intensity, repeated at irregular intervals
- May resemble gestures, normal behavior
What are the diagnostic criteria of tourette syndrome?
• Age of onset 1yr
What are the tics like in tourette syndrome?
• Motor
○ Simple
§ Grimacing, blinking, nose twitching, lip pouting
○ Complex
§ Hopping, clapping, touching, throwing, head banging
• Vocal
○ Grunts, throat clearing, barks, sniffing, shouting obsenities, utterances
What are the treatments for tourette syndrome?
• Patient, school, family education • Support groups • Treat tics only if interfere with life • Habit reversal therapy • Treat co-morbidities ○ OCD, ADHD • CBT
What’s up with chorea?
• Irregular, brief, dancing like, jerky • Randomly flit from one body part to another • Chorea-athetosis ○ Repetitive involuntary, slow, sinuous, writhing movements • Indicative of ○ Huntington ○ Sydenham chorea ○ Chorea gravidarum (BCP) ○ Lupus (antiphospholipid ab)
What’s up with dystonia?
• Co-contraction of muscle agonists and antagonists • Sustained muscle contractions causing twisting, abnormal postures • Can be associated with tremor • Can be caused by primary and secondary etiologies ○ Primary § Dyt1 - protein torsin ○ Secondary § Cerebral palsy § Degen disorders § Hypoxic-ischemic brain injury § Post-stroke § Post-traumatic § Medications § Psychogenic (conversion disorder)
What are the four different classification terms for dystonia?
• Focal ○ Blepharospasm ○ Oromandibular dystonia ○ Laryngeal dystonia ○ Cervical dystonia § Spasmodic torticollis ○ Writers cramp • Segmental • Multifocal • generalized
What are the pharm treatments for dystonia?
• Anticholinergics (artane, cogentin) • Muscle relaxants (baclofen) • Benzos • Botulinum toxin injections • Non pharm is DBS ○ Globus pallidus interna ○ Subthalamic nucleus
What is akathisia?
- Unpleasant sensation of inner restlessness
* Inability to sit still or remain motionless
What is hyperrekplexia?
• Exaggerated startle response
What is ballism
• Large amplitude proximal extremity flinging movements
What is myokymia?
- Localized quivering of a few muscles bundles within a muscle
- Insufficient to move a joint (eyelid twitch)
What is stereotypy?
• Repetitive or ritualistic movement, posture, or utterance
○ Autism, schizophrenia
What is myoclonus?
• Sudden, brief, shock-like movements
What is the constellation of symptoms that makes you really think parkinsonism?
- Resting tremor
- Bradykinesia or akinesia
- Rigidity
- Postural instability
- Festinating gait
- Propulsion and retropulsion
- Stooped posture
- Masked face, decreased blinking
- Hypophonia
- Dysphagia
- micrographia
What are the non-motor symptoms of parkinsons disease?
• Anosmia • Constipation • Depression • Anxiety • Cognitive impairment • Sialorrhea (drooling) • Sensory changes ○ Paresthesias ○ Muscle cramps ○ Pain • Autonomic instability ○ Orthostatic hypotension ○ Bladder dysfunciton ○ Constipation ○ Erectile dysfunction • Sleep disurbances ○ Insomnia ○ Rbd * Rls
**What are the major differences in tremor between dystonia, ET and PD?
• ET - essential tremor • PD - parkinson's disease • Direction ○ Varies - dystonia ○ Flexion/extenion - ET ○ Pronation/supination - PD • Influencing factors ○ Rest - increase in PD, decrease in ET ○ Action - decrease in PD, increase in ET ○ Mental concentration - temp decrease in dystonia, decrease in ET, increase in PD ○ Handwriting - increase in ET, decrease in PD ○ Walking - decrease in ET, increase in PD • Postural tremor ○ Position dependent - dystonia ○ Without latency - ET ○ Re-emergent - PD • Kinetic tremor ○ Frequently present - dystonia ○ Present - ET ○ Rare - PD
For limb tremor and frequency, what is the difference between PD and ET?
• Limb tremor ○ Symmetric in ET ○ Asymmetric in PD • Frequncy ○ Both about 5 Hz ○ Bit faster in ET, slower in PD • Characteristic ○ Action, intension, kinetic - ET ○ Pill-rolling, resting - PD
What besides parkinsons disease might result in the motor dysfunciton of parkinsonism?
- Vascular
- Drug-induced
- Post-traumatic
- Post-infectious
What are the syndromes that are “parkinson-plus”
- LBD - lewy bodies dementia
- PSP - progressive supranuclear palsy
- CBD - corticobasal degeneration
- MSA - multiple systems atrophy
What’s does PSP look like?
• PSP = progressive supranuclear palsy • Progressive onset (before 50) • Impaired eye movements ○ DOWNGAZE • Reptilian or scared look • Early onset of postrual instability ○ They fall in the first year of dx • Retrocollis ○ retrocollis(RC) is a form of cervical dystonia (CD) that pro- duces patterned, repetitive muscle contractions that result. in neck extension.
What’s up with MSA?
• Average life expectance 7-9 years
• Poor response to dopamine replacement
• Subtypes
○ P - parkinsonism from striatonigral degen
○ C - cerebellar symptoms from olivopontocerebellar degen
○ A - autonomic symptoms from shy-drager syndrome
Movement disorders are normally insidious in onset. When they are abrupt, what is the differential dx leaning towards?
- Post-ischemic
- Toxin - induced
- Infection
- Metabolic
- Autoimmune
- Hyperglycemic state
