Movement Disorders Flashcards
What are the components of the extrapyramidal system?
Paired subcortical nuclei of grey matter in the brain (basal ganglia)
Caudate nucleus Globus pallidus Putamen Thalamus Subthalamic nucleus Substantia nigra
What is the neurophysiology of movement disorders?
Neurotransmitters
Acetylcholine in striatum has an excitatory effect
Dopamine in substantia nigra has an inhibitory effect
ACh excess causes parkinsonism
D excess causes chorea
GABA deficits cause Huntington’s
What is the classification of movement disorders?
HYPOKINESIA
Parkinson’s
Secondary Parkinson’s
Parkinson’s plus syndrome
HYPERKINESIA
-non jerky
Tremor
Dystonia
-jerky
Chorea
Tics
Myoclonus
What is Parkinson’s disease?
An akinetic-rigid syndrome
Onset in 50 years old, peaks at 70
More common in men 3:2
Can be familial 5%
Slowly progressive degenerative disease involving dopaminergic pathways of the basal ganglia
Unilateral and asymmetrical
Excellent response to levodopa
TRAP
Tremor at rest (3 Hz pill rolling)
Rigidity (lead pipe / cog wheel)
Akinesia/bradykinesia (poverty, slowness)
Postural instability (stooped, shuffling, imbalance from loss of postural reflexes)
+
Others
What are the other clinical features of Parkinson’s disease?
Mask like face ( hypomimia) Reduced blinking Less arm swing Short stepped destination gait Turning en bloc Ignition failure Freezing Micrographia Dysarthria Dysphagia Up gaze palsy Greasy sweaty skin Depression Dementia Postural hypotension Sleep disorders
What are the DDx for primary Parkinson’s?
Multiple system atrophy
Progressive supranuclear palsy
Corticobasal ganglionic degeneration
Diffuse Lewy Body disease
Hypothyroidism
Depression
What are the causes of secondary Parkinsonism?
Drug induced
—- dopamine antagonist
Phenothiazine, reserpine, haloperidol, lithium
Metoclopramide
Pugilist’s post traumatic encephalopathy
Small vessel infarction (lacunar infarction)
Infection
Wilson disease
Hydrocephalus
What are UNLIKELY features for primary Parkinson’s?
Symmetry
Early instability or falls
Early severe dementia
Wise based gait
Pyramidal or cerebellar signs
Poor response to levodopa
What are the differences between spasticity and rigidity?
SPASTICITY is seen
UMN lesion Hypertonia Tone apparent in early movement (claspknife) Hyper reflexia Extensor plantars
RIGIDITY is felt
EPS lesion Hypertonia equal in flexors and extensors Tone apparent throughout ROM (lead pipe) Normal reflexes Flexor plantars
What are the side effects of neuroleptics and antiemetics?
Acute dystonias
- torticollis
- oculogyric crisis
- trismus
Akathisia
Tardive dyskinesia
Neuroleptic malignant syndrome
How do you manage PD?
MEDICAL
—-non pharmacologic
—- pharmacologic Levodopa + decarboxylase inhibitor D2 agonists (bromocriptine) Anticholinergics (benzhexol) MAO B inhibitors
NEUROSURGERY
deep brain stimulation
What is tremor?
Involuntary
Rhythmic
Oscillating movement
Of one or more body parts
Which disappear in sleep
Due to alternate contraction of agonist antagonist
What is the classification of tremor?
Aetiology wise
Amplitude wise
Position wise
POSITION
resting (PD)
Postural (physiological/ essential)
Kinetic (intention / terminal)
AETIOLOGY
physiological tremor mostly in hands
(Bilateral fine fast postural)
Pathological
(Asymmetrical coarse slow resting or kinetic)
What are the features of essential tremor?
Most common movement disorder
AD familial in 50%
Bimodal incidence
M=F
Postural action tremor
Symmetrical
Usually in the hands
50% respond to alcohol
Rx Propranolol
What is dystonia?
Sustained repetitive
Involuntary contraction
Of opposing muscle groups
Causing twisting movements
And abnormal posture
