Movement Disorders Flashcards
What is akathisia?
State of restlessness (can’t sit still)
What is ataxia?
Inability to coordinate movements of the trunk or limbs
What is athetosis?
Involuntary writhing limb movements
What is ballism?
Flailing, ballistic, involuntary movements in a limb
What is chorea?
Quick involuntary, dance-like movements
What are dyskinesias?
Involuntary movements, chorea-like or tic-like
What is dystonia?
Abnormal muscle tone with sustained posture
What is myoclonus?
Involuntary spasmodic jerky movements
What are tics?
Habitual, semi-voluntary, spasmodi, quick, brief movements
What PE to do for a movement disorder
MSE Handwriting sample Cranial nerves Motor (rest, posture and kinetic movements, rapid alternating movements) Reflexes Sensory Coordination Station/stance and pull-testing Gait
Types of Parkinsonisms
Idiopathic Parkinson's Disease Drug-induced parkinsonism Vascular parkinsonism Normal pressure hydrocephalus Progressive supranuclear palsy Multiple system atrophy Corticobasal degeneration Dementia with lewy bodies
Disease course of Idiopathic Parkinson’s
Symptom free honeymoon about 3 yrs after diagnosis
Motor complications at about 5-7 yrs
Onset to death about 20 years
Pathophysiology of Parkinsons
Degeneration of DA neurons in substantia nigra pars compacta
Cardinal features of Idiopathic Parkinson’s
Rest tremor
Rigidity
Akinesia-bradykinesia
Postural instability
Rest tremor of Idiopathic Parkinson’s
Unilateral
4-7 Hz and can be pill rolling (slow and at rest)
Rigidity of Idiopathic Parkinson’s
Sustained resistance through passive range of motion
Lead pipe or cog wheeling
Muscle stretch receptors are normal
Akinesia-bradykinesia of Idiopathic Parkinson’s
Masked facies, loss of manual dexterity, getting out of chairs, loss of spontaneous animation, loss of associated movements
Postural instability of Idiopathic Parkinson’s
Stooping and retropulsion
Falls with turning (center of gravity)
*should be the last of the 4 to be seen in PD
Rating scales for Idiopathic Parkinson’s
-Unified Parkinson’s Disease Rating scale (UPDRS):
I is mentation, mood and behavior
II is activities of daily living
III is motor exam
IV is complications of therapy
-Modifies Hoehn and Yahr staging (stages 0-5)
Drug-induced Parkinsonism
Find the offending drug (anti-nausea, anti-psychotic basically anything anti-dopamines)
Absence of rest tremor
Associated akathisia
SYMMETRIC sxs
Vascular Parkinsonsim
GAIT DISTURBANCE
Spasticity and hyperreflexia
Pseuchobulbar affect
Normal Pressure Hydrocephalus
APRAXIA OF GAIT Rigidity Cognitive impairment Urinary incontinence (wet, wacky and wobbly)
Corticobasal degeneration Parkinsonism
COGNITIVE DISORDER
Limb apraxia
Unilateral limb rigidity
Dystonia or myclonus
Progressive supranuclear palsy related Parkinsonism
Psuedobulbar affect
SUPRANUCLEAR GAZE PALSY (vertical gaze, down > up gaze)
Falls!!
Slowed saccades, axial rigidity, absence of tremor, spastic-ataxic dysarthria, poor L-dope response
Multi system atrophy Parkinsonsim
Falls, axial dystonia, respiratory stridor, akinesia, absence of rest tremor, dysmetria
Prominent autonomic features!!!
Poor l-dope response
Dementia with lewy bodies
HALLUCINATIONS
Cognitive disorder: prominent dream enactment behavior, mild autonomic sxs
When to do MRI of the brain
Gait disorder and falling
Cognitive disorder
Multisystem atrophy on MRI
Hot cross bun sign
Progressive supranuclear palsy on MRI
Hummingbird sign due to midbrain atrophy
What to rule out in all pts <50 with movement disorder
Wilson’s disease
How to rule out Wilson’s disease
Urine copper or serum ceruloplasmin
Eye exam for K-F rings
What to be done for all pts with cognitive or functional neuro sxs
Neuropyschometric testing
What to do for all pts with tremor
Thyroid studies
When to give vitamin D supplements
All pts with PD b/c increased risk of falling
When to do SPECt (DaTSCAN)
Mixed tremor disorders (rest and postural etc)
Types of tx for IPD
Carbidopa/levidopa DA agonists MAO-B inhibitors COMT inhibitors Anti-cholinergics MAO-B inhibitor/DA reuptake inhibitor NMDA antagonist/DA reuptake inhibitor Surgery Anti-psychotics
What is Sinemet?
Carbidopa/levodopa (IRimmedite release empty stomach and CR with meals)
Who gets Sinemet?
All pts with IPD over 70 YO
Pts <70 when other rx not working (like DA agonist)
Long term use of Sinemet
Motor fluctuations
Side effects of Sinemet
Nausea
Rare BP changes
Impulse control disorders
DA agonist options
Pramiprezole, Ropinirole, Rotigotine (titrate 6-8 wk process)
Side effects of DA agonists
Sleepiness, nausea, orthostatic hypotension, hallucinations, ICDs
Indications to use DA agonists
Patient <70 YO
Mild sxs
Dyskinesias
Tx of MCI or dementia associated with IPD
Anticholinesterases
Tx of sialorrhea (drooling) associated with IPD
Robinul (can cause confusion in elderly) or botulinum toxins
Types of surgical tx for IPD
Ablative, FUS, stimulation
Deep brain stim surgery sites
Vental immediate nucles: ET or tremor predominant
Subthalamic nuclues: PD
Globus pallidus interna: dystonia or rigidity prominent PD
Indications for DBS
Significant disability
Motor fluctuations wiht max medications
Still levodopa responsive
No cognitive impairment
How get essential tremor
Autosomal dominant (chromosome 2 or 3)
Tremor in essential tremor
4-11 Hz
Postural or kinetic, typically UEs
May have rest tremor later on
May improve with EtOH and worsen with caffeine
Tx of essential tremor
Weight weights and weighted utensils
Propranolol and primidone are best!
Gapapentin, topiramate, diazepam, botulinum (head tremor)
DBS of VIM if refractory to meds
Criteria for restless legs syndrome
Abnormal sensations with urge to move legs
Occurs at rest
Alleviated by movement
Sxs worse at night
(associated with periodic limb movements, can be seen in arms and torso too)
Secondary causes of RLS
Neuropathy, Fe deficiency, pregnancy, renal failure
Tx for RLS
Only at night!!! Fe replacement (ferritin <40) DA agonists, anti-epileptics, benzos, opioids, carbi/levodopa
What to watch out with tx of RLS
Rebound and augmentation (DA agonists, why take at night)
Pathophys of Huntington’s
HD gene on chromosome 4 leading to CAG repeats
Autosomal dominant
Motor sxs of Huntington’s
Chorea Motor impersistence (milk maid grasp and fly catcher tongue)
Tx for Huntingtons (when symptomatic)
Anti-DA drugs
Benzos
Anti-depressants
What are tic disorders?
Semi-voluntary, suppressible
Motor or phonic (vocal)
Simple-sniff, grunt, blink
Complex- words, chewing, scratching
Types of tic disorders
Provisional (Transient)
Chronic
Tourette’s
Tardive tics (from anti-psychotics)
Etiology of tics
Primary/genetic: Tourettes
Drug induced: stimulants, steroids, neuroleptics
Post-infectious: strep
Association of tics
OCD and ADD
Tx of tics
Clonidine
Neuroleptics
benzos
Criteria for Tourette’s
2 or more motor tics AND 1 or more phonic tics >1 yr No secondary causes Onset before 18 Copralalia (<10%)
Tx for Tourette’s
Meds, botulinum toxin, DBS
What is geste antagoniste?
Sensory trick in dystonia (focal) where can touch or do something to make it go away for a little
Types of dystonia
Generalize: usually childhood onset and genetic
Focal: cervical, blepharospasm, task-specific, lingaul etc
Tx of dystonia
Dopaminergic Muscle relaxers Benzos Anticholinergics Botulinum toxins (all focal) DBS
Hemifacial spasm
Involuntary, intermittent spasms of half the face (starts in periorbital muscles)
Most common cause of hemifacial spasm
CN VII compression (others like CVA, MS, Post-Bell’s palsy)
Tx for hemifacial spasm
Botox-A in spots on face
What is basically the movement disorder that doesn’t fit into any other category?
Functional/psychogenic (usually abrupt onset or triggered by minor trauma
Lots of characteristic features
