Movement Disorders

Question 1

Types of movement disorder

Answer 1

• Hypokinetic
  
  • Parkinsonism
• Hyperkinetic
  
  • Tremor disorders
  • Chorea
  • Tics
  • Myoclonus
  • Dystonia

Question 2

Definition of tremor

Answer 2

• Rhythmical oscillation of a body part due to alternate activation of agonist and antagonist muscles

Question 3

How to desribe tremor

Answer 3

• Position
  
  • Is tremor present at rest, or on posture or movement
• Body part affected
  
  • Head, jaw, upper limbs, lower limbs
  • Symmetry/asymmetry
• Frequency
  
  • Low or high frequency; measured in Hertz
  • Parkinson rest tremor - 3-5Hz
• Amplitude
  
  • Useful to divide clinically into small and large amplitude

Question 4

Causes of tremor

Answer 4

• Physiological
• Esential tremor
• PD
• Drugs (dopamine receptor antagonists, alcohol, lithium, amiodarone, beta-agoniss, AEDs - phenytoin/vaproate, theophylline, cyclosporin, caffeine, amphetamines)
• Cerebellar disease
• Metabolic (hyperthyroidism, Cushing’s syndrome)
• Orthostatic tremor
• Dystonia/dystonic tremor

Question 5

Causes of parkinsonism

Answer 5

• Degenerative
  
  • PD
  • Dementia with Lewy bodies
  • Parkinson plus disorders (MSA, PSP)
• Non-degenerative
  
  • Drugs (dopamine antagonists, valproate)
  • Vascular disease
  • Post-encephalitic
  • Post-taumatic
  • Toxic

Question 6

Chorea

Answer 6

• Brief irregular purposeless movements that move from one body part to another
• May be orofacial, generalised or hemichorea
• Multiple causes including SLE, antiphospholipid syndrome, Huntington’s disease, Wilson’s disease, lesions of basal ganglia and drugs (levodopa, OCP)

Question 7

Tics

Answer 7

• Involuntary, stereotyped movements or vocalisations
• Usually suppressible for short perod (including anxiety and followed by a flurry of tics)
• Simple
  
  • Motor includes eye blinking, eyebrow raising, pouting, nose wrinkling, shoulder raising
  • Vocal includes grunting, sniffing, coughing, humming, whistling
• Complex
  
  • Motor includes head shaking, kicking, jumping, hopping, echopraxia
  • Vocal includes coprolalia, echolalia, pallalia

Question 8

Myoclonus

Answer 8

• Brief shock-like muscle jerks

Question 9

Dystonia

Answer 9

• Involuntary muscle spasm which leads to sustained abnormal postures of the affected body part
• It is usually:
  
  • Mobile rather than fixed
  • Task or position-specific
  • Often improved by a sensory kick

Question 10

Primary dystonia

Answer 10

• Dystonia +/- termor is the only symptoms/sign
• No secondary cause and no underlying neurodegenerative disorder
• Young onset
  
  • Usually generalised (primary torsion or Oppenheim’s dystonia)
  • Often due to mutation in DYT1 gene
• Adult onset
  
  • Task specific (i.e. writer’s cramp or musicians dystonia)
  • Focal (i.e. torticollis, blepharospasm, dystonic tremor)
  • Genetic (i.e. DYT6, DYT7, DYT13)

Question 11

Parkinson’s disease vs benign essential tremor

Answer 11

Question 12

Benign essential tremor

Answer 12

• Features
  
  • Fine tremor
  • Symmetrical
  • More prominent on voluntary movement
  • Worse when tired, stressed or after caffiene
  • Improved by alcohol
  • Absent during sleep
• Management
  
  • No definitive management
  • Propranalol (BB) or primidone (barbituate anti-epileptic medication) for symptoms

Question 13

Huntington’s chorea

Answer 13

• AD condition
• Genetic mutation in HTT gene on chromosome 4
• Presents with chorea, eye movement disorders, dysarthria and dysphagia
• No current treatments
• Prognosis 15-20 years