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5. HDS Neuro Psych > Movement Disorders > Flashcards

Movement Disorders Flashcards

1
Q

Movement Disorders

Overview

A

Neurologic diseases affecting voluntary control of movement or result in involuntary movements

Movement disorders divided into two categories:

  • Hypokinetic diseases
    • Parkinson’s Syndrome
    • Lewy Body Dementia
    • Progressive Supranuclear Palsy
    • Corticobasal degeneration
    • Secondary Parkinsonism
      • Drug-induced
      • Vascular
      • Post-traumatic
      • Post-infectious
  • Hyperkinetic movements
    • Essential tremor
    • Huntington’s Disease
    • Dystonia
    • Tics
    • Ataxia
    • Tardive Dyskinesia
    • Psychogenic Movement Disorders
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2
Q

Hyperkinetic Movements

A
  • Tremor - Regular oscillations of a body part produced by alternating contractions of reciprocally innervated muscles
    • Can be at rest, w/ holding a posture, or w/ action
  • Myoclonus - Sudden “lightning-like” movements w/ irregular pauses between jerks
  • Dystonia - Sustained muscle contractions resulting in abnormal fixed posture or repetitive involuntary movement
  • Athetosis - Writhing movements due to continuous movement of adjacent muscle groups
  • Chorea - An excess of rapid, arrhythmic, unpredictable movements, “dance-like”
  • Ballism – Large amplitude, proximal, jerking or flinging movements
  • Tics - Repeated, individually recognizable, intermittent movements or movement fragments that are briefly suppressible and are usually associated w/ awareness of an urge to perform the movement
  • Akasthisia – sense of inner restlessness that often leads to voluntary movement
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3
Q

Hypokinetic Movements

A
  • Parkinsonism – a constellation of sx w/ multiple causes (one of which is Parkinson’s disease)
  • Freezing of gait
  • Psychomotor slowing
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4
Q

Parkinsonism

A

A constellation of sx:

  • Bradykinesia – slowness of movement
  • Akinesia – difficulty initiating movement
  • Rigidity
  • Shuffling gait
  • +/- tremor (mainly at REST)
  • Masked facies – decreased facial expression
  • Hypophonia – soft voice

Idiopathic Parkinson’s Disease is one cause of Parkinsonism

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5
Q

Motor Control

A

Corticospinal tract and premotor areas ⇒ motor strength

Basal ganglia and cerebellum ⇒ other aspects of motor control

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6
Q

Basal Ganglia

Components

A
  • Deep brain structures that facilitate or inhibit movement:
    • Caudate
    • Putamen
    • Globus pallidus – interna and externa
    • Substantia nigra – pars compacta and pars reticulata
    • Subthalamic nucleus (STN)
    • (Amygdala, nucleus accumbens, claustrum)
  • Other terminologies:
    • Lentiform (lenticular) nucleus = globus pallidus + putamen
    • Striatum = caudate + putamen
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7
Q

Basal Ganglia

Function

A

Controls the contralateral side of the body

Largely facilitates or inhibits movement

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8
Q

Basal Ganglia

Neurotransmitters

A

GABA (⊖) ⇒ striatum, globus pallidus

Glutamate (⊕) ⇒ subthalamic nucleus

Dopamine (⊕ or ⊖) ⇒ SN pars compacta

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9
Q

Basal Ganglia

Circuitry

A
  • Inputs to the basal ganglia: Cortex, substantia nigra pars compacta
  • Outputs from the basal ganglia: globus pallidus internal segment and substantia nigra pars reticulata
  • Mainly project to the thalamus → cortex ⇒ either stimulation or inhibition of movement
  • Two pathways are involved: direct pathway and indirect pathway ⇒ opposite effects on movement
  • Dopamine stimulates these pathways in different ways to facilitate movement
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10
Q

Basal Ganglia

Direct Pathway

A

Facilitates Movement

  • Inhibits output from basal ganglia
  • Increases likelihood of movement
  • Dopamine acting on D1 receptors is excitatory and stimulates this pathway
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11
Q

Basal Ganglia

Indirect Pathway

A

Inhibits Movement

  • Increases output from basal ganglia
  • Decreases likelihood of movement
  • Dopamine acting on D2 receptors is inhibitory on this pathway, thereby allowing movement
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12
Q

Parkinson’s Disease

Overview

A

Neurodegenerative disorder characterized by loss of dopaminergic neurons in the substantia nigra.

  • 2nd most common neurodegenerative disorder behind Alzheimer’s Disease
  • Up to 10% of cases have a specific gene mutation
  • Onset at age 50 or older but younger cases are seen
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13
Q

Parkinson’s Disease

Clinical Manifestations

A
  • Cardinal Features of PD: TRAP mnemonic
    • T: tremor – typically a resting tremor
    • R: rigidity
    • A: akinesia or bradykinesia
    • P: postural instability
    • Masked facies, hypophonia, micrographia
    • Symptoms are typically asymmetric
  • Non-motor features of PD
    • Depression/Apathy
    • Constipation
    • Sexual dysfunction
    • Urinary dysfunction
    • Orthostatic hypotension
    • Cognitive decline – typically late in the course
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14
Q

Parkinson’s Disease

Treatment

A
  • Mainstay of pharmacologic treatment is levodopa
  • Exercise – Studies show a possible disease modifying effect
  • Physical, occupational, and speech therapy – Programs specifically designed for Parkinsonism
  • Deep Brain Stimulation
    • Adjustable stimulation that modulates basal ganglia circuitry
    • Improves levodopa-responsive symptoms, tremor, bradykinesia, dystonia, increases ON time, reduces dyskinesia
    • Contraindications include atypical parkinsonism, dementia, uncontrolled psychiatric disease, high surgical risk due to other medical conditions
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15
Q

Atypical Parkinsonian Syndromes

A

Neurodegenerative diseases with parkinsonism as a clinical feature.

Both synucleinopathies and tauopathies can have features of Parkinsonism.

  • α-synucleinopathies often have REM sleep behavior disorder as a prodrome
  • All forms of atypical parkinsonism warrant a levodopa trial, up to high doses if tolerated
  • Otherwise, symptomatic treatment is utilized
    • PT/OT, botulinum toxin for dystonia, anti-depressants, tx for orthostatic hypotension
  • DBS is not efficacious
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16
Q

Lewy Body Dementia

A
  • 2nd most common form of neurodegenerative dementia
  • An α-synucleinopathy
  • Clinical features:
    • Parkinsonism starts w/ or follows dementia onset
    • Fluctuating cognition
    • Recurrent visual hallucinations – typically complex
  • Treatment: balance between levodopa for parkinsonism, and treating psychosis
17
Q

Multiple System Atrophy

A
  • An α-synucleinopathy
  • Clinical features:
    • Parkinsonism – Poorly responsive to levodopa, more symmetric, faster progression
    • Autonomic failure – Orthostatic hypotension, erectile dysfunction, urinary difficulty
    • Cerebellar dysfunction
    • Relative preservation of cognition
    • Anterocollis – patterned, repetitive muscle contractions that result in neck flexion
  • Subtypes:
    • MSA-P (Striatonigral degeneration) – mostly parkinsonism
    • MSA-C (Olivopontocerebellar atrophy) – mostly ataxia
    • MSA-A (Shy-Drager, no longer considered a distinct subtype) – mostly autonomic failure
18
Q

Progressive Supranuclear Palsy

A

Tauopathy

Clinical features:

  • Early falls – often due to retropulsion and postural instability
  • Parkinsonism that is poorly responsive to levodopa, more rapid progression
  • Ophthalmoplegia, or impaired vertical eye movements
    • Square wave jerks
    • Loss of downgaze is fairly specific
    • Can involve horizontal eye movements over time
  • “Stare” – wide stare, procerus activation
  • Dementia
19
Q

Corticobasal Degeneration

A

Tauopathy

  • Parkinsonism w/ poor response to levodopa (sometimes markedly asymmetric)
  • Alien limb phenomenon – arm or leg assumes postures without the patient’s voluntary control
  • Cortical sensory deficits
    • Graphesthesia – unable to identify numbers drawn on the hand
    • Loss of stereognosis – unable to identify objects by feel
  • Significant dystonia, spasticity, rigidity (often unilateral)
  • Cortical myoclonus, apraxia
  • Dementia later in the course of disease
20
Q

Secondary Parkinsonism

A
  • Drug-induced parkinsonism
    • Most common extra-pyramidal syndrome
    • Often caused by dopamine-blocking drugs
      • Including some antipsychotics and antiemetics
    • Can take months to a year to resolve after stopping the offending medication
  • Other secondary causes include:
    • Vascular parkinsonism
    • Post-encephalitic parkinsonism
    • Post-traumatic parkinsonism
21
Q

DATscan

A
  • Uses ioflupane iodine-123 injection w/ SPECT to image presynaptic dopamine transporters in the striatum
  • Does not differentiate between PD, MSA, PSP
  • Useful in differentiating essential tremor from PD/MSA/PSP
  • Also helpful in differentiating drug-induced parkinsonism from PD
  • Is not needed to confirm diagnosis, but can provide info if dx is not clear
22
Q

Hypokinetic Conditions

Comparison

A
  • Parkinson’s Syndrome: tremor, asymmetry, slower progression
  • Lewy Body Dementia: early dementia, visual hallucinations
  • Multiple System Atrophy: associated autonomic sx; parkinsonism type, cerebellar type
  • Progressive Supranuclear Palsy: early falls, opthalmoplegia
  • Corticobasal degeneration: unilateral dystonia, alien hand, apraxia
  • Secondary Parkinsonism
    • Drug-induced (Dopamine blockade)
    • Vascular
    • Post-traumatic
    • Post-infectious
23
Q

Essential Tremor

Overview

A

Very common cause of tremor

Clinical features:

  • Tremor that slowly worsens over years
  • Tremor is worst w/ posture and action (unlike rest tremor of Parkinson’s disease)
  • Affects arms/hands first, but can also affect head, jaw, voice, legs trunk
  • Bilateral, usually roughly symmetric
  • Can become disabling in severe cases
  • Fhx in ~60%
  • Often improves acutely w/ alcohol
24
Q

Essential Tremor

Treatment

A
  • Propranolol (β-blocker) ⇒ first-line therapy
  • Primidone (older anti-epileptic med) is another option
  • There are other second line treatments which are less likely to be effective
  • Deep brain stimulation can be considered if medication fails ⇒ target is typically the VM nucleus of the thalamus
25
Q

Huntington’s Disease

Overview

A
  • Autosomal dominant CAG repeat disease on chromosome 4 affecting the Huntingtin gene
  • Onset typically in adulthood
  • Duration 5-20 years
  • Triad of clinical signs: chorea, cognitive deficits, psychiatric disease
    • In later stages, can develop into bradykinesia/rigidity
    • Higher rates of suicide in this population
26
Q

Huntington’s Disease

Treatment

A
  • Treatment is symptomatic
  • Tetrabenazine is FDA approved ⇒ ⊗ reuptake and depletes storage of dopamine and other monoamines
  • Other dopamine-blocking medications such as haloperidol, risperidone have been used
27
Q

Dystonia

A

Sustained or intermittent muscle contractions causing abnormal (often repetitive) movements, postures, or both.

  • Causes:
    • Idiopathic (most cases)
    • Medication-induced (dopamine blockade)
    • Genetic causes
    • Structural – Trauma, stroke
  • Can affect one part of the body, multiple parts of the body, or can be generalized to affect the whole body
    • Focal – Cervical dystonia (affects neck, most common form), blepharospasm, spasmodic dysphonia
    • Task-specific – embouchure dystonia in musician’s, writer’s cramp, “yips” in golfers
    • Segmental – Meige syndrome
    • Generalized – many of the genetic dystonias such as DYT-1, dopa-responsive dystonia, or secondary dystonias in conditions like Lesch-Nyhan syndrome
  • Can be associated w/ geste antagoniste (sensory trick which temporarily relieves the dystonia)
  • Treatment includes botulinum toxin for more focal dystonias
28
Q

Tics

A

Semi-voluntary (e.g. suppressible), repetitive, rapid, non-rhythmic movements or sounds.

  • Sensory component – urge to perform the movement
  • Associated compulsions
  • May be associated w/ OCD, ADHD
  • Occasionally tics are disabling
29
Q

Tourette Syndrome

A

A syndrome consisting of both motor and vocal tics, beginning in childhood and lasting over a year.

30
Q

Tics

Treatment

A
  • Alpha-agonists such as clonidine
  • Anti-psychotics such as haloperidol
  • DBS in severe cases – also option for treatment of refractory OCD
31
Q

Ataxia

Overview

A
  • Physical finding, not a disease
  • Results from damage to cerebellum or cerebellar pathways
  • Features:
    • Dysmetria – poor targeting of planned movements
    • Dysdiadokinesia – poor sequencing of planned movements
    • Intention tremor – typically coarse, worse closer to the intended target
    • Gait abnormalities – wide based gait w/ poor balance “Drunken sailor’s walk”
    • Eye movement abnormalities
32
Q

Ataxia

Etiologies

A
  • Lesion in the following areas of the brain (caused by strokes, demyelination, brain tumors, etc.):
    • Cerebellum
    • Pons
    • Midbrain (Red Nucleus)
    • Olivary Nucleus
    • Thalamus (Cerebellar Inflow Nucleus)
  • Acute intoxication
    • Alcohol, phenytoin, others
  • Chronic substance abuse
    • Including alcohol which causes cerebellar degeneration
  • Genetic Ataxias
    • Autosomal Dominant Ataxias (Spinocerebellar ataxias)
    • Autosomal Recessive Ataxias (e.g. Friedreich’s ataxia)
  • Metabolic
    • Vitamin E deficiency, Thiamine deficiency, hypothyroidism
  • Autoimmune/paraneoplastic
    • Gluten ataxia
    • Anti-YO, HU, TR
  • Multiple System Atrophy, Cerebellar Type (MSA-C)
33
Q

Psychogenic Movement Disorders

A
  • Key features:
    • Sudden onset
    • Variability – changing phenomenology (frequency, amplitude, direction)
    • Distractibility
    • Entrainment – will change in rhythm to match other movements
    • Coherence – all body parts moving to the same rhythm
    • Suggestibility
  • Not uncommon – up to 10% of new pt visits in movement disorders clinic
  • Risk factors:
    • Having other neurologic conditions
    • Recent significant stress/trauma (emotional or physical)
    • Psychiatric disorders
    • H/O childhood abuse/neglect
  • Treatment consists of engaging the pt in the diagnosis, physical therapy, psychiatric care, and psychotherapy
34
Q

Movement Disorders

Take Home Points

A
  • Dopamine acts on the basal ganglia on both the indirect and direct pathways to facilitate movements
  • Parkinson’s disease and other movement d/o are clinical diagnoses
    • Based on carful hx and PE
  • Parkinson’s disease has many available treatments
    • With appropriate management, pts can sustain a good QOL

5. HDS Neuro Psych (46 decks)

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