Movement Disorders and Parkinson's Disease

Question 1

What are the two main categories of movement disorders?

Answer 1

Hypokinetic

Hyperkinetic

Question 2

Describe hypokinetic movement disorders?

Answer 2

too little movements e.g. parkinsons disease and other akinetic rigid syndromes

Question 3

Describe hyperkinetic movement disorders?

Answer 3

too much movements, different types of abnormal movements including:
Tremor, tics, chorea, myoclonus, dystonia, athetosis, others

Question 4

Describe what akinetic rigid syndrome means?

Answer 4

The akinetic–rigid syndromes are defined by paucity (only in small or insufficient amounts) and slowness of movement accompanied by muscle stiffness and resistance to passive movement. The akinetic–rigid syndrome is typical of idiopathic Parkinson’s disease, so is often described as the syndrome of parkinsonism.

Question 5

What are the four features of Parkinsonism/ the akinetic rigid syndrome?

Answer 5

TRAP

T= Tremor
R= Rigidity
A= Akinesia/ bradykinesia 
P= Postural disturbances (flexed posture and postural instability)

Question 6

Explain how rigidity differs from spasticity?

Answer 6

There is no increase with higher mobilising speed in rigidity whereas in spasticity due to UMN lesions there is an increase with higher mobilising speeds.

Question 7

Rigidity can be ___________

Answer 7

leadpipe or cogwheel

Question 8

Define lead pipe rigidity?

Answer 8

smooth resistance to passive movement due to increased tone

Question 9

Define cogwheel rigidity?

Answer 9

not smooth resistance, the rigidity occurs with a tremor so a ratchet-like jerkiness is felt

Question 10

What is a positive Froment’s manoeuvre?

Answer 10

rigidity increases in examined body segment by voluntary movement of contralateral body parts

Question 11

Define akinesia and bradykinesia?

Answer 11

Akinesia is absence of movement and bradykinesia is slow movement

Question 12

Describe examination of akinesia and bradykinesia?

Answer 12

Can test for with Rapid repetitive and alternating movements- finger tapping, open and closing fist, pronating and supination of wrist, toe and heel tapping
Look at speed amplitude and rhythm
Speed is slow, amplitude is small and there is a tendency to continuously become smaller also arrests of speed
Often these conditions are asymmetrical so can ask them to shoulder shrug or arm swing
Want to see movements about 10-20 times

Question 13

Describe a parkinsonian posture and gait?

Answer 13

A stooped posture is a characteristic. Gait gradually becomes shuffling with small stride length, slow turns, freezing and reduced arm swing.

Question 14

Festination occurs in parkinsons, what is it?

Answer 14

Involuntary gait in which stride length is shortened and steps become progressively more rapid. The patient with afestinatinggait appears to be hurrying or shuffling along, though forward propulsion is decreased overall. The trunk and lower extremities are typically flexed.

Question 15

Define a tremor?

Answer 15

Rhythmical sinusoidal oscillation of a body part

Question 16

Describe the 3 classifications of tremor?

Answer 16

Rest (typical tremor seen with parkinsons)
Postural (occurs when the arms are outstretched)
Kinetic (occurs with movement)

Question 17

Define dystonia?

Answer 17

Characterised by sustained or intermittent muscle contractions causing abnormal often repetitive movements postures or both
Dystonic movements are typically patterned twisting and may be tremulous
Dystonia is often initiated or worsened by voluntary action and associated with overflow muscle activation

Question 18

Define chorea?

Answer 18

Brief irregular purposeless movements that flit and flow from one body part to another
Patients appear constantly restless or fidgety
Often generalised but it may be confined to one region e.g. the face

Question 19

Explain the difference between chorea, myoclonus and tics?

Answer 19

Myoclonus is shorter and does not change around from one body part to another in the same way chorea does
Tics are suppressible but chorea and myoclonus are not

Question 20

Define Myoclonus?

Answer 20

• Brief electric shock like jerks
  
  • Hiccups or hypnic jerks when falling asleep are common and normal forms of myoclonus
  • Caused by brief activation of a group of muscles leading to a jerk to the affected body part. The activation can arise from the cortex, subcortical structures, spinal cord or nerve root and plexus

Question 21

Define tics?

Answer 21

• “un” voluntary repetitive stereotyped movements or vocalisations
  
  • Tics are suppressible (major distinguishing feature) by the patient for a short period of time
  • Typically the patient experiences a growing feeling of anxiety and discomfort during tic suppression and when allowed to relax will respond with a flurry of tics

Question 22

When do tics almost always start?

Answer 22

in childhood

Question 23

Give some examples of tics?

Answer 23

Motor: eye blinking, head jerks, arm or leg jerks, complex sequence
Vocal: sniffing, grunting, snorting, complex sequences

Question 24

Describe what an essential tremor is?

Answer 24

• Most common type of postural tremor
  
  • Most commonly seen in hands when holding hands outstretched
  • May continue throughout motor execution like finger nose test (but unlike cerebellar dysfunction the tremor doesn’t get worse as you get closer to the target)
  • May run in families
  • No other significant movement abnormalities

Question 25

What is parkinsons disease?

Answer 25

Neurodegenerative disorder caused by loss of dopaminergic neurons from the substantia nigra and surviving cells contain inclusions called Lewy bodies.

Question 26

Risk factors for parkinsons?

Answer 26

genetics not fully understood but do play a role
older age is a risk factor particularly over 70 yo
prevalence is slightly higher in men

Question 27

Describe initial presentation of parkinsons disease?

Answer 27

almost always presents with motor symptoms of tremor and slowness of movement but likely pathological processionals has been going on much longer

Question 28

Describe prodromal non motor symptoms in parkinsons disease?

Answer 28

non motor symptoms often occur years before motor symptoms but are non-specific so generally diagnosis doesn't occur until motor symptoms set in:
anosmia 
depression and anxiety
aches and pains
REM sleep behaviour disorder
Autonomic features- urinary urgency, hypotension
constipation 
restless leg syndrome

Question 29

Describe the main motor features of parkinsons?

Answer 29

akinesia
tremor (typically starts in fingers)
rigidity 
postural and gait disturbances (stooped posture, shuffling gait, slow turns, freezing and reduced arm swing)
speech and swallowing

Question 30

Describe how diagnosis of parkinsons is made?

Answer 30

No lab test for confirmation, clinical diagnosis.

Dopamine transporter imaging using SPECT or PET can be useful to visualise dopamine transporter levels

Question 31

Describe overview of management of parkinsons?

Answer 31

education
encourage physical activity 
treatment of non-motor symptoms 
L dopa 
Dopamine agonists

Question 32

Explain the differences in MOA of dopamine agonists vs L dopa?

Answer 32

L dopa is converted in the brain into dopamine whereas dopamine agonists mimic the affect of dopamine but aren’t actually converted

Question 33

Difference between myoclonus and dystonia?

Answer 33

Myoclonus is the abnormal contractions and dystonia is the abnormal movements and postures created by the contractions

Question 34

Describe L dopa therapy vs dopamine agonists and the pros and cons?

Answer 34

L dopa is converted in the brain into dopamine. It provides the most improvement in motor symptoms and in activities of daily living. However, this drug causes more motor complications that dopamine agonists but it does cause less adverse events (although still get adverse events such as excessive sleepiness and impulse control disorders)

Dopamine agonists mimic the effect of dopamine but aren’t actually converted to dopamine like L dopa is. These provide less improvement in motor symptoms and activities of daily living. However, they have fewer motor complications but do cause more adverse events (including excessive sleepiness, hallucinations and impulse control disorders)

Question 35

List motor complications of L dopa therapy?

Answer 35

• Motor fluctuations
• Dyskinesias
• Need for higher doses to get same effect (because L dopa eventually causes dopamine producing cells to stop working by methylation which is why the dose keeps needing increased and dyskinesia becomes worse)
• On/off phenomena where patients go suddenly from mobile to immobile state

Question 36

First line pharmacological treatment in parkinsons?

Answer 36

• First line treatment should be L dopa to anyone who has Parkinsons disease with motor symptoms affecting quality of life
• In those with early stage disease whose motor symptoms are not affecting quality of life could consider a choice of L dopa, dopamine agonists or MAO inhibitors

Question 37

Explain what is meant by Parkinsonism?

Answer 37

Parkinsonism encompasses any condition that causes TRAP (tremor, rigidity, akinesia/ bradykinesia, postural disturbances) which are extrapyramidal symptoms. Parkinsonism can be caused by anything that causes a relative dopamine deficiency in the nigrostriatal pathway. An example would be antipsychotic drugs which block the D2 receptors and therefore can cause parkinsonism as well as other extrapyramidal side effects.

Question 38

Description of tremor in parkinsons disease?

Answer 38

pin rolling tremor (dragging thumb across hand)