Movement Disorders and Parkinson's Disease Flashcards
What are the two main categories of movement disorders?
Hypokinetic
Hyperkinetic
Describe hypokinetic movement disorders?
too little movements e.g. parkinsons disease and other akinetic rigid syndromes
Describe hyperkinetic movement disorders?
too much movements, different types of abnormal movements including:
Tremor, tics, chorea, myoclonus, dystonia, athetosis, others
Describe what akinetic rigid syndrome means?
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.
What are the four features of Parkinsonism/ the akinetic rigid syndrome?
TRAP
T= Tremor R= Rigidity A= Akinesia/ bradykinesia P= Postural disturbances (flexed posture and postural instability)
Explain how rigidity differs from spasticity?
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.
Rigidity can be ___________
leadpipe or cogwheel
Define lead pipe rigidity?
smooth resistance to passive movement due to increased tone
Define cogwheel rigidity?
not smooth resistance, the rigidity occurs with a tremor so a ratchet-like jerkiness is felt
What is a positive Froment’s manoeuvre?
rigidity increases in examined body segment by voluntary movement of contralateral body parts
Define akinesia and bradykinesia?
Akinesia is absence of movement and bradykinesia is slow movement
Describe examination of akinesia and bradykinesia?
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
Describe a parkinsonian posture and gait?
A stooped posture is a characteristic. Gait gradually becomes shuffling with small stride length, slow turns, freezing and reduced arm swing.
Festination occurs in parkinsons, what is it?
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.
Define a tremor?
Rhythmical sinusoidal oscillation of a body part
Describe the 3 classifications of tremor?
Rest (typical tremor seen with parkinsons)
Postural (occurs when the arms are outstretched)
Kinetic (occurs with movement)
Define dystonia?
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
Define chorea?
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
Explain the difference between chorea, myoclonus and tics?
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
Define Myoclonus?
- 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
Define tics?
- “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
When do tics almost always start?
in childhood
Give some examples of tics?
Motor: eye blinking, head jerks, arm or leg jerks, complex sequence
Vocal: sniffing, grunting, snorting, complex sequences
Describe what an essential tremor is?
- 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
What is parkinsons disease?
Neurodegenerative disorder caused by loss of dopaminergic neurons from the substantia nigra and surviving cells contain inclusions called Lewy bodies.
Risk factors for parkinsons?
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
Describe initial presentation of parkinsons disease?
almost always presents with motor symptoms of tremor and slowness of movement but likely pathological processionals has been going on much longer
Describe prodromal non motor symptoms in parkinsons disease?
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
Describe the main motor features of parkinsons?
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
Describe how diagnosis of parkinsons is made?
No lab test for confirmation, clinical diagnosis.
Dopamine transporter imaging using SPECT or PET can be useful to visualise dopamine transporter levels
Describe overview of management of parkinsons?
education encourage physical activity treatment of non-motor symptoms L dopa Dopamine agonists
Explain the differences in MOA of dopamine agonists vs L dopa?
L dopa is converted in the brain into dopamine whereas dopamine agonists mimic the affect of dopamine but aren’t actually converted
Difference between myoclonus and dystonia?
Myoclonus is the abnormal contractions and dystonia is the abnormal movements and postures created by the contractions
Describe L dopa therapy vs dopamine agonists and the pros and cons?
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)
List motor complications of L dopa therapy?
- 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
First line pharmacological treatment in parkinsons?
- 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
Explain what is meant by Parkinsonism?
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.
Description of tremor in parkinsons disease?
pin rolling tremor (dragging thumb across hand)
