Movement Disorders CPC

Question 1

Describe the basic examination of coordination and gait

Answer 1

Mostly looking for extrapyramidal signs (not weakness or sensory loss)

Examination of muscle tone
Speech rapid alternation movements 
Hand rapid alternating movements
Precision hand movements 
Foot rapid alternating movements
Rebound
Check reflex
Finger Nose Finger
Heel: shin to toes 

Station and gait: 
Romberg
Pull test
Tandem gait
Forced gait
Casual gait

Question 2

“Extrapyramidal signs” that accompany disorders of the cerebellum

Answer 2

Synergy (ataxia)- 3 D's (dysmetria, dysdiadochokinesia, decomposition of mvmt)
Equilibrium
Tone (hypotonia)
Tremor (action)
Nystagmus

Question 3

“Extrapyramidal signs” that accompany disorders of the basal ganglia

Answer 3

Tremor
Hypokinetic
Bradykinesia

Question 4

Mnemonic for cerebellar lesion signs

Answer 4

HANDS Tremor

Hypotonia
Ataxia/asynergia (3 D's)
Nystagmus
Dysarthria 
Stance and gait

Tremor

Question 5

Dysmetria

Answer 5

under and over shooting of a target

Question 6

Dysdiadochokinesia

Answer 6

Trouble with rapid alternating movements (flipping hand on other hand for ex)

Question 7

Decomposition of movement

Answer 7

Breakdown of a movement into its parts with impaired timing

Question 8

Rebound

Answer 8

Increased range of movement with lack of normal recoil to original position

Seen in cerebellar disease

Question 9

Romberg test

Answer 9

Patient stands with feet together, eyes closed

The Romberg is subjective and is deemed “positive” if the patient shows unsteadiness.

Assessment of vestibular, cerebellar, and proprioceptive contributions to balance, with the contribution of vision removed.

Question 10

Pull test

Answer 10

Examiner pulls back on the patient’s shoulders abruptly (again ready to catch), and any step backwards is deemed positive.

Question 11

Tandem gait

Answer 11

Heel to toe walking

Question 12

Forced gait

Answer 12

Patient walks on heels, toes, and with ankles inverted (walking on the outside of the foot)

Question 13

Pronator drift

Answer 13

Patient stands with eyes closed and arms extended in front with palms facing upward.

A positive result is the affected limb pronating and drifting downward.

Seen with pyramidal tract dysfunction (contralateral cortex), parietal lobe dysfunction (contralateral), or cerebellar disease (ipsilateral).

Question 14

Hemiparetic gait

Answer 14

Unilateral UMN injury (from a hemispheric stroke for example)

The affected side demonstrates arm flexion, adduction, and internal rotation.

The lower extremity is in extension with plantar flexion of the foot and toes. When walking, the patient will hold his or her arm to one side and drags his or her affected leg in a semicircle (circumduction) due to weakness of distal muscles (foot drop) and extensor hypertonia in lower limb.

Question 15

Diplegic/Paraparetic gait

Answer 15

Spasticity in lower extremities worse than upper extremities

Patient walks with an abnormally narrow base, dragging both legs and scraping the toes.

Seen in bilateral periventricular lesions (cerebral palsy).

Characteristic extreme tightness of hip adductors which can cause legs to cross the midline referred to as a scissoring gait.

Question 16

Neuropathic gait

Answer 16

Seen in patients with foot drop (weakness of foot dorsiflexion).

Cause of this gait is due to an attempt to lift the leg high enough during walking so that the foot does not drag on the floor.

If unilateral, causes include peroneal nerve palsy and L5 radiculopathy.

If bilateral, causes include amyotrophic lateral sclerosis, Charcot-Marie-Tooth disease and other peripheral neuropathies including those associated with uncontrolled diabetes

Question 17

Myopathic gait

Answer 17

Hip girdle muscles are responsible for keeping the pelvis level when walking. If you have weakness on one side, this will lead to a drop in the pelvis on the contralateral side of the pelvis while walking (Trendelenburg sign).

With bilateral weakness, you will have dropping of the pelvis on both sides during walking leading to waddling.

This gait is seen in patient with myopathies, such as muscular dystrophy.

Question 18

Bradykinetic gait

Answer 18

Patient will have rigidity and bradykinesia

Posture is often stooped with the head and neck forward, with flexion at the knees.

The whole upper extremity is also in flexion with the fingers usually extended.

The patient walks with slow little steps known at marche a petits pas (walk of little steps).

Patient may also have difficulty initiating steps. The patient may show an involuntary inclination to take accelerating steps, known as festination.

This gait is seen in Parkinson’s disease or any other condition causing parkinsonism, such as side effects from drugs.

Question 19

Choreiform gait

Answer 19

Is seen with certain basal ganglia disorders including Huntington’s Disease and other forms of chorea, athetosis or dystonia.

The patient will display irregular, jerky, involuntary movements in all extremities. Walking may accentuate their baseline movement disorder. This is also sometimes called a “dancing” or “Prancing” gait.

Question 20

Ataxic gait

Answer 20

Most commonly seen in cerebellar disease

Clumsy, staggering movements with a wide-based gait

While standing still, the patient’s body may swagger back and forth and from side to side, known as titubation.

Patients will not be able to walk from heel to toe or in a straight line.

The gait of acute alcohol intoxication will resemble the gait of cerebellar disease.

Patients with more truncal instability are more likely to have midline cerebellar disease at the vermis.

Question 21

Sensory gait

Answer 21

Loss of this propioreceptive input

In an effort to know when the feet land and their location, the patient will slam the foot hard onto the ground in order to sense it.

Exacerbated when patients cannot see their feet (i.e. in the dark).

Patients may lift their legs very high to hit the ground hard.

This gait can be seen in disorders of the dorsal columns (B12 deficiency or tabes dorsalis) or in diseases affecting the peripheral nerves (uncontrolled diabetes).

In its severe form, this gait can cause an ataxia that resembles the cerebellar ataxic gait.

Question 22

Diseases with alpha synuclein problems

Answer 22

Parkinsons, Diffuse Lewy Body dementia, and multiple system atrophy

Question 23

Propagation in neurodegenerative conditions

Answer 23

Taken up by exocytosis and transported back up synapse (retrograde) to cell body and causing cell death

Question 24

Path seen in parkinson’s

Answer 24

Loss of pigmented neurons beginning in lower brainstem nuclei (dorsal motor n X, locus coeruleus), and progressively involving more rostral pigmented nuclei including the (dopaminergic) nigral neurons which can be evident grossly as loss of nigral pigmentation.

Residual clusters of pigment microglia and astrogliosis become evident in substantia nigra.

Lewy bodies, are characteristic. Alpha synuclein comprises the component filaments in Lewy bodies, and can be demonstrated immunocytochemically.

Alpha synuclein can also be demonstrated in neuron processes

Question 25

Diffuse Lewy Body disease

Answer 25

Also alpha synuclein problem

More diffuse Lewy body distribution in brain, can be associated with dementia, especially when found in extralimbic neocortices (as well as in brainstem, amygdala and limbic cortices).

Dementia with Lewy bodies (DLB) is a condition characterized by the onset of dementia within a year of onset of parkinsonism. PD with dementia (PDD): onset of dementia more than a year (often up to 10 years) after onset of parkinsonism

Diffuse Lewy body disease often co-exists with AD-related cortical neuritic plaques and neurofibrillary tangles

Question 26

Progressive Supranuclear Palsy

Answer 26

Characterized by akinesia, and rigidity, usually with characteristic supranuclear gaze palsy; dysarthria or dysphagia variable and frontotemporal dementia can be a feature

Degeneration with neurofibrillary tangles (Tau) in neurons, along with Tau-immunoreactive cortical and subcortical glia - concentrated in at least three of: pallidum, subthalamic nucleus, substantia nigra, or pons.

Question 27

Corticobasal Degeneration

Answer 27

Patients are clumsy and stiff at first, then rigid and akinetic, sometimes showing ’alien limb’ phenomenon, apraxia, sensorimotor disturbances as well; a frontotemporal clinical dementia syndrome can be prominent.

Astrocytic plaques

Tau inclusions are seen in neurons in substantia nigra, locus ceruleus, tegmental and raphe nuclei; they are also seen in glia; similar changes can also be seen in striatum; subcortical white matter gliosis is not uncommon.

Cerebral cortical atrophy is common and typically peri-rolandic, often asymmetrical (even focal) and associated with variable neuron loss and gliosis, but with prominent achromatic (“ballooned”) neurons in deeper cortical layers

Question 28

Multiple Systems Atrophy

Answer 28

Alpha synuclein

This is a distinct neurodegenerative disease characterized by a spectrum of overlapping clinical expression, including:
–parkinsonism
–progressive ataxia
–dysautonomia (Shy-Drager syndrome)

Degeneration involves multiple central “systems”:
–striatonigral (results in putamenal atrophy; loss of striatal neurons; loss of associated white matter tracts)
–(olivo)pontocerebellar (Pontocerebellar atrophy; olives can be affected too)
–intermediolateral columns

Question 29

What degenerates in Huntington’s?

Answer 29

medium spiney neurons in the caudate

Question 30

Degenerative ataxias

Answer 30

Autosomal recessive

Disease stays in pontocerebellar region (unlike MSA)

Cerebellar cortical degeneration usually accompanied by degeneration in olivocerebellar pathways and spinocerebellar tract degeneration.

In many cases, degeneration of interconnecting pontocerebellar pathways is also present

Thus, olivopontocerebellar atrophy - as a degenerative pattern –can be seen in conditions other than MSA

Question 31

Friedreich’s Ataxia

Answer 31

One of the degenerative ataxias
Autosomal recessive
Triple repeat expansion

Clinically- limb ataxia, dysarthria, loss of distal position and vibration sense, upper limb wasting, areflexia, can have upper motor neuron-like lower extremity weakness

Pathologically- loss of neurons in dorsal root ganglia with resulting loss of peripheral sensory fibers as well as fibers in dorsal columns; loss of cerebellar afferents, cerebellar efferents from dentate nuclei and degeneration in corticospinal tracts in some cases

Question 32

Tauopathies

Answer 32

Picks
AD
PSP
Corticobasal degeneration

Question 33

Which ones give Parkinsonism?

Answer 33

Idiopathic Parkinson’s
Diffuse Lewy Body Disease
PSP
Some MSA

All affect Substantia Nigra compacta