Movement Disorders (Hon) Flashcards
Movement disorders are generally classified into what two types?
Bradykinetic
Hyperkinetic
What are some bradykinetic disorders (akinetic rigid syndromes)?
Most common is parkinsonism which encompasses many disorders:
Idiopathic Parkinson’s disease
Postencephalitic (Von economo’s encephalitis)
Toxin-induced (manganese, canbon disulfide, carbon monoxide)
MPTP (meperidine analogue)
Others:
Progressive supranuclear palsy (PSP)
Shy-Drager syndrome (Multiple systems atrophy (MSA))
Cortical basal (ganglionic) degeneration (CBD)
What causes idiopathic Parkinson’s disease?
Depletion of dopamine in nigrostriatal system, disrupting balance of dopamine and acetylcholine
What are the cardinal features of idiopathic Parkinson’s disease?
Tremor:
- resting tremor often unilateral at first
- “pill-rolling” quality
- may see mouth or chin tremor
Rigidity:
- increased resistance to passive movement
- cogwheel quality
Bradykinesia:
- slowness of movement
- often difficulty initiating movement
What are other clinical features (not cardinal features) of idiopathic Parkinson’s disease?
Postural instability (inability to correct change in balance/posture)
Hypophonia
Hypomimia (masked facies, reptilian stare)
Decreased frequency of eye blink
May see Myerson’s sign (repetitive tapping on forehead leads to sustained blink response)
Gait disturbance (typically slow, stooped forward posture; small steps; may have festinating quality)
Many have dysautonomia (orthostatic hypotension, incontinence, impotence, anhydrosis)
Many will develop dementia
Describe progressive supranuclear palsy (PSP)
Bradykinesia and rigidity
Loss of voluntary control of eye movements (especially vertical gaze)
Describe Shy-Drager Syndrome (Multiple System Atrophy)
Bradykinesia and rigidity
Pronounced autonomic dysfunction
Describe Cortical Basal (Ganglionic) Degeneration (CBD)
Characterized by both cortical and basal ganglionic dysfunction
Bradykinesia and rigidity
May also see cortical sensory loss, apraxia, myoclonus, aphasia
Describe anti-parkinsonian treatment
Dopamine agonists (bromocriptine, pergolide, pramipexole, ropinirole)
Levodopa (Sinemet)
COMT inhibitors (COMTAN)
Anticholinergics (benzotropine, trihexyphenidyl)
MAO-B inhibitor (selegiline)
Amantadine
Surgery: most common is Deep Brain Stimulation (DBS)
Define chorea
Irregular, brief, “dancelike” movements
May be incorporated into purposeful movements
Define athetosis
Writhing, sinous movements (often occur in combination with chorea)
Define dystonia
Sustained muscle contractions that produce twisting and repetitive movements and abnormal postures
Define ballism
Large amplitude, flinging movement, usually from proximal part of extremity
Define tic
Brief, rapid, repetitive, seemingly purposeless stereotyped action that may involve single or multiple muscle groups
Describe Huntington’s disease
Gradual onset and progression of chorea and dementia caused by inherited trinucleotide repeat gene defect on chr 4
Autosomal dominant inheritance, so offspring of affected person has 50% chance of inheriting disease
Prevalence is 5 per 100,00
Symptoms generally begin between age 30-50 with avg lifespan 15 yr after onset of symptoms
Genetic testing provides accurate and definitive means to establish diagnosis. Caution: multiple ethical issues!
No known prevention or cure
Describe Sydenham’s chorea
Occurs mainly in children and adolescents as a complication of previous infection with group A hemolytic streptococcus. May be a form of arteritis
Characterized by unilateral choreiform movements which when mild can be confused for restlessness or fidgeting. May also behavioral changes
Treatment: bedrest and antibiotics
Describe Idiopathic Torsion Dystonia
Characterized by dystonic movements and postures without other signs
May be inherited as AD, AR, or X-linked recessive disorder
Onset may be in childhood or later life but remains throughout life
Describe Idiopathic Torsion Dystonia
May see a variety of findings
Torticollis (cervical dystonia): neck twisted to one side
Blepharospasm: spontaneous involuntary forced closure of eyelids
Oromandibular dytonia: spasms of muscles around mouth
Arm may be held in hyperpronated position with wrist flexed and fingers extended
Leg may be held in extension with pronation and inversion of foot
Describe treatment of Idiopathic Torsion Dystonia
Low doses levodopa Anticholinergics Benzodiazepines Neuroleptic drugs Baclofen Carbamazepine
Describe Focal Torsion Dystonia
Dystonia confined to a focal area
Blepharospasm
Oromandibular dystonia
Spasmodic torticollis
Writer’s cramp: dystonic posturing of hand and forearm when used for specific task like writing, using tools or utensils
Medications as for Idiopathic Torsion Dystonia
BOTOX injections may be helpful to weaken involved. Probably treatment of choice for this
Describe Wilson’s Disease
Autosomal recessive disorder of copper metabolism that produces neurologic and hepatic dysfunction, localized to chr 13
Decreased binding of copper to cerruloplasmin leading to large amounts of free copper deposited into tissues
Usually presents in childhood or young adult life
Describe diagnosis of Wilson’s disease
Based on history, exam findings
Increased amounts of copper excretion in 24 hr urine collection
Decreased serum cerruloplasmin level
Kayser-Fleischer Ring on eye exam
What are the clinical features of Wilson’s disease?
Both bradykinetic and hyperkinetic features Resting or postural tremor Choreiform movements Rigidity Bradykinesia Dysarthria, dysphagia Ataxia Personality/behavioral changes Dementia Psychosis/hallucinations
What is the treatment of Wilson’s disease?
Penicillamine (copper chelating agent)
Restriction of dietary copper
What are tic disorders?
Single motor tics (blinking, coughing, throat clearing) often occur as a benign entity
Gilles De La Tourette’s syndrome: chronic multiple motor and vocal tics with onset before age of 21
Describe Gilles De La Tourette’s Syndrome
Most cases are sporadic
More common in males
Vocal tics vary in presentation but can involve barks, hisses, grunts, throat clearing, coughing among others
May also see:
-Coprolalia (vulgar or obscene speech)
-echolalia (parroting speech of others)
-echoproxia (imitation of others’ movements)
-palillalia (repetition of words or phrases)
Describe treatment of Gilles De La Tourette’s Syndrome
Clonidine
Haldol
Phenothiazines
Describe clinical presentation of Essential Tremor (Benign Familial Tremor)
Postural or kinetic tremor of both hands and may involve head or voice
Can begin in early adulthood but often not until later in life
Usually progresses slowly over years to decades
Usually does not result in significant disability, but social embarrassment is common
As disease progresses, can get impaired coordination
Alcohol often decreases tremor temporarily
What is the treatment for Essential Tremor (Benign Familial Tremor)?
Beta blockers (propranolol)
Primidone
Benzodiazepines
Deep brain stimulation (DBS)
