S2_L2: Movement Disorders Flashcards by MindMed Official

What are the cardinal features of Parkinson’s disease?

Tremor (Resting tremor)
Rigidity
Akinesia/ Bradykinesia
Postural Instability

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Most common toxic substance that can cause
Parkinsonism

Manganese (Mn)

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Most common synthetic substance that can cause Parkinsonism

MPTP (1-methyl-4-phenyl-1,2,3,6)

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Males more affected than females
A. Parkinson’s Disease
B. Multiple Sclerosis
C. Both

A. Parkinson’s Disease

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It occurs in 21-40 years old individuals
A. Parkinson’s Disease
B. Multiple Sclerosis
C. Both

B. Multiple Sclerosis

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Chief complaints include intention tremor, visual changes, fatigue, weakness, balance deficits and
incoordination, pain or paresthesia, and weakness
A. Parkinson’s Disease
B. Multiple Sclerosis
C. Both

B. Multiple Sclerosis

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Chief complaints include resting tremor, rigidity/stiffness, slowness of movement or inability to move, frequent falls, difficulty initiating movement, shortness of breath
A. Parkinson’s Disease
B. Multiple Sclerosis
C. Both

A. Parkinson’s Disease

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Parkinson’s disease is a chronic and progressive disorder of the central nervous
system affecting the ___ with motor and
non-motor symptoms.

basal ganglia

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TRUE OR FALSE: Parkinson’s disease has an insidious onset with a rapid rate of progression.

False, it has a slow rate of progression (gradual)

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What cells degenerate in Parkinson’s disease?

Dopaminergic cells of the substantia nigra

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The following symptoms are present in patients with Parkinson’s Disease, EXCEPT:
A. Tremor
B. Rigidity
C. Akinesia
D. Postural Instability
E. None of the above

E. None of the above

Reference: De Lisa

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The following symptoms are present in patients with Parkinson’s Disease, EXCEPT:
A. Tremor
B. Rigidity
C. Akinesia
D. Postural Instability
E. Bradykinesia

C. Akinesia

Reference: Braddom

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2nd most common neurodegenerative disorder among
elderly people older than 65 years of age

Parkinson’s Disease

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Most common neurodegenerative disorder affecting
elderly people

Alzheimer’s disease

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3rd most common neurodegenerative disorder affecting
elderly people

Lewy body dementia

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Average age of onset of Parkinson’s disease

50 to 60 y/o

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Age range of Young-onset Parkinson’s Disease

21 to 40 y/o

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Age range of Juvenile-onset Parkinson’s Disease

Less than 21 y/o

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In Parkinson’s disease, women are more affected than men. In multiple sclerosis, women are more affected than men.
A. Only the 1st statement is true
B. Only the 2nd statement is true
C. Both statements are true
D. Both statements are false

B. Only the 2nd statement is true

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also known as Paralysis agitans
A. Primary Parkinsonism
B. Secondary Parkinsonism
C. Parkinsonism Plus Syndromes

A. Primary Parkinsonism

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Has an identifiable cause due to toxins, drugs, and viruses
A. Primary Parkinsonism
B. Secondary Parkinsonism
C. Parkinsonism Plus Syndromes

B. Secondary Parkinsonism

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Syndromes that mimic Parkinson’s disease, but it is caused by other
neurodegenerative disorders
A. Primary Parkinsonism
B. Secondary Parkinsonism
C. Parkinsonism Plus Syndromes

C. Parkinsonism Plus Syndromes

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(+) Apomorphine Test
A. Primary Parkinsonism
B. Secondary Parkinsonism
C. Parkinsonism Plus Syndromes

A. Primary Parkinsonism

Pt improves after taking PD medication (levodopa)

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Can be classified as Tremor Predominant or Postural Instability Gait Disturbance (PIGD)
A. Primary Parkinsonism
B. Secondary Parkinsonism
C. Parkinsonism Plus Syndromes

A. Primary Parkinsonism

Note: PIGD is more severe, but tremor predominant is more common.

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(-) Apomorphine Test A. Primary Parkinsonism B. Secondary Parkinsonism C. Parkinsonism Plus Syndromes

C. Parkinsonism Plus Syndromes Do not react to the medication for Parkinson’s Disease (Levodopa)

Drugs that can produce extrapyramidal dysfunction that can mimic the signs of Parkinson’s Disease or cause it. A. Primary Parkinsonism B. Secondary Parkinsonism C. Parkinsonism Plus Syndromes

B. Secondary Parkinsonism

Post-infectious / Post-encephalitic Parkinsonism, where a slow virus affects the brain A. Primary Parkinsonism B. Secondary Parkinsonism C. Parkinsonism Plus Syndromes

B. Secondary Parkinsonism

What are the 3 classes of drugs that can induce Parkinsonism?

1. Neuroleptic drugs 2. Antidepressant drugs 3. Anti-hypertensive drugs

Metabolic Parkinsonism is caused by?

Problem with calcium metabolism Note: Calcium can cause calcification in the basal ganglia, which can lead to sx of PD

Corticostriatal Fibers release glutamate. Striatopallidal Fibers release GABA. A. Only the 1st statement is true B. Only the 2nd statement is true C. Both statements are true D. Both statements are false

C. Both statements are true

Striatonigral fibers release GABA. Nigrostriatal fibers release glutamate. A. Only the 1st statement is true B. Only the 2nd statement is true C. Both statements are true D. Both statements are false

A. Only the 1st statement is true Nigrostriatal fibers release dopamine

Tremor occurs with overactivity of direct pathway and underactivity of indirect pathway. Bradykinesia occurs with overactivity of direct pathway and underactivity of indirect pathway. A. Only the 1st statement is true B. Only the 2nd statement is true C. Both statements are true D. Both statements are false

A. Only the 1st statement is true Bradykinesia: overactivity of indirect pathway and underactivity of direct pathway

Postural instability occurs with overactivity of indirect pathway and underactivity of direct pathway. Rigidity occurs with overactivity of direct pathway and underactivity of indirect pathway. A. Only the 1st statement is true B. Only the 2nd statement is true C. Both statements are true D. Both statements are false

C. Both statements are true

Leadpipe rigidity is jerky-ratchet-like resistance to passive movement. Cogwheel rigidity is Sustained resistance to passive movement with no fluctuation. A. Only the 1st statement is true B. Only the 2nd statement is true C. Both statements are true D. Both statements are false

D. Both statements are false

TRUE OR FALSE: Rigidity is not velocity-dependent.

True

Increased resistance to passive motion due to simultaneous contraction of both agonist and antagonist muscles.

Rigidity

Tremor present in both rest and with movement

Senile tremor

Known as tremor in the hands

Pill rolling tremor

Most common sx of PD according to De Lisa

Tremors

Frequency of tremors

4-6 Hz

The substantia nigra pars compacta (SNc) and ventral tegmental area (VTA) release what neurotransmitter?

Dopamine

Enumerate all structures in the direct & indirect pathways that release GABA

1. Striatum 2. Substantia nigra pars reticulata (SNr) 3. Globus pallidus interna (GPI) 4. Globus pallidus externa (GPE)

The subthalamic nucleus and thalamus release what neurotransmitter?

Glutamate

Progression of Parkinson's disease is evident because of the presence of the ___ in MRI.

lewy bodies - Sign of basal ganglia degeneration. Imaging hallmark of PD.

It has more resistance in one direction than the other direction. It is velocity-dependent and more noticeable with faster movements. A. Spasticity B. Rigidity C. Dystonia

A. Spasticity

Rigidity is commonly seen in Parkinson’s Disease. Rigidity doesn’t increase with the speed of movement, you can feel it even with very slow movements and it’s present in both directions of limb movement. A. Only the 1st statement is true B. Only the 2nd statement is true C. Both statements are true D. Both statements are false

C. Both statements are true

The most common type of high muscle tone. It’s common in people who have had a stroke, brain injury, or cerebral palsy.

Clonus

Sustained muscle contraction causing abnormal postures and twisting or repetitive movements. It is worse with intention or when you really try to do something. A. Spasticity B. Rigidity C. Dystonia

C. Dystonia

1. Dysmetria, hypermetria, hypometria 2. Resting tremor 3. Athetosis 4. Asynergia, Dyssynergia 5. Akinesia, Bradykinesia, Hypokinesia A. Cerebellum pathology B. Basal ganglia pathology C. Both D. Neither

1. A 2. B 3. B 4. A 5. B

1. Asthenia 2. Rigidity 3. Hemiballismus 4. Dysdiadochokinesia 5. Gait disorders A. Cerebellum pathology B. Basal ganglia pathology C. Both D. Neither

1. A 2. B 3. B 4. A 5. A

1. Chorea 2. Rebound phenomenon 3. Dystonia 4. Intention tremor 5. Dysarthria A. Cerebellum pathology B. Basal ganglia pathology C. Both D. Neither

1. B 2. A 3. B 4. A 5. B

Gait pattern where the person is usually in trunk flexion, has a prolonged movement preparation (start hesitation), and excessive forward movement with fast and decreased step length (quick walking).

Festinating gait

Gait pattern characterized by clumsy voluntary movement, the pt will present with clumsy walking. Foot goes in different directions when walking.

Gait ataxia (specifically, cerebellar ataxia)

What cranial nerve/s are important to assess in Multiple Sclerosis?

CN II (Optic)

What cranial nerve/s are important to assess in Parkinson's disease?

CN III, VII, IX

TRUE OR FALSE: Multiple sclerosis has a genetic predisposition due to the human leukocyte antigen major histocompatibility complex gene.

True

Most disabling sign of PD according to O'Sullivan

Bradykinesia

Reduced amplitude of movements, referring to slowed and reduced movements

Hypokinesia

Enumerate the contributory factors for bradykinesia

1. tremor 2. weakness 3. rigidity

The most disabling and least specific sign of Parkinson's according to De Lisa

Postural instability

Slouched posture even during supine that is usually seen in pts with Parkinson's disease

Phantom pillow posture

Motor planning manifestation: prolonged movement hesitation that is aka motor en block A. Start hesitation B. Micrographia C. Freezing episodes D. Hypomimia E. Uniplanar movements

A. Start hesitation

Related to uniplanar movements. Once rotatory movement occurs, the individual experiences ____

Freezing episodes

Has intact immediate, short and long term memory but struggles in step-by-step procedure of motor tasks

Procedural learning

Excessive drooling as a result of increased saliva production and decreased spontaneous swallowing.

Sialorrhea

Decreased voice volume, monotonous tone, problem in articulation, imprecise or distorted articulation, and uncontrollable speech rate

Hypokinetic dysarthria

According to O'Sullivan, this is the most common complaint in pulmonary function because of the restrictive lung dysfunction

Airway obstruction

Enumerate components of striatal toe

big toe extension

Enumerate components of striatal hand

ulnar deviation of the wrist, MCP flexion, and IP extension

Most common virus causing infection and autoimmune disease in Multiple Sclerosis

Epstein-Barr virus

Document the finding: Shaking of both hands was evident at rest and disappeared during movement.

O > OI > (+) resting tremor on (B) hands

Document the finding: Upon passive range of motion of the (B) UE, you felt alternating resistance and relaxation of the muscles. You moved the part slowly.

O > Palpation > (+) cogwheel rigidity on (B) UE

Document the finding: Patient has parkinson's disease. During examination, the patient was unable to balance himself after a backward pull on his shoulders.

O > Neurological Examination > Basal Ganglia > Equilibrium > Unable to recover on retropulsion test

Continuous progression of symptoms A. Relapsing remitting MS B. Primary progressive MS C. Secondary progressive MS D. Progressive relapsing MS

B. Primary progressive MS

Progression of relapsing remitting MS to steady and irreversible decline with or without continued acute attacks. A. Relapsing remitting MS B. Primary progressive MS C. Secondary progressive MS D. Progressive relapsing MS

C. Secondary progressive MS

Example: Optic neuritis and spasticity Presentation of both → intensity lessens → presentation of both & weakness → intensity lessens → the intensity of all Sx will increase → the intensity of all Sx will decrease A. Relapsing remitting MS B. Primary progressive MS C. Secondary progressive MS D. Progressive relapsing MS

D. Progressive relapsing MS

Initial symptom of multiple sclerosis

Optic neuritis

Enumerate the cardinal symptoms of multiple sclerosis

1. Scanning speech or dysarthria 2. Intention tremor 3. Nystagmus or oscillation of the eye Aka Charcot’s triad

Uthoff's symptoms: Adverse reaction to (1)___ for temperatures (2)___ degrees celsius.

1. heat 2. > 29

Most disabling symptom of Multiple Sclerosis according to O’Sullivan

Fatigue

Upon pupillary light reflex, instead of constriction of the pupil, there was dilation (paradoxical widening) of the pupil. This manifestation is known as?

Marcus Gunn pupil

The accommodate reflex is spared/intact, but upon pupillary light reflex, the eyes did not react whether dilating or constricting.

Argyll-Robertson pupil / Prostitute's eye

Frequent blinking of the eyes

Blepharospasm

Blinking / fluttering of the eyes even when the eyes are closed.

Blepharoclonus

The imaging hallmark of Multiple Sclerosis that indicates demyelination has occurred

Dawson’s fingers

Multiple sclerosis usually occurs in the white matter. Enumerate its 4 areas of predilections.

1. Optic nerves 2. Cerebellar peduncles 3. Spinal cord (corticospinal and posterior white columns) 4. Periventricular white matter

Unilateral symptoms, minimal or absent A. Hoehn-Yahr Stage 1 B. Hoehn-Yahr Stage 2 C. Hoehn-Yahr Stage 3 D. Hoehn-Yahr Stage 4 E. Hoehn-Yahr Stage 5

A. Hoehn-Yahr Stage 1

Minimal bilateral or midline involvement. Balance is spared / not impaired. A. Hoehn-Yahr Stage 1 B. Hoehn-Yahr Stage 2 C. Hoehn-Yahr Stage 3 D. Hoehn-Yahr Stage 4 E. Hoehn-Yahr Stage 5

B. Hoehn-Yahr Stage 2

Can live independently, and continue some forms of employment. Has impaired righting reflexes, and there is unsteadiness when turning or rising from a chair. A. Hoehn-Yahr Stage 1 B. Hoehn-Yahr Stage 2 C. Hoehn-Yahr Stage 3 D. Hoehn-Yahr Stage 4 E. Hoehn-Yahr Stage 5

C. Hoehn-Yahr Stage 3

All symptoms are present & severe. Standing and walking are possible only with assistance A. Hoehn-Yahr Stage 1 B. Hoehn-Yahr Stage 2 C. Hoehn-Yahr Stage 3 D. Hoehn-Yahr Stage 4 E. Hoehn-Yahr Stage 5

D. Hoehn-Yahr Stage 4

Confined to bed and wheelchair A. Hoehn-Yahr Stage 1 B. Hoehn-Yahr Stage 2 C. Hoehn-Yahr Stage 3 D. Hoehn-Yahr Stage 4 E. Hoehn-Yahr Stage 5

E. Hoehn-Yahr Stage 5

Enumerate the positive prognosticating factors for Parkinson's disease

1. Early onset 2. Family history 3. Rigidity 4. Early tremor

Determine the affected structure causing the ff signs & symptoms 1. Asynergia 2. Scotoma 3. Loss of consciousness 4. Loss of epicritic sensation 5. Visual agnosia 6. Vertical diplopia A. Reticular activating system B. Trochlear nerve C. Dorsal column medial lemniscus D. Optic nerve E. Cerebellum F. Cerebrum

1. E 2. D 3. A 4. C 5. F 6. B

Gait pattern characterized by lateral movement with fast and decreased step and stride length, decreased cadence and velocity

Shuffling gait

Parkinson's disease is diagnosed with the presence of at least 2 of the 4 cardinal signs. One of which must be _____.

Resting tremors

A criteria for diagnosing Parkinson's disease is clinical course of at least ___ years.

Occurs in females more than males A. Parkinson's Disease B. Multiple Sclerosis C. Both

B. Multiple Sclerosis

In Parkinson's disease, proprioception is usually affected, with less problem on superficial sensations. In multiple sclerosis, the priority is on superficial sensations (pain, paresthesia, pins & needles) as these sensations are usually affected. A. Only the 1st statement is true B. Only the 2nd statement is true C. Both statements are true D. Both statements are false

C. Both statements are true

The most common rating scale for multiple sclerosis

Kurtzke Expanded Disability Status Scale

1. Change in EDSS was two levels (one full point) 2. Pyramidal and cerebellar signs with involvement at multiple sites 3. Benign and relapsing remitting multiple sclerosis A. Good prognosticating factor for Multiple Sclerosis B. Poor prognosticating factor for Multiple Sclerosis

1. A 2. B 3. A

1. One symptom; initial attack of optic neuritis 2. Female 3. Primary progressive multiple sclerosis 4. Half-point changes in EDSS score A. Good prognosticating factor for Multiple Sclerosis B. Poor prognosticating factor for Multiple Sclerosis

1. A 2. A 3. B 4. B

1. Young age at onset (<40 y/o) 2. Longer time first to second attack (>5 years) 3. Fewer than two relapses in the first 5 years 4. Complete recovery at first attack (RRMS) A. Good prognosticating factor for Multiple Sclerosis B. Poor prognosticating factor for Multiple Sclerosis

1. A 2. A 3. A 4. A

In the McDonald Criteria for MS, 2 or more attacks and 1 lesion site require what additional criteria for diagnosis as MS?

Dissemination in space on MR

In order for the patient to be diagnosed with definite Multiple sclerosis, there should be how many attacks and lesion sites?

2 or more attacks 2 or more lesion sites

In the McDonald Criteria for MS, 1 attack and 2 lesion sites require what additional criteria for diagnosis as MS?

Dissemination in time on MR

TRUE OR FALSE: There is no cure for Parkinson's disease.

True

Most common medication for treating Parkinson's disease

Sinemet -Combination of carbidopa & levodopa

Characterized by dramatic initial functional improvements from symptoms of Parkinson's disease

Honeymoon period

Characterized by worsening of symptoms during expected time frame of medication effectiveness in Parkinson's disease

Wearing-off state -End of dose deterioration

TRUE OR FALSE: In the early rigidity stages, the presentation is asymmetric and more in the proximal parts (neck & the head). In the later stages, it becomes symmetrical and usually on the distal extremities.

True

In multiple sclerosis, migration studies indicate that the geographical risk associated with an individual’s birthplace is retained if emigration occurs after the age of ____.

15 years

Most common, characterized by discrete attacks of neurological deficits with either full or partial recovery in subsequent weeks to months A. Relapsing remitting MS B. Primary progressive MS C. Secondary progressive MS D. Progressive relapsing MS

A. Relapsing remitting MS

Type of multiple sclerosis in which the pt. remains fully functional in all neurological systems 15 years after onset.

Benign MS

Type of multiple sclerosis characterized by rapid onset and almost continual progression leading to significant disability or death within a relatively short time after onset.

Malignant MS / Marburg disease