Movement Disorders Flashcards
classify hypo v hyperkinetic types of movement disorders
Hypokinetic: slow & less numerous movements
- Parkinson’s Disease
- Secondary parkinsonism
- atypical parkinsonism
Hyperkinetic: increased movements
- Huntington’s Disease
- Chreoathetosis/Ballism
- Dystonia
- Tics/Tourette’s Syndrome
How are Tremors Classified
what are the following Classifications
1. Resting Tremor
2. Postural Tremor
3. Kinetic Tremor
4. Intention Tremor
Resting Tremor
- relaxed and completely supported limb against gravity; the tremor will be apparent
- think of parkinson’s disease
Postural Tremor
- when held voluntarily against gravity (like hands out in front), the tremor will arise
- this is seen in an essentail tremor, cerebellar tremor, physiologic tremor, dystonic tremor
Kinetic Tremor
- during voluntary movement; the tremor is apparent
- some essnetail tremors will be present as kinetic, and cerebellar too
Intention Tremor
- during voluntary movement, when the pt. is concentrating the tremor will be most apparent as the target is reached
- think cerebellar disease
where are the following tremors most apparent within the body
Parkinson’s Tremor (resting)
- most common in teh hands, fingers, forearms, feet, lips and tongue
- this is a 3-6 Hz frequency
Essential Tremor
- in the hands, head and vocal cords
Cerebellar (intention tremor, ataxic, rubral)
- in the limbs, trunk and head
Orthostatic (rare)
- legs
Essential Tremor
what is it & when does it occur
Symptoms & PE Findings
Essentail Tremor
- a postural and action tremor of the hands, ehad or voice
- commonly a family history of tremor in these pts.
- can improve with alcohol use
- usuall a bilateral tremor, but one side can be worse than the other
- no other abnormalities on exam
Symptoms & PE Findings
- interferes with dexterity and handwriting
- speech affected if it invovles laryngeal muscles
- affect quality of life usually (cant do things they want to)
PE:
- see a postural and kinetic tremor
- doing a archimedes spiral and handwriing will elict the tremor, drinking from a cup, etc.
Essentail Tremor
Diagnosis
Treatment
Diagnosis
- do the PE to see the finsings
- labs (to rule out other causes)include: CBC, CMP, TSH (looking for hyperthyroid)
- a throughout history will help distinguish an ET from PD
- rule out Wilson’s disease with copper and ceruloplasmin
Treatment
- FIRST LINE = Beta blockers: Propranolol (ensure no bradycardia or asthma/copd)
- Primidone: barbituate
- gabapentin, benzos, botox?
others…
- Cala trio: wearable device to decrease tremor
- Focused US: to beam to the thalamus and ablate the tremor area
- Deep Brain Stimulation: in the VIM: ventralis intermedius of the thalamus
Huntinton’s Disease
Etiology
Symptoms
PE
Etiology
- HD is a genetic autosomal dominant disease of chromosomes 4: CAG repeat secetions : the more sections the more symptomatic
- a neurodegenerative disaese which is characterized by its CHOREA, and DEMENTIA/BEHVAIORAL CHANGES
Patho
- atrophy and breakdown of the caudate in the BG: degeneration of the GABAergic pathways: in theindirect basal ganglia pathway: this leads to a decrease in inhibition of movement
- evidence of intranuclear inclusions of huntingtin proteins
Symptoms
- onset between 30-50 with fatailt after 15-20 years of symptom onset
- earliest signs: mental changes which manifest as irritability, mood change, antisocial, & mood disorders
- these chagnes become dementia
- chorea: large rhythmic movements
- dystonic posture & akinetic rigid state
- dancelike gait when walking
- occular abnormalities: consistent blinking
Huntinton’s Disease
Chorea: what is it and what are they
Chorea: involuntary, abrut and irregular movements
- pt. is unaware of these movements
Chorea results in…
- clumsiness
- dsyarthia
- dysphagia
- inabilty to maintain a muscle contraction (like tongue protrusion or hold a grip)
Huntinton’s Disease
Diagnosis
Treatment
Diagnosis
- CT/MRI imagings: cerebral atrophy and atrophy of the caudate
- genetic testing and counceling
always consider other neurologica processes when working this up
Treatment (symptomatic)
Tetrabenzine : VMAT2 inhibitor (will help decrease DA to help them move less)
- help with the dyskinesias
- SE: depression, postural hypotensions, parkinsonism (depleteing DA)
Deutetrabenazine (better SE profile for pts.) : VMAT2 inhibitor (decreased DA)
- good for chorea
other things.
Haldol: to decrease psychosis (but watch parkinsonsim)
Quetiapine: for psychosis
Amatadine: for the chorea/dyskinesia
Clozapine: to enhacne GABA activity
+/- DBS
Tourette’s Syndrome
Etiology
Symptoms
Etiology
- a movement disorder related to and characteristics by tics: sudden, involuntary/semivoluntary, brief movements or sounds that mimic fragments of normal behavior
- pts. usall have multiple motor and phonic tics
- symptoms beginning before age 18 & the tics occur in frequency for > 1 year
- the #, frequency and nature of the tics may change over time
- assocaited with OCD and ADHD diagnoses
Symptoms
- Tics: which are preceed by an urge that is relieved by the carrying out of the tic
- the “urge” component can be suppressed; but not for long as eventually it will trigger the tic to occur
- Motor Tics: sniffing, blinking, frowning, shrugging, echopraxia
- Phonic Tics: grunts, barks, hiss, cough, coprolaiai (obscene speech), echolailia, palilia (repeating phrases)
- Self-Mutalation: nait biting, hair pulling, bitting lip/tongue
Tourette’s Syndrome
Diagnosis
Treatment
Diagnosis
- clincally based on the signs and symptoms
- always screen and observe for concurrent OCD/ADHD & psychiatric disturbances
- must rule out Wilson’s Disease with ceruloplasmin and urine copper
Treatment
- CBT and habit reversal can help with the tics
FIRST LINE = Alpha 2 Agonists (work within the cortico-striatial pathway)
- Clonidine
- Guanfecine
Second Line = Antipsychotics (dopmaine receptor blockers)
- Haldol, aripiprazole, pimozide
- SE: weight gain, tartive dyskinesia
VMAT 2 Inhibitors (like whats used for HD)
- Tetrabenzine, deutetrabenazine, valbenazine
- help to decrease DA in the body
- Botox injections (for face) & DBS
Dystonia
what is it
types
diagnosis
treatment
Etiology: what is Dystonia
- a sustained muscle contraction: leading to a repitive twisting movement and abnormal posturing
- this abnormal posturing = a result of co-contraction of agonist and antagonist muscle groups
- this is sustained, but can be spasmodic in nature
- can be provoked = by action
- can be releived: by tactile feedback : “geste antagoniste”; if you press on the face, it will “unlock” the sustained postion and relax for example
Types of Dystonia
- Cervical Dystonia/spasmodic torticollis MC
- Blepharospasm
- Oromandibular dystonia
- Spasmodic dystonia
- Task Specific Dystonia: Writer’s Cramp & Musician’s dystonia
Diagnosis
clinical
Treatment
BOTOX: first line
Cerebellar Ataxia
what is it
What is it
- ataxia with a broad-based & staggering gait : lossed cerebellar function (drunk walking!)
- dysmetria: finger to nose test (they will overshoot) & can’t do the heal to shin test
- dysdiadochokinesia: unable to alternate rapid movement: like hands on thighsback and forth
- scanning dysarthiria
- nystagmus
Drug Induced Movement Disorder: Dopamine Receptor Blockers
how to treat the following side effects
- Akathisia
- Acute Dystonia
- Tartive Dyskinease
- Neurleptic Malingnat Syndrome
Drug-Related: will often be those medications which are blocking dopamine from being able to regualte and control movments
Akathisia
- the subjective desire to be in constant motion, inability to sti still
- treatment: anticholenergics, beta blockers & amantadine
Acute Dystonia Reaction
- involuntary muscle contration of a major muslce group
- this is a rapid onset
- Treatment: benztropine or dipehnhydramine (prophlatic too)
- if you are giving IM haldol for psychosis: give prophlatic diphenhydramine or benztropine to prevent this from happening!
Tartive Dyskineas
- a late side effect of antipsychotic use
- sucking, lip smacking, facial grimicing, jaw movements
- treatment: D/C MED!!!, tetrabenzine, detetrabenzine, valbenzie
Neuoleptic Malignant Syndrome
- muscular rigidity, autonomic variabiliy, altereed LOC, increased CK
- treatment: D/C MED IMMEDIATELY and rehydrate asasp
