Movement Disorders + Parkinson

Question 1

Dyskinesia vs Bradykinesia vs Akinesia

Answer 1

• Dyskinesia = abnormal, uncontrolled, involuntary movement.
• Bradykinesia = slowness of movement.
• Akinesia = absence of movement

Question 2

Tremor

Answer 2

• Involuntary periodic oscillation of a body part
• Continuous and rhythmical
• Differentials: Parkinson’s disease, Lewy body dementia
  physiological tremor, Hypoglycaemia, Thyrotoxicosis Alcohol withdrawal, Drug-induced tremor

Question 3

What are the types of tremor?

Answer 3

• resting = present in a body part that is supported and relaxed eg parkinsonian
• postural = appears when a body part is maintained in a posture eg essential (benign tremor)
• intention = occurs during a movement which is goal directed eg cerebellar

Question 4

What is dystonia?

Answer 4

• abnormal contraction of a body part due to sustained contraction of agonist and antagonist muscles
• 1ary or 2ary (stroke, brain injury, encephalitis and Parkinson’s disease)

Question 5

What is chorea?

Answer 5

• Involuntary dance like movements
• can occur with athetosis, which adds twisting and writhing movements.
• Huntington’s
• Sydenham’s chorea (complication of rheumatic fever)
• pregnancy (chorea gravidarum)

Question 6

What is myoclonus?

Answer 6

• Involuntary quick jerk like movement
• benign or 2ary: infection, hyperosmolar hyperglycemic state, head or spinal cord injury, stroke, stress, brain tumors, kidney or liver failure etc.

Question 7

Ballistic movements (hemiballismus)

Answer 7

• Involuntary large amplitude proximal limb movements

- causes: stroke (basal ganglia), traumatic brain injury, ALS, neoplasm etc.

Question 8

Motor tics

Answer 8

• semi-voluntary semi-purposeful movements,
  can be suppressed for a short while
• chronic motor tic disorder (either motor or vocal)
• tourette syndrome (both motor and vocal)

Question 9

Parkinson’s - definition

Answer 9

• Chronic progressive neurological disorder characterised by motor symptoms of resting tremor, rigidity, bradykinesia, and postural instability.
• Insidious, often asymmetrical onset.
• Associated with numerous, often disabling non-motor symptoms

Question 10

Genes in Parkinson’s

Answer 10

• SNCA (alpha-synuclein)
• Parkin
• PINK-1
• DJ-1
• LRRK2
• GBA (glucocerebrosidase)

Question 11

Parkinson’s - risk factors

Answer 11

increasing age
history of familial PD in younger-onset disease
mutation in GBA gene
1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) exposure (lab neurotoxin)

Question 12

Parkinson’s - clinical features

Answer 12

bradykinesia = Slowness of movements, delay in initiating movements, and freezing of gait, fixed facial expression, slow soft speech, reduced blinking
resting tremor = asymmetrical onset. Chin tremor may occur. May reoccur when arms are outstretched
rigidity: leadpipe (resist throughout whole range of movement, no fluctuations) or cogwheel (stiff + tremor)
postural instability = Imbalance or falling, retropulsion, stoop and gait shuffling, reduced arm swing
non-motor: pain, depression, constipation, dementia, sleep disorder, hallucinations

Question 13

Parkinson’s - investigations

Answer 13

• Clinical Dx

- dopaminergic agent trial can confirm Dx (positive response to L-dopa or other dopaminergic agent)

Question 14

Parkinson’s - management

Answer 14

• MDT approach: physio, OT, speech therapy
• if symptoms affect daily life = levodopa
• adjuvant = dopamine agonist (ropinirole) or MAO-B inhibitor (rasagiline), or COMT inhibitor
• alternative: amantidine
• physical activity (improves functional performance on motor tasks)