Movement Disorders

Question 1

Bradykinesia=

Answer 1

reduced speed of mvmt.

Question 2

hypokinesia =

Answer 2

reduced amplitude of mvmt.

Question 3

akinesia =

Answer 3

lack of mvmt.

Question 4

sensory ataxia:

Answer 4

Dysfunction of large-fiber sensory nerves and/or posterior columns of spinal cord.
Will have impaired vibratory and position sense in lower extermities.
Evaluate for Vit B12 deficiency.

Question 5

cerebellar ataxia:

Answer 5

Normal sensory function.

Signs of cerebellar disease: dysarthria, scanning speech, head tremor/titubation or eye movement abnormalities.

Question 6

Atrophy of caudate nucleus, think this disease:

Answer 6

Huntington’s disease

Question 7

Lesions in globus pallidus, think this:

Answer 7

carbon monoxide intoxication (parakinsonism/dystonia)

Question 8

Acute lesions of subthalamic nucleus, think this:

Answer 8

contralateral hemiballismus

Question 9

Loss of dopiminergic neurons in substantia nigra (pars compacta), think this:

Answer 9

Parkinson’s disease

and or Dementia with Lewy Bodies, but in Lewy bodies dementia the Lewy bodies are widespread through hemishperes

Question 10

2 examples of trinucleotide repeat expansion disorders:

3 characteristics of these disorders:

Answer 10

1. Huntington’s
2. Spinocerebellar ataxias (SCAs)
   Characteristics:
3. Autosomal dominant
4. More repeats –> earlier onset, higher severity.
5. Anticipation: # of repeats can expand with generations. In HD it’s worse through paternal inheritance.

Question 11

Prevalence of different movement disorders:

Answer 11

Most common to see in general practice:
Restless legs syndrome
Essential tremor
Parkinson's
Dystonia and tics

Question 12

4 cardinal features of parkinsonism:

Answer 12

1. Resting tremor
2. Bradykinesia
3. Rigidity
4. Loss of postural reflexes/postural instability
   - need at least 2 for diagnosis and bradykinesia is a required feature

Question 13

Etiologies of parkinsonism:

Answer 13

1. Idiopathic: Parkinson’s disease
2. Secondary: drugs!
3. Atypical parkinsonian disorders:
   - Multiple System Atrophy: parkinsonism + autonomic dysfunction
   - Progressive Supranuclear Palsy: parkinsonim+falls and eye mvmt abnormalities.
   - Corticobasal Degeneration: parkinsonism + dystonia and aparxia; unilateral cortical and basal ganglia features and atrophy on imaging.
   - Dementia with Lewy Bodies: parkinsonism + early dementia, visual hallucinations, fluctuations.
4. Heredodegenerative: more rare, inherited PD

Question 14

Parkinson’s Disease epidemiology:

Answer 14

Avg age onset: 50-60s
M>F
Younger patients - tremor predominant disease.
Older patients - akinetic-rigidity/PIGD (postural instability gait difficulty)
Slower progression in younger.

Question 15

PD tremor:

Answer 15

pill-rolling, unilateral resting hand tremor.

Question 16

ET looks like:

Answer 16

bilateral, low amplitude, faster action tremor.

Question 17

Non-motor features of PD:

Answer 17

anosmia/hyposmia
constipation
sleep disorders
anxiety/depression
cognitive dysfunction

Question 18

PD medication of the dopamine enhancing type (synthesis):

Answer 18

-Levodopa - precursor of dopamine
-Carbidopa - inhibits enzyme to prevent synthesis of dopamine before crossing BBB.
Dopamine Agonists:
-Pramipexole, Ropinirole, Rotigotine

Question 19

PD medication of the dopamine inhibiting type (catabolism):

Answer 19

• MAOb inhibitors: selegiline, rasagiline

- COMT inhibitors: tolcapone, entacapone - extend half life of levodopa

Question 20

Nonspecific PD treatments:

Answer 20

Amantidine - for dyskinesias
Anticholinergics
Surgical - DBS

Question 21

Essential tremor (ET):

Answer 21

Slowly progressive, bilateral arm action tremor without other significant motor features, and that can also affect the neck and voice. It is often familial ~50%
Improves with EtOH for a couple hrs.

Question 22

Dystonia is:

Answer 22

A movement disorder characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive, movements, postures, or both. Dystonic movements are typically patterned, twisting, and may be tremulous. Dystonia is often initiated or worsened by voluntary action and associated with overflow muscle activation.

Question 23

How is dystonia classified?

Answer 23

• Age of onset (younger patients are more likely to have inherited forms)
• Distribution (focal, segmental, hemidystonia, multifocal or generalized).
• Body part involved. Neck = cervical dystonia (or spasmodic torticollis); blepharospasm = dystonia eye closure; oromandibular dystonia involves the jaw, tongue and lips, etc.

Question 24

Etiologies of dystonia:

Answer 24

Idiopathic (most adult)
Inherited (most childhood onset)
Secondary to brain insult or disease.
- can begin with tremor.
- sensory tricks or geste antagoniste - temporary relief by gentle touch
- task specificity - appear with specific activity

Question 25

Treatment of dystonia:

Answer 25

For focal/segmental dystonia - botulinum toxin injections.
For generalized dystonia - anticholinergics.
Children with idiopathic dystonia - levodopa.
DBS for specific forms.

Question 26

Ataxia definition:

Answer 26

“absence of order” or incoordination: lack of accuracy of movement not secondary to paresis, abnormal tone or involuntary movements.

Question 27

If patient has gait ataxia - determine what?

Answer 27

If it is cerebellar or sensory: tuning fork.

Sensory ataxia is more severe with eyes closed. Cerebellar ataxia not.

Question 28

Vestibular/unilateral cerebellar syndrome:

Answer 28

Frequent deviation to one side, Vertigo/dizziness

Prominent nystagmus.

Question 29

Limb ataxia

Answer 29

Kinetic if in movement

Static if in resting state.

Question 30

Treatable causes of ataxia:

Answer 30

Vitamin B12 or E deficiencies.

Copper deficiency in sensory ataxia.

Question 31

Chorea =

Answer 31

Involuntary, irregular, purposeless, non-rhythmic, abrupt, rapid, unsustained movements that seem to flow from one body part to another. Movements are unpredictable.
Causes: Huntington’s, Sydenham’s (post-infec), autoimmune (lupus), meds, hemiballism - contralateral cerebrovascular etiology.