Oct17 M2,3-Movement disorders

Question 1

3 synucleinopathies

Answer 1

• PD (Parkinson’s dz)
• DLB (Dementia with Lewy bodies)
• MSA (multiple system atrophy)

Question 2

3 tau-opathies

Answer 2

• CBD (corticobasal degeneration)
• PSP (progressive supranuclear palsy)
• AD (Alzheimer’s dz)

Question 3

classif of symptoms of Parkinson’s

Answer 3

• cardinal motor symptoms (are the TRAP sx of parkinsonism)

- important non-motor sx

Question 4

TRAP sx of parkinsonism

Answer 4

• tremor at rest
• rigidity
• bradykinesia (A for akinesia)
• postural instability

Question 5

non motor sx of PD

Answer 5

• psychiatric disturbance
• autonomic disturbance
• cognitive impairment
• sleep disturbance

Question 6

how PD is dx

Answer 6

• need 2 or more symptoms
• one of these HAS to be bradykinesia
• 3 things that make it more likely to be PD than a parkinsonism variant of PD: asymmetry, tremor, response to levodopa*

Question 7

charact of the rest tremor of parkinsonism and PD

Answer 7

• at rest (as opposed to tremor when hold something which is NOT worrisome)
• 3-5 Hz
• asymmetrical (one side)
• typically the pill rolling tremor of the hand but can affect chin, jaw, arms, legs
• 30% of PD pts = no rest tremor

Question 8

charact of the bradykinesia of parkinsonism and PD

Answer 8

• charact. of PD
• slowness in activities and reaction time
• lack of facial expression (hypomimia) and less blinking
• slow movement
• monotonous and hypophonic speech
• reduced arm swing
• loss of spontaneous movement and gesturing

Question 9

charact of the rigidity in parkinsonism and PD

Answer 9

• in >90% of PD pts
• increased resistance + cog-wheeling (catch)
• is caused by an underlying tremor causing interruption in the tone
• detected by doing a slow movement (velocity independent) whereas spasticity is a quick catch that is velocity dependent (need quick movement)
• to catch rigidity, slow mvmt at wrist, elbow, ankle
• proximal and distal

Question 10

charact of postural instability of parkinsonism and PD

Answer 10

• late in PD progression so now a minor criteria
• caused by loss of postural reflexes
• is the most common cause of falls and contributes significantly to the risk of hip fractures (along with freezing gait of PD).
• Freezing gait = PD gait = small, slow, shuffling steps + back and neck bent forward. is also called festinations which means hurrying small steps forward to keep balance
• postural instability assessed by the pull test (3+ steps backwards = abnormal)
• early = red flag

Question 11

some helpful clinical findings in PD dx

Answer 11

• masked face, reduced eye blink
• change in voice
• trouble arising from chair
• difficulty turning in bed
• trouble buttoning shirt
• flexed posture with loss of arm swing
• sialorrhea (drooling) (bc don’t swallow as frequently)
• change in handwriting (micrographia specifically meaning amplitude of the writing wanes as they are writing)

Question 12

direction of spread of PD in the brain

Answer 12

caudal to rostral

Question 13

stage 1 PD charact

Answer 13

• still pre-motor phase of dz
• olfactory bulb + dorsal motor nucleus of the vagus
• related to viscera
• main sx = changed smell and constipation*

Question 14

stage 2 PD charact

Answer 14

• still pre motor phase of the dz
• locus ceruleus
• LC = a brainstem region imp for arousal, mood, sleep
• main sx = sleep disorders (REM behavior disorders) years before PD*

Question 15

stage 3 PD charact

Answer 15

• now motor phase
• SN affected
• main sx = rest tremor and bradykinesia*

Question 16

stage 4 PD charact

Answer 16

• in motor phase of the dz
• cortex now affected
• main sx = cognitive impairment, hallucinations*

Question 17

premotor sx of PD

Answer 17

• hyposmia (change in smell)
• REM sleep behaviour disorder (acting out dreams, moving, kicking)
• excessive daytime sleepiness
• anxiety or depression
• constipation
• erectile dysfunction
• once have motor PD, can help for dx*

Question 18

clinical and pathological correlations in HD

Answer 18

• between time 0 and 5 years: neuronal cell loss leading to subtle, non motor sx
• 5 yrs: 70% of dopaminergic neurons are lost = get diagnosis bc first clinical sx appear
• 10 yrs: neuronal cell loss continues and sx progress (wearing off phenomena and + random fluctuations)
• 15+ years: severe presynaptic cell loss leading to decreasing response to L-dopa

Question 19

theory of PD dx based on diff types of sx

Answer 19

dopaminergic neurons loss in SN in PD CORRESPONDS (but DOESN’T mean causes) to premotor sx crossing threshold to dx much earlier than motor sx crossing threshold for dx

Question 20

non-motor sx in PD

Answer 20

• autonomic (constipation, urinary frequency, sexual dysfunction, orthostatic hypotension)
• sleep (insomnia and fractured sleep, REM Behaviour disorder)
• neuropsychiatric (depression, anxiety, apathy)
• cognitive (dementia, hallucinations)
• other (pain) = rare

Question 21

what explains the non-motor sx in PD

Answer 21

degeneration of other ntr pathways

• noradrenergic
• serotonergic
• cholinergic

Question 22

typical presentation for PD

Answer 22

• 1 year hx of tremor in right arm at rest
• loss of dexterity
• slowness of gait
• anxiety
• constipation
• mild cogwheel rigidity and bradykinesia in RUE and RLE
• normal power all limbs
• slow to rise from chair
• loss of arm swing on R when walking

Question 23

for how long are the PD sx unilateral

Answer 23

stay unilateral for 5 years. after that, become bilateral

-if stay unilateral > 5 yrs = check for focal lesion

Question 24

some neuro exam (PE) tests in PD

Answer 24

• finger taping: see small ampltiude waning + hesitating (bradykinesia)
• hand opening and closing, pronation supination, finger taping = to check for the bradykinesia
• gait = stiff leg + arm not swinging
• pull back test 3 steps+

Question 25

common hyperkinetic disorders

Answer 25

- chorea (athetosis, ballism = rare) - dystonia - restless leg syndrome - tics and Tourette's syndrome - tremor

Question 26

tremor definition

Answer 26

oscillatory movement that is regular, rhythmic, stereotyped, has a specific distribution (is not random)

Question 27

most common location of tremors

Answer 27

hands

Question 28

where to look for tremors (maneuvers for examination)

Answer 28

- hands (outstretched, then fingers together. finger to nose. spiral. handwriting. cup of water) - face (open eyes wide) - head (observation, check positions, should be same in most) - voice (say ahhhh) - legs (outstretched)

Question 29

tremors classification (imp: classification is based on charact. tremors named based on cause are not classified in this)

Answer 29

2 main categories: -rest tremor -action tremor (when contract mm) 2 types of action tremor: -kinetic tremor (reaching a target) -postural tremor (maintaining a position) 2 types of kinetic tremor -intention tremor (worse when reach the target) -simple kinetic tremor (all throughout the mvmt) *note: essential, physiologic, etc. tremors are named based on their cause so not classif here* *note: essential tremor has postural + kinetic component

Question 30

what is cerebellar dysmetria

Answer 30

- is NOT a tremor - is defined as missing the target (examiner's finger) in the finger to nose test (indicating LACK OF CEREBLLAR COORDINATION) - kinetic tremor is oscillation when reaching the finger (in pts with essential tremor) and is NOT dysmetria

Question 31

most common tremor

Answer 31

essential tremor | -most commonly in hands

Question 32

essential tremor charact

Answer 32

- postural, worse with action, absent at rest - variable location (hands, head, voice, legs) - alcohol responsive - faster than PD tremor (is 6-10 Hz whereas PD is 3-5 Hz) - 50-60% with FHx - slow progression (it gets worse)

Question 33

testing of essential tremor

Answer 33

- finger to nose test = kinetic tremor when reach for the finger - circles drawing - pouring cup of water

Question 34

resting tremor think of what

Answer 34

PD and atypical PD

Question 35

chin tremor most likely cause

Answer 35

parkinsonian dz