2. Approach to Movement Disorders ..

7/25/2019 2. Approach to Movement Disorders ..

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An Approach to Movement

Disorders


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Outline

1.Overview of approach to the clinicalproblem

2.Definition of movement types

3.Elements of history

4.Physical examination

5.Detailed discussion about each movementtype


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GENERAL APPROACH TOMOVEMENT DISORDERS


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Broadly . . .

Hyperkinetic Movements Hypokinetic Movements


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Specifically . . .

Hyperkinetic Movements

Tremor

Chorea

Dystonia Ballism

Myoclonus

Tics

Hypokinetic Movements

Parkinsonism


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Or More Specifically . . .

Hyperkinetic Movements

Tremor Chorea/Athetosis Dystonia Ballism Myoclonus Tics Ataxia Myokymia

Myorrhythmia Restless Legs Hyperkplexia Akathesia

Hypokinetic Movements

Parkinsonism

Apraxia

Hesitant gaits Hypothyroid slowness

Rigidity


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LETS DEFINE SOME TERMS


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Bradykinesia/Akinesia

Decreased movement Common to parkinsonism

6 Cardinal Features of Parkinsonism: Tremor at rest Bradykniesia/Hypokinesia/akinesia Rigidity

Flexed posture of the neck, trunk and limbs Loss of postural reflexes Freezing


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Types of Parkinsonism

Parkinsons Disease (most commonencountered by neurologists)

Drug-induced Parkinsonism (probably themost common overall)


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Features Suggestive of Atypical PD


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Akathitic Movements

Unable to sit still

Feeling of inner, general restlessness thatis reduced or relieved by moving about

Complex and usually stereotypedmovements

Can be both generalized and focal

Can usually be briefly suppressed

Most common cause is iatrogenic


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Asynergia/Ataxia

Asynergia refers to decomposition of movementdue to breakdown of normal coordinatedexecution of a voluntary movement

One of the cardinal features of cerebellardisease

Frequently accompanied by: Dysmetria (misjudging of distance) HypometriaHypermetria

The ataxic gait is typified by unsteadiness with awide base, body sway and inability to tandemwalk


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Athetosis

Describes a class of slow, writhing,continuous and involuntary movements.

Can affect any set of musculature, butusually the distal limbs

Can blend with movements seen in chorea

Pseudoathetosis = distal athetoid

movements of the fingers and toes due toloss of proprioception


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Chorea

Describes a class of involuntary, irregular,purposeless, nonrthymic, abrupt, rapid,unsustained movements that seem to flow

from one body part to anotherCharacteristically unpredictable in timing,direction and distribution

Can be partially suppressed or camouflaged

into semi-purposeful voluntary movementsPrototypical example is Huntingtons disease


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Ballism

Large amplitude choreic movements of theproximal parts of the limbs

Flailing or flinging movements

Most common cause of hemi-ballism:Stroke

Second most common cause of ballism:Overdose of levodopa


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Dystonia

Refers to twisting movements that tend tobe sustained at the peak of the movement,are frequently repetitive and often progress

to prolonged abnormal posturesTend to be patterned (in the same muscles)


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Classification of Dystonia

Focal When a single body part is affected

Segmental

Involvement of 2 or more contiguous regions of thebody are affected

Multifocal Involves 2 or more regions, not conforming tosegmental or generalized dystonia

Generalized Movements of one or both of the legs, trunk andsome other part of the body


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Hemifacial Spasm

Unilateral facial muscle contractions

Continual, rapid, brief, repetitive spasms

Can evolve into sustained tonic spasms

Can often be brought out when patientvoluntarily and forcefully contracts the facialmuscles


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Myoclonus

Sudden, shock-like involuntary movementscaused by muscular contractions orinhibitions

Can occur at rest or during activity (actionmyoclonus)

Can be both arrhythmic or rhythmic

Numerous classification schemes


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Myoclonus ClassificationSchemes

Clinical Spontaneous Action Reflex

Focal Axial Multifocal Generalized

Irregular Repetitive Rhythmic

PathophysiologyCorticalFocalMultifocalGeneralized

ThalamicBrainstemReticularStartlePalatal

SpinalSegmentalPropriospinal


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Myoclonus by Etiology


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Paroxysmal Dyskinesias

Refer to dyskinetic movements that appearsuddenly and then disappear after a variable periodof time

1.Paroxysmal kinesigenic dyskinesia- Triggered by sudden movement and lasts seconds tominutes

- Can be hereditary or symptomatic- Can be dystonic, ballistic or choreic

2.Paroxysmal nonkinesigenic dyskinesia- Often familial, triggered by stress, fatigue, caffeine oralcohol

- Lasts minutes to hours

3. Episodic ataxias


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Stereotypy

Refers to coordinated movements thatrepeat continually and identically

Resemble motor tics but there is no drivingurge

Often repeat themselves in a uniform,repetitive fashion for long periods of time


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Tics

Consist of abnormal movements and abnormalsounds

Vary in severity over timeUsually preceded by uncomfortable feeling orsensory urge that is relieved by carrying outthe movement

unvoluntary May be simple or complex Often suppressible


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Tourettes Syndrome Criteria

Both multiple motor tics and one or more phonic tics must bepresent at some time during the illness, although notnecessarily concurrently

Tics must occur many times a day, nearly every day, orintermittently throughout a period of more than one year

Anatomical location, number, frequency, type, complexity, orseverity of tics must change over time

Onset of tics before the age of 21 years (the DSM-IV criteriarequire onset of tics before age 18)

Involuntary movements and noises must not be explained by

another medical condition Motor tics, phonic tics, or both must be witnessed by a reliableexaminer at some point during the illness or be recorded byvideotape or cinematography


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Causes of Tics


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Tremor

An oscillatory, typically rhythmic and regularmovement that affects one or more bodyparts

Produced by rhythmic alternating orsimultaneous contractions of agonists andantagonists

Distinction between rest, postural, action orwith intention or task specific


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SOME SUMMARY SLIDES


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Parkinsonism

A clinical syndrome with bradykinesia as thedefining features, almost alwaysaccompanied by rigidity and often by tremor


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Dyskinesia

May be applied to any involuntary movement,although commonly used to refer to inducedchorea and dystonia


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Tremor

A rhythmical, involuntary oscillatorymovement of a body part; subdivided intowhether the problem occurs at rest, with

posture, on action or with intention


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Chorea

A quick, irregular, semi-purposive, andpredominantly distal involuntary movement


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Dystonia

An abnormal movement characterized bysustained muscle contraction, frequentlycausing twisting, and repetitive movements or

abnormal postures


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Ballism

A proximal, high-amplitude movement, oftenviolent and flinging in nature; usuallyunilateral and may resolve though a choreic

phase


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Tic

An abrupt, jerky non-rhythmic movement(motor tic) or sound (vocal tic) that istemporarily suppressible by will power


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Stereotypy

Purposeless voluntary movements carriedout in a uniform fashion at the expense ofother activity


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CLINICAL APPROACH


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Any approach begins with . . .

1.A good history

2.A good physical exam

3.Keen sense of observation

4.A systematic differential diagnosis


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Lets Talk About History


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Elements of the history

Time course/functional disability/effect uponquality of life

Past medical history, including infections andtoxin exposures

Drug history (current, previous, recreational) Alcohol responsiveness Family history

Neuropsychiatric features Autonomic symptoms Sleep problems


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Other elements of history

Do specific actions provoke the movement?

Do the movements occur in relation to otheractions?

Do the movements occur during sleep?

Are there any associated sensorysymptoms?

Can the movements be suppressed?

Are there aggravating or alleviating factors?


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LETS TALK ABOUT THE EXAM


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Points to remember on exam

Observe casually during history: Any involuntary movements and their distribution

Utterances and vocalizations

Blink frequency Excessive sighing

Cognitive assessment

Cardiovascular orthostatics, limb colourGait, axial tone


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Points to remember of physical 2

Eye movements (range, speed)

Limb examination (writing, hand posture)

Tremors/postures

Tone

Power and co-ordination

Fine finger and rapid alternatingmovements

Reflexes/plantars


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Observation

Rhythmic vs. arrhythmic Sustained vs. nonsustained Paroxysmal vs. Nonparoxysmal Slow vs. fast

Amplitude

At rest vs. action Patterned vs. non-patterned

Combination of varieties of movements

Supressibility


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Rhythmic vs. arrhythmic

Rhythmic

Tremor Dystonic tremor

Dystonic myorhythmia Myoclonus (segmental) Myoclonus (oscillatory) Moving toes/fingers Periodic movements of

sleep Tardive dyskinesia(stereotypy)

Arrhythmic

Akathitic movements Athetosis

Ballism Chorea Dystonia Hemifacial spasm Hyperekplexia Arrhythmic myoclonus Tics


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Observation


Amplitude

At rest vs. action Patterned vs non-patterned


Supressibility


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Paroxysmal vs. Nonparoxysmal

Paroxysmal

Tics

PKD

PKND Sterotypies

Akathicmovements

Moving toes Myorhythmia

Continous

Abdominaldyskinesias

Athetosis Tremors Dystonicpostures

Myoclonus,

rhythmic Tardive sterotypy Myokymia Tic status

Continual

Abdominaldyskinesias

Athetosis

Tremors

Dystonicpostures

Myoclonus,

rhythmic Tardive sterotypy

Myokymia

Tic status


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Observation


Amplitude

At rest vs. action Patterned vs non-patterned


Supressibility

H ki i tht itd i


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Hyperkinesias that persist duringsleep

Secondary palatal myoclonus

Ocular myoclonus

Oculofaciomasticatory myorhythmia

Moving toes

Myokymia

Neuromyotonia


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Investigations

Very dependent on phenomenology of themovement and clinical impression

Some ideas: Routine blood work can be useful

Low threshold for copper testing

Utility of MRI?

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