AnApproachtoPatientswithMovementDisorders

JoaquimFerreira,MD,PhDLaboratoryofClinicalPharmacologyandTherapeutics

FacultyofMedicineUniversityofLisbon

• MDSvideolibrary

• MDS-OwnedRatingScales• GlobalAssessmentScaleforWilson'sDisease |Scale• GlobalDystoniaScale |Scale• ModifiedBradykinesiaRatingScale |Scale• Non-MotorSymptomsScale(NMSS) +(IncludesNMSQ) |Scale• QualityofLifeEssentialTremorQuestionnaire |ScoreSheet• RatingScaleforPsychogenicMovementDisorders |Scale• RushDyskinesiaRatingScale* |Scale• RushVideobasedTicRatingScale |Scale• UFMGSydenham'sChoreaRatingScale(USCRS) |Scale• UnifiedDyskinesiaRatingScale(UDysRS) +*• UnifiedDystoniaRatingScale(UDRS) |Scale• UnifiedMultipleSystemAtrophyRatingScale(UMSARS) |Scale• UnifiedParkinson'sDiseaseRatingScale(MDS-UPDRS) +*|Scale

• UHDRStrainingvideos• …

EDUCATIONALTOOLS

• Definition:Agroupofsymptomsorsyndromes

characterizedbyinvoluntaryorabnormal

movements

MOVEMENTDISORDERS

• History–When(started…worsened…)– How(rest…movement…)–Whereinthebody–Why(trigger…facilitator…)

MDAPPROACH

1. Localization1. whereinthebody?

2. Phenomenology1. whattypeof

movements?

3. Aetiology1. whatisthecause?

4. Pathophysiology1. Whichmechanismsare

involved?

5. Treatment1. Howcanwetreat?

6. Prognosis1. Howwillthedisease

progress?2. Shouldtherebe

geneticcounselingtopatient/offspring?

MDAPPROACH

• Focal– Musclesofonelocalizedpartofthebody

• Segmental– Cranial/axial/scapula/arm/leg…

• Hemi-focal– Hemibodywithorwithoutheadandneck

• Multifocal– >1nonadjacentfocalbodyparts

• Generalized– Segmental+anyotherpartofbody

LOCALIZATION

• Observepatient:– asheenterstheroomandwhileheisnotbeingquestioned–segmentbysegment(wheneverpossible)

LOCALIZATION

• Lookfordiscretesymptoms– Slighttremor–Minordystonicmovement– …

• Lookformaskingmovements– Handinthepocketforrestingtremor– Handbehindbackforchorea– …

LOCALIZATION

• Physiological– Tremor,myoclonus

• Primary,idiopathic,essential• Secondary,symptomatic,acquired• Psychogenic

AETIOLOGY

• Classificationofmovements– Voluntary

• Intentionallyinitiatedorevokedasareactiontoexternalstimulus– Automatic

• Learnedmotorbehaviours,performedwithoutconsciousactivation(walking,cycling,speech)

– Unvoluntary(Semi-automatic)• Initiatedbyinternalstimulus(scratchingduetoitch),orbyunpleasantfeelingorcompulsion(Restlesslegs,tics,Akathisia);canbevoluntarilysuppressedforashortduration

– Involuntary• Involuntaryinitiationandprogression,(althoughsomevoluntarymodulationmayoccur)

PHENOMENOLOGY

• Classificationofmovementdisorders

• Movementdisordersoccurwhenthereiseither– Toomuchmovement(Hyperkinesias)

or– Insufficientmovement(Hypokinesias)

PHENOMENOLOGY

• Hyper/Hypokinesia• Rhythmic/Nonrhythmic• Simple/Complex– Simple:tremor,myoclonus;– complex:tics,stereotypies

• Resting/Inducedorincreasedwithaction/tasks(mental/motor)

• Spontaneous/Provoked

PHENOMENOLOGY

Hyperkinesias• Akathisia• Ballism• Chorea• Dystonia• Myoclonus• Restlesslegs• Startlereflex• Tics• Tremor

Hypokinesias• Akinesia/Bradykinesia/

Hypokinesia• Catatonia/Catalepsy• Freezing• Rigidity• Stiffmuscles

PHENOMENOLOGY

14

CHOREA

15

ATETOSIS

16

BALLISM

DYSTONIA

MYOCLONUS

TICS

• Gait• Wheelchair• Facialexpression• Neckposture• Upper-limbposture• Handshake• …

WALKINGIN

WALKING

WHEELCHAIR

FACIALEXPRESSION

NECKPOSTURE

Arq.Neuro-Psiquiatr.vol.68no.6SãoPauloDec.2010

HANDPOSTURE

HANDSHAKE

• Firstcomplain– Tremor,bradykinesiavs.cognition,axialsigns

• Durationsofsymptoms– NotPD,PDvsessentialtremor

• Familyhistory• RedflagsforIPD

– Memory/cognitiveimpairment– Falls– OH/diziness– Urinarycomplains– Sexualdysfunction– Dysphagia– Dysarthria

CLINICALHISTORY

• Eyemovements• Oromandibular movements

FACE

EYEMOVEMENTS

OROMANDIBULARMOVEMENTS

• Tardive• LD• HDlike• MSA

• Bradykinesia• Tremor• Rigidity• Posturalinstability

CARDINALSIGNSPARKINSONISM

BRADYKINESIA

• Head• Chin• Voice• Upperlimbs• Lowerlimbs

• Stretchoutthearms– Re-emergenttremor– Polyminimyoclonus

TREMOR

TREMOR

TREMOR

“Jerks”

• Cogwheel!• Intensity0vs.1• Assimetry

RIGIDITY

• Armswing– Hall– Dystonia

• Turning• Footdystonia• Orthostatichypotension

GAIT

TURNING

FOOTDYSTONIA

• Edema• Livedo reticularis

LEGS

OTHEREVALUATIONS

OTHEREVALUATIONS

• Bloodpressure– Orthostatichypotension– Bradycardia• Acetylcholinesterase inhibitors• Propranolol

OUTRASAVALIAÇÕES

• Worstandbestmomentsoftheday• Mosttroublesomeproblems• RelationwithLDintake

– Earlymorning– Afterlunch

• Somnolence/driving• Mood

– Treatwhatistreatable!

• Familymembers/caregiver– Nocturnalsleep– Mood– Hallucinations/delusions– Shopping/eating/gambling/sex

OTHERQUESTIONS

SLEEP

• Homevideos–smartphone

• Spendsomehoursatthehospital(“close”tothedoctor)

STRATEGIES

• Pharmacologicalhistory• Drug-inducedparkinsonism

NOTTOMISS

49

NOTTOMISS