Stacy Peterson, D.C., D.A.C.R.B. Associate Professor Northwestern Health Sciences University...

Stacy Peterson, D.C., D.A.C.R.B. Associate Professor Northwestern Health Sciences University Stereotypy Akathisia Chorea Dystonia Myoclonus Tic Tremor

By the end of this lecture series and after associated outside reading, the student should be able to: Define and describe the various abnormalities of movement. Identify different neurologic conditions by the type of movement abnormality that the disorder is characterized by, particularly as it relates to the following conditions: multiple sclerosis (MS), Parkinsons disease and amyotrophic lateral sclerosis (ALS)

FibrillationMyokymia Fasciculation TremorTremor Ballismus AkathisiaBallismus Akathisia MyoclonusMyoclonus Dystonia StereotypyDystonia Stereotypy AsterixisAthetosis Tardive dyskinesia ChoreaTic

Spontaneous, independent contractions of individual muscle fibers. These contractions can not be observed or palpated.

Electromyographic (EMG) evidence can be found in denervated muscle beginning 10-21 days after the muscle has been deprived of its nerve supply.

Twitches observed (or palpated) in resting muscle that result from spontaneous firing of one or more motor units. Fasciculations do not produce joint movement (a brief twitch of a muscle that produces joint movement is likely chorea)

Association with: * ALS (amyotrophic lateral sclerosis) A patient with ALS rarely seeks medical attention because of fasciculations alone. Question: What is the M/C chief complaint for a patient who has ALS?

What is the M/C chief complaint for a patient who has ALS? Weakness Association with: * Diseases of the LMN * Intrinsic diseases of the spinal cord * Normal individuals Video Video

Rippling movements observed under the skin, usually in the face. VideoVideo Association with: * Neuromyotonia (peripheral nerve excitability disorder that is autoimmune in nature) * Multiple sclerosis * Lesions of the brainstem

Enhanced Physiologic Toxic Parkinsonian Essential Midbrain Dystonic

These tremors occur transiently in normal persons who are under emotional stress, extremely fatigued, hyper- or hypo- glycemic, hyperthyroid, cold or taking sympathomimetic medications. Fast 14 cycles/sec

When EPT becomes clinically symptomatic with posture or movement without provoking factors, it becomes phenomenologically similar to Essential Tremor (ET) and may be difficult to separate early in its course. Press to return to list of tremors

These tremors occur in toxic-metabolic derangements, sometimes in conjunction with encephalopathy. Disorders such as uremia, thyrotoxicosis and alcohol or drug withdrawal may be precipitants, as are certain antipsychotic or neuroleptic drugs.

Lithium and Valproate are frequent causes of this tremor type. Video Video Press to return to list of tremors

This tremor occurs with other manifestations of parkinsonism and is characterized by tremor when the limb or other body part is at rest. The tremor usually diminishes with action.

PD rest tremors typically start unilaterally and distally as the classic 3-6 Hz pill-rolling sinusoidal oscillations and progress more proximally as they generalize to both sides, though tremor may occasionally start anywhere (e.g., the lower lip). Video

Tremor severity does not appear to be correlated with the loss of dopamine. In fact, in some patients with PD, the tremor does not improve or even worsens with levodopa. It is generally believed that rest tremors are modulated predominantly centrally within the corticobasal ganglia and the corticocerebellar circuitry. Press to return to list of tremors

Essential tremor (ET) asymmetrically involves the limbs, head and voice in various combinations. This tremor is typically absent in the resting position but develops with sustained postures and action. The hand tremor (usually most prominent) often becomes exacerbated with action as the target is approached (terminal tremor).

An essential voice tremor may be appreciated during normal conversation or may be noted only when the patient is asked to hold a musical note (ahhhh). A family history of this tremor is prominent in approximately half the cases. Alcohol consumption tends to decrease this type of tremor. Advancing age is the most obvious risk factor.

While traditionally considered a functional monosymptomatic condition, an accumulation of both epidemiologic & pathologic studies have argued that ET may be a neurodegenerative disease with both an risk of non- tremulous co-morbidities & structural pathologic changes in the cerebellum or olivocerebellothalamic pathway. Treatment: Primidone (anticonvulsant drug) or MRI-guided focus ultrasound Video Video Press to return to list of tremors

This tremor is typical of that seen in multiple sclerosis, Wilsons disease or certain brain injuries. It is characterized by wide tremor amplitude that is prominent with sustained postures or actions. Video

This tremor frequently involves the upper limbs, but may also involve the trunk, head & lower limbs. Midbrain tremors are caused by lesions of the cerebellothalamic & nigrostriatal pathways, thus causing tremors at rest, with posture & kinetically. Press to return to list of tremors

DT is typically postural or task-related & is characterized by an irregular or jerky rhythmic low-to-mid-frequency tremor secondary to co-contraction of agonist & antagonist muscles. The key identifiable feature of the DT is the Null point, a position in which the tremor almost fully abates, and/or geste antagoniste (a tactile or proprioceptive sensory trick that reduces the abnormal posture) as well as its jerky quality. Video

Treatment: Deep-Brain Stimulation Therapy (for ET, PD & Dystonia) Video Video Press to return to list of tremors

Involuntary, lightening-like jerk of an area of the body. Movements are * Simple, subtle or overt VideoVideo for myoclonus-dystonia syndrome VideoVideo for palatal myoclonus

Any level of the CNScortex, basal ganglia, brain stem, spinal cord, etc. Epilepsy, toxic / metabolic encephalopathy (narcotic drugs, renal/hepatic failure), Alzheimers disease, Creutzfeldt-Jacob disease, Lewy-Body disease

Sudden relaxation of muscles held against gravity Negative myoclonus Video of a flapping tremor Video

Causes: Toxic / metabolic encephalopathies, structural lesions of the cerebral hemispheres

A rapid and flowing movement of one or more body parts that is not stereotyped, & is manifested as a random event. Looks semi-voluntary, but is not voluntary

Referred to as a dance (but not a very good dance) VideoVideo

Sydenhams chorea (chorea caused by rheumatic fever) Pregnancy (chorea gravidarum) Lupus (lupus chorea) Neuroleptic drugs (such as too much dopamine) Females >>males

Wild, flailing, sometimes violent movements. Subtype of chorea (big chorea) Fast, usually proximal movements; usually one side hemiballism Video Video

Cause: stroke in subthalamic nucleus

Continuous, intermittent contraction of many muscles, making body part turn, eventually in a fixed way

Spasmodic torticollis (focal dystonia)

Blepharospasm - spasmodic winking of the eyelids VideoVideo Meige Syndrome - Forceful dystonic spasms of the face, in particular when trying to speak or to eat Henry Meige (1866-1940)

Writers cramp Scott Adams, and his creation Dilbert

Cramping of Parkinsons disease Voice dystonias (3 types): Abductor spasmodic dystonia Adductor spasmodic dystonia Mixed VideoVideo

Rx: botulinum toxin; dopamine (this may be a dopamine responsive dyskinesia)

Moving dystonia Slow, writhing dystonic posturing of the distal limbs, especially fingers, hand & wrist. Video Video

Video Video Question: What do you think? Is this an accurate representation of dystonia, voice dystonia and athetosis?

Subjective feeling, defined as a sense of inner restlessness, that may be associated with adventitious movements. The sensation of inner restlessness tends to elicit movements that help relieve the inner tension.

Unlike other movement disorders, akathisia can be diagnosed solely on the basis of the patients subjective symptoms in the absence of any objective signs. Parkinsons disease, neuroleptic drugs, restless leg syndrome, OCD; dopamine responsive dyskinesia

Orobuccolingual movements (typically opening & closing mouth movements with pursing of the lips are intermixed with intermittent protrusion of the tongue)

Anti-psychotic medications, such as those used to treat Schizophrenia Individuals with fetal alcohol syndrome, other developmental disabilities, and other brain disorders are vulnerable to the development of TDs, even after receiving only 1 dose of the causative agent Video Video

A repetitive or ritualistic movement, posture, or utterance Stereotypies may be simple movements such as body rocking, or complex, such as self-caressing, crossing and uncrossing of legs, and marching in place. Video

They are associated with mental retardation, autism spectrum disorders, tardive dyskinesia, schizophrenia Stereotypic movement disorder (SMD) Common repetitive movements of SMD include head banging, arm waving, hand shaking, rocking and rhythmic movements, self-biting, self-hitting, skin-picking; other stereotypies are thumb-sucking, nail biting, trichotillomania (hair pulling), bruxism and abnormal running or skipping.

Simple or complex stereotyped motor behaviors that occur in response to an irresistible urge. Partial voluntary control Simple: eye blinking, shoulder shrugs, grimacing, grunting & sniffing Complex: vocalizations, jumping, kicking, squatting or compulsive touching; coprolalia is rare Obsessive-compulsive association is strong

Chronic tic disorder starting in youth that includes vocalizations Organic disorder & does not simply reflect psychological factors Genetic link

Nicotinic agonists appear to relieve dyskinesias in some people with Tourettes Syndrome Video Video

How well can you recognize the various movement disorders? Lets review!

A patient presents with the following tremor: Video Video Which of the following tremor types does this patient demonstrate? a. DystonicDystonic b. HolmesHolmes c. ParkinsonianParkinsonian d. EssentialEssential

I can see why you chose this answer: Holmes tremors DO involve the head The amplitude of Holmes tremors are wide, similar to this presentation. However, this is not the best answer. Try again!

This answer cannot be supported based on the presentation of the patient. Try again!

I can see why you chose this answer: Essential tremors DO involve the head. Essential tremors are WORSE with sustained postures. Essential tremors CAN involve phonation. However, this is not the best answer based on the presentation. Also, we do not have evidence of a family history correlation or amelioration with alcohol consumption. Try again!

The following points support the answer chosen: The patient has a moderate-high amplitude neck tremor. The tremor has a jerky quality, predominantly in the no-no direction. There is a corresponding left laterocollis and retrocollis. Click here for Next Question

A patient presents with the following tremor: Video Video Which of the following tremor types does this patient demonstrate? a. DystonicDystonic b. HolmesHolmes c. ParkinsonianParkinsonian d. EssentialEssential

Dystonic tremors are jerky and do not have the smooth sinusoidal movement seen here. Try again!

Rubral tremors are wide amplitude tremors. If this were a rubral tremor, the tremor would be apparent with sustained postures AND action. Try again!

Essential tremors do not abate with movement. Try again!

The following points support the answer chosen: This tremor demonstrates latency between the resting tremor (right hand) and (6 seconds later) the appearance of a postural tremor. The tremor is sinusoidal (pronation/supination) and low frequency. Click here for Next Question

Review the following video: Video Video Which of the following terms best describes these movements? a. FibrillationFibrillation b. FasciculationFasciculation c. MyokymiaMyokymia d. MyoneuriaMyoneuria

Fibrillations are only seen via electromyography. Try again!

Fasciculations have a twitching versus rippling characteristic. Fasciculations do not produce joint movement, as is seen with the individuals great toe. Try again!

This is a nonsense word. Try again!

The following point supports the answer chosen: The most common location for myokymia is in the face (last portion of the video). Facial myokymia is a fine rippling of muscles on one side of the face and may reflect an underlying tumor in the brainstem (typically a brainstem glioma), loss of myelin in the brainstem (associated with multiple sclerosis) or the recovery stage of GuillainBarr syndrome. Click here for Next Question

Which of the following is the most likely cause of ballismus? a. Stroke in the subthalamic nucleusStroke in the subthalamic nucleus b. Systemic lupus erythematosusSystemic lupus erythematosus c. Cerebellar cortex structural lesionCerebellar cortex structural lesion d. Metabolic encephalopathyMetabolic encephalopathy

SLE is known to cause chorea (lupus chorea). Try again!

Cerebral infarcts can cause ballismus, affecting the contralateral basal ganglia or subthalamic nucleus. Try again!

Metabolic encephalopathies are known to cause numerous movement disorders, most notably myoclonus and asterixis. Try again!

The following point supports the answer chosen: Ballismus is m/c observed in the setting of structural lesions of the contralateral basal ganglia & subthalamic nucleus. Cerebral infarct is the m/c cause, but tumors of the same region have also resulted in ballismus. Systemic derangements including fever & hyperglycemia have been reported to cause or exacerbate hemiballismus in patients with underlying lesions or a history of less severe movement disorders. Medications including levodopa, phenytoin & oral contraceptives have also been implicated. Click here for Next Question

Which of the following terms describes a non-voluntary, violent flinging movement of the arm? a. ChoreaChorea b. BallismusBallismus c. AthetosisAthetosis d. EpilepsyEpilepsy

See table below for comparisons: ChoreaBallismusAthetosis Rapid Slow Involuntary Non-stereotypical Semi-purposeful or non-purposeful Non-purposeful Dance-likeViolent flinging movement Writhing > Distally> ProximallyPropensity for affecting upper limbs

Epilepsy is a condition that can be a cause of movement disorders (typically myoclonus), but is not a descriptor of the abnormal movement. Try again!

See table below for comparisons: ChoreaBallismusAthetosis Rapid Slow Involuntary Non-stereotypical Semi-purposeful or non-purposeful Non-purposeful Dance-likeViolent flinging movement Writhing > Distally> ProximallyPropensity for affecting upper limbs Click here for the last Question!

Pacing back and forth in a room is an example of _________. a. AkathisiaAkathisia b. AthetosisAthetosis c. TourettesTourettes d. SchizophreniaSchizophrenia

Athetosis is a writhing (snake-like) type of movement. Try again! This is a catnip snake.

Tourettes is a complex disorder involving many tics or stereotypiesnot just one. Also, it involves learning & mood disorders as well as many other components. Try again!

Schizophrenia can cause various movement disorders, the most common being tardive dyskinesias. Try again!

Examples of akathisia include pacing back and forth, repetitively crossing legs, and foot tapping or leg shaking.

Venn Diagram (Slide 1): modified from http://emedicine.medscape.com/article/1151826-overview#showallhttp://emedicine.medscape.com/article/1151826-overview#showall Fibrillation pic: http://www.dartmouth.edu/~dons/electrodiagnosis/EDXfigures/Fig_1.htmhttp://www.dartmouth.edu/~dons/electrodiagnosis/EDXfigures/Fig_1.htm Muhammad Ali & Michael J Fox pic: http://static.ddmcdn.com/gif/parkinsons-disease-4.jpghttp://static.ddmcdn.com/gif/parkinsons-disease-4.jpg Asterixis flapping tremor pic: http://1.bp.blogspot.com/-7vYIsM8GP38/T0tINewxqYI/AAAAAAAAAEY/40tZa_duKVw/s1600/med- 9780199204854-graphic0152204001.jpeghttp://1.bp.blogspot.com/-7vYIsM8GP38/T0tINewxqYI/AAAAAAAAAEY/40tZa_duKVw/s1600/med- 9780199204854-graphic0152204001.jpeg Chorea dance pic: http://1.bp.blogspot.com/e9VRgsp1Vf8/UWwAMQ1jznI/AAAAAAAABNA/zuPW42w7mug/s1600/vitus.jpghttp://1.bp.blogspot.com/e9VRgsp1Vf8/UWwAMQ1jznI/AAAAAAAABNA/zuPW42w7mug/s1600/vitus.jpg Miley Cyrus mimicking TDs: http://rack.3.mshcdn.com/media/ZgkyMDEzLzEwLzAyLzMzL01pbGV5Q3lydXNULmI0YTdkLmpwZwpwCXRodW1iCTEyMDB4OTYwMD4/c bea3bcf/06e/Miley-Cyrus-Tongue.jpg http://rack.3.mshcdn.com/media/ZgkyMDEzLzEwLzAyLzMzL01pbGV5Q3lydXNULmI0YTdkLmpwZwpwCXRodW1iCTEyMDB4OTYwMD4/c bea3bcf/06e/Miley-Cyrus-Tongue.jpg Antipsychotic meds effect on schizophrenia (TDs): http://writhesafely.wordpress.com/2007/01/15/you-should-have-seen-her-before- the-abilify/http://writhesafely.wordpress.com/2007/01/15/you-should-have-seen-her-before- the-abilify/ Pic of leg/foot (akathisia): http://thoughtbroadcast.com/tag/akathisia/http://thoughtbroadcast.com/tag/akathisia/ Stroke in subthalamic nucleus MRI pic: http://test.classconnection.s3.amazonaws.com/726/flashcards/196726/jpg/hemivallismus.jpghttp://test.classconnection.s3.amazonaws.com/726/flashcards/196726/jpg/hemivallismus.jpg Spasmodic torticollis pic: http://www.torticollis.org/spasmodic-torticollis-symptoms.htmlhttp://www.torticollis.org/spasmodic-torticollis-symptoms.html Writers cramp 2 pics: http://ocdinformation.wordpress.com/2010/09/30/http://ocdinformation.wordpress.com/2010/09/30/ Meige pic: http://www.infodystonia.com/tagged/meigehttp://www.infodystonia.com/tagged/meige Diagram Tourettes Syndrome: http://pertobello.com/2012/03/20/how-to-ask-for-money-without-sounding-like-jimmy-whales/http://pertobello.com/2012/03/20/how-to-ask-for-money-without-sounding-like-jimmy-whales/ Rubral tremor PET pic: http://jnnp.bmj.com/content/72/suppl_1/i3/F6.large.jpg&http://jnnp.bmj.com/content/72/suppl_1/i3/F6.large.jpg& Nonsense pic: http://serendip.brynmawr.edu/exchange/node/6777http://serendip.brynmawr.edu/exchange/node/6777 Smiley face in flower pic: http://www.google.com/imgres?imgurl=&imgrefurl=http%3A%2F%2Fwww.smiley-faces.org%2Fsmiley-face wallpaper.php&h=0&w=0&sz=1&tbnid=LS0KRbYm4VxxEM&tbnh=194&tbnw=259&zoom=1&docid=wn6EjDqZsJ3N9M&ei=h8MKU_upH8 n8rAGL2IDICQ&ved=0CAsQsCUoAwhttp://www.google.com/imgres?imgurl=&imgrefurl=http%3A%2F%2Fwww.smiley-faces.org%2Fsmiley-face wallpaper.php&h=0&w=0&sz=1&tbnid=LS0KRbYm4VxxEM&tbnh=194&tbnw=259&zoom=1&docid=wn6EjDqZsJ3N9M&ei=h8MKU_upH8 n8rAGL2IDICQ&ved=0CAsQsCUoAw Epilepsy pic: http://www.end-epilepsy.org/api/Index.cfm/cms.page/i/2669/The-Epilepsies/http://www.end-epilepsy.org/api/Index.cfm/cms.page/i/2669/The-Epilepsies/ Cat & snake pic: http://pattihaskins.wordpress.com/2012/06/14/catnip-snake-love-2/http://pattihaskins.wordpress.com/2012/06/14/catnip-snake-love-2/ The End pic: Microsoft Word 2007 Clip Art Question mark pics: Microsoft Word 2007 Clip Art All sounds were obtained from www.soundjay.com, except for the clapping hands, which was obtained from Microsoft Office PowerPoint 2007www.soundjay.com

Stacy Peterson, D.C., D.A.C.R.B. Associate Professor Northwestern Health Sciences University...

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