Stacy Peterson, D.C., D.A.C.R.B. Associate Professor
Northwestern Health Sciences University Stereotypy Akathisia Chorea
Dystonia Myoclonus Tic Tremor
Slide 3
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)
Spontaneous, independent contractions of individual muscle
fibers. These contractions can not be observed or palpated.
Slide 6
Electromyographic (EMG) evidence can be found in denervated
muscle beginning 10-21 days after the muscle has been deprived of
its nerve supply.
Slide 7
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)
Slide 8
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?
Slide 9
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
Slide 10
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
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
Slide 13
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
Slide 14
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.
Slide 15
Lithium and Valproate are frequent causes of this tremor type.
Video Video Press to return to list of tremors
Slide 16
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.
Slide 17
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
Slide 18
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
Slide 19
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).
Slide 20
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.
Slide 21
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
Slide 22
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
Slide 23
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
Slide 24
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
Slide 25
Treatment: Deep-Brain Stimulation Therapy (for ET, PD &
Dystonia) Video Video Press to return to list of tremors
Slide 26
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
Slide 27
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
Slide 28
Sudden relaxation of muscles held against gravity Negative
myoclonus Video of a flapping tremor Video
Slide 29
Causes: Toxic / metabolic encephalopathies, structural lesions
of the cerebral hemispheres
Slide 30
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
Slide 31
Referred to as a dance (but not a very good dance)
VideoVideo
Slide 32
Sydenhams chorea (chorea caused by rheumatic fever) Pregnancy
(chorea gravidarum) Lupus (lupus chorea) Neuroleptic drugs (such as
too much dopamine) Females >>males
Slide 33
Wild, flailing, sometimes violent movements. Subtype of chorea
(big chorea) Fast, usually proximal movements; usually one side
hemiballism Video Video
Slide 34
Cause: stroke in subthalamic nucleus
Slide 35
Continuous, intermittent contraction of many muscles, making
body part turn, eventually in a fixed way
Slide 36
Spasmodic torticollis (focal dystonia)
Slide 37
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)
Slide 38
Writers cramp Scott Adams, and his creation Dilbert
Rx: botulinum toxin; dopamine (this may be a dopamine
responsive dyskinesia)
Slide 41
Moving dystonia Slow, writhing dystonic posturing of the distal
limbs, especially fingers, hand & wrist. Video Video
Slide 42
Video Video Question: What do you think? Is this an accurate
representation of dystonia, voice dystonia and athetosis?
Slide 43
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.
Slide 44
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
Slide 45
Orobuccolingual movements (typically opening & closing
mouth movements with pursing of the lips are intermixed with
intermittent protrusion of the tongue)
Slide 46
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
Slide 47
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
Slide 48
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.
Slide 49
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
Slide 50
Chronic tic disorder starting in youth that includes
vocalizations Organic disorder & does not simply reflect
psychological factors Genetic link
Slide 51
Slide 52
Nicotinic agonists appear to relieve dyskinesias in some people
with Tourettes Syndrome Video Video
Slide 53
How well can you recognize the various movement disorders? Lets
review!
Slide 54
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
Slide 55
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!
Slide 56
This answer cannot be supported based on the presentation of
the patient. Try again!
Slide 57
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!
Slide 58
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
Slide 59
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
Slide 60
Dystonic tremors are jerky and do not have the smooth
sinusoidal movement seen here. Try again!
Slide 61
Rubral tremors are wide amplitude tremors. If this were a
rubral tremor, the tremor would be apparent with sustained postures
AND action. Try again!
Slide 62
Essential tremors do not abate with movement. Try again!
Slide 63
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
Slide 64
Review the following video: Video Video Which of the following
terms best describes these movements? a. FibrillationFibrillation
b. FasciculationFasciculation c. MyokymiaMyokymia d.
MyoneuriaMyoneuria
Slide 65
Fibrillations are only seen via electromyography. Try
again!
Slide 66
Fasciculations have a twitching versus rippling characteristic.
Fasciculations do not produce joint movement, as is seen with the
individuals great toe. Try again!
Slide 67
This is a nonsense word. Try again!
Slide 68
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
Slide 69
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
Slide 70
SLE is known to cause chorea (lupus chorea). Try again!
Slide 71
Cerebral infarcts can cause ballismus, affecting the
contralateral basal ganglia or subthalamic nucleus. Try again!
Slide 72
Metabolic encephalopathies are known to cause numerous movement
disorders, most notably myoclonus and asterixis. Try again!
Slide 73
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
Slide 74
Which of the following terms describes a non-voluntary, violent
flinging movement of the arm? a. ChoreaChorea b. BallismusBallismus
c. AthetosisAthetosis d. EpilepsyEpilepsy
Slide 75
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
Slide 76
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!
Slide 77
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!
Slide 78
Pacing back and forth in a room is an example of _________. a.
AkathisiaAkathisia b. AthetosisAthetosis c. TourettesTourettes d.
SchizophreniaSchizophrenia
Slide 79
Athetosis is a writhing (snake-like) type of movement. Try
again! This is a catnip snake.
Slide 80
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!
Slide 81
Schizophrenia can cause various movement disorders, the most
common being tardive dyskinesias. Try again!
Slide 82
Examples of akathisia include pacing back and forth,
repetitively crossing legs, and foot tapping or leg shaking.
Slide 83
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