1
Movement Disorders
Source: DAMS, The Neurophile on YouTube
Case Table of Contents
57, M
(+) history of hypertension and hypothyroidism
(+) right arm shaking for 2-years
Onset first noted in right thumb, then slowly
progressed to involve the hand
Associate occurs predominantly at rest
d Factors
Relieving improves its movement
Factors
(-) changes in walking or balance
(+) decreased sense of smell
(+) constipation
(-) changes in sleep pattern
Medications: Lisinopril & Levothyroxine
Overall this is a fairly mild presentation, so why is he in your office
now?
The arm shaking is now becoming bothersome.
1
Movement Disorders
HYPOKINETIC HYPOKINETIC
Parkinsonism
BRADYKINESIA
⁃ slowness in movement, slowness in initiation of movement,
Arms: starts distally
⁃ Decreased manual dexterity of the fingers
⁃ Difficulty with tasks that require precision
• Buttoning buttons
• Typing shoelaces
• Grasping pills
Legs: foot dexterity decreased
o Festinating Gait
• Drag their legs when walking
• Shorter steps
o Difficulty in standing up
o Getting out of the car
When walking: less arm swinging
Face:
o Masked face (hypomimia)
o Delayed nasal speech
o Monotonous speech (soft low pitched voice, whispering)
Parkinsonism
1. BRADYKINESIA
⁃ slowness in movement, slowness in
initiation of movement,
Arms: starts distally
⁃ Decreased manual dexterity of the fingers
⁃ Difficulty with tasks that require precision
• Buttoning buttons
• Typing shoelaces
• Grasping pills
Legs: foot dexterity decreased
o Festinating Gait
• Drag their legs when walking
• Shorter steps
o Difficulty in standing up
o Getting out of the car
When walking: less arm swinging
Face:
o Masked face (hypomimia)
o Delayed nasal speech
Monotonous speech (soft low pitched voice,
whispering)
2.
Globus pallidus
3. G-A-P
2
Movement Disorders
1. Athetosis Slow
a.k.a. Hammond’s Disease Sinous distal limb
Writhing
(crawling, snake-like movement)
2. Chorea (dance-like movement) Non-rhythmic Caudate
a.k.a. St. Vitus Dance Semi purposeful Nucleus
ETIOLOGY
S Sydenham chorea
V Vascular (Stroke)
I Increased RBC (Polycythemia
T Toxins (CO, Mn, Hg)
U Uremia
S SLE - MCC
senile
D Drugs: AED (phenytoin, CBZ), levodopa, Lithium
A APLA Syndrome
N Neuroacanthocytosis
- AR
- peripheral smear: acanthocytes
- self-mutilating
- rubber man gait
- dystonia: sustained contraction of the leg
C Conception
- pregnancy: chorea gravidarum
- OCPs
E Endocrine
- Hyperthyroidism
- Hypo/hyperglycemia (transient chorea)
3. Hemiballismus Large amplitude flinging movement of the proximal limb Subthala
Usually unilateral mic
nucleus
(contralate
ral lesion)
4. 0 neurodegeneration/ atrophy of the substantia nigra (hypopigmented)
ETIOLOGY:
1. Drugs (mcc secondary parkinsonism)
DA antagonists
Typical Antipsychotics
Metoclopramide
DA depleters
Methyldopa
Tetrabenzine
CCB: Flunarazine, Cinnazarine
Amiodarone
Lithium
2. Genetic/Familial (5-15%)
AD AR
Classical PD
Genes LRRK-2 (chr 12) Parkin (chr 6)
mutated ⍺ synuclein (chr 4) PINK-1
DJ-1
Age of >40 years <40 years
onset
3. Toxins – CO, Manganese, Heroi
4. Trauma
5. Idiopathic (85-90%) = PARKINSON’S DISEASE aka Paralysis agitans, Kampa Vatain Sanskrit (shaking tremors)
Parkinson’s Disease Substanti
T Tremors MC a nigra
sympto
m
(85%)
4-6 Hz
resting
(upper
limb >
LL)
R Rigidity
A Akinesia
3
Movement Disorders
P Postural instability – common to falls Loss of
postural
reflexes
Stoope
d
posture
cannot
maintai
n the
spine
and
F Festinating Gait
g Kinesia paradoxa (increased acceleration when
K running)
d
M Micrographia
S Monotonous speech (soft, low pitched voice
~whispering )
M Mask-like face (aka hypomimia)
M Meyerson sign (glabellar tap sign)
sustained blinking after 5 taps on forehead
D Depression
D Dementia (usually after 1 year of onset)
A Anosmia
1st (earliest) = anosmia
Last to happen = postural instability
Onset = asymmetrical but later it can be bilateral
If onset is bilateral = Atypical PD (PK+)
1. Progressive Supranuclear Palsy (PSP) aka Steel
Richardson Syndrome
PSPP form – resembles PK in early stages, responds to
levodopa
PSPR form (classical) – extended posture, defective
downward gaze, falls down easily, dementia, (-) tremors,
Gunslinger’s gait (flexed elbow, thus less arm swinging
while walking), omega sign (forehead muscle dystonia) or
procerus sign (vertical wrinkling due to sustained procerus
contraction)
2. 3. Dementia of Lewy Body MC NOT Only
PK + Visual Hallucinations + Dementia (<1 year of onset) substranti
a nigra
but also
autonomi
c nervous
system or
cerebellu
m
4. 5. Multiple System Atrophy (MSA) (+) Pisa sign – l;ateral bending of the spine
MSAp (MORE COMMON)
Autonomic instability
(-) trmonrs
Sym,metrical onset
MSAC (cerebellar)
Cerebellar symptoms + PK
6. 7. Coricobasilar Degeneration Least common
Similar to PK
Asymmetrical onset
Dystonia
Alien limb phenomena unintended motor acitons like graspinfg, drifting of
hand
Myoclonus
Treatment
Problems :
Decrease in Dopamine
Increase in Acetylcholine
Decrease in Dopamine
1) Levodopa
MOA strictly speaking, Targets Rigidity & Bradykinesia
but because of the enzyme decarbooxtylase, there will be Peripheral conversion ∫thus persistence of rigidity and
bradykinesia)
4
Movement Disorders
Wearing of. effect or ON-OFF phenomenon
Thus
+ Carbidopa/Benseraside
2) Amantandine
Increases levels
3) Dopamine Agonists
( Pramipraxole
Ropinorole
Rotigotin
4) Apomorphine (non-opioid) injectibkle
5
Movement Disorders
TREMORS RIGIDITY
- resistance to passive movement
- resistance between the flexors & extensors are the same (bidirectional)
BEST JOINT: wrist joint
Resting Tremors - MC symptom (85%) in PD Parkinson’s Disease Lead pipe rigidity Extrapyramidal syndrome
- 4-6 Hz
- Affects upper limb > LL
Intention tremor Cerebellar lesions Cog wheel rigidity Parkinson’s Disease
UL = cogwheel
LL = leadpipe, because
itremors are more prominent
in UL
Flapping tremors negative = Drop of tone myoclonus = jerky Hepatic encephalopathy Clasp knife rigidity UMN lesion
a.k.a. asterixis, negative Uremic encepalothtty (spasticity)
myoclonus CO2 narcosis (respiratory - resistance of the flexors > extensors
encephalopathy) (unidirectional)
- velocity dependent
Fine tremors Thyrotoxicosis
Essential tremors - MC movement disorder affecting elderly and young age
- Age onset at 70
- 6-10 Hz
- Bilateral
- Symmetrical
- Kept on shaking
- UL > head > voice/tongue>LL
- 50% multiple sites
- Autosomal dominant inheritance
- Increased in:
stress and anxiety
alcohol
- Tx: beta blocker
Propranolol [DOC]
Primidone
- If no response to medical tx -- > deep brain stimulation
(DBS) for ventro intermediate nucleus of thalamus (VIN)
