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MOVEMENT DISORDER Basjiruddin Ahmad Department of Neurology Andalas University Padang 6

Movement Disorder

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MOVEMENT DISORDER

Basjiruddin AhmadDepartment of Neurology

Andalas UniversityPadang

6

A. HYPERKINESIA TREMOR Chorea Dystonia Athetosis Tics

B. HYPOKINESIA Parkinsonism Spasticity Drop attack

MOVEMENT DISORDER GENERAL OVERVIEW

TREMOR : rhytmical involuntary oscilations around a fixed point occur at rest

outstretching (postural), during anxiety, caffeine drugs

On action (intention) :Cerebral dysfunctionDrugs (phenitoin)StrokeTrauma

A. HYPERKINESIA

TREMOR

Essential tremor : retlatively benign, embarrasing disorder, familial, sporadic forms, aggravated by stress,excitement

Dystonic tremor : involuntary torsion movement, affected muscle group, movement ussually slow

Resting tremor (Parkinsonism)

Exaggerated physiologic tremor : Small amplitude, high frequency

ESSENTIAL TREMOR

Upper extremity tremor with posture and/or action

Bilateral, usually roughly symmetric

Tremor may produce disability

No clear association with other diseases or disorders

ESSENTIAL TREMOR contd….

TREATMENT

Primodone

Propanolol 10-20 mg/day and other Beta blockers

Tremors of some patients are quite responsive to alcohol, and patients may self-medicate

CHOREA Excessive spontaneous movements , rapid,

arrhytmic movements of muscle group The movement are often incorporated into

deliberate movements by the patient to camouflage their disorder

Irreguler, brief and aburpt non stereotype (non repetitive)

Distal predominance Facial grimacing

A. HYPERKINESIA Tremor

CHOREA Dystonia Athetosis Tics

CHOREA contd….

CAUSES :

Medications Haldol, other antipsychotics Reglan is an important cause of tardive

dyskinesia

Huntington’s disease

Hemibalism

Post-infection

CHOREA

1. Chorea sydenham 2. Huntington disease

1. Chorea sydenham Acute movement Paroxismal Uncoordinated movement Involuntary Emotional disturbances Diminish while sleeping and increase by stress

CHOREA contd….

2. Huntington disease : is a neurodegenerative disease charactized by progresive choreoathetosis, psychological changes

Clinical appearance Choreatic Cognitive dysfunction Gait disorder Clumsiness Speech disorder Bladder and bowel incontinence Sexual dysfunction

CHOREA contd….

TREATMENT

Valproic acid : 15-20 mg/kg/days

Carbamazepine : 10-15 mg/kg/days

Corticosteroid

Dopaminergic blocker : • Halloperidol : 3 -40 mg/days• Primazole

DYSTONIA Dystonia is a slow, purpose, involuntary

movements affecting muscle groups of face, limb, trunk

Agonist and antagonist Clinical findings :

Repetitive twisting and squeezing movements Fixed posture

Caused : Idiopathic (most cases) Drug related :

Antipsychotics and Reglan

A. HYPERKINESIA Tremor ChoreaDYSTONIA Athetosis Tics

ATHETOSIS

A movement charactherized by slow, writhing of groups of muscle

More pronounce in the distal extremities Associated with weakness and rigidity Aggravated by stress Disappears during sleep Athetosis is slower than chorea and may

occur together

A. HYPERKINESIA Tremor Chorea Dystonia ATHETOSIS Tics

TICS Definition : brief, sudden, irresistible,

inapposite, reccurent movement These movements are either isolated or

represent an act for a particular purpose For a time tics can be suppresed or

inhibited Patients often feel actively in performing

a tic Tics can be tiggered by environmental

stimuli, exciting events or life event

A. HYPERKINESIA Tremor Chorea Dystonia Athetosis TICS

PARKINSON’S DISEASE

Parkinson’s disease is a chronic neurodegenerative disease associated with substantial morbidity, increased mortality, and high economic burden

Parkinson’s results from the degeneration of dopamine-producing nerve cells in the brain, specifically in the substantia nigra.

B. HYPOKINESIAPARKINSON Spasticity Drop attack

PARKINSON DISEASE contd….

EPIDEMIOLOGY

The most common movement disorder affecting 1 – 2 % of the general population over the age of 65 years.

Prevalence rate in men are slightly higher than in women

Age onset usually between 50-70 years

Rarely in people less than 30 years old

Incidence is 20 every 100.000 population

PARKINSON DISEASE contd....

RISK FACTORS Age - the most important risk factor Positive family history Male gender Environmental exposure: Herbicide and pesticide

exposure, metals (manganese, iron), well water, farming, rural residence, wood pulp mills; and steel alloy industries

Race Life experiences (trauma, emotional stress,

personality traits such as shyness and depressiveness)?

An inverse correlation between cigarette smoking and caffeine intake in case-control studies

PATHOPHYSIOLOGY

The etiology of parkinson disease is not yet clear

It’s widely believed that genetic and enviromental factor induce neuronal death

The most common pathological feature is degeneration of dopaminergic neurons in pars compacta of substansia nigra

The lost of dopaminergic neuron decreased activity of thalamus,thus reducing excitatory input to motor cortex and initiate ivoluntary movement

The presence of lewy bodies is another classic

pathological finding in parkinson disease

CLINICAL FEATURES

Four cardinal symptoms:

® Resting tremor

® Bradykinesia (generalized slowness of movements)

® Muscle rigidity

® Postural instability

CLINICAL FEATURES contd….

Resting tremor: most common first symptom, usually asymmetric and most evident in one hand with the arm at rest.

Shaking or trembling in the hand, arm, leg, face, and it spreads, sometimes affecting only one side of the body.– Worsen when the muscles are relaxed or individual is

stressed– Dissapears during sleep or during intentionally moved

Bradykinesia: spontaneus and automatic movement are lost and all movement becomes extremely slow. Diffiulty with daily activities such as writing, shaving, using a knife and fork and opening buttons

Decreased blinking, masked facies, slowed chewing and swallowing.

CLINICAL FEATURES contd....

Rigidity: muscle tone increased in both flexor and extensor muscles providing a constant resistance to passive movements of the joints

Stooped posture, anteroflexed head, and flexed knees and elbows.

Postural instability: due to loss of postural reflexes. balance and coordination become impaired.

Patients tend to lean forward or backward, and to develop a stooped posture. Walking with quick and small steps.

ADDITIONAL CLINICAL FEATURES

• Dysfunction of the autonomic nervous system: impaired gastrointestinal motility, bladder dysfunction, excessive head and neck sweating, and orthostatic hypotension.

• Depression: mild to moderate depression in 50% of patients.

• Cognitive impairment: mild cognitive decline including impaired visual-spatial perception and attention

Slowness in execution of motor tasks At least 1/3 become demented during the course

of the disease.

OTHER SYMPTOMS

• Difficulty swallowing or chewing• Urinary problems• Constipation• Irregular sleep• Short breathing

NON-MOTOR FEATURES OF PD :

Include :mental health problems

• depression• psychotic symptoms• dementia

sleep disturbancefallsautonomic disturbance

PARKINSON DISEASE contd….

DIAGNOSIS

No specific test or marker for PD

Diagnosis is made on clinical ground

Depends on the presence of at least two of the three major signs : tremor at rest, rigidity, and bradykinesia.

Bradykinesia is tested by determining how quickly the person can tap the finger and thumb together.

Clinical criteria for diagnosis (by Hughes)

Possible Alt least one of TRAP symptoms (tremor, rigiditas,

akinesia, postur tak stabil)

Probable Combining 2 major symptoms (including postural

instability) or 1 of 3 asymetrical cardinal signs

Definite Combining 3 of 4 major symptoms or 2 symptoms

with another asymetrical symptom (3 cardinal signs)

TREATMENT

The goal of therapy is to reverse functional disability, abolition of all symtoms and signs is not currently possible even with high dose of medication

Treatment highly individualized

no universal first choice drug therapy

choice of adjuvant drug should take into account

• clinical and lifestyle characteristics• patient preference

TREATMENT contd….

1. Supporting treatment Explanation to the patient, giving

support, and and occupational

counseling

education for the patient, in order

obtain general picture of the disease

Emotional support and professsional

counseling

Training in accordance with their

physical condicions

TREATMENT contd….

2. Medication

• Anticholinergic : benztropine mesylate 1-8 mg/day

thyhexyphenidil 3 -6 mg/ day

• NMDA antagonist : amantadine (symetrel) 100-300mg/day

• Dopaminergic : carbidopa+levodopa 10/100mg, 25/100mg,

25/250 mg

• Dopamine agonist : bromocryptine 5-40mg/day

pramipexole 1,5-4,5 mg/day

ropinirole 0,75-2,4mg/day

• COMT inhibitors : entacapone 200 mg/day

• MAO-B inhibitors : selegiline 5 mg/day

TREATMENT contd….

2. Operative treatment

Deep brain Stimulation

2. Rehabilitation treatment: physic, occupation,

speech, psychotherapy

SUGGESTED ACTIONS

make sure there are enoughphysiotherapistsoccupational therapistsspeech and language therapists

PD patients should have regular access to monitoring and alteration of medication a continuing point of contact a reliable source of information

COMPLICATION OF PARKINSON DISEASE

Complication of long-term levodopa therapy Dyskinesia Freezing Falls Response fluctuations

Behavioral / psychiatric disorder Dementia Depression Psycoses

REFERENCE

1. Waters CH. Diagnosis and maanagement of Parkinson’s disease, second edition. Caddo, Professional Communications nc; 1999: 31-71.

2. Basjiruddin A. Management of late’s Parkinson’s disease. In: Sjahrir H, dkk (eds). Parkinson’s disease and other movement disordres. Medan; 2007: 124-43.

3. Wolter’s EC, Bosboom JLW. Parkinson’s disease. In: Wolters et al (eds). Parkinsonism and related disorders. Amsterdam, VU University Press; 2007:143-155.

4. Parkinsons: Clinical features and differential diagnosis. Fahn S, Jankovic J. Principles and practice of movement disorders. Philadelphia, Churchill Livingstone Elsevier; 2007: 79-96.

5. Benazzouz A. Parkinson’s disease and implication of basal ganglia in its pathoophysiology. Egypt, June 2009.

6. NHS National Institu for Health and Clinical Excellence. Parkinson’s disease.June, 2006

7. Jakala P. Parkinson’s disease, finland, 2008

THANK YOU