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Detailing the approach to a patient with a movement disorder. A presentation made at a grand round in LUTH .
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APPROACH TO TREATMENT OF MOVEMENT DISORDERS
DR MALLUM C.BSENIOR REGISTRAR
NEUROLOGY LUTH
• Movement disorders are a complex group of disorders spanning all aspects of neurological illnesses and range from conditions characterized by too little movement (hypokinesis) to those where movement is excessive (hyperkinesis).
INTRODUCTION
• This diverse group of hypokinetic and hyperkinetic neurologic diseases is characterized by abnormal function of the basal ganglia.
• The most common diagnoses encountered in subspecialty movement disorders clinics are Parkinson disease(the classic example)
• Movement-related problems, such as tremor, chorea, dystonia, myoclonus, hemiballism, and tics, occur in a range of inherited, drug-induced and sporadic disorders.
INTRODUCTION
• These disorders vary widely in terms of
age of onset, anatomic distribution, and severity.
Things to consider in evaluation include
the demographics,clinical characteristics, diagnostic criteria, natural history.
• Neurology is a field in which the diagnosis is primarily derived by use of old-fashioned methods: the clinical history and examination.
• Assessing and treating patients with movement disorders requires a substantial amount of clinical savvy(parkinson's disease and
• movement disorders)
• Other levels of the nervous system obviously can also mediate problems of movement
• This includes lesions of the spinal cord and the peripheral nervous system (nerve, neuromuscular junction, muscle).
• Genetics plays an important part in the genesis of several conditions characterized by various movement disorders, such as Huntington’s disease, dystonic conditions and myoclonus.
• Somatization from psychologically determined conditions can also manifest as movement disorders.
• Sleep may be affected by movement disorders and a typical example would be restless legs syndrome
• Diagnosis is based mostly on observation
and examination rather than radiology and serological assessments.
• movement disorders often first present in accident and emergency departments or in primary care settings
• most of these patients receive their follow-up care from a primary care physician or “general” neurologist who must be versed in the characteristics and treatment plans of this diverse group of disorders.
• diagnostic considerations, and treatment options.
• Age –
The most common movement disorder of childhood is that of tics.
• the prototypical condition causing of muscle spasm is stiff man syndrome.
• diagnosis largely depends on a careful, detailed history and examination coupled with pattern recognition.
HISTORY
• time course in which symptoms developed (hours vs days vs months)
• whether the condition is getting worse
• whether involuntary movements are suppressible
• what factors trigger or ameliorate their symptoms
• whether movements
• are present only while awake or also while asleep.
HISTORY
• Drug history-
Past and present medications, including those purchased without a prescription
• Exposure to environmental chemicals, occupational toxins, or illicit drugs,
• Family history- draw pedigree
• Psychiatric history- somatization
• History of trauma-
EXAMINATION
• Simply watch patients for several minutes
• it is far more important to define the phenomenology of the movements than to determine their origin.
• speed of the movements,
• frequency and amplitude,
• whether they are regular or irregular,
• stimulus-sensitivity
GAIT
Assessment of gait is a good prelude to more
detailed analysis of neurologic system
Rising from the office couch.
Hesitation, pushing off with the arms (parkinsonism, proximal lower extremity weakness)
First step.
Hesitation(parkinsonism)
GAIT
• Walking
foot moves parallel to the ground(or slides along), short stride Parkinsonism
Intorted feet dystonia
inappropriate steps to the side - chorea
widened base - Ataxia
GAIT
• Arm swing
Reduced in parkinsonism
overactive in hyperkinetic movement disorders.
• Trunk
Stooping - parkinsonian disorder
excessive trunk movements- hyperkinetic condition,such as chorea or dystonia.
GAIT
• Turning
Taking several steps to turn may suggest parkinsonism
• Sitting
Plopping into the chair with the feet rising off the floor - truncal instability - PSP
The Motor Examination
RAPID ALTERNATING MOVEMENTS
• analysis of repetitive voluntary movements can be applied to any moving body part.
• repetitive tapping of the finger and thumb
• Alternating pronation-supination of the hand
• foot tapping
• alternating opening and closing of a fist with the arm extended can be assessed.
RAPID ALTERNATING MOVEMENTS
• Speed,
• Amplitude
• Rhythm
are assessed among other things
• nutrition and dietary issues
• role of physical therapy
MEDICATIONS
• Dystonia-
• Anticholinergics, baclofen, and clonazepam are most commonly used in patients with generalized dystonia,
• Focal dystonia- local injection of botulinumtoxin
• Chorea
Most neuroleptics will help to control chorea regardless of etiology
Valproic acid-poststreptococcal cases.
Tetrabenazine
TICS
• Clonazepam, clonidine, guanfacine, serotonin-specific reuptake inhibitors,neuroleptics, and tetrabenazine have been used to treat tics.
Myoclonus
• No drugs are approved for the treatment of myoclonus
• Several antiepileptic agents including
valproic acid, clonazepam, levetiracetam and zonisamide are used.
Tremor
• Propranolol and primidone help ameliorate the symptoms of essential tremor,
• NEUROTOXIN INJECTION FOR MOVEMENT DISORDERS
Movement DisorderEmergencies
• Patients with movement disorders also have acute manifestations leading to emergency presentations, often in an emergency room setting.
• movement disorder emergency as any neurological disorder, evolving acutely or subacutely, in which the clinical presentation is dominated by a primary movement disorder, and in which failure to accurately diagnose and managethe patient may result in significant morbidity or even mortality.
Movement DisorderEmergencies
• Dystonic Storm
• Neuroleptic Malignant Syndrome
• Tardive and Neuroleptic-Induced Emergencies
• Sydenham’s Chorea and Other PoststreptococcalNeurological Disorders
• Serotonin Syndrome
• Hemiballism–Hemichorea
• Malignant Phonic Tics
• Tic emergencies
Movement DisorderEmergencies
• Abductor paresis in multiple system atrophy
• malignant catatonia
• hyperekplexia (exaggerated startle syndrome)
• Tardive and Neuroleptic-Induced Emergencies
“DON’T-MISS-DIAGNOSES”
• Wilson’s disease
• Dopa-responsive dystonia
• Whipple’s disease
Acute Parkinsonism
Secondary parkinsonism as a result of an identifiable, nondegenerative disorder
is common, primarily occurring following exposure to medications that block
dopamine D2 receptors
DYSTONIC STORM