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DIFFERENTIATING MOVEMENT DISORDERS

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Title: DIFFERENTIATING MOVEMENT DISORDERS


1
DIFFERENTIATING MOVEMENT DISORDERS
  • B. WAYNE BLOUNT, MD, MPH
  • PROFESSOR,
  • EMORY S.O.M.

2
QUESTION 1
  • WHICH OF THE BELOW ARE FEATURES TO USE IN
    DIFFERENTIATING MOVEMENT DISORDERS?
  • A. WHETHER OR NOT THE MOVEMENTS ARE HYPOKINETIC
    VS. HYPERKINETIC
  • B. PRESENCE OF A TREMOR
  • C. TYPE GAIT
  • D. COGWHEEL VS PLASTIC RIGIDITY

3
ROADMAP
  • AN APPROACH TO DIFFERENTIATION
  • EVALUATION
  • THE TYPES
  • HYPOKINETIC
  • HYPERKINETIC
  • PARKINSONS

4
EVALUATION
  • HISTORY PHYSICAL
  • DETERMINE HYPO- OR HYPER- KINETIC
  • DETERMINE WHICH COMPONENTS OF MOTOR CONTROL ARE
    AFFECTED
  • CLASSIFY BODY PART, ACTIVATION CONDITION,
    FREQUENCY AND AMPLITUDE
  • CLUSTER SIGNS SX TO DETERMINE DX

5
TYPES OF MOVEMENT DISORDERS
  • HYPOKINETIC
  • HYPERKINETIC

6
HYPOKINETIC CHARACTERISTICS
  • PARKINSONIAN APPEARANCE
  • DIMINISHED INITIATION
  • SLOWED EXECUTION
  • RIGIDITY
  • MAY HAVE RESTING TREMOR

7
QUESTION 2 WHICH OF THE
FOLLOWING ARE HYPOKINETIC DISORDERS?
  • A. PARKINSONS
  • B. AIDS
  • C. HUNTINGTONS
  • D. TARDIVE DYSKINESIA

8
HYPOKINETIC DISORDERS
  • PARKINSONISM
  • PROGRESSIVE SUPRANUCLEAR PALSY
  • LACUNAR STATE
  • TOXIC
  • HYPOTHYROID
  • HYPOPARATHYROID
  • SHY-DRAGER
  • TAURINE DEFICIENCY

9
HYPERKINETIC CHARACTERISTICS
  • INCREASED MOVEMENTS
  • DYSTONIA
  • ATHETOSIS
  • CHOREA
  • DYSKINESIA
  • TICS
  • TREMOR
  • MYOCLONUS

10
HYPERKINETIC DISORDERS (CHOREA)
  • HUNTINGTONS
  • AIDS
  • TARDIVE DYSKINESIA
  • HYPERTHYROIDISM
  • DRUG-INDUCED
  • POST-HEMIPLEGIC CHOREOATHETOSIS

11
BALLISMUS
  • INVOL JERKING FLINGING OF PROXIMAL MUSCLES
  • STROKE
  • TRAUMA
  • MULTIPLE SCLEROSIS
  • INFECTIONS

12
DYSTONIA
  • ABN TONE ANYWHERE IMPAIRED MOVEMENT
  • MEIGES SYNDROME
  • BLEPHAROSPASM, OROMANDIBULAR DYSTONIA
  • TORTICOLLIS
  • TARDIVE DYSTONIA
  • HYPOCALCEMIA

13
MYOCLONUS
  • BRIEF, LIGHTNING-LIKE CTX OF A MUSCLE
  • JAKOB-CREUTZFELDT
  • ALZHEIMERS AIDS
  • ANOXIA
  • TOXIC-METABOLIC ENCEPHALOPATHY

14
TICS
  • BRIEF, RAPID, INVOL MOVES STEREOTYPICAL
    REPETITIVE
  • IDIOPATHIC CHRONIC MOTOR TIC
  • CARBON MONOXIDE PSN-ING
  • TARDIVE DYSKINESIA WITH TICS

15
TREMOR
  • REPETITIVE, REGULAR OSCILLATORY MOVES IRREG CTX
    OF OPPOSING MUSCLES, USU INVOL
  • EXAGGERATED PHYSIOLOGIC TREMOR
  • ESSENTIAL TREMOR
  • PARKINSONIAN TREMOR
  • CEREBELLAR TREMOR

16
CHOREA ATHETOSIS
  • CHOREA
  • BRIEF, PURPOSELESS, INVOLUNTARY MOVEMENTS OF
    EXTREMITIES AND FACE
  • ATHETOSIS
  • WRITHING MOVEMENTS

17
QUESTION 3 FOR WHICH OF
THE FOLLOWING DO WE KNOW THE PATHOPHYSIOLOGY?
  • A. TARDIVE DYSKINESIA
  • B. HUNTINGTONS CHOREA
  • C. SHY DRAGER
  • D. NONE OF THE ABOVE

18
PATHOPHYSIOLOGY
  • PARKINSONS DOPAMINE DEPLETION IN SUBSTANTIA
    NIGRA LEWY BODIES
  • PROGRESSIVE SUPRANUCLEAR PALSY CELL LOSS, GLIOSIS
    NEUROFIBRILLARY TANGLES IN MESENCEPHALIC-DIENCEP
    HALIC JXN
  • LACUNAR STATE NECROSIS/OCCLUSION OF ARTERIES IN
    CAUDATE, PUTAMINE, GLOBUS, THALAMUS INT. CAPSULE

19
PATHOPHYSIOLOGY
  • HUNTINGTONS NEURONAL LOSS OF CAUDATE
    PUTAMEN DEPLETED GAMMA- AMINOBUTYRIC ACID
  • TARDIVE DYSKINESIA AFTER gt 3 MO EXPOSURE TO
    NEUROLEPTIC AGENT
  • Now have 1 FDA approved drug for Huntingtons
    tetrabenazine (8/08)

20
QUESTION 4 WHICH OF THE
FOLLOWING IS 1 OF THE CLASSIC TRIAD FOR
PARKINSONS
  • A. RESTING TREMOR
  • B. ACTION TREMOR
  • C. COGWHEEL REFLEXES
  • D. SHUFFLING GAIT

21
PARKINSONS
  • MEAN AGE _at_ ONSET 58-62
  • HIGHEST PREVALENCE IN 70S
  • INSIDIOUS ONSET
  • CLASSIC TRIAD
  • BRADYKINESIA
  • RIGIDITY
  • RESTING TREMOR
  • (POSTURAL INSTABILITY)

22
Question 5
  • True or False ? Early PD has little or no motor
    complaints.
  • A. True
  • B. False

23
EARLY PD
  • MUSCLE WEAKNESS
  • DYSTONIA
  • ANXIETY
  • INSOMNIA
  • LITTLE C/0 MOVEMENT DISORDER
  • MOTOR PROBLEMS ON P.E.

24
PARKINSONS BRADYKINESIA
  • FACIAL HYPOMIMIA (APATHY LOOK)
  • LONG LATENCY RESPONSES
  • SLOW, SHUFFLING GAIT
  • DIMINISHED ARM SWING
  • EN BLOC TURNS
  • DROOLING
  • MICROGRAPHIA
  • HYPOPHONIC SPEECH

25
Question 6
  • The rigidity in Parkinsons is different between
    the upper extremities and the lower extremities.
  • A. True
  • B. False

26
PARKINSONS RIGIDITY
  • COGWHEEL TYPE IN UPPER LIMBS
  • PLASTIC HYPERTONICITY IN LEGS

27
PARKINSONS TREMOR
  • RESTING
  • DISAPPEARS WITH ACTION
  • ALTERNATING FLEXION EXTENSION MOVEMENTS OF THE
    FINGERS AND WRISTS
  • PILL-ROLLING

28
OTHER COMMON PD SIGNS
  • FORWARD FLEXION OF THE NECK
  • FLEXION OF LIMBS
  • AUTONOMIC DYSFUNCTION
  • ORTHOSTASIS, IMPOTENCE
  • DEMENTIA, DEPRESSION
  • SLEEP SWALLOWING DISTURBANCE
  • FATIGUE

29
PD EXAM
  • MENTAL STATUS
  • CRANIAL NERVES
  • SENSATION
  • MOTOR
  • TONE POSTURE
  • STRENGTH GAIT
  • REFLEXES KINESIS
  • COORDINATION

30
QUESTION 7 TO MAKE THE
DIAGNOSIS OF PARKINSONS, YOU NEED
  • A. 1 OF 3 CARDINAL SIGNS 2 LESSER SIGNS
  • B. 2 OF THE 3 CARDINAL SIGNS
  • C. 3 OF THE 3 CARDINAL SIGNS
  • D. 2 OF THE 3 CARDINAL SIGNS 2 LESSER SIGNS

31
PD DIAGNOSIS
  • gt 2 OF 3 CARDINAL SIGNS
  • ABSENCE OF 2ND-ARY CAUSE

32
PD WORK-UP
  • CT OR MRI
  • IF CLASSIC FEATURES PRESENT, LITTLE ELSE NECESSARY

33
PD DIFFERENTIAL
  • OTHER PARKINSONIAN DISORDERS
  • PROGRESSIVE SUPRANUCLEAR PALSY
  • SHY DRAGER
  • LACUNAR STATE
  • TOXIC
  • DEPRESSION
  • METABOLIC
  • HYPOTHYROID
  • HYPOPARATHYROID

34
PD TREATMENT
  • RELIEVE SYMPTOMS
  • PREVENT COMPLICATIONS
  • SLOW DISEASE PROGRESSION (THEORETICAL)

35
PD PHARMACOTHERAPY
  • STIMULATE DOPAMINE RECEPTORS
  • INHIBIT DOPAMINE METABOLISM
  • ANTI- HISTAMINES/CHOLINERGICS
  • INCREASE DOPAMINE LEVELS

36
QUESTION 8 WHICH OF THE
FOLLOWING IS THE IST LINE TREATMENT FOR
PARKINSONS
  • STIMULATE DOPAMINE RECEPTORS
  • B. INHIBIT DOPAMINE METABOLISM
  • C. ANTI- HISTAMINES/CHOLINERGICS
  • D. INCREASES DOPAMINE LEVELS

37
INCREASE DOPAMINE LEVELS
  • LEVODOPA-CARBIDOPA (SINEMET)
  • AMANTADINE (SYMMETREL)

38
INCREASE DOPAMINE LEVELS
  • LEVODOPA IS DOPAMINE PRECURSOR
  • CARBIDOPA BLOCKS PERIPHERAL CONVERSION
  • THE MOST EFFICACIOUS TREATMENT
  • FREQUENT DOSING
  • DONT USE IN GLAUCOMA
  • LONG USE ON-OFF, WEAR OFF
  • AMANTADINE IS SYNERGISTIC WITH LEVODOPA

39
STIMULATE DOPAMINE RECEPTORS
  • BROMOCRIPTINE (PARLODEL)
  • PERGOLIDE (PERMAX)
  • PRAMIPEXOLE (MIRAPEX)
  • ROPINIROLE (REQUIP)

40
STIMULATE RECEPTORS
  • ADJUNCT TO LEVODOPA
  • START WHEN LEVODOPA IS LOW-TO- MEDIUM DOSAGE ( lt
    600 MG/DAY)
  • AS MONOTHERAPY, THEY MAY NOT PROVIDE ADEQUATE
    IMPROVEMENT.
  • PTs NOT RESPONSIVE TO LEVODOPA UNLIKELY TO BE TO
    RECEPTOR AGONISTS
  • 1ST 2 ON SLIDE RETROPERITONEAL PULMONARY
    FIBROSIS

41
INHIBIT DOPAMINE METABOLISM
  • SELEGILINE (ELDEPRYL) MAO INHIBITOR
  • TOLCAPONE (TASMAR) COMT CATECHOL
    O-METHYLTRANSFERASE INHIBITOR
  • ENTACAPONE COMT

42
INHIBIT METABOLISM
  • PREVENTS BREAKDOWN OF DOPAMINE ALLOWS MORE TO
    REACH CNS
  • ADJUNCTS TO LEVODOPA, ESPECIALLY IN PTs WITH SX
    FLUCTUATIONS OR DO NOT RESPOND TO OTHER RX

43
OTHERS
  • DIPHENHYDRAMINE (BENADRYL)
  • TRIHEXYPHENIDYL (ARTANE)
  • BENZTROPINE (COGENTIN)
  • ? BOTULINUM TOXIN ?
  • ADJUNCTIVE RX TO LEVODOPA, ESP FOR TREMOR
  • DIFFICULT IN OLDER PTs
  • BEST IN DRUG-INDUCED PARKINSONISM

44
Question 9
  • Which of the following is the preferred surgical
    technique for Parkinsons?
  • A. Pallidotomy
  • B. Deep Brain Stimulation
  • C. Thalamotomy

45
SURGERY FOR PD
  • THALAMOTOMY
  • PALLIDOTOMY
  • DEEP BRAIN STIMULATION (DBS)
  • HAS REPLACED THE OTOMIES
  • May increase suicide risk, esp in those already
    depressed

46
HOW TO SELECT MEDS
  • EACH PT NEEDS INDIVIDUAL RX
  • CONSIDER AGE, OCCUPATION LIFESTYLE
  • CONSIDER FUNCTIONAL IMPAIRMENT WHICH SX IS MOST
    BOTHERSOME
  • CONSIDER EFFICACY SIDE EFFECTS

47
THERAPY MOTOR SX
  • START EARLY
  • LEVODOPA/CARBIDOPA FIRST CR FORMULATION
  • THEN ADD COMT
  • THEN DOPAMINE AGONIST
  • MAO-B INHIBITOR
  • DBS

48
NON-MOTOR SX
  • PSYCHOSIS ATYPICAL ANTIPSYCHOTIC
  • ORTHOSTASIS STOCKINGS FLUDROCORTISONE
  • CONSTIPATION BOWEL HYGIENE

49
OTHER TREATMENTS
  • NUTRITION
  • NORMAL PROTEIN
  • HIGH FIBER
  • VITAMINS OK, BUT NO SPEC. BENEFIT
  • EXERCISE can improve motor fxn
  • PHYSICAL OCC THERAPY
  • No Treatment is neuroprotective

50
BIBLIOGRAPHY
  • CHARLES PD, ESPER GJ ET AL. CLASSIFICATION OF
    TREMOR UPDATE ON TREATMENT. AFP MAR 15,
    199959.
  • SMAGA S. TREMOR. AFP OCT 15, 2003 8.
  • YOUNG R. UPDATE ON PARKINSONS DISEASE. AFP APR
    15, 1999 8.
  • BAGHERI M, ET AL. RECOGNITION MANAGEMENT OF
    TOURETTES SYNDROME TIC DISORDERS. AFP APR 15,
    1999 8.
  • Dewey RB. Management of motor disorders in PD.
    Neurology 200462S3-S7.

51
BIBLIOGRAPHY
  • GURVICH T, CUNNINGHAM J. APPROPRIATE USE OF
    PSYCHOTROPIC DRUGS IN NURSING HOMES. AFP MAR 1,
    2000 61.
  • MOTSINGER CD, ET AL. USE OF ATYPICAL ANTIPSCHOTIC
    DRUGS IN PATIENTS WITH DEMENTIA. AFP JUNE 1,
    2003 67.
  • THE MERCK MANUAL, CHAPTER 179, DISORDERS OF
    MOVEMENT, 2005
  • TEUISSEN TAM, ET AL. TREATING URINARY
    INCONTINENCE IN THE ELDERLY. JFP 2004 53 25-30.
  • Natl. Instit. Neuro Dirders Stroke.
    Parkinsons Disease. Available _at_
    www.ninds.nih.gov/index.htm

52
ANSWERS
  • 1. A
  • 2. A
  • 3. B
  • 4. A
  • 5. A
  • 6. A
  • 7. B
  • 8. D
  • 9. B
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