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

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differentiating movement disorders

DIFFERENTIATING MOVEMENT DISORDERS

B. WAYNE BLOUNT, MD, MPH

PROFESSOR,

EMORY S.O.M.

question 1
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
roadmap
ROADMAP
  • AN APPROACH TO DIFFERENTIATION
  • EVALUATION
  • THE TYPES:
    • HYPOKINETIC
    • HYPERKINETIC
  • PARKINSON’S
evaluation
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
types of movement disorders
TYPES OF MOVEMENT DISORDERS
  • HYPOKINETIC
  • HYPERKINETIC
hypokinetic characteristics
HYPOKINETIC CHARACTERISTICS
  • PARKINSONIAN APPEARANCE
  • DIMINISHED INITIATION
  • SLOWED EXECUTION
  • RIGIDITY
  • MAY HAVE RESTING TREMOR
question 2 which of the following are hypokinetic disorders
QUESTION # 2 WHICH OF THE FOLLOWING ARE HYPOKINETIC DISORDERS?
  • A. PARKINSON’S
  • B. AIDS
  • C. HUNTINGTON’S
  • D. TARDIVE DYSKINESIA
hypokinetic disorders
HYPOKINETIC DISORDERS
  • PARKINSONISM
  • PROGRESSIVE SUPRANUCLEAR PALSY
  • LACUNAR STATE
  • TOXIC
  • HYPOTHYROID
  • HYPOPARATHYROID
  • SHY-DRAGER
  • TAURINE DEFICIENCY
hyperkinetic characteristics
HYPERKINETIC CHARACTERISTICS
  • INCREASED MOVEMENTS
    • DYSTONIA
    • ATHETOSIS
    • CHOREA
    • DYSKINESIA
    • TICS
    • TREMOR
    • MYOCLONUS
hyperkinetic disorders chorea
HYPERKINETIC DISORDERS (CHOREA)
  • HUNTINGTON’S
  • AIDS
  • TARDIVE DYSKINESIA
  • HYPERTHYROIDISM
  • DRUG-INDUCED
  • POST-HEMIPLEGIC CHOREOATHETOSIS
ballismus
BALLISMUS
  • INVOL JERKING & FLINGING OF PROXIMAL MUSCLES
  • STROKE
  • TRAUMA
  • MULTIPLE SCLEROSIS
  • INFECTIONS
dystonia
DYSTONIA
  • ABN TONE ANYWHERE; IMPAIRED MOVEMENT
  • MEIGE’S SYNDROME
    • BLEPHAROSPASM, OROMANDIBULAR DYSTONIA
  • TORTICOLLIS
  • TARDIVE DYSTONIA
  • HYPOCALCEMIA
myoclonus
MYOCLONUS
  • BRIEF, LIGHTNING-LIKE CTX OF A MUSCLE
  • JAKOB-CREUTZFELDT
  • ALZHEIMER’S AIDS
  • ANOXIA
  • TOXIC-METABOLIC ENCEPHALOPATHY
slide14
TICS
  • BRIEF, RAPID, INVOL MOVES; STEREOTYPICAL & REPETITIVE
  • IDIOPATHIC CHRONIC MOTOR TIC
  • CARBON MONOXIDE PSN-ING
  • TARDIVE DYSKINESIA WITH TICS
tremor
TREMOR
  • REPETITIVE, REGULAR OSCILLATORY MOVES; IRREG CTX OF OPPOSING MUSCLES, USU INVOL
  • EXAGGERATED PHYSIOLOGIC TREMOR
  • ESSENTIAL TREMOR
  • PARKINSONIAN TREMOR
  • CEREBELLAR TREMOR
chorea athetosis
CHOREA & ATHETOSIS
  • CHOREA:
    • BRIEF, PURPOSELESS, INVOLUNTARY MOVEMENTS OF EXTREMITIES AND FACE
  • ATHETOSIS:
    • WRITHING MOVEMENTS
question 3 for which of the following do we know the pathophysiology
QUESTION # 3 FOR WHICH OF THE FOLLOWING DO WE KNOW THE PATHOPHYSIOLOGY?
  • A. TARDIVE DYSKINESIA
  • B. HUNTINGTON’S CHOREA
  • C. SHY DRAGER
  • D. NONE OF THE ABOVE
pathophysiology
PATHOPHYSIOLOGY
  • PARKINSON’S : DOPAMINE DEPLETION IN SUBSTANTIA NIGRA; LEWY BODIES
  • PROGRESSIVE SUPRANUCLEAR PALSY CELL LOSS, GLIOSIS & NEUROFIBRILLARY TANGLES IN MESENCEPHALIC-DIENCEPHALIC JXN
  • LACUNAR STATE : NECROSIS/OCCLUSION OF ARTERIES IN CAUDATE, PUTAMINE, GLOBUS, THALAMUS & INT. CAPSULE
pathophysiology19
PATHOPHYSIOLOGY
  • HUNTINGTON’S : NEURONAL LOSS OF CAUDATE & PUTAMEN; DEPLETED GAMMA- AMINOBUTYRIC ACID
  • TARDIVE DYSKINESIA : AFTER > 3 MO EXPOSURE TO NEUROLEPTIC AGENT
  • Now have 1 FDA approved drug for Huntington’s : tetrabenazine (8/08)
question 4 which of the following is 1 of the classic triad for parkinson s
QUESTION # 4 WHICH OF THE FOLLOWING IS 1 OF THE CLASSIC TRIAD FOR PARKINSON’S
  • A. RESTING TREMOR
  • B. ACTION TREMOR
  • C. COGWHEEL REFLEXES
  • D. SHUFFLING GAIT
parkinson s
PARKINSON’S
  • MEAN AGE @ ONSET = 58-62
  • HIGHEST PREVALENCE IN 70’S
  • INSIDIOUS ONSET
  • CLASSIC TRIAD :
    • BRADYKINESIA
    • RIGIDITY
    • RESTING TREMOR
    • (POSTURAL INSTABILITY)
question 5
Question # 5
  • True or False ? Early PD has little or no motor complaints.
    • A. True
    • B. False
early pd
EARLY PD
  • MUSCLE WEAKNESS
  • DYSTONIA
  • ANXIETY
  • INSOMNIA
  • LITTLE C/0 MOVEMENT DISORDER
  • MOTOR PROBLEMS ON P.E.
parkinson s bradykinesia
PARKINSON’S BRADYKINESIA
  • FACIAL HYPOMIMIA (APATHY LOOK)
  • LONG LATENCY RESPONSES
  • SLOW, SHUFFLING GAIT
  • DIMINISHED ARM SWING
  • EN BLOC TURNS
  • DROOLING
  • MICROGRAPHIA
  • HYPOPHONIC SPEECH
question 6
Question # 6
  • The rigidity in Parkinson’s is different between the upper extremities and the lower extremities.
    • A. True
    • B. False
parkinson s rigidity
PARKINSON’S RIGIDITY
  • COGWHEEL TYPE IN UPPER LIMBS
  • PLASTIC HYPERTONICITY IN LEGS
parkinson s tremor
PARKINSON’S TREMOR
  • RESTING
  • DISAPPEARS WITH ACTION
  • ALTERNATING FLEXION & EXTENSION MOVEMENTS OF THE FINGERS AND WRISTS
  • “PILL-ROLLING”
other common pd signs
OTHER COMMON PD SIGNS
  • FORWARD FLEXION OF THE NECK
  • FLEXION OF LIMBS
  • AUTONOMIC DYSFUNCTION :
    • ORTHOSTASIS, IMPOTENCE
  • DEMENTIA, DEPRESSION
  • SLEEP & SWALLOWING DISTURBANCE
  • FATIGUE
pd exam
PD EXAM
  • MENTAL STATUS
  • CRANIAL NERVES
  • SENSATION
  • MOTOR :
    • TONE POSTURE
    • STRENGTH GAIT
    • REFLEXES KINESIS
    • COORDINATION
question 7 to make the diagnosis of parkinson s you need
QUESTION # 7 TO MAKE THE DIAGNOSIS OF PARKINSON’S, 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
pd diagnosis
PD DIAGNOSIS
  • > 2 OF 3 CARDINAL SIGNS
  • ABSENCE OF 2ND-ARY CAUSE
pd work up
PD WORK-UP
  • CT OR MRI
  • IF CLASSIC FEATURES PRESENT, LITTLE ELSE NECESSARY
pd differential
PD DIFFERENTIAL
  • OTHER PARKINSONIAN DISORDERS ;
    • PROGRESSIVE SUPRANUCLEAR PALSY
    • SHY DRAGER
    • LACUNAR STATE
    • TOXIC
    • DEPRESSION
    • METABOLIC :
      • HYPOTHYROID
      • HYPOPARATHYROID
pd treatment
PD TREATMENT
  • RELIEVE SYMPTOMS
  • PREVENT COMPLICATIONS
  • SLOW DISEASE PROGRESSION (THEORETICAL)
pd pharmacotherapy
PD PHARMACOTHERAPY

STIMULATE DOPAMINE RECEPTORS

  • INHIBIT DOPAMINE METABOLISM
  • ANTI- HISTAMINES/CHOLINERGICS
  • INCREASE DOPAMINE LEVELS
question 8 which of the following is the ist line treatment for parkinson s
QUESTION # 8 WHICH OF THE FOLLOWING IS THE IST LINE TREATMENT FOR PARKINSON’S
  • STIMULATE DOPAMINE RECEPTORS

B. INHIBIT DOPAMINE METABOLISM

C. ANTI- HISTAMINES/CHOLINERGICS

D. INCREASES DOPAMINE LEVELS

increase dopamine levels
INCREASE DOPAMINE LEVELS
  • LEVODOPA-CARBIDOPA (SINEMET)
  • AMANTADINE (SYMMETREL)
increase dopamine levels38
INCREASE DOPAMINE LEVELS
  • LEVODOPA IS DOPAMINE PRECURSOR
  • CARBIDOPA BLOCKS PERIPHERAL CONVERSION
  • THE MOST EFFICACIOUS TREATMENT
  • FREQUENT DOSING
  • DON’T USE IN GLAUCOMA
  • LONG USE : “ON-OFF”, “WEAR OFF”
  • AMANTADINE IS SYNERGISTIC WITH LEVODOPA
stimulate dopamine receptors
STIMULATE DOPAMINE RECEPTORS
  • BROMOCRIPTINE (PARLODEL)
  • PERGOLIDE (PERMAX)
  • PRAMIPEXOLE (MIRAPEX)
  • ROPINIROLE (REQUIP)
stimulate receptors
STIMULATE RECEPTORS
  • ADJUNCT TO LEVODOPA
  • START WHEN LEVODOPA IS LOW-TO- MEDIUM DOSAGE ( < 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
inhibit dopamine metabolism
INHIBIT DOPAMINE METABOLISM
  • SELEGILINE (ELDEPRYL) MAO INHIBITOR
  • TOLCAPONE (TASMAR) COMT : CATECHOL O-METHYLTRANSFERASE INHIBITOR
  • ENTACAPONE COMT
inhibit metabolism
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
others
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
question 9
Question # 9
  • Which of the following is the preferred surgical technique for Parkinson’s?
    • A. Pallidotomy
    • B. Deep Brain Stimulation
    • C. Thalamotomy
surgery for pd
SURGERY FOR PD

THALAMOTOMY

PALLIDOTOMY

  • DEEP BRAIN STIMULATION (DBS)
    • HAS REPLACED THE –OTOMIES
    • May increase suicide risk, esp in those already depressed
how to select meds
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
therapy motor sx
THERAPY : MOTOR SX
  • START EARLY
  • LEVODOPA/CARBIDOPA FIRST: CR FORMULATION
  • THEN ADD COMT
  • THEN DOPAMINE AGONIST
  • MAO-B INHIBITOR
  • DBS
non motor sx
NON-MOTOR SX
  • PSYCHOSIS : ATYPICAL ANTIPSYCHOTIC
  • ORTHOSTASIS : STOCKINGS; FLUDROCORTISONE
  • CONSTIPATION : BOWEL HYGIENE
other treatments
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
bibliography
BIBLIOGRAPHY
  • CHARLES PD, ESPER GJ ET AL. CLASSIFICATION OF TREMOR & UPDATE ON TREATMENT. AFP MAR 15, 1999;59.
  • SMAGA S. TREMOR. AFP OCT 15, 2003; #8.
  • YOUNG R. UPDATE ON PARKINSON’S DISEASE. AFP APR 15, 1999; #8.
  • BAGHERI M, ET AL. RECOGNITION & MANAGEMENT OF TOURETTE’S SYNDROME & TIC DISORDERS. AFP APR 15, 1999; #8.
  • Dewey RB. Management of motor disorders in PD. Neurology 2004;62:S3-S7.
bibliography51
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.
  • Nat’l. Instit. Neuro Dirders & Stroke. Parkinson’s Disease. Available @ www.ninds.nih.gov/index.htm
answers
ANSWERS
  • 1. A
  • 2. A
  • 3. B
  • 4. A
  • 5. A
  • 6. A
  • 7. B
  • 8. D
  • 9. B