Movement disorders

Question 1

Temor

Answer 1

rhythmic, oscillating movement of body part (hand)

Question 2

ataxia

Answer 2

clusiness, instability, imbalance, or lack of coordination with voluntary movements

movements appear disjointed, unsteady gait, falls

(looks like they have been drinking too much)

Question 3

Dystonia

Answer 3

• involuntary muscle spasms
• can be generalized or focal

Question 4

tardive dyskinesia

Answer 4

• repetitive, purposeless, involuntary movements
• grimacing, lip-smacking, rapid arm/leg movements
• prolonged exposure to antipsychotics, neuroleptics

Question 5

dysdiadochokinesia

Answer 5

impaired ability of rapid alternating movements

Question 6

chorea

Answer 6

non-repetitive jerking movements of limbs, face or trunk

Question 7

Essential tremor general

Answer 7

• involuntary, rhythmic, oscillatory movements (alternating contraction of opposing muscles)
• TWO TYPES
  
  • Kinetic - tremmor with movement of body part (writing)
  • Postural - tremor when body part held against gravity
• no related to neurologic disease or medications
• ONSET = 50’s

Question 8

essential tremor Diagnosis****

Answer 8

• Based on history and physical
  
  • usually asymmetic, hands > lower extremities
  • tremor of head may sole symptoms or associated with extremity tremor
• Need to rule out other disorders that may mimic essential tremor
  
  • check thyroid function, ceruloplasmin

Question 9

what would be some differential diagosis for essential tremor

Answer 9

• Hyperthyroidism –> bilateral tremor
• Parkinson’s disease –> tremor at rest
• enhanced physiologic tremor
• wilson’s disease
• medications = amiodarone, beta agonists, lithium, theophylline

Question 10

TX of essential tremors**

Answer 10

targeted at symtpom management

• Propranolol
  
  • beta blocker, non-selective
  • improved clinical symptoms and reported severity
• Primidone
  
  • GABA effect
  • may be more beneficial in the setting of Kinetic or intention tremors

Question 11

pathophys of parkinsons

Answer 11

• loss of dopaminergic neruons in substania nigra
• neurons die and degenerate
• imbalance in DA:Ach in striatum = improper signalling pathway for cortical motor commands

Question 12

DIANGOSIS OF PARKINSONS******

Answer 12

• Cardinal Signs/symptoms
  
  • RESTING TREMOR (4-6Hz)
  • COGWHEEL RIGIDITY
  • BRADYKINESIA
  • POSTURAL INSTABILITY
• Early motor symptoms
  
  • micrographia, decreased exterity
  • intermittent unilateral resting tremor
  • hypophonia (softening of voice)
  • stooping posture
  • masked face
  • shorter steps with unstead gait

Question 13

describe the two main classifications of parkinsons

Answer 13

• Primary
  
  • idiopathic parkinsons disease
• secondary parkinsons disease
  
  • Infectious
  • atherosclerotic
  • drug induced
  • toxic agents
  • Head trauma, tumors

Question 14

What is MPTP

Answer 14

• MPTP is a precursor to MPP+, a neurotoxin that destorys dopaminergic receptors in substania nigra
• Can be cause of secondary parkinsons disease

Question 15

Describe general tx strategies

Answer 15

• treatment is targeted to symptom management (tx most bothersome symptoms first)
• Initiate treatment when patients begins having functional disability
• LIMIT Levadopa therapy in younger patients or those with expected long-term tx

Question 16

Levodopa and carbidopa

(combo = Sinemet)

Answer 16

• Levodopa –> crosses BBB to act as dopamine
• Carbidopa –> inhibits peripheral degradation of levodopa by inhibiting dopamine decarboxylation
• ADVANTAGES: MOST EFFICACIOUS PD med, symptoms may improve
• DISADVANTAGE: does not STOP progression, require higher and higher doses due to wearing off effect (motor fluctuations)
  
  • develop dyskinesia, choreoathetotic movements, dystonia
• DOES NOT STOP: freezing, instability, autonomic dysfunction
• High protein diets can effect absorption

Question 17

DOPAMINE AGONISTS

• Bromocriptine

Answer 17

• Advantages
  
  • direct dopamine stimulation
  • good monotherapy in early PD
  • no interference with dietary proteins/AA
  • longer duration
  • less motor complications
• Disadvantages
  
  • not long term monotherapy
  • still some motor complications
  • DOES NOT STOP PROGRESSION
  • DOES NOT TX: freezing, instability, autonomic dysfunction

Question 18

MAO-B Inhibitors (B means Brain)

Selegiline, rasaligine

Answer 18

• Monoamine oxidase inhibits –> inhibits dopamine metabolism in the brain
• may be initial tx of pts with minimal functional disability
• Rasaligine –> may have neuroprotective effect

Question 19

Anticholinergics

(Trihexyphenidyl, Benztropine)

Answer 19

• when dopamine decreases, cholinergic effects predominate
• TX is inteded to DECREASE CHOLINERGIC activity and balance the decreased dopamine effect
• Predominantly used for tremor
• ASE: dry mouth, urinary retention, altered mental status

Question 20

COMT inhibitors

(entacapone, tolcapone)

Answer 20

• Increases duration of levodopa by inhibiting metabolism of levodopa by COMT
• adjunctive therapy with levodopa/carbidopa to decrease WEARING OFF effect
• NOT MONOTHERAPY
• monitor LFTs with tolcapone due to possible hepatotoxicity

Question 21

Amantadine

Answer 21

Antiviral agent

• possibly useful early on, or as adjunct to levodopa therapy
• some antiparkinson activity

Question 22

Surgical options

Answer 22

• intended for disabling PD despite optimal medical management
• poor candidates include those with high operative risk or significant congnitive decline
• OPTIONS:
  
  • Ablation –> thalamotomy, pallidotomy
  • DEEP BRAIN STIMULATION –> placed with stereotactic approach wtih MRI or CT
  • Restorative –> fetal human/porcine nigral transplant