DIFFERENTIATING MOVEMENT DISORDERS

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DIFFERENTIATING MOVEMENT DISORDERS

• B. WAYNE BLOUNT, MD, MPH
• PROFESSOR,
• EMORY S.O.M.

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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

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ROADMAP

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

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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

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TYPES OF MOVEMENT DISORDERS

• HYPOKINETIC
• HYPERKINETIC

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HYPOKINETIC CHARACTERISTICS

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

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QUESTION 2 WHICH OF THE
FOLLOWING ARE HYPOKINETIC DISORDERS?

• A. PARKINSONS
• B. AIDS
• C. HUNTINGTONS
• D. TARDIVE DYSKINESIA

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HYPOKINETIC DISORDERS

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

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HYPERKINETIC CHARACTERISTICS

• INCREASED MOVEMENTS
• DYSTONIA
• ATHETOSIS
• CHOREA
• DYSKINESIA
• TICS
• TREMOR
• MYOCLONUS

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HYPERKINETIC DISORDERS (CHOREA)

• HUNTINGTONS
• AIDS
• TARDIVE DYSKINESIA
• HYPERTHYROIDISM
• DRUG-INDUCED
• POST-HEMIPLEGIC CHOREOATHETOSIS

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BALLISMUS

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

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DYSTONIA

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

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MYOCLONUS

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

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TICS

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

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TREMOR

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

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CHOREA ATHETOSIS

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

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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

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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

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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)

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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

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PARKINSONS

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

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Question 5

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

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EARLY PD

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

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PARKINSONS BRADYKINESIA

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

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Question 6

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

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PARKINSONS RIGIDITY

• COGWHEEL TYPE IN UPPER LIMBS
• PLASTIC HYPERTONICITY IN LEGS

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PARKINSONS TREMOR

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

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OTHER COMMON PD SIGNS

• FORWARD FLEXION OF THE NECK
• FLEXION OF LIMBS
• AUTONOMIC DYSFUNCTION
• ORTHOSTASIS, IMPOTENCE
• DEMENTIA, DEPRESSION
• SLEEP SWALLOWING DISTURBANCE
• FATIGUE

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PD EXAM

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

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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

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PD DIAGNOSIS

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

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PD WORK-UP

• CT OR MRI
• IF CLASSIC FEATURES PRESENT, LITTLE ELSE NECESSARY

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PD DIFFERENTIAL

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

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PD TREATMENT

• RELIEVE SYMPTOMS
• PREVENT COMPLICATIONS
• SLOW DISEASE PROGRESSION (THEORETICAL)

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PD PHARMACOTHERAPY

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

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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

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INCREASE DOPAMINE LEVELS

• LEVODOPA-CARBIDOPA (SINEMET)
• AMANTADINE (SYMMETREL)

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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

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STIMULATE DOPAMINE RECEPTORS

• BROMOCRIPTINE (PARLODEL)
• PERGOLIDE (PERMAX)
• PRAMIPEXOLE (MIRAPEX)
• ROPINIROLE (REQUIP)

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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

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INHIBIT DOPAMINE METABOLISM

• SELEGILINE (ELDEPRYL) MAO INHIBITOR
• TOLCAPONE (TASMAR) COMT CATECHOL
  O-METHYLTRANSFERASE INHIBITOR
• ENTACAPONE COMT

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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

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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

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Question 9

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

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SURGERY FOR PD

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

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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

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THERAPY MOTOR SX

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

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NON-MOTOR SX

• PSYCHOSIS ATYPICAL ANTIPSYCHOTIC
• ORTHOSTASIS STOCKINGS FLUDROCORTISONE
• CONSTIPATION BOWEL HYGIENE

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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

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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.

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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

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ANSWERS

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