approach to treatment of movement disorders

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