Phenomenology of Movement Disorders

Transcription

1 Phenomenology of Movement Disorders Raja Mehanna MD

2 Anatomical reasoning

3 Anatomical reasoning

4 Phenomenological reasoning Abnormal movement Hypokinetic Hyperkinetic Ataxia

5 Video 1

6 But there is a tremor! UK Parkinson s Disease Society Brain Bank s clinical criteria for the diagnosis of probable Parkinson disease Hughes et al., 1992; Hughes et al., 1992; Fahn et al., 2011.

7 Parkinsonism PD MSA PSP CBS DLB Vascular parkinsonism Drug induced With FTD or AD

8 Hyperkinetic movement disorders Tremor (non parkinsonian) Dystonia Chorea Myoclonus Tics RLS, PMLS, PLMT

9 Questions to ask Immediate impressions Rhythmic or arrhythmic? Sustained or non-sustained? Paroxysmal or continuous? More prolonged observations At rest or with action? Patterned or non patterned? Fahn et al., 2011

10 Rhythmic versus arrhythmic Rhythmic -regular Rhgytmic-Irregular Arrhythmic Akathitic movements Tremor resting postural action intention Segmental Myoclonus Oscillatory Myoclonus Moving toes/fingers Myorhythmia Periodic movements in sleep Tardive stereotypy (Dystonic tremor) Cortical myoclonus Minipolymyoclonus Dystonic tremor Athetosis Ballism Chorea Dystonia Hemifacial spasm Hyperekplexia Myoclonus Stereotypy Tics Fahn et al., 2011

11 Sustained contractions or postures Dystonia Torticollis SPS Neuromyotonia Dystonic tics Pseudodystonias Oculogyric crisis Orthop edic Congenital

12 Paroxysmal Tics Paroxysm al dyskinesia Episodic ataxias Hypereplexia Stereotypies Akathitic movements

13 At rest only (disappears with action) 1.Akathitic movements 2.Paradoxical dystonia 3.Resting tremor, but can reemerge with posture holding 4.Restless legs 5.Orthostatic tremor (only on standing) With action only 1.Ataxia 2.Action dystonia 3.Action myoclonus 4.Tremor: postural, action, intention 5.Task-specific tremor 6.Task-specific dystonia Fahn et al., 2011

14 Patterned Dystonia Stereotypies Tremor Moving toes Segm myoclonus Myorhythmia Myokymia Tardive stereotypy Hemifacial spasm

15 Video 2

16 Tremor Alternating contraction of antagonist muscles Regular Sinusoidal/oscillatory Rest and/or action

17 Video 3

18 Twisting=Dystonia Co-contraction of antagonist muscles Abnormal posturing Can cause tremor Stereotyped and predictable

19 Video 4

20 Dancing= Chorea Irregular Unpredictable Seems to flow from one body part to another No volitional control Can try to mask it initially (parakinesias???)

21 Athethosis and ballismus Chorea Athetosis: Slow Writhing Continuous Ballism: Very large amplitude Proximal limbs

22 Video 5

23 Jerking= Myoclonus Literally: a quick movement of muscle. active muscle contractions = positive myoclonus lapses of muscle contraction in active postural muscles = negative myoclonus or asterixis Irregular

24 Myoclonus Spontaneous Action Reflex Focal/segmental Axial Multifocal Generalized Repetitive Rhythmic or not Regular or not

25 Video 6

26 Can be clonic, dystonic Stereotyped, but can change over years Key Premonitory feeling Voluntary control (with rebound) Relief after completion Pitfalls: Fluctuate Can disappear completely when focused Tics

27 References Fernandez HH, Rodriguez RL, Skidmore FM, Okun MS. A practical approach to movement disorders. Diagnosis and surgical and medical management. Demos Medical Pusblishing, NY, Fahn S, Jankovic J, Hallet M. Principles and practice of movement disorders, 2 nd edition. Elsevier Saunders, NY, 2011 Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical diagnosis of idiopathic Parkinson s disease: A clinicopathological study of 100 cases. J Neurol Neurosurg Psychiatry 1992;55: Hughes AJ, Ben-Shlomo Y, Daniel SE, Lees AJ: What features improve the accuracy of clinical diagnosis in Parkinson s disease: A clinical pathological study. Neurology 1992;42: