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1 Professor Tim Anderson Neurologist University of Otago Christchurch 11:00-11:55 WS #91: Shakes Jerks and Spasms - Recognition and Differential Diagnosis 12:05-13:00 WS #102: Shakes Jerks and Spasms - Recognition and Differential Diagnosis (Repeated)
2 Shakes, Jerks and Spasms Recognition and differential diagnosis Tim Anderson Christchurch
3 Phenomenology hyperkinetic disorders tremor jerks spasms stereotypy akithisia hypokinetic disorders bradykinesia rigidity postural instability
4 Types of Movement Disorders Tremor Jerks Spasms
5 Types of Movement Disorders Tremor Jerks Spasms
6 Tremor rhythmical oscillation of a body part tremor frequency is usually not relevant diagnosis of cause is on the basis of: the type of tremor the associated features
7 Tremor - Classification Rest Action
8 Tremor - Classification Rest Action Postural Kinetic (tremor during movement) Simple kinetic (non goal directed) Intention (goal directed) Task specific isometric
9 Tremor types (Rest) Rest Tremor The only true rest tremor is Parkinsonian
10 Parkinson s Disease Bradykinesia (slowness)
11 Parkinson s Disease
12 Tremor Types (postural) Rest tremor ActionTremor Postural Kinetic Postural Tremor Essential tremor Enhanced Physiological Drugs hyperthyroidism brainstem/red nucleus Wilson's disease Tremor present on sustained posture
13 Tremor Types (intention) Rest Action Postural Kinetic Simple kinetic (non goal directed) Intention (goal directed) Task specific isometric Intention Tremor Brainstem disease, or Cerebellar disease Multiple sclerosis Cerebellar degeneration Tremor during target-directed movements
14 Tremor Syndromes Additional data from a medical history and the results of a neurologic examination can be combined into one of the following clinical syndromes: enhanced physiologic tremor classical essential tremor (ET) primary orthostatic tremor task- and position-specific tremors dystonic tremor cerebellar tremor palatal tremor tremor in Parkinson's disease Holmes' tremor drug-induced and toxic tremor tremor in peripheral neuropathies psychogenic tremor.
15 Classical Essential Tremor
16 Essential Tremor 50% hereditary (no specific gene established) 50% alcohol responsive always involves the hands (postural) symmetrically then head, tongue, voice (rarely jaw or legs) head tremor usually side-to-side no other neurologic features note! can get "cogwheeling" at wrists (due to superimposed tremor) Louis EL. Lancet Neurology 2005; 4:100-10
17 Essential Tremor Treatment oral medications Nimodipine 120mg, 120mg Propranolol 10mg/day = start dose mg = normal daily dose Gabapentin 300mg, mg Topiramate 25mg, mg Primidone 62 5mg, mg Alprazolam 0 75mg, mg
18 Essential Tremor Treatment Other therapies Botulinum toxin Into forearm muscles Reduces tremor but no functional improvement Better for head tremor Thalamotomy Thalamic deep brain stimulation (DBS
19 Tremor Syndromes Additional data from a medical history and the results of a neurologic examination can be combined into one of the following clinical syndromes: enhanced physiologic tremor classical essential tremor (ET) primary orthostatic tremor task- and position-specific tremors dystonic tremor cerebellar tremor palatal tremor tremor in Parkinson's disease Holmes' tremor drug-induced and toxic tremor tremor in peripheral neuropathies psychogenic tremor.
20 primary orthostatic tremor Treatment: clonazepam, L-dopa, gabapentin
21 Tremor Syndromes Additional data from a medical history and the results of a neurologic examination can be combined into one of the following clinical syndromes: enhanced physiologic tremor classical essential tremor (ET) primary orthostatic tremor task- and position-specific tremors dystonic tremor cerebellar tremor palatal tremor tremor in Parkinson's disease Holmes' tremor drug-induced and toxic tremor tremor in peripheral neuropathies psychogenic tremor.
22 task and position-specific tremors e.g. vocal tremor and writing tremor
23 Tremor Syndromes Additional data from a medical history and the results of a neurologic examination can be combined into one of the following clinical syndromes: enhanced physiologic tremor classical essential tremor (ET) primary orthostatic tremor task- and position-specific tremors dystonic tremor cerebellar tremor palatal tremor tremor in Parkinson's disease Holmes' tremor drug-induced and toxic tremor tremor in peripheral neuropathies psychogenic tremor.
24 dystonic tremor
25 Tremor Syndromes Additional data from a medical history and the results of a neurologic examination can be combined into one of the following clinical syndromes: enhanced physiologic tremor classical essential tremor (ET) primary orthostatic tremor task- and position-specific tremors dystonic tremor cerebellar tremor palatal tremor tremor in Parkinson's disease Holmes' tremor drug-induced and toxic tremor tremor in peripheral neuropathies psychogenic tremor.
26 cerebellar tremor
27 Types of Movement Disorders Tremor Jerks Spasms
28 Types of Jerk Chorea continuous flow of brief jerky movements which flit from one part of the body to the next in random fashion
29 Chorea continuous flow of brief jerky movements which flit from one part of the body to the next in random fashion
30 Types of Jerk Chorea Huntington s disease Sydenham s chorea Drugs Levodopa Antipsychotics Anticholinergics Stroke Treatment Tetrabenazine 12.5mg od max 50mg tds
31 athetosis from stroke
32 Chorea from L-dopa Jerks chorea myoclonus tics continuous flow of brief jerky movements which flit from one part of the body to the next in random fashion
33 Types of Jerk Chorea Myoclonus rapid shock-like muscle jerks, often repetitive, sometimes rhythmic
34 Myoclonus rapid shock-like muscle jerks, often repetitive, sometimes rhythmic
35 Types of Jerk Chorea Myoclonus Can be due to many brain and spinal cord disorders After cardiac arrest drugs Treatment 1. clonazepam 0.25mg od 2mg tds 2. sodium valproate 200mg od 500mg tds 3. levetiracetam 500mg 1000mg bd
36 Types of Jerk Chorea Myoclonus Tics repetitive, stereotyped jerks which can be mimicked voluntarily, and briefly held in check
37 Types of Jerk Tics Predilection around face/head Single (simple) or multiple Common in childhood transient Tourettes Syndrome Start in childhood Multiple motor tics Sonic tics Improves in adulthood
38 Types of Jerk Chorea Myoclonus Tics Treatment (if necessary) tetrabenazine clonidine haloperidol dopamine agonists CBT (esp. teens)
39 Types of Movement Disorders Tremor Jerks Spasms = Dystonia
40 Dystonia (spasms) "sustained contraction of voluntary muscles causing twisting and repetitive movements or abnormal posture Treatment anticholinergics e.g. procyclidine, benztropine botulinum toxin
41 Dystonia - classification Focal spasmodic torticollis (cervical dystonia) blepharospasm oromandibular dystonia spasmodic dysphonia (laryngeal dystonia) dystonic writers cramp limb dystonia Segmental Meige syndrome cranio-cervical dystonia Generalised idiopathic torsion dystonia Hemidystonia post stroke Other structural lesions
42 focal and segmental dystonia
43 Hemidystonia and generalised dystonia
44 stereotypies Huntington s disease Intellectually impaired
45 stereotypies post stroke
Professor Tim Anderson
Professor Tim Anderson Neurologist University of Otago Christchurch 11:00-11:55 WS #91: Shakes Jerks and Spasms - Recognition and Differential Diagnosis 12:05-13:00 WS #102: Shakes Jerks and Spasms - Recognition
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