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Movement Disorders: Introduction

by Carlo Raj, MD

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    00:01 Hello. Here, we’ll take a look at the movement disorders.

    00:04 At first what we will do is under the category of movement disorder we will then organize our thoughts and think of it as being either hyperkinetic or hypokinetic.

    00:18 Under hyperkinetic -- tremors, chorea, dystonia, myoclonus, tics, and stereotypical movement come on the category of being hyperkinetic.

    00:30 Now, is it possible for the patient might be then exhibiting both hyper and hypokinetic simultaneously? Very much so, for example, an example of a hypokinetic type of disorder such as Parkinson could show you that shuffling gait, hypokinetic type of disorder but then could also have resting tremors.

    00:53 Elements of both categories are movement disorders. Is that clear? Our topic continuous with discussing tremors in greater detail. Under tremors, you would have different types, and the different types or behavior patterns of your tremor will then clue you in that a particular diagnosis should be thought of as being your high differential.

    01:21 For example, I want you to think of the motion or the action or intention of going after a cup of coffee or a mug of coffee.

    01:31 Let’s say that the tremors that exist to you which are going to be the shaking, jerking movement of let’s say the hands, is taking place prior to going for the coffee.

    01:43 So meaning to say that at rest, there were tremors taking place of the hand; you should be thinking about Parkinson for example.

    01:50 But when you're actually going for the cup at that point intentionally, now the tremors at that point would be, well, if not halted, then maybe subsided.

    02:02 A partial type of tremor would be more or less essential tremor would being the most common, meaning to say that the cause here would be more or less idiopathic.

    02:13 You have action type of tremor.

    02:17 An action tremor in which you have this jerk like movements of the hand, well, at rest, you're once again you're going for that cup or that mug of coffee, but this time at rest, your hand is more or less stable and it’s not moving, but then upon intention or action of needing to grab that cup of coffee, it is at that point when you grab the cup in which the tremors would set in and you're having this tremors and perhaps spilling the fluid all over the place.

    02:48 There is a difference between an action tremor versus a resting tremor and when you're thinking about an intentional or action tremor, you then should be thinking that, okay, well, is there some type of injury or lesion taking place in the cerebellum? Continue our discussion of hyperkinetic movement disorder, we now move on to chorea.

    03:08 By definition chorea would be involuntary abrupt, irregular movement a of the body from one to another.

    03:17 So here we have this flow like movement that’s taking place from one part of the body to another and here for example, something that you might find with Huntington disease.

    03:27 The causes of chorea, well, you've heard of CAG as being trinucleotide repeat expansion, an anticipation.

    03:37 And if you start having damage taking place with the basal ganglia, then Huntington’s disease should come into play.

    03:45 If you have a patient we’ll deal with this patient later on or we will address this patient later on in which around the iris you'll notice a particular type of observation and this is then known as Kayser-Fleischer ring and here with this patient with such copper disease or a copper transport disease, Wilson’s Disease may also cause a movement disorder such as chorea.

    04:14 Drugs such as neuroleptics or even perhaps dopaminergic type of medications.

    04:19 Toxic, ethanol or alcohol, carbon monoxide or thyrotoxicosis may then bring about chorea type of movement.

    04:27 Remember, an involuntary jerky flow like movement from one body part to another.

    04:31 Immunologically, SLE maybe post-streptoccocal, pregnancy related and perhaps even vascular when you have this penetrating blood vessels down deep subcortically, remember, we're talking about this in terms of lacunar infarcts in which if the basal ganglia has been interrupted then it may result in chorea type of movements.

    04:56 Here will take a look in another hyperkinetic movement disorder and here we have dystonia.

    05:01 Dystonia does be sustained in the muscle contraction that’s taking place leading to repetitive twisting movement, abnormal posturing, maybe focal and by that we mean blepharospasms, think about your eyelids, spasmodic and dysphonia or it could be torticollis, writer’s cramp, there would be more or less focal versus it being postures, segmental or perhaps even generalized.

    05:29 The causes of dystonia would be perhaps idiopathic symptomatic.

    05:35 Well, what symptomatic maybe being primary versus secondary. What primary? Idiopathic something called torsion dystonia will be an inheritance pattern of autosomal dominant, whereas that which is secondary. Once again here you can have the common suspects or the usual suspects of diseases that may result in damage taking place to the basic ganglia region, once again, Huntington, Parkinson, maybe anoxia, stroke or drug induced types of movement.

    06:06 At this point, it is of utmost importance that you understand the definitions of these type of hyperkinetic disorders.

    06:14 Here we have myoclonus, yet another hyperkinetic movement disorder -- a sudden, lightning like movement produced by abrupt and brief muscle contraction, so I need you to compare myoclonus versus dystonia.

    06:30 Myoclonus will be extremely quick in nature but still would result in a muscle - like a contraction or clonus, and myo referring to the muscle? Causes or types of myoclonus include, that could be physiologic, and by physiologic maybe its jerk or even hiccups taking place.

    06:48 Essential epileptic, primary generalized epilepsy, revert of myoclonus type of epilepsy that’s something that we've also discussed.

    06:58 Symptomatic metabolic encephalopathy, hypoxic brain injury, or Wilson’s disease; all different causes and types of myoclonus.

    07:08 For the most part, if you wish to manage your patient’s myoclonus, you wanna slow things down, you're thinking about benzodiazepines such as clonazepam or perhaps even antiepileptic known as valporate or valoporic acid, you've heard of Depakote.

    07:23 A hyperkinetic disorder here known as your tics.

    07:28 Abrupt, stereotypical, coordinated movement or perhaps even vocalization, can be voluntarily suppressed if the patient has enough awareness of this particular issue taking place and suppression causes anxiety that tics relieve the anxiety is the theory that you wanna keep in mind when dealing with tics, a hyperkinetic disorder.

    07:53 A hyperkinetic disorder which we refer to as being Tourette’s syndrome is a genetic disorder must have both the vocal and motor tics for diagnosis and what do we mean by a motor tic? A tic would be a coordinated movement that’s taking placed of the muscle.

    08:11 So we have motor and both the vocal type of issue is taking place.

    08:16 There is something called a rare but we have something called coprolalia, is rare in Tourette’s, associated with obsessive-compulsive behavior and perhaps even your ADHD.

    08:29 The management of tics here remember that dopamine has a number of pathways and here you’re trying to control the movement and so therefore dopamine antagonist seem to be most effective in management of tics, clonidine maybe helpful as well.


    About the Lecture

    The lecture Movement Disorders: Introduction by Carlo Raj, MD is from the course Movement Disorders. It contains the following chapters:

    • Movement Disorders
    • Hyperkinetic Movement Disorders: Tremor
    • Hyperkinetic Movement Disorders: Chorea
    • Hyperkinetic Movement Disorders: Dystonia
    • Hyperkinetic Movement Disorders: Myoclonus
    • Hyperkinetic Movement Disorders: Tics

    Included Quiz Questions

    1. Resting tremor.
    2. Chorea.
    3. Tics.
    4. Essential tremor.
    5. Postural tremor.
    1. Essential tremor.
    2. Action tremor.
    3. Resting tremor.
    4. Shuffling gait.
    5. Chorea.
    1. Huntington's disease.
    2. Epilepsy
    3. Wilson's disease.
    4. Thyrotoxicosis.
    5. Systemic Lupus Erythematosus.
    1. Hyperkinetic, secondary dystonia.
    2. Hyperkinetic, idiopathic dystonia.
    3. Hypokinetic, myoclonus.
    4. Hyperkinetic, tremor.
    5. Hypokinetic, chorea.
    1. Parkinson's disease.
    2. Primary generalized epilepsy.
    3. Metabolic encephalopathy.
    4. Wilson's disease.
    5. Hypoxic brain injury.
    1. Dopamine antagonist, Tourette's syndrome.
    2. Dopamine agonist, Parkinson's disease.
    3. Anticholinergics, Wilson's disease.
    4. Tricyclic antidepressants, stroke.
    5. Dopamine antagonist, absence seizure.

    Author of lecture Movement Disorders: Introduction

     Carlo Raj, MD

    Carlo Raj, MD


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    I would like to see patients or role playing
    By michael g s. on 08. August 2018 for Movement Disorders: Introduction

    However, I would like to see patients or role playing to demonstrate the condition.