Movement Disorders: Introduction

by Carlo Raj, MD

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

    00:05 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.

    00:19 Under hyperkinetic, tremors, chorea, dystonia, myoclonus, tics, and stereotypical movement come under the category of being hyperkinetic.

    00:31 Now, is it possible if the patient might be then exhibiting both hyper and hypokinetic simultaneously very much so.

    00:39 For example, an example of a hypokinetic type of disorder such as Parkinson’s could show you that shuffling gait, hypokinetic type of disorder, but then could also have resting tremors.

    00:55 Elements of both categories of movement disorders.

    00:58 Is that clear? Our topic continues with discussing tremors in greater detail.

    01:07 Under tremors, you would have different types.

    01:10 And the different types or behavior patterns of your tremor would 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 mug of coffee.

    01:33 Let’s say that the tremors that exist here which are going to be the shaking, jerking movement of let’s say the hands is taking place prior to going for the coffee.

    01:44 So meaning to say that at rest, there were tremors, taking place of the hand.

    01:48 You should be thinking about Parkinson for example.

    01:51 But when you’re actually going for the cup at that point intentionally, the tremors at that point would be, well, if not halted, then maybe subsided.

    02:04 You have postural.

    02:05 A postural type of tremor would be more or less essential tremor, being the most common.

    02:10 Meaning to say that the cause here would be more less idiopathic.

    02:15 You have action type of tremor.

    02:18 An action tremor in which you have these jerk-like movements of the hand.

    02:22 Well, at rest, once again you’re going for that cup or that mug of coffee.

    02:26 But this time, at rest, your hand is more or less stable.

    02:32 And it’s not moving.

    02:34 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 maybe the tremors would set in and you’re having these tremors and perhaps spilling the fluid all over the place.

    02:48 There’s a difference between an action tremor versus a resting tremor.

    02:53 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?” Continuing our discussion of hyperkinetic movement disorder, we now move on to chorea.

    03:09 By definition, chorea would be involuntary, abrupt, irregular movement of the body from one to another.

    03:18 So here, you have this flow-like movement that’s taking place from one part of the body to another.

    03:23 And here, for example, something that you might find with Huntington disease.

    03:30 The causes of chorea, well, you’ve heard of CAG as being your trinucleotide expansion and anticipation.

    03:38 And if you start having damage taking place with the basoganglia, then Huntington’s disease should come into play.

    03:45 If you have a patient and 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.

    03:58 And this is then known as a 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, in involuntary jerky flow-like movement from one body part to anther.

    04:32 Immunologically, SLE, maybe post-streptococcal, pregnancy-related and perhaps even vascular when you have these penetrating blood vessels down deep subcortically.

    04:42 Remember, we talked 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.

    04:57 Here, we’ll take a look at another hyperkinetic movement disorder and here we have dystonia.

    05:02 With dystonia, this would be sustained muscle contraction that’s taking place leading to repetitive twisting movement, abnormal posturing.

    05:11 Maybe focal, and by that we mean blepharospasms, think about your eyelids, spasmodic dysphonia, or it could be torticollis, writer’s cramp, those will be more or less focal versus it being postural.

    05:26 Segmental or perhaps even generalized.

    05:30 The causes of dystonia would be perhaps idiopathic, symptomatic.

    05:35 Well, with symptomatic, maybe being primary versus secondary.

    05:38 With primary idiopathic is something called torsion dystonia, will be an inheritance pattern of autosomal dominant.

    05:48 Where is that with your secondary? Once again, here, you can have the common suspects or usual suspects of diseases that may result in damage taking place to the basoganglia region.

    06:01 Once again, Huntington, Parkinson, maybe anoxia, stroke or drug-induced type of movement.

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

    06:15 Here, we have myoclonus, yet another hypokinetic movement disorder.

    06:20 A sudden lightning-like movement produced by abrupt and brief and muscle contraction.

    06:26 So I need you to compare myoclonus versus dystonia.

    06:30 Myoclonus would be extremely quick in nature, but still would result in a muscle -- like a contraction or clonus.

    06:36 And myo- referring to the muscle.

    06:40 Causes or types of myoclonus include: It could be physiologic.

    06:43 And by physiologic, maybe it’s jerk or even hiccups taking place.

    06:49 Essential.

    06:50 Epileptic, primary generalized epilepsy.

    06:54 And you’ve heard of myoclonus type of epilepsy and that’s something that we’ve also discussed.

    06:59 Symptomatic, metabolic encephalopathy, hypoxic brain injury or Wilson’s disease, all different causes and type of myoclonus.

    07:09 For the most part, if you wish to manage your patient with myoclonus, you want to slow things down, you’re thinking about a benzodiazepines such as clonazepam or perhaps even antiepileptic known as valproate or valproic acid, you’ve heard of Depakote.

    07:26 A hyperkinetic disorder here known as your tics.

    07:29 Abrupt, stereotypical, coordinated movement or perhaps even vocalization.

    07:35 It can be voluntarily suppressed if the patient has enough awareness of this particular issues taking place and suppression causes anxiety.

    07:45 The tics relieve the anxiety is the theory that you want to keep in mind when dealing with tics, a hyperkinetic disorder.

    07:55 A hyperkinetic disorder in which we refer to as being Tourette’s syndrome.

    08:00 It’s a genetic disorder, must have both vocal and motor tics for diagnosis.

    08:05 And what do we mean by a motor tic? A tic would be a coordinated movement that’s taking place of the muscle.

    08:12 So we have motor and both vocal type of issues taking place.

    08:17 There’s something called the rare -- but we have something called coprolalia, is rare in Tourette’s.

    08:23 Associated with obsessive-compulsive behavior and perhaps even your ADHD.

    08:31 The management of tics, here, remember the dopamine has a number of pathways, and here, you’re trying to control the movement, and so therefore dopamine antagonists seem to be most effective in management of tics.

    08:44 Clonidine may be 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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