Parkinson's and other movement disorders + case

Intro

Introduction and definition

2 types of movement.... hyperkinesia vs hypokinesia (excess movement vs less movement) Parkinsons is an example for hypokinesia -

TRAP menominic for parkinsons 3 types of tremors = at rest, posture, or during action

PD tremor at rest mainly...in PD like re-emergent remor..when moving it disaapears and takes time to come back

Classification

Etiology

Mainly idiopathic 1. typical parkinsons - ideopathic parkinsons - will reespond to treatment

2. atypical parkinsons - not as responsive

3. Patholgies that can minimic parkinsons - parkinsonism

Pathophysiology

Clinical manifestations

Cog wheel become superimpose tremor on the rigidity so will perceive as rigidty cog wheel

rigidity vs spasticity (spasticity is like clasp knife - velocity depednant and intial dificult)

Typical counting money like

To diagnose must have bradykineia plus or minus the other three to diagnose parkinsons

In idiopathic - it often starts

Feel like falling over. lack of motivation wirth regards to movement.

Bradykinesia - it also reuces volume of speech hypophonia and handwriting because smaller and smaller micrographia also drooling of saliva (late in idopathic and early in atypical) automic like postural hypotension too, resting tachycardia, urine urgency,

Tap test or tap with their legs....bradykinesia ⇒ reduction in amplitude and frequency over time. Not just slowness.

Difficult in turning over the bed = important to ask and so sleep is disturb becase stiffness to change psoitions in bed and stuffness in upper respiratpry tract can cause obstructive sleep apnea and disturb sleep REM sleep behaviour disorder and NREm sleep 4 stages. Certain behaviour disturb rem example... feature of rem sleep = completely atonic Polysonaraphy put a lead on the chin and absence of muscle acitity in RAM Abcense of atonia during REM sleep is a feature of REM disorders like parkinsons They dont remmeber the dreams but they act out their dreams ⇒ so rem disorders and partner can say. idiopathic parkinsons. Sleep disorders associated with parkinsons ⇒ REM sleep disorder and sleep apnea and dif in turning over?

one side effected more than the other

festination = difficulty in starting and then propelled and then come to the stop. More steps than required to turn. ignition failure

Postural instability = stand up suddenly postural hypotension Decresed fluid intake to not go to the toilet in night

Anticholinergic to reduce urgency like oxypas Dont take drugs that delay onset of sleep Clonazepam or benzodiazepine for REM sleep disorder good sleep hygience Basic edcuation

Depression, anxiety,

Psyhosis and delirum in infection Clozapine and blurgh used to treat parkinsons psychosis Executive fucntions decisions may be poor intiially All of this should be addressed!!!! Eg c

mes Speech therapist to assess swollowing Postural/orthostatus hypotension like pseudocortisone, pyridostigmin e and increase salt intake for this Need to see neurologist atleast annually NEed to hospitalised if:

psyhosis

hallucinations and delusions

significant mood disorders ⇒ depression, mania

Profiund fluctaution in mobility ⇒ need to admit to tritrare the doses

frequent or serious falling ⇒ why theyre falling?

Infections ⇒ parkisnons can get worse ———————————————————

non motor like consitpation often precedes the motor sympotms sometimes for years

And psyhciatric disturbances

and loss of sense of smell during degereation of olfactry bulb - sniff test can be done to dx ideopathic and atypical parkinsons

In history very important to as what drugs theyre on. Drugs that can be cause parkinsons ⇒ antipsyhcotic ...can often develop parkisnonism

Difficult to Dx idiopathic or drug induced parkinsonis

Both respond to levodopa. Sometimes genetic forms of parkinsonism. Both dominant and recessive.

Mask like face name for this because of slow moving facial muscles Slow blinking

Tremor - keep the hands on the lap and observe, Can ask to count backwards and when they focus on a mental task the tremor goes up.

Alterative movements and finger tapping Rigdiity .

Pill rolling or pin rolling tremour and walking augments the tremor

Observe the gaits and see ...check videos gait!!! Ideopathic because unilateral!!!! Assymetrical!! check the video !!!!

Gait features ⇒ Reduced arm swing

swooped posture

shuffling gait

festination

Festination is an involuntary gait in which stride length is shortened and steps become progressively more rapid. The patient with a festinating gait appears to be hurrying or shuffling along, though forward propulsion is decreased overall. The trunk and lower extremities are typically flexed.

PRonation and supination tremor more typical of parkinsons

archimedes spiral = tell to draw if not sure about the cause of the tremor . Mivrographia DD with essential tremor ⇒ posture sustained and action prominent and PD especially at rest. But with progression it all gets blurred. Usually using the test above DIAGNOSIS IS BY HISTORY AND EXAMINATION.

Assymetrical onset and persistence of assympetry its a sign of ideopathic parkinsonismms and predictor for good prognosis with ndrugs wirh levodopa and dopamine agonists

s Assymetrical resting tremor + assymterical progression + good response to levodopa DD and checking comorbities

Must check whether have encephalitis ⇒ one type with after virusus

Vascular parinsonism ⇒ multiple small injuries to basal ganglia ⇒ mimixking parkisnons Lower his

Meotchlopamide ⇒ can cause side effects of parkinsonisms and long term can cuase parinsonism oculogyric crisis metachrompramide used

antipshycotics and dopaimineergic bockers can cuase etra medullar that mimick parkinsonism

Tumour can

supra neuclear gaze palsy = horizontal sacccahdes and vertical sacahhades supra nuclear gaze palsy example for atypical parkinsons (dsiaapropairate slowing of vertical saccades)

How to test for sacchades?

Frequent falls early in the disease Dementia , frequency of cognitive decline early in the disease ⇒ atyoical parkinsonism Eg: lewy body parkinsonisms Celebella signs

Autonomic dsction Extramedullar and medullary sign Typical vs aytypical parkinsons

Remains always and uni lateral parkinsonisms wihtout progression on the other side maybe structural parkinsonism s

absolute symmetry also maybe atypical syndrome

No need to do imaging if its clear but may do MRI (CT might be adequate) to check for parkinson mimics like multiple stroke can be vascular parkinsons (like vascular dementia) ⇒ basal ganglia, subcortical white matter, and patients has lower body prominent then maybe vascular Normopressure hydrocephalus ⇒ enlarged ventirvles may have urinary continence and cognitive decline with dementia ⇒ respond to ventricular periotnal shunt diversion of CSF

PET scans = done in very few when diagnosis is obscur DaTscan scan = nuclear scan only available in some centers in the UK and US. n this test, a radioactive tracer, Ioflupane 123I, also known as DaTscan, is injected into the blood, where it circulates around the body and makes its way into the brain. It attaches itself to the dopamine transporter, a molecule found on dopamine neurons

If eary onset like 40 years can be genetic, or long term antipshyoctics, or drugs or acquired Wilsons disease ⇒ extra medullary features (if less than 40 years its better to screen for wilsons disease - because its easily reversible and to prevent progression as its easy with chelating === must check for kleisher flesher rings.

Multi sstem atrophy

progressive supra nuclear palsy = vertical gaze palsy

REad about atypical parkinsons syndromes (read and not absoutely necssaery to know . Need to know that there are parkinson mimics for this that doesnt respond to treatment)

Management

Can cause dyskinesia ⇒ excess movement = late feature of levodopa (peak dose and end dose dyskinesia and end dose dyskinesia) Peak dose = within half an hour after medication. If dyskinesia closer to the end dose then end dose dyskinesia or can have biphasic dyskinesia Also can lose effect with time

Precautions ⇒ drowsiness, side effects, pyridoxine?

pramipexole, and ropinirole available in sri lanka

Might be first line drog in young patients

selegiline and other drugs used as second line once the levodopa effects go down

Benzhexols used for anticholinergics to control tremors but cognitive effects limit its use And may increase the likelihood of dementia (but tremor responds well)

Summary

Dementia pugilistica or 'punch drunk' syndrome is a form of acquired cognitive impairment that occurs in up to a fifth of professional boxers

chriform movement side effect = we reduce the dose and increase the freqency to prevent side effects

Dystonia = abnormal posture due to agonist and antagonist muscles contracting at the same time Striatal tone = straita toe if big toe effected with parkinsons

Dystonia is a movement disorder in which a person's muscles contract uncontrollably. The contraction causes the affected body part to twist involuntarily, resulting in repetitive movements or abnormal postures. Dystonia can affect one muscle, a muscle group, or the entire body.

A “striatal toe” has been defined as an apparent spontaneous extensor plantar response, without fanning of the toes, in the absence of any other signs suggesting dysfunction of the cortico-spinal tract

VIDEO = effect of cycling on parkisnons = check out parkinsons videos to familairse yourself with this...go on and on check out videos

PAtients with parkinsons have no rpoblem s with cycling....amazing thing REcommend cycling for these patienst

rigidity (increased tone = no active contraction) vs hypertonia vs dystonia (abnormal posturing= active contraction of muscle of both agonists and antagonists)

hypertonia two types 1. rigidity 2. spasticity (go trthough the short case has all these explaination of all these terms dvisiions)

if end dose diskinesia then can shroten the dose frequency to that time where it occurs = we try to even out variance and decrease variation by reducing dose and increase freqency so even out the peaks and circumvent wearing off as well).....advantage of reducing dose and freqency and can reduce the dopa requirement by introduing other drugs as well. Can reduce dopa requiremtn by introduing dopamine agonist and then MAO inhibitors. Atypical are parkinsons mimics If vascular risk factors and lower motor stuff can do scans and see

1/3rd of aytipical will respond to levodopa and thats why its important to see this whether its atypical or not.

Cerebellar disease will have tremor worse when reaching target

Essental tremor vs resting tremor (both becomes blurred later on) ...treatment is completely different. If essential tremor then starting on beta blocker. If parkinsons another.