Movement disordersMovement disorders

Dr. Zana A. MohammedDr. Zana A. Mohammed

M.B.Ch.B., F.I.B.M.S.M.B.Ch.B., F.I.B.M.S.

University of SulaimaniahUniversity of Sulaimaniah

School of medicineSchool of medicine

What is a Movement What is a Movement disorder?disorder?

“A disorder which impairs the regulation of voluntary motor activity without directly affecting strength, sensation or cerebellar function ”

• Sometimes also known as “ extrapyramidal disorders”

It is a disorder of basal ganglia which are group of the neuclei located subcortically which take part in motor movements of body.

Abnormal increment or decrement in its parts causes various movements disorders. 

classificationclassification

Hyperkinetic Hyperkinetic Movements Movements

••Tremor (ET-Most Tremor (ET-Most common) common)

••Chorea/ Athetosis Chorea/ Athetosis

••Dystonia Dystonia

••Ballism Ballism

••Myoclonus Myoclonus

••Tics Tics

Hypokinetic Hypokinetic Movements Movements

••Parkinsonism (2nd Parkinsonism (2nd most common) most common)

••Apraxia Apraxia

••Hypothyroid slowness Hypothyroid slowness

••Rigidity Rigidity

Hyperkinetic Movements Hyperkinetic Movements

TremorTremor RhythmicRhythmic

Involuntary movements of fingers, hand, arms, Involuntary movements of fingers, hand, arms, legs, tongue, or headlegs, tongue, or head

Due to alternate contraction and relaxation of Due to alternate contraction and relaxation of agonist and antagonist muscle groupsagonist and antagonist muscle groups

Sometimes they can be so fine that they cant be Sometimes they can be so fine that they cant be easily recognizedeasily recognized– Put a paper on dorsum of an out streched Put a paper on dorsum of an out streched

handhand

• May be coarse May be coarse

Common Causes of TremorCommon Causes of Tremor

• Postural Tremor

1. Enhanced physiologic tremor

2. Essential tremor3. Drugs ( coffee,

salbutamol)4. thyrotoxicosis

• Rest Tremor

1. Parkinson disease2. Drug-induced

parkinsonism3. Vascular

parkinsonism

• Kinetic Tremor

1. Cerebellar disease 2. Wilson disease3. Psychogenic (functional)

Ballismus, Chorea, Athotosis and Ballismus, Chorea, Athotosis and DystoniaDystonia

These should NOT be thought of as These should NOT be thought of as separate entities amenable to specific separate entities amenable to specific definition but rather as a definition but rather as a SPECTRUMSPECTRUM of of movements that blend into one-anothermovements that blend into one-another

WHY?WHY?

Because……..Because……..

• They often co-exist They often co-exist

• They often ( with some notable They often ( with some notable exceptions ) have the same exceptions ) have the same significance in terms of aetiology. significance in terms of aetiology.

The spectrumThe spectrum

Ballismus DystoniaChorea Athetosis

Movements become - Less violent / explosive / jerky

- Smoother and more flowing

- More sustained

They differ from tics in that they cannot be suppressed by voluntary control

BallismusBallismus• Violent “flinging” movement of entireViolent “flinging” movement of entire limblimb

• Almost always unilateral and therefore use Almost always unilateral and therefore use term “ HEMIBALLISMUS”term “ HEMIBALLISMUS”

• Involves proximal musculature and is Involves proximal musculature and is sometimes thought of as a “ proximal sometimes thought of as a “ proximal unilateral chorea ”unilateral chorea ”

• Usually due to a stroke in contralateral Usually due to a stroke in contralateral subthalamicsubthalamic nucleus nucleus

Chorea ( “dance” in Greek)Chorea ( “dance” in Greek)• Rapid irregular muscle jerksRapid irregular muscle jerks• May affect limbs, head, face and tongueMay affect limbs, head, face and tongue

• In the limbs chorea refers more to distal In the limbs chorea refers more to distal movements ( as proximal movements usually movements ( as proximal movements usually called ballismus)called ballismus)

• Patients often attempt to conceal involuntary Patients often attempt to conceal involuntary movements by superimposing voluntary movements by superimposing voluntary movements onto them e.g. an involuntary movements onto them e.g. an involuntary movement of arm towards face may be adapted to movement of arm towards face may be adapted to look-like an attempt to look at watchlook-like an attempt to look at watch

Athetosis “ changeable” in Athetosis “ changeable” in GreekGreek

• Slow, flowing, often twisting movementsSlow, flowing, often twisting movements

• Occurs mainly distally ( hands, fingers)Occurs mainly distally ( hands, fingers)

• Can also affect face and tongueCan also affect face and tongue

• Often use term “ choreoathetosis ” due to Often use term “ choreoathetosis ” due to overlap between syndromes ( chorea referring overlap between syndromes ( chorea referring to less smooth , more jerky movements)to less smooth , more jerky movements)

DystoniaDystonia

• “ “ condition in which the patient assumes a condition in which the patient assumes a sustained, abnormal posture or limb position”sustained, abnormal posture or limb position”

• Due to co-contraction of agonist and Due to co-contraction of agonist and antagonist muscles in part of bodyantagonist muscles in part of body

• The part of the movement when the limb was The part of the movement when the limb was held, unmoving, in an abnormal position would held, unmoving, in an abnormal position would be considered a dystonia ( may occur alone).be considered a dystonia ( may occur alone).

Classification:Classification:focalfocal (single body part); (single body part); affect one part of the body affect one part of the body

such as eyes, neck, arm or vocal cords. such as eyes, neck, arm or vocal cords. Usually idiopathicUsually idiopathicMost common typeMost common type

Blepharospasm

Torticollis Writer’s cramp Musician’s cramp

HemidystoniaHemidystonia affects an arm and a leg affects an arm and a leg on one side of the body. on one side of the body.

Generalized dystonia Generalized dystonia affects most of affects most of the body, frequently involving the legs and the body, frequently involving the legs and back. back.

Causes of Chorea, Dystonia and Causes of Chorea, Dystonia and athetosisathetosis

• HereditaryHereditary

• Static Encephalopathy ( Cerebral Palsy )Static Encephalopathy ( Cerebral Palsy )

• DrugsDrugs

• strokestroke

• Secondary to medical disordersSecondary to medical disorders

• MiscellaneousMiscellaneous - Sydenham’s chorea- Sydenham’s chorea

- Chorea Gravidarum- Chorea Gravidarum

- Sporadic idiopathic torsion - Sporadic idiopathic torsion dystonia dystonia

• Anoxic brain damage ( post – CPR ) Anoxic brain damage ( post – CPR )

• Systemic lupus erythematosisSystemic lupus erythematosis

• Hepatic failureHepatic failure

• EndocrineEndocrine - Thyrotoxicosis- Thyrotoxicosis

- Addisons- Addisons

• ElectrolyteElectrolyte - Low Ca, Mg, - Low Ca, Mg,

- High Na- High Na

• Polycythemia rubra veraPolycythemia rubra vera

Secondary to medical Secondary to medical disordersdisorders(A SHEEP)(A SHEEP)

MyoclonusMyoclonus•Brief, isolated, random, non-purposeful jerks of muscle Brief, isolated, random, non-purposeful jerks of muscle groups in the limbs, may occur normally at the onset of sleep groups in the limbs, may occur normally at the onset of sleep (hypnic jerks). (hypnic jerks). • May be caused by active muscle contraction May be caused by active muscle contraction

- positive myoclonus- positive myoclonus• May be caused by inhibition of on going muscle activityMay be caused by inhibition of on going muscle activity

- negative myoclonus ( eg. Asterixis ) - negative myoclonus ( eg. Asterixis )

• Generalised - widespread throughout bodyGeneralised - widespread throughout body• Focal / segmental – restricted to particular part of bodyFocal / segmental – restricted to particular part of body

Causes Causes PhysiologicPhysiologic - Nocturnal ( usually on falling - Nocturnal ( usually on falling

asleep )asleep )- Hiccups- Hiccups

• EpilepticEpileptic - Demonstrable cortical source- Demonstrable cortical source

Symptomatic Symptomatic hypoglycemia hypoglycemia- hepatic failure ( “ - hepatic failure ( “

asterixis” )asterixis” )- renal failure- renal failure- hyponatremia- hyponatremia

TicsTics

• Recurrent, sterotyped abnormal movementsRecurrent, sterotyped abnormal movements

• May be suppressed voluntarily or with May be suppressed voluntarily or with distractiondistraction

• Voluntary suppression leads to anxiety and Voluntary suppression leads to anxiety and a build-up of internal unrest.a build-up of internal unrest.

• Worsen under stressWorsen under stress

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