ABNORMAL MOVEMENT

Ambulatory Conference

10th August,2015
Presented by : Nichanan Osataphan
Consultant : Aj.Surat Tanprawate

Case
Thai male 55 years old
Government employer

Case
Chief complaint :

Tremor of both hands 1 year PTA

Case
1 year PTA , He has tremor which occur at rest and during working.

He developed difficult on movement . No falling

4 months PTA , The symptom progressed, The tremor affected his

daily activity. He cant work.

Case
Past History
No underlying disease
No history of head trauma
No current medication

Case
GA:

An middle aged man with normal consciousness

HEENT: No pale, No jaundice ,No neck vein engorgement, No lymph

node enlargement, No thyroid gland enlargement,

Lung: Symmetrical contour , normal chest movement ,Clear and

equal breath sound

Heart : No heaving, No thrill, PMI at 5th ICS MCL, Regular rhythm,

Normal S1S2, No murmur

Abdomen: Normal contour, Splenectomy scar at left-sided abdomen

,active BS, soft ,not tender, No hepatosplenomegaly

Extremities : CRT< 2 secs, No pitting edema, Peripheral pulses 2+ all

Case
Neuro exam

E4V5M6 Pupil 3 mm RTLBE

Motor power grade V all
Sensory intact all
Cranial nerve : intact all

Problem lists

Discussion

Abnormal movement
Hyperkinetic Movements

Tremor
Chorea/Athetosis
Dystonia
Ballism
Myoclonus
Tics
Ataxia
Myokymia
Myorrhythmia
Restless Legs
Hyperkplexia
Akathesia

Hypokinetic Movements

Parkinsonism
Apraxia
Hesitant gaits
Hypothyroid slowness
Rigidity

Tremor
Most common movement disorders
Cause by either alternating or synchronous contractions of

antagonistic muscles
Rhythmic oscillation of a body part with a relatively constant

frequency and variable amplitude

Tremor classification
Resting tremor
Action tremor

Postural tremor
Intention tremor
Kinetic tremor
Task specific tremor
Isometric tremor

Deuschol,G.,Bain,P.&Brin,M. Consensus statement of

the movement disorder society on Tremor. Mov.
Disord.13(Suppl.3),2-23(1998)

2
3
4
5

Consensus Statement of the Movement Disorder Society

Cardinal signs of Parkinsonism

Bradykinesia
With at least 1/3 for diagnosis
Resting tremor
Rigidity
Postural instability

Classification of Parkinsonism
Primary or Idiopathic Parkinsonism (Parkinsons disease)
Secondary Parkinsonism
Parkinsonism plus syndromes
Heredodegenerative

Parkinsonism

Primary or Idiopathic
(Parkinsons disease)

Secondary
Parkinsonism

Parkinsonism

Heredodegenerative
Parkinsonism

Parkinsonism plus
syndrome
- Progressive supranuclear palsy (PSP)
- Corticobasal degeneration (CBD)
- Multiple system atrophy (MSA)

- Wilsons disease
- Huntingtons disease

Secondary
Parkinsonism
Drug-induced

Antipsychotic : Haloperidol,
Chlorpromazine, Risperidone
Antiemetics : Metoclopramide
Antiepileptic : Sodium valproate, Dilantin
Antivertigo : Flunarizine, Cinnarizine
Miscellaneuos : Amiodarone, Lithium,
Fluoxetine

Vascular
Parkinsonism
Toxic/metabolic

Toxin : MPTP, CO, Cyanide

Metabolic : Hypo/Hyperthyroid,
Hypo/Hyperparathyroid,

Hydrocephalus
Infection

Japanese
encephalitis

Parkinsons disease

Epidemiology
The worldwide prevalence of PD is approximately 300 per 100000

(In population age > 40 years)

Incidence 18 per 100000 per year
7.5 million people worldwide with PD
Age related disease

Gradually increase after age 50 years and disease before age 30 years is
rare

Equal sex incidence

Pathophysiology

Progressive loss of pigmented

neurons in the substantia nigra,
decrease in dopamine

Symptoms of PD appear after 6080% of these cells become

impaired or die

The presence of Lewy bodies is

the hallmark of PD

UK Parkinsons disease society brain

bank clinical diagnostic criteria
3 Steps to The Diagnosis of Parkinsons
disease
Step 1 : Diagnosis of Parkinsonism
Step 2 : Exclude other causes of Parkinsonism

Step 3 : Features that support a diagnosis of

Parkinsons disease (three or more required for
diagnosis of definite Parkinsons disease)

Hughes AJ, Daniel SE, Kilford L, Lees AJ. JNNP 1992 Mar;55(3):181-4

Step 1 : Diagnosis of Parkinsonism

Bradykinesia
At least one of the following

Muscular rigidity
4-6 Hz rest tremor
Postural instability not caused by primary visual, vestibular, cerebellar or
proprioceptive dysfunction

Hughes AJ, Daniel SE, Kilford L, Lees AJ. JNNP 1992 Mar;55(3):181-4

Step 2 : Exclusion criteria for

Parkinsons disease
History of repeated strokes with
stepwise progression of
parkinsonian features

Supranuclear gaze palsy

Cerebellar signs

History of repeated head injury

History of definite encephalitis

Early severe autonomic

involvement

Occulogyric crises

Neuroleptic treatment at onset of

symptons

Early severe dementia with

disturbances of memory, language
and praxis

Babinski sign

More than one affected relative

Sustained remission

Presence of cerebral tumor or

communication hydrocephalus on
imaging study

Strictly unilateral features after 3

years

Negative response to large doses

of levodopa in absence of
malabsorption

Hughes AJ, Daniel SE, Kilford L, Lees AJ. JNNP 1992 Mar;55(3):181-4

Step 3 : Features that support a

diagnosis of Parkinsons disease
3 or more required
Unilateral onset
Rest tremor present
Persistent

asymmetry affecting side of onset most

Excellent response (70-100%) to levodopa

Severe levodopa-induced chorea
Levodopa response for 5 years or more
Clinical course of ten years or more

Hughes AJ, Daniel SE, Kilford L, Lees AJ. JNNP 1992 Mar;55(3):181-4

Non-motor symptoms
Sleep disturbance
Depression
Dementia(late stage)
Psychosis and confusion
Orthostatic

hypotension

Sexual dysfunction

Management
Medical treatment

Levodopa
Dopamine agonist
MAO-inhibitor
COMT-inhibitor
Anticholinergic agents

Surgical treatment

Lesioning-pallidotomy or thalamotomy
Deep brain stimulation

Sites of action of PD drugs

4.COMT
Inhibitor

2.Dopamine agonist

1.Levodopa

3.MAO-B
Inhibitor
Decarboxylase
Inhibitor

Levodopa
Most effective drug
Given with decarboxylase inhibitor (Carbidopa or Benserazide) to

block peripheral conversion to dopamine

Improves disability and prolongs capacity to maintain ADLs
Effective in treating bradykinesia

and rigidity

Less effective in reducing tremor

SE : Nausea, Vomiting, Orthostatic

hallucinations and psychosis

hypotension, Dyskinesias, Visual

Dopamine agonist
Stimulate dopamine receptors

Ergot : Pergolide
Non-Ergot : Pramipexole , Ropinirole

Monotherapy or adjunct therapy

SE : same as levodopa plus drowsiness and peripheral edema

MAO inhibitor
Selegiline, Rasagaline
Irreversible

MAO-B inhibitor , Inhibiting DA metabolism in brain

Use : Monotherapy in early PD

: Prolong L-dopa effects in moderate to advanced PD

SE : nausea, insomnia, Cognitive impairment, weight loss, headache,

arthralgias

Cathechol-O-methyltrasferase
inhibitor (COMT inhibitors)
Newest class : Tolcapone, entacapone
Prevent peripheral degradation of levodopa by inhibiting COMT
Triple therapy : Levodopa + Decarboxylase inhibitor + COMT

inhibitor
Helpful for both early and fluctuating PD

SE : nausea,diarrhea, urine discoloration

Anticholinergics
Trihexyphenidyl, Benztropine
Dopaminergic depletion Cholinergic overactivity
Effective mainly for tremor (rigidity)
SE : Dry mouth, Sedation , Delirium,

Constipation

Take Home Message

Four cardinal signs with gradual progression
Autonomic dysfunction and cognitive deficits may occur with

progressive disease
Exclude other causes

of parkinsonism

Levodopa-carbidopa is the most effective medication

Surgical intervention may be considered for patients with disabling

symptoms refractory to medications

THANK YOU