AnApproachtoPatientswithMovementDisorders
JoaquimFerreira,MD,PhDLaboratoryofClinicalPharmacologyandTherapeutics
FacultyofMedicineUniversityofLisbon
• MDSvideolibrary
• MDS-OwnedRatingScales• GlobalAssessmentScaleforWilson'sDisease |Scale• GlobalDystoniaScale |Scale• ModifiedBradykinesiaRatingScale |Scale• Non-MotorSymptomsScale(NMSS) +(IncludesNMSQ) |Scale• QualityofLifeEssentialTremorQuestionnaire |ScoreSheet• RatingScaleforPsychogenicMovementDisorders |Scale• RushDyskinesiaRatingScale* |Scale• RushVideobasedTicRatingScale |Scale• UFMGSydenham'sChoreaRatingScale(USCRS) |Scale• UnifiedDyskinesiaRatingScale(UDysRS) +*• UnifiedDystoniaRatingScale(UDRS) |Scale• UnifiedMultipleSystemAtrophyRatingScale(UMSARS) |Scale• UnifiedParkinson'sDiseaseRatingScale(MDS-UPDRS) +*|Scale
• UHDRStrainingvideos• …
EDUCATIONALTOOLS
• Definition:Agroupofsymptomsorsyndromes
characterizedbyinvoluntaryorabnormal
movements
MOVEMENTDISORDERS
• History–When(started…worsened…)– How(rest…movement…)–Whereinthebody–Why(trigger…facilitator…)
MDAPPROACH
1. Localization1. whereinthebody?
2. Phenomenology1. whattypeof
movements?
3. Aetiology1. whatisthecause?
4. Pathophysiology1. Whichmechanismsare
involved?
5. Treatment1. Howcanwetreat?
6. Prognosis1. Howwillthedisease
progress?2. Shouldtherebe
geneticcounselingtopatient/offspring?
MDAPPROACH
• Focal– Musclesofonelocalizedpartofthebody
• Segmental– Cranial/axial/scapula/arm/leg…
• Hemi-focal– Hemibodywithorwithoutheadandneck
• Multifocal– >1nonadjacentfocalbodyparts
• Generalized– Segmental+anyotherpartofbody
LOCALIZATION
• Observepatient:– asheenterstheroomandwhileheisnotbeingquestioned–segmentbysegment(wheneverpossible)
LOCALIZATION
• Lookfordiscretesymptoms– Slighttremor–Minordystonicmovement– …
• Lookformaskingmovements– Handinthepocketforrestingtremor– Handbehindbackforchorea– …
LOCALIZATION
• Physiological– Tremor,myoclonus
• Primary,idiopathic,essential• Secondary,symptomatic,acquired• Psychogenic
AETIOLOGY
• Classificationofmovements– Voluntary
• Intentionallyinitiatedorevokedasareactiontoexternalstimulus– Automatic
• Learnedmotorbehaviours,performedwithoutconsciousactivation(walking,cycling,speech)
– Unvoluntary(Semi-automatic)• Initiatedbyinternalstimulus(scratchingduetoitch),orbyunpleasantfeelingorcompulsion(Restlesslegs,tics,Akathisia);canbevoluntarilysuppressedforashortduration
– Involuntary• Involuntaryinitiationandprogression,(althoughsomevoluntarymodulationmayoccur)
PHENOMENOLOGY
• Classificationofmovementdisorders
• Movementdisordersoccurwhenthereiseither– Toomuchmovement(Hyperkinesias)
or– Insufficientmovement(Hypokinesias)
PHENOMENOLOGY
• Hyper/Hypokinesia• Rhythmic/Nonrhythmic• Simple/Complex– Simple:tremor,myoclonus;– complex:tics,stereotypies
• Resting/Inducedorincreasedwithaction/tasks(mental/motor)
• Spontaneous/Provoked
PHENOMENOLOGY
Hyperkinesias• Akathisia• Ballism• Chorea• Dystonia• Myoclonus• Restlesslegs• Startlereflex• Tics• Tremor
Hypokinesias• Akinesia/Bradykinesia/
Hypokinesia• Catatonia/Catalepsy• Freezing• Rigidity• Stiffmuscles
PHENOMENOLOGY
14
CHOREA
15
ATETOSIS
16
BALLISM
DYSTONIA
MYOCLONUS
TICS
• Gait• Wheelchair• Facialexpression• Neckposture• Upper-limbposture• Handshake• …
WALKINGIN
WALKING
WHEELCHAIR
FACIALEXPRESSION
NECKPOSTURE
Arq.Neuro-Psiquiatr.vol.68no.6SãoPauloDec.2010
HANDPOSTURE
HANDSHAKE
• Firstcomplain– Tremor,bradykinesiavs.cognition,axialsigns
• Durationsofsymptoms– NotPD,PDvsessentialtremor
• Familyhistory• RedflagsforIPD
– Memory/cognitiveimpairment– Falls– OH/diziness– Urinarycomplains– Sexualdysfunction– Dysphagia– Dysarthria
CLINICALHISTORY
• Eyemovements• Oromandibular movements
FACE
EYEMOVEMENTS
OROMANDIBULARMOVEMENTS
• Tardive• LD• HDlike• MSA
• Bradykinesia• Tremor• Rigidity• Posturalinstability
CARDINALSIGNSPARKINSONISM
BRADYKINESIA
• Head• Chin• Voice• Upperlimbs• Lowerlimbs
• Stretchoutthearms– Re-emergenttremor– Polyminimyoclonus
TREMOR
TREMOR
TREMOR
“Jerks”
• Cogwheel!• Intensity0vs.1• Assimetry
RIGIDITY
• Armswing– Hall– Dystonia
• Turning• Footdystonia• Orthostatichypotension
GAIT
TURNING
FOOTDYSTONIA
• Edema• Livedo reticularis
LEGS
OTHEREVALUATIONS
OTHEREVALUATIONS
• Bloodpressure– Orthostatichypotension– Bradycardia• Acetylcholinesterase inhibitors• Propranolol
OUTRASAVALIAÇÕES
• Worstandbestmomentsoftheday• Mosttroublesomeproblems• RelationwithLDintake
– Earlymorning– Afterlunch
• Somnolence/driving• Mood
– Treatwhatistreatable!
• Familymembers/caregiver– Nocturnalsleep– Mood– Hallucinations/delusions– Shopping/eating/gambling/sex
OTHERQUESTIONS
SLEEP
• Homevideos–smartphone
• Spendsomehoursatthehospital(“close”tothedoctor)
STRATEGIES
• Pharmacologicalhistory• Drug-inducedparkinsonism
NOTTOMISS
49
NOTTOMISS