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Movement Abnormalities

Topic updated on 06/07/17 6:30pm

Snapshot
  • A 65-year-old man is brought to his primary care physician by his wife due to "abnormal movement." She states that her husband appears depressed and has a tremor that occurs at rest. She also reports that he "moves very slowly." The patient says that he has no current concerns. Past medical history includes hypertension, which is treated with hydrochlorothiazide. On physical exam, there is a right-sided 3-5 Hz resting "pill-rolling" tremor and cogwheel rigidity of the right upper extremity. On gait testing, the patient takes short steps and has a stooped posture. (Parkinson disease)
Introduction
  • Abnormal movements can result from impairment of the
    • upper and lower motor neurons
    • motor cortex
    • motor association cortex
    • cerebellum
    • basal ganglia
      • e.g., Wilson's disease

Movement Disorders
Type
Comments
Tremor
  • Essential tremor 
    • presentation
      • most commonly affects the hands or arms
        • typically bilateral
        • can cause functional impairment
      • the tremor worsens with stress and improves with
        • alcohol
        • β-blockers
      • often familial with an
        • autosomal dominant inheritance pattern
    • treatment
      • β-blockers (e.g., propranolol)
      • primidone
  • Physiologic tremor
    • presentation
      • affects all people but may become visible with
        • caffeine
        • beta-agonists
        • hypoglycemia
        • anxiety
        • excitement
        • alcohol and opioid withdrawal
        • thyrotoxicosis
    • treatment
      • dependent on etiology
        • e.g., decrease caffeine intake
  • Intention tremor
    • presentation
      • appendicular ataxia
        • when using their extremity towards a target there is
          • irregular and oscillating moevment
        • associated with cerebellar disorders
  • Resting tremor
    • presentation
      • tremor that occurs when the limbs are relaxed
        • can be best observed when distracting the patient
        • tremor improves when the patient moves their limbs
        • can be described as "pill rolling"
      • this is an important of Parkinson's disease
Dystonia
  • Presentation
    • sustained or slowed abnormal positions of the limb, trunk, or face
      • examples of dystonia include
        • torticollis
        • blepharospasm
        • spasmodic dysphonia
        • writer's cramp
  • Believed to be due to dysfunction of the
    • basal ganglia
  • Treatment
    • many cases have a good response to
      • botulinum toxin injection
Myoclonus
  • Presentation
    • rapid muscular jerk that can be due to multiple causes
      • seizure
        • e.g., juvenile myoclonic epilepsy
      • anoxi brain injury
      • encephalitis
      • toxic or metabolic encephalopathy
      • paraneoplastic syndromes
      • Creutzfeldt-Jakob disease
Chorea 
  • Presentation
    • dance-like involuntary movement
  • An important cause of chorea is
    • Huntingon's disease
Athetosis
  • Presentation
    • writhing and twisting movement
      • of the limbs, face, and trunk
      • that can merge with chorea to form
        • choreoathetosis
Ballismus 
  • Presentation
    • rotatory or flinging movement of the proximal limb muscles
  • The most common type of ballismus is
    • hemiballismus
      • contralateral extremity flinging movement secondary to
        • a lesion (e.g., lacunar stroke) to the subthalamic nucleus
Tics
  • Presentation
    • a sudden and brief movement that is preceded by
      • an urge that is then relieved after
        • the movement is performed
  • The types of tics include
    • motor tics
    • vocal tics
      • e.g., barking-like noises and coprolalia
  • An important syndrome to know is
    • Tourette's syndrome
 


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