MOVEMENT DISORDER

BASJIRUDDIN A
BAGIAN/SMF ILMU PENYAKIT SARAF FK
UNAND/

MOVEMENT DISORDER
GENERAL OVERVIEW

A. HYPERKINESIA
TREMOR
Chorea
Dystonia
Athetosis
Tics
B. HYPOKINESIA
Parkinsonism
Spasticity
Drop attack

A. HYPERKINESIA
TREMOR : rhytmical involuntary
oscilations around a fixed point occur
at rest
outstretching (postural), during
anxiety, caffeine drugs
On action (intention) :
Cerebral dysfunction
Drugs (phenitoin)
Stroke
Trauma

TREMOR
Essential
tremor
:
retlatively
benign,
embarrasing disorder, familial, sporadic forms,
aggravated by stress,excitement
Dystonic
tremor
:
involuntary
torsion
movement, affected muscle group, movement
ussually slow
Resting tremor (Parkinsonism)
Exaggerated physiologic tremor : Small
amplitude, high frequency

 ESSENTIAL TREMOR
Upper extremity tremor with posture
and/or action
Bilateral, usually roughly symmetric
Tremor may produce disability
No clear association with other
diseases or disorders

ESSENTIAL TREMOR

contd.

TREATMENT

Primodone
Propanolol 10-20 mg/day and
other Beta blockers
Tremors of some patients are
quite responsive to alcohol, and
patients may self-medicate

A. HYPERKINESIA

Tremor

CHOREA

Dystonia

Athetosis

Tics

CHOREA
Excessive spontaneous movements , rapid,
arrhytmic movements of muscle group
The movement are often incorporated into
deliberate movements by the patient to
camouflage their disorder
Irreguler, brief and aburpt non stereotype
(non repetitive)
Distal predominance
Facial grimacing

CHOREA

contd.

CAUSES :

Medications
Haldol, other antipsychotics
Reglan is an important cause of tardive
dyskinesia

Huntingtons disease
Hemibalism
Post-infection

CHOREA

1. Chorea sydenham
2. Huntington disease
1. Chorea sydenham
Acute movement
Paroxismal
Uncoordinated movement
Involuntary
Emotional disturbances
Diminish while sleeping and increase
by stress

CHOREA

contd.

2. Huntington disease : is a neurodegenerative disease

charactized by progresive choreoathetosis,
psychological changes
Clinical appearance
Choreatic
Cognitive dysfunction
Gait disorder
Clumsiness
Speech disorder
Bladder and bowel incontinence
Sexual dysfunction

CHOREA contd.

TREATMENT

Valproic acid : 15-20 mg/kg/days

Carbamazepine : 10-15 mg/kg/days
Corticosteroid
Dopaminergic blocker :
Halloperidol : 3 -40 mg/days
Primazole

A. HYPERKINESIA
Tremor
Chorea

DYSTONIA
Athetosis
Tics

DYSTONIA
Dystonia is a slow, purpose, involuntary movements
affecting muscle groups of face, limb, trunk
Agonist and antagonist
Clinical findings :
Repetitive twisting and squeezing movements
Fixed posture

Caused :
Idiopathic (most cases)
Drug related :
Antipsychotics and Reglan

A. HYPERKINESIA
Tremor
Chorea
Dystonia

ATHETOSIS
Tics

ATHETOSIS

A movement charactherized by
slow, writhing of groups of
muscle
More pronounce in the distal
extremities
Associated with weakness and
rigidity

A. HYPERKINESIA
Tremor
Chorea
Dystonia
Athetosis

TICS

TICS
Definition : brief, sudden, irresistible,
inapposite, reccurent movement
These movements are either isolated or
represent an act for a particular purpose
For a time tics can be suppresed or
inhibited
Patients often feel actively in performing
a tic
Tics can be tiggered by environmental
stimuli, exciting events or life event

B. HYPOKINESIA

PARKINSON
Spasticity
Drop attack

PARKINSONS DISEASE

Parkinsons disease is a chronic

neurodegenerative disease
associated with substantial
morbidity, increased mortality,
and high economic burden
Parkinsons results from the
degeneration of dopamine-

PARKINSON DISEASE

contd.

EPIDEMIOLOGY

The most common movement disorder

affecting 1 2 % of the general population
over the age of 65 years.
Prevalence rate in men are slightly higher
than in women
Age onset usually between 50-70 years
Rarely in people less than 30 years old
Incidence is 20 every 100.000 population

PARKINSON DISEASE

contd....

RISK FACTORS

Age - the most important risk factor

Positive family history
Male gender
Environmental exposure: Herbicide and
pesticide exposure, metals (manganese,
iron), well water, farming, rural residence,
wood pulp mills; and steel alloy industries
Race
Life experiences (trauma, emotional
stress, personality traits such as shyness
and depressiveness)?
An inverse correlation between cigarette
smoking and caffeine intake in casecontrol studies

PATHOPHYSIOLOGY
The etiology of parkinson disease is not yet clear
Its widely believed that genetic and enviromental
factor induce neuronal death
The most common pathological feature is
degeneration of dopaminergic neurons in pars
compacta of substansia nigra
The lost of dopaminergic neuron decreased activity
of thalamus,thus reducing excitatory input to motor
cortex and initiate ivoluntary movement
The presence of lewy bodies is another classic
pathological finding in parkinson disease

CLINICAL FEATURES
Four cardinal symptoms:

Resting tremor

Bradykinesia (generalized
slowness of movements)
Muscle rigidity
Postural instability

CLINICAL FEATURES

contd.

Resting tremor: most common first symptom,

usually asymmetric and most evident in one hand
with the arm at rest.
Shaking or trembling in the hand, arm, leg, face, and
it spreads, sometimes affecting only one side of the
body.
Worsen when the muscles are relaxed or individual is
stressed
Dissapears during sleep or during intentionally moved

Bradykinesia: spontaneus and automatic movement

are lost and all movement becomes extremely slow.
Diffiulty with daily activities such as writing, shaving,
using a knife and fork and opening buttons
Decreased blinking, masked facies, slowed chewing
and swallowing.

CLINICAL FEATURES

contd....

Rigidity: muscle tone increased in both flexor

and extensor muscles providing a constant
resistance to passive movements of the joints
Stooped posture, anteroflexed head, and
flexed knees and elbows.
Postural instability: due to loss of postural
reflexes. balance and coordination become
impaired.
Patients tend to lean forward or backward,
and to develop a stooped posture. Walking
with quick and small steps.

ADDITIONAL CLINICAL FEATURES

Dysfunction of the autonomic nervous system:
impaired gastrointestinal motility, bladder dysfunction,
excessive head and neck sweating, and orthostatic
hypotension.
Depression: mild to moderate depression in 50% of
patients.
Cognitive impairment: mild cognitive decline including
impaired visual-spatial perception and attention
Slowness in execution of motor tasks
At least 1/3 become demented during the course of the
disease.

OTHER SYMPTOMS

Difficulty swallowing or chewing

Urinary problems
Constipation
Irregular sleep
Short breathing

NON-MOTOR FEATURES OF PD :

Include :
mental health problems
depression
psychotic symptoms
dementia
sleep disturbance
falls
autonomic disturbance

PARKINSON DISEASE

contd.

DIAGNOSIS

No specific test or marker for PD

Diagnosis is made on clinical ground
Depends on the presence of at least two
of the three major signs : tremor at
rest, rigidity, and bradykinesia.
Bradykinesia is tested by determining
how quickly the person can tap the finger
and thumb together.

Clinical criteria for diagnosis (by Hughes)

Possible
Alt least one of TRAP symptoms (tremor,
rigiditas, akinesia, postur tak stabil)

Probable
Combining 2 major symptoms (including postural
instability) or 1 of 3 asymetrical cardinal signs

Definite
Combining 3 of 4 major symptoms or 2
symptoms with another asymetrical symptom (3
cardinal signs)

TREATMENT

The goal of therapy is to reverse functional

disability, abolition of all symtoms and signs is
not currently possible even with high dose of
medication
Treatment highly individualized
no universal first choice drug therapy
choice of adjuvant drug should take into
account
clinical and lifestyle characteristics
patient preference

TREATMENT contd.

1. Supporting treatment
Explanation to the patient, giving support,

and and occupational counseling

education for the patient, in order obtain

general picture of the disease

Emotional support and professsional

counseling
Training in accordance with their physical

condicions

TREATMENT contd.

2. Medication
. Anticholinergic : benztropine mesylate 1-8 mg/day

thyhexyphenidil 3 -6 mg/ day

. NMDA antagonist : amantadine (symetrel) 100-300mg/day
. Dopaminergic : carbidopa+levodopa 10/100mg, 25/100mg,

25/250 mg
. Dopamine agonist : bromocryptine 5-40mg/day

pramipexole 1,5-4,5 mg/day

ropinirole 0,75-2,4mg/day
. COMT inhibitors : entacapone 200 mg/day
. MAO-B inhibitors : selegiline 5 mg/day

TREATMENT contd.

2. Operative treatment
.Deep brain Stimulation
2. Rehabilitation treatment: physic, occupation,
speech, psychotherapy

SUGGESTED ACTIONS

make sure there are enough

physiotherapists
occupational therapists
speech and language therapists

PD patients should have regular

access to
monitoring and alteration of medication
a continuing point of contact
a reliable source of information

COMPLICATION OF PARKINSON DISEASE

Complication of long-term levodopa therapy
Dyskinesia
Freezing
Falls
Response fluctuations
Behavioral / psychiatric disorder
Dementia
Depression
Psycoses

REFERENCE
1. Waters CH. Diagnosis and maanagement of Parkinsons disease, second
edition. Caddo, Professional Communications nc; 1999: 31-71.
2. Basjiruddin A. Management of lates Parkinsons disease. In: Sjahrir H, dkk
(eds). Parkinsons disease and other movement disordres. Medan; 2007:
124-43.
3. Wolters EC, Bosboom JLW. Parkinsons disease. In: Wolters et al (eds).
Parkinsonism and related disorders. Amsterdam, VU University Press;
2007:143-155.
4. Parkinsons: Clinical features and differential diagnosis. Fahn S, Jankovic J.
Principles and practice of movement disorders. Philadelphia, Churchill
Livingstone Elsevier; 2007: 79-96.
5. Benazzouz A. Parkinsons disease and implication of basal ganglia in its
pathoophysiology. Egypt, June 2009.
6. NHS National Institu for Health and Clinical Excellence. Parkinsons
disease.June, 2006
7. Jakala P. Parkinsons disease, finland, 2008

THANK YOU