A.

HYPERKINESIA TREMOR Chorea Dystonia Athetosis Tics

B. HYPOKINESIA Parkinsonism Spasticity Drop attack

oscilations around a fixed point occur at rest outstretching (postural), during anxiety, caffeine drugs On action (intention) :
Cerebral

TREMOR : rhytmical involuntary

dysfunction Drugs (phenitoin) Stroke Trauma

 Essential

tremor : retlatively benign, embarrasing disorder, familial, sporadic forms, aggravated by stress,excitement tremor : involuntary torsion movement, affected muscle group, movement ussually slow
tremor (Parkinsonism)

Dystonic

Resting

Exaggerated

physiologic tremor : Small amplitude, high frequency

 Upper

extremity tremor with posture and/or

action
Bilateral, Tremor No

usually roughly symmetric

may produce disability

clear association with other diseases or disorders

 Primodone
Propanolol

10-20 mg/day and other Beta

blockers
Tremors

of some patients are quite responsive to alcohol, and patients may selfmedicate

A. HYPERKINESIA

Tremor

Dystonia Athetosis Tics

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

 Medications

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

Huntingtons

disease

Hemibalism
Post-infection

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

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

 Valproic

acid : 15-20 mg/kg/days : 10-15 mg/kg/days

Carbamazepine Corticosteroid

Dopaminergic

blocker : Halloperidol : 3 -40 mg/days Primazole

A. HYPERKINESIA Tremor Chorea Athetosis Tics

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 Tics

movement charactherized by slow, writhing of groups of muscle More pronounce in the distal extremities Associated with weakness and rigidity Aggravated by stress Disappears during sleep Athetosis is slower than chorea and may occur together

A. HYPERKINESIA Tremor Chorea Dystonia Athetosis

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
Spasticity Drop attack

Parkinsons

disease is a chronic neurodegenerative disease associated with substantial morbidity, increased mortality, and high economic burden results from the degeneration of dopamine-producing nerve cells in the brain, specifically in the substantia nigra.

Parkinsons

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

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 case-control studies

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

 Four

cardinal symptoms:

Resting tremor Bradykinesia (generalized slowness of movements) Muscle rigidity Postural instability

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.

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.

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.

Difficulty swallowing or chewing Urinary problems Constipation Irregular sleep Short breathing

Include :
mental

health problems depression psychotic symptoms dementia sleep disturbance falls autonomic disturbance

 No

specific test or marker for PD is made on clinical ground

Diagnosis Depends

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

Bradykinesia

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)

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

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

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

2.

Operative treatment

Deep brain Stimulation

2.

Rehabilitation treatment: physic, occupation, speech,

psychotherapy

 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 long-term levodopa therapy Dyskinesia Freezing Falls Response fluctuations

Behavioral / psychiatric disorder Dementia Depression Psycoses

1.

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

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Jakala P. Parkinsons disease, finland, 2008