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Hyperkinesia - in a shell - Dr.Kasyapa
The document provides a comprehensive overview of hyperkinetic movement disorders, classifying them into various types such as tremors, chorea, dystonia, and myoclonus. It details the clinical examinations required to differentiate these disorders and their characteristics, such as amplitude, frequency, and patterns of movement. Additionally, information about associated conditions and examples of specific disorders is included.
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Hyperkinesia - in a shell - Dr.Kasyapa
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- 2. Movement Disorders Movement disordersare classified into two groups Hypokinetic Movement Disorders Hyperkinetic Movement Disorders
- 3. Examination • Part ofthe body involved • Exact Location • Extent and Distribution • Part of the muscle/ entire muscle/ muscle groups/ joints/ complex • Pattern, Rhythmicity, Uniformity/ Multiformity • Recurrence regularity
- 4. Examination • Course, Speed,Frequency of each movement • Amplitude & Force of Movement • Relationship with • Posture/ Rest/ Voluntary activity/ Exertion/ Time of day/ Various stimuli/ Emotional state/ Sleep • Response to heat & cold
- 5. Examination • Aggravating factors •Stress/ Anxiety/ activity/ etc.. • Relieving factors • sleep/ Rest/ etc.. • Differentiation from complex/ bizarre voluntary movements • Mannerisms/ Compulsions • Palpation of Movements (for underlying fine and clear movement) • Videos
- 6. Clinical Classification of HyperkineticMovement Disorders
- 7. Tremor • Relatively rhythmic •Purposeless • Oscillatory • Amplitude : Fine/ Coarse • Involvement: Simple (Single muscle group)/ Compound (Multiple muscle groups) • May involve: Agonists/ Antagonists/ Fixators/ Synergists • Rate: Slow (3-5 Hz)/ Medium (6-9 Hz)/ Fast (10- 20 Hz)
- 8. Tremor • Rhythmicity: Continuous/Intermittent • Types • Resting(Static) Tremors: PD & other Parkinsonian • Action Tremors: • Postural: during antigravity posture (Physiologic & ET) • Kinetic: with voluntary movement, ↑ with precision requirement (Cerebellar) • Task-specific: along with a specific task (writing) • Isometric: when in isometric contraction (Shaky leg syndrome/ Orthostatic tremor)
- 10. Physiologic Tremor • 8-10Hz • Young adults > anyone • Distal extremities • Fine • At rest & with activity • Disappear during Sleep • ↑ with Emotion/ Stress/ Alcohol/ Nicotine/ Caffeine • Seen in Ⓝ individuals & Hyperthyroidsm (Rosenbach’s sign – closed eyelid tremor) • Frequency is same at different sites for the same person
- 11. Essential Tremor • 8-10Hz • Fine, Coarse (in severe) • Postural/ Kinetic • Hands, Head (yes-yes/ no-no), Voice • ↑ with Anxiety • Disappear during Sleep • Slowly progressive • Familial/ Non familial (Senile tremors) • 20 – 60 yrs onset
- 12. Cerebellar abnormality insome pt (loss of purkinjefibres, dendritic swellings)
- 13. Tremors In PD •Slow, Coarse, Compound (pill rolling type) • 2-6 Hz (4-5 Hz) • Relatively Rhythmic • At rest (temporarily suppressed by movement) • Alternating tremor (Uniformly alternating movements) • U/l @ onset B/l • Disappear during Sleep • ↑ with Emotion/ Fatigue
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- 15. Tremor in Parkinson’sDisease Essential Tremor Low amplitude Medium Amplitude Low rate Medium rate ↑ at rest ↑ with posture Dampens with outstretch (at least partially) ↑ with out stretch, ↑ more with precise action Do not spills water while drinking Can’t drink from a cup Rare involvement of Voice Usually involves No effect with alcohol/ beta blockers Improves with alcohol/ beta blockers
- 16. Cerebellar Tremor • 3-5Hz • Slow • Postural & Kinetic • Progressive towards the end of the movement • Associated with cerebellar ataxia (past pointing) • Relieves with Rest • Starts at Fingers, extremities
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- 18. Cerebellar Outflow Tremor •Combined features of Tremors in PD along with Cerebellar Tremor • Tremor is • Slow (2-5 Hz), Severe (sometimes throw the patient off balance) • Large amplitude (as Wing-beating movement) • Often associated with cerebellar ataxia • Predominantly unilateral may progress B/L • Usually Disappears during sleep may seen if severe • Develops within 4 weeks to 48 months of the insult, if not familial • Severely disabling • Unpredictable course on long term
- 19. • Ex: vascular,tumor Involvesdentato-rubro-thalamictract
- 20. Chorea • Involuntary, irregular,purposeless, Random, non- rhythmic • Spontaneous, abrupt, brief, rapid, jerky, unsustained • Chaotic, multiform, constantly changing movements that seem to flow from one body part to another • Seen at rest and action • ↑ with activity/ Emotion/ Self consciousness • May temporarily able to supress • Disappear in sleep
- 21. Chorea • Disturbs motorfunctions/ daily activities • Associated with hypotonia, no paralysis, Pendular DTR • Distal parts of UL anywhere • Distribution: one limb/ one half (hemichorea)/ generalised • Inability to sustain contraction • Parakinesia: incorporate purpose to mask chorea • Huntington’s disease, Sydenhams chorea, etc..
- 22. CaudateNucleus,Putamen, Cerebral cortex involvement Ex:Huntington’s,Sydenham
- 23. Athetosis (Hammond’s Ds) •Slower, more sustained, large amplitude when compared to chorea • Involuntary, irregular, coarse, relatively rhythmic, writhing/squirming in character • Extremities, face, neck, trunk or combination • Constant & continuous motion • Over flow: ↑ with movement of other body part • Difficulty for routine activities • U/L; B/L (double athetosis)
- 24. • Caudate nucleusand Putamen involvement • Ex: Cerebral Palsy, vascular, Vogt’s syndrome
- 25. Dystonia • Spontaneous, involuntary,sustained muscle contractions (co- contraction of agonist & antagonist) • Constant/ intermittent • Generalised/ segmental/ focal/ multifocal/ hemi-distribution • patterned, recur in same location • Sensory tricks can work • Speed: • <1 sec (dystonic spasm) • Several sec (dystonic movements) • Min-Hrs (dystonic posture) • Rapid, rhythmic (dystonic tremor) • During voluntary action (Action dystonia)
- 26. Ex: Dystonia MusculorumDeformans, Wilson’s, Parkinson’s, Drugs, Segawa syndrome.
- 27. Hemiballismus • Wild, flinging,incessant movement of one side of body • Resembles chorea but more pronounced • Involuntary, purposeless, more rapid, forceful • Proximal extremities (spares face & trunk) • U/L; B/L (Bi-ballismus), single extremities (Mono- ballismus) • Disappears only with deep sleep
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- 29. Dyskinesia • All hyperkineticmovements are technically • Complex involuntary movements that do not neatly fit with another category • ↑ by movement (kinesigenic)/ stress/ heat/ fatigue (non-kinesigenic)/ sleep (hypnogenic) • Paroxysmal: strike suddenly & unexpectedly while engaging in normal motor activity
- 30. Ex: Drug related(Tardive dyskinesia), Rabbit sydrome
- 31. Myoclonus • Single/ repetitive,abrupt, brief, rapid, lightening like, jerky, arrythmic, asynergic, involuntary contractions • Multifocal, diffuse, widespread compared to chorea • Extremities> trunk, face, jaw, tongue, pharynx • Successive, simultaneous involvement of many muscles • Symmetric on both sides of the body • At rest/ action • ↑ with emotion/ auditory, tactile, visual stimuli
- 32. Myoclonus • Positive /negative (asterixis) • Physiological: hiccups, benign nocturnal myoclonus • With epilepsy (JME) • Without seizures (metabolic encephalopathy, SSPE, CJD, Wilson’s, etc)
- 33. Ex: CJD, Metabolic Encephalopathy,Essential, JME
- 34. Palatal Myoclonus • Involuntary,relatively rhythmic • Soft palate, pharynx, larynx, eye muscles • Not influenced by sleep Tremor Palatal Myoclonus Contraction of agonist & antagonist Only Agonist’s contraction & relaxation Disappears with sleep Do not disappear
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- 36. Myorhythmia • Slow, rhythmicalternating movements • Resembles tremor ( but slow & wide spread) • Intermittent/ continuous • Synchronus/ Asynchronus (when multiple parts involved) • Absent during sleep
- 37. Ex: CNS Whipples(Occulo- masticatory myorhythmia)
- 38. Unvoluntary Movements • Patientwill have some degree of awareness • He must make the movement in response to the urge of some compelling inner force • Pt feels restless until he performs the action. • Ex: Tics, Akathesia, Stereotypy
- 39. Tic (Habit spasms) •Quick, irregular, repetitive (child > adults) • Coordinated, seemingly purposeful, brief, involves group of muscles in their normal synergistic relations • Suppressible temporarily • ↑ by emotion & tension • Disappear during sleep • Any body part (repetitive blinking, shrugging, throat clearing)
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- 41. Akathesia • Continuous innerurge and restlessness to move • Remains almost in constant motion • Mainly drug related/ PD
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- 43. Stereotypy • Repetitive, purposeless(seemingly purposeful), involuntary, patterned motor activity • Simple/ complex (in OCD) • Compared to Tic • Suppressible • Less Variable • Less tension/ compulsion
- 44. Ex: Autism, MR,Tourette’s, TD
- 45. Hyperekplexia • Pathological startle •Excessive startle in absence of neuro disorder • Sporadic/ hereditary
- 46. Ex: Tay sachs,lipidoses, CJD
- 47. Sleep related dyskinesia •Primarily during sleep • Restless leg syndrome: • Unpleasant, difficult to describe sensation in legs that are temporarily relieved by movement • Gets up and walks (Night-walkers) • Diagnosed by Polysomnography
- 48. Central disturbance indopa metabolism
- 49. Fasiculations • Fine, rapid,flickering/ vermicular twitching movements • Not extensive enough to cause joint movement • Random, irregular • At times abundant • ↑ by cold, fatigue, mechanical stimulation of muscle • Difficult to see in women • Usually unaware, persists during sleep • Usually appear when not looking at
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- 51. Myokimea • Involuntary, spontaneous,localised, transient/ persistent, quivering movement • Involves few muscle bundles in single muscle • Not extensive to cause joint movements • Coarse, slow, undulating (worm like) • Not affected by motion/ position • Persists during sleep
- 52. Ex: Demyelination, Toxins, Hypocalcemia,Issac’s (generalised)
- 53. Psychogenic (Non-Organic) • Cansimulate any type • Not corresponds to any of the organic types • Bizarre, change in type from time to time • Influenced by emotion and suggestion • Sudden onset • Always a disease of Exclusion
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