1. The document discusses various movement disorders including tics, dystonia, chorea, and Wilson's disease. 2. Tics are involuntary, repetitive movements or vocalizations that can be either simple or complex. Dystonia causes sustained muscle contractions resulting in twisting postures or movements. 3. The causes, characteristics, classifications, and treatments of these various movement disorders are explained. Non-medication treatments include cognitive behavioral therapy, habit reversal therapy, and deep brain stimulation for severe cases.

1. TICS,
DYSTONIA,
CHOREA,
WILSON’S
DISEASE,
ESSENTIAL
TREMORS
Presented by:
Miss. Shweta Sharma
M.Sc. Nursing
II Year

2. INTRODUCTION
•Physiological movements or normal movements are the natural
movements that occur in human joints. They are also known as
osteokinematic movements.
•The study of these movements is known as kinesiology.
•The term "movement disorders" refers to a group of nervous
system (neurological) conditions that cause abnormal increased
movements, which may be voluntary or involuntary. Movement
disorders can also cause reduced or slow movements.

4. TICS
• A tic is a sudden, repetitive,
nonrhythmic motor movement or
vocalization involving discrete muscle
groups. Tics can be invisible to the
observer, such as abdominal tensing
or toe crunching. Common motor
and phonic tics are, respectively, eye
blinking and throat clearing.

5. Classification
Motor or phonic
•Motor tics are movement-based tics
affecting discrete muscle groups.
•Phonic tics are involuntary sounds
produced by moving air through the nose,
mouth, or throat. They may be alternately
referred to as verbal tics or vocal tics.

6. Simple or complex
•Simple motor tics are typically sudden, brief, meaningless movements
that usually involve only one group of muscles, such as eye blinking,
head jerking, or shoulder shrugging. Motor tics can be of an endless
variety and may include such movements as hand clapping, neck
stretching, mouth movements, head, arm or leg jerks, and facial
grimacing.
•A simple phonic tic can be almost any sound or noise, with common
vocal tics being throat clearing, sniffing, or grunting.

7. •Complex motor tics. They may involve a cluster of movements and
appear coordinated. Examples of complex motor tics are pulling at
clothes, touching people, touching objects, echopraxia (repeating or
imitating another person's actions) and copropraxia (involuntarily
performing obscene or forbidden gestures).

8. • Complex phonic tics
Echolalia (repeating words just spoken by someone else)
Palilalia (repeating one's own previously spoken words)
Lexilalia (repeating words after reading them)
Coprolalia (the spontaneous utterance of socially objectionable or taboo
words or phrases)

10. Etiology and pathophysiology
• Idiopathic
• Stress and sleep deprivation
• Certain medications, including
some used to treat attention
deficit hyperactivity disorder
• Some specific gene mutations
• Brain chemistry, especially the
brain chemicals glutamate,
serotonin, and dopamine.

11. •Tics that have a direct cause fit into a different
category of diagnosis. These include tics due to:
head injuries
stroke
infections
poisons
Surgery
Huntington’s disease

12. Characteristics
•Tics may increase as a result of stress, fatigue, boredom, or high-
energy emotions, which can include negative emotions, such as
anxiety, as well as positive emotions, such as excitement or
anticipation.
•Relaxation may result in a tic increase (for instance, watching
television or using a computer), while concentration on an absorbing
activity often leads to a decrease in tics.
•Immediately preceding tic onset, most individuals are aware of an
urge that is similar to the need to yawn, sneeze, blink, or scratch an
itch.

13. •Examples of this premonitory urge are the feeling of having
something in one's throat or a localized discomfort in the
shoulders, leading to the need to clear one's throat or shrug
the shoulders. The actual tic may be felt as relieving this
tension or sensation, similar to scratching an itch.

14. • Another example is blinking to relieve an uncomfortable
sensation in the eye. Some people with tics may not be aware
of the premonitory urge.
• Children may be less aware of the premonitory urge
associated with tics than are adults, but their awareness
tends to increase with maturity.

15. Diagnosis
• History collection and Physical examination
• The child must be under 18 at the onset of symptoms for a tic
disorder to be diagnosed. Also, the symptoms must not be
caused by other medical conditions or drugs.
• Transient tic disorder- presence of one or more tics, occurring for
less than 12 months in a row.
• Chronic motor or vocal tic disorders- one or more tics have
occurred almost daily for 12 months or more. People with a
chronic tic disorder that is not TS, will experience either motor
tics or vocal tics, but not both.

16. •TS is based on the presence of both motor and vocal tics,
occurring almost daily for 12 months or more. Most
children are under the age of 11 when they are diagnosed.
•To rule out other causes of tics, a doctor may suggest:
Blood tests
MRI scans or other imaging

17. Treatment
Therapies for tic disorders
• Cognitive behavioral therapy
• Exposure and response prevention (ERP)
• Habit reversal therapy

18. Medication
• Anti-seizure medications
• Botox injections (to treat several muscle contraction or spasms)
• Muscle relaxants
• Medications that interact with dopamine

19. Deep brain stimulation
• Deep brain stimulation (DBS) is an option for people with TS whose
tics do not respond to other treatments and impact quality of life.

20. Coping and self-help tips
• avoiding stress and anxiety
• getting enough sleep
• join a support group for people with TS and other tic disorders
• reach out to friends and others for help and support
Parents of children with tics may wish to:
• inform teachers, caregivers, and others who know the child and
about the condition
• help boost the child’s self-esteem by encouraging interests and
friendships
• ignore times when a tic occurs, and avoid pointing it out to the
child

21. DYSTONIA
• Dystonia is a neurological
hyperkinetic movement disorder
syndrome in which sustained or
repetitive muscle contractions result
in twisting and repetitive movements
or abnormal fixed postures. The
movements may resemble a tremor.
Dystonia is often intensified or
exacerbated by physical activity, and
symptoms may progress into adjacent
muscles.

22. • Primary dystonia is suspected when the dystonia is the only sign
and there is no identifiable cause or structural abnormality in the
central nervous system.
• Secondary dystonia refers to dystonia brought on by some
identified cause, such as head injury, drug side effect (e.g. tardive
dystonia), or neurological disease (e.g. Wilson's disease).
• Meningitis and encephalitis caused by viral, bacterial, and fungal
infections of the brain have been associated with dystonia.
Etiology and pathophysiology

23. • Environmental and task-related factors are suspected to trigger the
development of focal dystonias because they appear disproportionately
in individuals who perform high precision hand movements such as
musicians, engineers, architects, and artists.
• Chlorpromazine can also cause dystonia, which can be often misjudged
as a seizure. Neuroleptic drugs often cause dystonia, including
oculogyric crisis.
• Malfunction of the sodium-potassium pump may be a factor in some
dystonias.

24. Classification
Dystonia Classification by Age
•Childhood onset – 0 to 12 years of age
•Adolescent onset – 13 to 20 years of age
•Adult onset – older than 20 years

25. Dystonia Classification by Body Part
1.Focal Dystonia
• Neck (cervical dystonia or spasmodic torticollis)
• Eyes (blepharospasm)
• Jaw/mouth/lower face (oromandibular dystonia)
• Vocal cords (laryngeal dystonia)
• Arms/legs (limb dystonia)
• Unusual stretching, bending or twisting of the trunk (truncal
dystonia)
• Sustained contractions and involuntary, writhing movements of
the abdominal wall (abdominal wall dystonia)

27. 2.Segmental Dystonia
Segmental dystonia affects two or more parts of the body that are
adjacent or close to one another. A common form of segmental
dystonia affects the eyelids, jaw, mouth and lower face.
Other types of dystonia include multifocal, which involves two or
more body parts distant from one another; hemi dystonia, which
affects half of the body; and generalized, which begins with leg
involvement, but generally spreads to one or more additional
regions of the body.

28. Dystonia Classification by Cause
1.Primary (idiopathic)
Primary (idiopathic) dystonia is the only sign, and secondary causes
have been ruled out. Most primary dystonias are variable, have adult
onset, and are focal or segmental in nature. However, there are
specific primary dystonias with childhood or adolescent onset that
have been linked to genetic mutations.

29. 2.Secondary (symptomatic)
Secondary (symptomatic) results primarily from secondary causes.
These include environmental, such as exposure to carbon monoxide,
cyanide, manganese or methanol; underlying conditions and
diseases such as brain tumors, cerebral palsy, Parkinson’s disease,
stroke, multiple sclerosis, hypoparathyroidism or vascular
malformations; brain/spinal cord injuries; inflammatory, infectious or
postinfectious brain conditions; and specific medications.

30. 3.Heredodegenerative Dystonia
Heredodegenerative dystonia generally results from neurodegenerative
disorders in which other neurological symptoms are present and in which
heredity plays a role. These include numerous disorders such as certain X-
linked recessive, autosomal dominant, autosomal recessive and/or
parkinsonian syndromes. Included in this category: X-linked dystonia-
parkinsonism (Lubag), Huntington's disease, Wilson's disease,
neuroacanthocytosis, Rett’s syndrome, Parkinson's disease and juvenile
parkinsonism.

31. Signs and symptoms
• Abnormal posturing, in particular on movement
• Continuous pain, cramping, and relentless muscle spasms due to
involuntary muscle movements
• Possible including lip smacking.
• Loss of precision muscle coordination (sometimes first
manifested in declining penmanship, frequent small injuries to
the hands, and dropped items), cramping pain with sustained
use, and trembling.

32. • It may become difficult to find a comfortable position for arms
and legs with even the minor exertions associated with holding
arms crossed causing significant pain similar to restless leg
syndrome.
• Affected persons may notice trembling in the diaphragm while
breathing, or the need to place hands in pockets, under legs
while sitting or under pillows while sleeping to keep them still
and to reduce pain.
• Trembling in the jaw may be felt and heard while lying down,
and the constant movement to avoid pain may result in the
grinding and wearing down of teeth, or symptoms similar to
temporomandibular joint disorder.

33. • The voice may crack frequently or become harsh,
triggering frequent throat clearing. Swallowing can
become difficult and accompanied by painful cramping.
• Disturbed sleep patterns, exhaustion, mood swings,
depression, mental stress, difficulty concentrating, blurred
vision, digestive problems, and short temper.

34. Diagnosis
• Medical history and physical examination.
• Blood or urine tests
• MRI or CT scan
• Electromyography (EMG)
• Genetic testing

35. Treatment
Therapy
• Physical therapy or occupational therapy or both to help ease
symptoms and improve function.
• Speech therapy if dystonia affects voice.
• Stretching or massage to ease muscle pain.
• Reducing stress, getting plenty of rest and relaxation techniques.
• Therapeutic exercise, soft tissue and joint mobilization, postural
training and bracing, neuromuscular electrical stimulation,
environmental modification, and gait training.

36. Medication
• Injections of botulinum toxin (Botox).Injections are usually
repeated every three to four months.
• Carbidopa-levodopa (Duopa). This medication can increase levels
of the neurotransmitter dopamine.
• Trihexyphenidyl and benztropine (Cogentin). These two
medications act on neurotransmitters other than dopamine.

37. • Tetrabenazine (Xenazine) and deutetrabenazine (Austedo). These
two medications block dopamine.
• Diazepam (Valium), clonazepam (Klonopin) and baclofen (Lioresal,
Gablofen). These medications reduce neurotransmission and
might help some forms of dystonia.

38. Surgery
• Deep brain stimulation
• Selective denervation surgery

39. CHOREA
• Chorea (or choreia) is an abnormal involuntary movement
disorder, one of a group of neurological disorders called
dyskinesias. The term chorea is derived from the Ancient Greek
word “χορεία” which means dance, as the quick movements of the
feet or hands are comparable to dancing.
• The term hemichorea refers to chorea of one side of the body.

40. Causes
Huntington's disease
• Huntington's disease is a chronic, progressive, neurodegenerative
disease and most common inherited cause of chorea. The condition
was formerly called Huntington's chorea but was renamed because of
the important non-choreic features including cognitive decline and
behavioural change.
• A genetic mutation in Huntington disease, the presence of a repeat in
the Huntington gene (HTT), has been identified.

41. Other genetic causes
• The classical Huntington's disease 'mimic' or phenocopy
syndromes, called Huntington's disease-like syndrome types 1, 2
and 3; inherited prion disease, the spinocerebellar ataxias type 1,
3 and 17, neuroacanthocytosis, dentatorubral-pallidoluysian
atrophy (DRPLA), brain iron accumulation disorders, Wilson's
disease, benign hereditary chorea, Friedreich's ataxia,
mitochondrial disease and Rett syndrome.

42. Acquired causes
• Cerebrovascular disease
• HIV infection—usually through its association with cryptococcal disease.
• Sydenham's chorea occurs as a complication of streptococcal infection.
• Chorea gravidarum refers to choreic symptoms that occur during
pregnancy.
• Chorea may also be caused by drugs (commonly levodopa, anti-
convulsants and anti-psychotics).
• Other acquired causes include CSF leak, systemic lupus erythematosus,
thyrotoxicosis, polycythaemia rubra vera, transmissible spongiform
encephalopathies and coeliac disease.

44. Sign and symptoms
•Brief, semi-directed, irregular movements that are not repetitive or
rhythmic, but appear to flow from one muscle to the next. These 'dance-
like' movements of chorea often occur with athetosis, which adds twisting
and writhing movements. Walking may become difficult, and include odd
postures and leg movements.
•Unlike ataxia, which affects the quality of voluntary movements, or
Parkinsonism, which is a hindrance of voluntary movements, the
movements of chorea and ballism occur on their own, without conscious
effort. Thus, chorea is said to be a hyperkinetic movement disorder.
•When chorea is serious, slight movements will become thrashing
motions; this form of severe chorea is referred to as ballism, or ballismus.

45. Clinical Manifestations of Huntington chorea
(1)motor dysfunction (the most prominent is chorea, or rapid,
jerky, involuntary, purposeless movements)
(2) cognitive impairment (problems with attention and emotion
recognition)
(3) behavioral features, such as apathy and blunted affect

46. •All of the body musculature is involved. Facial movements produce
tics and grimaces. Speech becomes slurred, hesitant, often explosive,
and eventually unintelligible. Chewing and swallowing are difficult,
and there is a constant danger of choking and aspiration.
•Choreiform movements persist during sleep but are diminished. As
with speech, the gait becomes disorganized to the point that
ambulation eventually is impossible.
Although independent ambulation should be encouraged for as long
as possible, a wheelchair usually becomes necessary.

47. •Eventually, the patient is confined to bed when the chorea interferes
with walking, sitting, and all other activities. Bladder and bowel
control are lost.
•Cognitive impairment, such as problems with attention emotion
recognition, occurs early on while in later stages, marked dementia is
present.
•The behavioral changes may be more devastating to the patient and
family than the abnormal movements. Personality changes may result
in nervous, irritable, or impatient behaviors. In the early stages,
patients are particularly subject to uncontrollable fits of anger,
profound and often suicidal depression, apathy, anxiety, psychosis, or
euphoria.

48. • Judgment and memory are impaired, and dementia eventually
ensues. Hallucinations, delusions, and paranoid thinking may
precede the appearance of disjointed movements. Emotional
and cognitive symptoms often become less acute as the disease
progresses.

49. Diagnosis
•History taking- Family history
•Physical examination
•CT and MRI- Shows symmetrical striatal atrophy before motor
symptoms appear.
•EEG
•Serological tests
•Peripheral blood smear
•Genetic testing- Known presence of the genetic marker CAG
repeats in HTT.

50. Treatment
•Huntington's-related- A common treatment is dopaminergic
antagonists, although treatment is largely supportive. Tetrabenazine is
the only FDA approved drug for the treatment of Huntington's disease-
related chorea.
•Sydenham's chorea- Haloperidol, carbamazepine and valproic acid.
Usually involves antibiotic drugs to treat the infection, followed by
drug therapy to prevent recurrence.
•Chorea gravidarum- Haloperidol, chlorpromazine alone or in
combination with diazepam, and pimozide can also be used.
•Drug-induced chorea- Adjusting medication dosages.
•Metabolic and endocrine-related choreas- Treated according to their
causes.

51. Surgery
Deep brain stimulation is a surgical approach for chorea treatment.

52. WILSON’S DISEASE
• Wilson's disease is a rare inherited disorder that causes
copper to accumulate in liver, brain and other vital organs.
• Most people with Wilson's disease are diagnosed between the
ages of 5 and 35, but it can affect younger and older people, as
well. Wilson's disease occurs in about 1 in 30,000 people.

53. Causes
Wilson's disease is inherited as an autosomal recessive trait.The
gene for Wilson's disease (ATP7B) was mapped to chromosome 13.
Risk factors
Family history of Wilson’s disease.

55. Pathophysiology
• Copper begins to accumulate immediately after birth but the
symptoms usually appear in the 2nd to 3rd decade. The first
signs are hepatic (liver) in about 40% of cases, neurological
(brain) in about 35% of cases and psychiatric, renal (kidney),
haematological (blood), or endocrine (glands) in the
remainder.

57. Symptoms
•Fatigue, lack of appetite or abdominal pain
•Golden-brown eye discoloration (Kayser-Fleischer rings)
•Liver-related symptoms include vomiting, weakness, fluid
build-up in the abdomen, swelling of the legs, yellowish skin
and sclera and itchiness.
•Brain-related symptoms include tremors, muscle stiffness,
trouble speaking, swallowing, personality changes, anxiety,
and psychosis.

58. Diagnosis
•Blood and urine tests. Blood tests can monitor liver function and check
the level of a protein that binds copper in the blood (ceruloplasmin) and
the level of copper in blood. The doctor also might want to measure the
amount of copper excreted in urine during a 24-hour period.
•Eye exam. Kayser-Fleischer rings and sunflower cataract
•Liver biopsy
•Genetic testing

59. Kayser-Fleischer rings

60. Sunflower cataract

61. Treatment
Medications
• Penicillamine (Cuprimine, Depen). A chelating agent, penicillamine
can cause serious side effects, including skin and kidney problems,
bone marrow suppression, and worsening of neurological
symptoms. It also keeps vitamin B-6 (pyridoxine) from working, so
one will need to take a supplement in small doses.
• Trientine (Syprine). Trientine works much like penicillamine but
tends to cause fewer side effects.
• Zinc acetate (Galzin). This medication prevents body from
absorbing copper from the food eaten.

62. Surgery
If liver damage is severe, one might need a liver transplant. During
a liver transplant, a surgeon removes diseased liver and replaces it
with a healthy liver from a donor.
Most transplanted livers come from donors who have died. But in
some cases, a liver can come from a living donor, such as a family
member. In that case, the surgeon removes diseased liver and
replaces it with a portion of the donor's liver.

63. Complications
• Scarring of the liver (cirrhosis)
• Liver failure
• Persistent neurological problems
• Kidney problems
• Psychological problems
• Blood problems

64. ESSENTIAL TREMORS
• Essential tremor (ET), also called benign tremor, familial tremor,
and idiopathic tremor, is a medical condition characterized by
involuntary rhythmic contractions and relaxations (oscillations or
twitching movements) of certain muscle groups in one or more
body parts of unknown cause.
• It typically is symmetrical, and affects the arms, hands, or fingers;
but sometimes involves the head, vocal cords, or other body parts.

65. Causes
About half of essential tremor cases appear to result from a genetic
mutation. This form is referred to as familial tremor. It isn't clear
what causes essential tremor in people without a known genetic
mutation.
Risk factors
•Genetic mutation. The inherited variety of essential tremor (familial
tremor) is an autosomal dominant disorder. A defective gene from
just one parent is needed to pass on the condition.
•Age. Essential tremor is more common in people age 40 and older.

66. PATHOPHYSIOLOGY

67. Symptoms
•Begin gradually, usually more prominently on one side of the body
•Worsen with movement
•Usually occur in the hands first, affecting one hand or both hands
•Can include a "yes-yes" or "no-no" motion of the head
•May be aggravated by emotional stress, fatigue, caffeine or
temperature extremes

68. Essential tremor vs. Parkinson's disease
•Timing of tremors. Essential tremor of the hands usually occurs
when one uses their hands. Tremors from Parkinson's disease are
most prominent when one’s hands are at their sides or resting in lap.
•Associated conditions. Essential tremor doesn't cause other health
problems, but Parkinson's disease is associated with stooped
posture, slow movement and shuffling gait. However, people with
essential tremor sometimes develop other neurological signs and
symptoms, such as an unsteady gait (ataxia).
•Parts of body affected. Essential tremor mainly involves hands, head
and voice. Parkinson's disease tremors usually start in hands, and can
affect legs, chin and other parts of body.

69. Diagnosis
History taking
• Personal history
• Family history
• Medication history
Physical examination
• Part of body involved
• Frequency and duration of tremor

70. Neurological examination
• Tendon reflexes
• Muscle strength and tone
• Ability to feel certain sensations
• Posture and coordination
• Gait
Laboratory tests
Blood and urine may be tested for several factors, including:
• Thyroid disease
• Metabolic problems
• Drug side effects
• Levels of chemicals that may cause tremor

71. Performance tests
• Drink from a glass
• Hold arms outstretched
• Write
• Draw a spiral

72. Treatment
Medications
• Beta blockers- Propranolol (Inderal).Beta blockers may not be an option
if one has asthma or certain heart problems. Side effects may include
fatigue, lightheadedness or heart problems.
• Anti-seizure medications- Primidone (Mysoline), gabapentin (Gralise,
Neurontin) and topiramate (Topamax, Qudexy XR). Side effects include
drowsiness and nausea, which usually disappear within a short time.

73. • Tranquilizers- Clonazepam (Klonopin). Side effects can include
fatigue or mild sedation.
• OnabotulinumtoxinA (Botox) injections. Botox injections might be
useful in treating some types of tremors, especially head and voice
tremors. Botox injections can improve tremors for up to three
months at a time.
• However, if Botox is used to treat hand tremors, it can cause
weakness in fingers. If Botox is used to treat voice tremors, it can
cause a hoarse voice and difficulty swallowing.

74. Therapy
• Physical or occupational therapy. Physical therapists can teach
exercises to improve muscle strength, control and coordination.
• Occupational therapists can help adapt to living with essential
tremor. Therapists might suggest adaptive devices to reduce the
effect of tremors on daily activities, including:
Heavier glasses and utensils
Wrist weights
Wider, heavier writing tools, such as wide-grip pens

75. Surgery
Deep brain stimulation
Side effects of deep brain stimulation can include:
• equipment malfunction
• problems with motor control, speech or balance
• Headache
• weakness

76. Focused ultrasound thalamotomy.
• This non-invasive surgery involves using focused sound waves
that travel through the skin and skull. The waves generate heat to
destroy brain tissue in a specific area of the thalamus to stop a
tremor.
• A surgeon uses magnetic resonance imaging to target the correct
area of the brain and to be sure the sound waves are generating
the exact amount of heat needed for the procedure.
• Focused ultrasound thalamotomy creates a lesion that can result
in permanent changes to brain function. Some people have
experienced altered sensation, trouble with walking or difficulty
with movement.

78. Nursing Diagnosis
1.Risk for injury from falls and possible skin breakdown (pressure
ulcers, abrasions), resulting from constant movement.
Nursing Interventions -
•Pad the sides and head of the bed; ensure that the patient can
see over the sides of bed.
•Use padded heel and elbow protectors.
•Keep the skin meticulously clean.

79. •Apply emollient, cleansing agent and skin lotion as needed.
•Use soft sheets and bedding.
•Encourage ambulation with assistance to maintain muscle tone.
•Secure the patient (only if necessary) in bed or chair with
padded protective devices, making sure that they are loosened
frequently.

80. 2. Imbalanced nutrition: less than body requirements due to inadequate
intake and dehydration resulting from swallowing or chewing
disorders and danger of choking or aspirating food .
Nursing Interventions-
•Administer phenothiazines (chlorpromazine) as prescribed before meals
(calms some patients).
•Talk to the patient before mealtime to promote relaxation; use mealtime
for social interaction. Provide undivided attention and help the patient
enjoy the mealtime experience.
•Use a warming tray to keep food warm.
•Learn the position that is best for the patient. Keep patient as close to
upright as possible while feeding. Stabilize patient's head gently with one
hand while feeding.

81. •Show the food, explain what the foods
are, and temperature.
•Encircle the patient with one arm and get
as close as possible to provide stability and
support while feeding. Use pillows and
wedges for additional support.
•Do not interpret stiffness, turning away, or
sudden turning of the head as rejection;
these are uncontrollable choreiform
movements.
•For feeding, use a long-handled spoon
(iced tea spoon). Place spoon on middle of
tongue and exert slight pressure.

82. •Place bite-sized food between patient's
teeth.
•Disregard messiness, and treat the person
with dignity.
•Wait for the patient to chew and swallow
before introducing another spoonful. Make
sure that bite-sized food is small.
•Give between-meal feedings. Constant
movement expends more calories. Patients
often have voracious appetites, particularly
for sweets.

83. Use blenderized meals if patient cannot
chew; do not repeatedly give the same
strained baby foods. Gradually introduce
increased textures and consistencies to the
diet.
•For swallowing difficulties:
Apply gentle deep pressure around the
patient's mouth.
Rub fingers in circles on the patient's
cheeks and then down each side of the
patient's throat.
Develop skill in the abdominal thrust (to
be used in the event of choking).

84. 3.Impaired communication from excessive grimacing and
unintelligible speech.
Nursing Interventions-
•Employ biofeedback and relaxation therapy to reduce stress.
•Consult with speech therapist to help maintain and prolong
communication abilities.
•Try to devise a communication system.
•Learn how a particular patient expresses needs and wants-
particularly nonverbal messages (widening of eyes, responses).
•Patients can understand even if unable to speak. Do not isolate
patients by ceasing to communicate with them.

85. 1. Exercise regularly.
2. Get plenty of sleep.
3. Pay attention to diet.
4. Get social.
5. Learn to meditate.
6. Learn something new.

86. RESEARCH ARTICLES
Effectiveness of a modified comprehensive behavioral intervention for tics for children and
adolescents with tourette's syndrome: A randomized controlled trial
A randomized controlled trial was conducted by Chia-Wen Chen, Huei-Shyong Wang, Hsiu-Ju
Chang, Chang-Wei Hsueh to evaluate the effectiveness of a modified four-session
Comprehensive Behavioural Intervention for Tics programme for decreasing tics in children
and adolescents with Tourette's syndrome. Participants aged 6-18 years with Tourette's
syndrome or chronic tic disorder were recruited. Participants in the control and intervention
groups (N = 23 each) received the routine care (daily pyridoxine [50 mg] and
psychoeducation). The intervention group received additional four behavioural intervention
sessions over a 3-month period that included psychoeducation, habit reversal training,
relaxation training, and education on tic relapse prevention. The outcome measures, Yale
Global Tic Severity Scale scores, were assessed at before and after the completion of
programme for both groups and again at 3 months follow-up for the intervention group.
Comparison of scores before and after intervention showed that the intervention significantly
decreased the severity of total motor tics and total tics as compared with control treatment.
The study concluded that modified four-session Comprehensive Behavioural Intervention
for Tics programme was more effective than routine care for decreasing tic severity in our
cohort of 6 to 18-year olds. This improvement was maintained 3 months after intervention.

87. Tremor in Dystonia: A Cross-sectional Study from India
A cross-sectional study was conducted by Sanjay Pandey and Neelav Sarma to
assess for tremor in the head and in different body parts. It included 90 patients
with adult-onset, isolated dystonia from a tertiary care movement disorder center
in India. Surface electromyography studies of tremor were recorded of the involved
limb in different positions. Tremor was present in 41 patients who had dystonia,
including 21 patients with cervical dystonia, 15 with limb dystonia, and 5 with
cranial dystonia. Significantly, later age at presentation and longer disease duration
observed in patients with versus without tremor. Upper limb tremor was present in
33 patients, head tremor was present in 14, and leg tremor was present in 2.
Tremor was present in 17 of 25 patients with segmental dystonia and in 6 of 9 with
multifocal dystonia. The study concluded that tremor was least frequent in
patients with focal dystonia. Tremor was common in patients with primary adult-
onset dystonia. Patients who had tremor were older and had a longer duration
of symptoms. Patients with segmental and multifocal dystonia had more tremor
than those with focal dystonia. The patients had more upper limb tremor than
head tremor, and a combination of dystonic tremor and tremor associated with
dystonia was more common than isolated dystonic tremor.

88. SUMMARY AND CONCLUSION
• Movement disorders are neurologic conditions that cause
problems with movement, such as increased movement that can
be voluntary or involuntary or decreased or slow voluntary
movement.
• The Movement disorders (MD) Nurse Specialist has several key
functions : provide advanced levels of nursing care, assist other
nurses and health professionals in establishing and meeting
health goals of patients and families, integrate advanced
knowledge in a holistic assessment and focus on the functional
problems and behavior that require nursing interventions.

89. REFERENCES
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•Lewis. Medical Surgical Nursing Assessment and Management of clinical problems.2015.
New Delhi. Elsevier. 2nd Edition. Volume II. Pg. no.1498.
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