Movement disorders

1. Movement Disorders

2. Basal ganglia

3. Functional circuits
of the basal ganglia

4. Classification
of movement disorders
• Hypokinetic-hypertonic movement disorders
– parkinsonism
• Hyperkinetic-hypotonic movement disorders
(dyskinesias)
– tremor
– chorea
– dystonia
– tics
– myoclonus
– ballism

5. Classification
of parkinsonism
1. Primary, idiopathic parkinsonism
Parkinson’s disease - 80 %
2. Secondary parkinsonism
• drug-induced
• toxic
• vascular
• post-hypoxic
• post-encephalitic
• post-traumatic
3.Parkinsonism-plus syndromes
• Progressive supranuclear palsy
• Levy body dementia
• Multiple system atrophy
• Cortico-basal degeneration

6. Pathophysiology
of parkinsonism

7. Pathogenesis of Parkinson’s disease
Dopamine loss
basal ganglia
Neurodegeneration
of substantia nigra

8. Neurodegeneration in Parkinson’s disease
enviromental factors ageing genetic factors
oxydative stress excitotoxity
lack of protective mechanisms
mitochondrial damage
loss of nigral cells
- loss of dopamine
loss of other cell populations
- loss of other
neurotransmitters
APOPTOSIS

9. • hypokinesia
• rigidity
• rest tremor
• postural
instability
Clinical features
of parkinsonism

11. Diagnostic criteria
of Parkinson's disease
 Hypokynetic-hypertonic
syndrome
 Unilateral beginning of
the disease
(+) effect of levadopa
 The absence of postural
instability, autonomic
symptoms, cognitive
disturbances at early stage

12. Dopaminergic treatment
of Parkinson’s disease
COMT
catabolism
catabolism
МАО-В
hemato-encephalic barrier
L - DOPA
decarboxylase inhibitor
reuptake
dopamine agonists

13. Treatment of Parkinson’s disease
• Levadopa drugs (nakom, madopar)
• Dopamine agonists (mirapex, pronoran)
• MAO-B inhibitors (selegiline)
• Amantidine (midantan)
• COMT – inhibitors
• Anticholinergic drugs (ciclodol)

14. Motor fluctuations
"OFF" state

15. "ON" state
Motor fluctuations

16. Drug-induced dyskinesias

17. Surgical treatment of Parkinson's disease
• Stereotactic destruction of
– thalamus
– pallidum
• Deep brain stimulation of
– thalamus
– internal segment of pallidum
– subthalamic nucleus
• Transplantation of dopamine-producing cells
– embrional cells

18. tremor
chorea
dystonia
tics
myoclonus
ballism
Hyperkinesis

19. Tremor
involuntary
rhytmic oscillating movements
in limbs or the whole body due to
alternating contraction of agonist and
antagonist muscles

20. • Rest (pill-rolling) tremor
• Action tremor
– postural (occurs during maintenance of a
posture )
– kinetic (occurs during voluntary movement )
– intentional (appears in movements and
increases near of the aim)
Types of tremor

21. • Physiological
• Pathological: essential tremor
Classification of tremor

22. • Fatigue
• Anxiety
• Cold
• Hypoglycemia
• Hyperthyriodism
• Drugs (coffein, steroids)
Increased physiological tremor

23. Essential tremor
• It’s type of postural tremor
• Rhythmic, usually symmetric movement in the
hands, may involve the head
• Autosomal-dominant inheritance
• Onset may be in adolescence or early adult
years; if it’s develops late – senile tremor
• Aggravated by emotional stress, disappears
with a small amount of alcohol
• Neurological examination is normal except for
tremor

24. Essential tremor

25. • β-adrenoblockers (propranolol)
• Anti-epileptic drugs (primidone,
clonazepam)
Treatment of tremor

26. sustained muscle contractions
frequently causing twisting and
repetitive movement or abnormal
postures
Dystonia

27. Dystonia
Focal (affects only one region of
the body)
Segmental (two adjacent
regions)
Multifocal (two or more
nonadjacent regions)
Hemidystonia
Generalized

28. Dystonia

29. Focal dystonia
blepharospasm
oromandibular dystonia
cervical dystonia: torticollis (head
rotation), laterocollis (head tilt to
one side), anterocollis,
posterocollis (flexion or extension
of the neck)
graphospasm (writer’s cramp)
spastic dysphonia
toy or foot dystonia
Cranial
distonia

30. • clonazepam
• Myorelaxants (baclofen, tizanidin)
• Anticholinergic drugs
• Botulotoxin (botox, disport)
Treatment of dystonia

31. is irregular, arrhythmic,
unpredictable, jerky movement,
which involves the extremities and
the face in continuous, random
sequence
Chorea

32. • Hereditary: Huntington disease, Wilson disease
• Secondary: Sydenham chorea (rheumatic),
infections, encephalitis, systemic lupus
erythematosus
• Drug-induced chorea: antipsychotic, estrogens,
levadopa
• Metabolic and endocrine: hyperthyroidism,
hyperglycemic non-ketotic encephalopathy
• Senile chorea
Classification of chorea

33. Huntington disease
• Autosomal-dominant inheritance
• Abnormal irregular rapid jerky movements
• Progressive dementia
• The gait is unsteady with a tendency to bob
and weave
• Facial grimacing with involuntary movements
of the tongue

34. Chorea

35. • Psychotic drugs
– Haloperidol 3-6 mg daily
– sulpiride
– sonopax
Treatment of chorea

36. is involuntary,
brief, sudden
(till 0,1 sec) muscle contractions
producing visible movement
Myoclonus

37. Essential
Symptomatic (Alzheimer disease,
Huntington disease, liver disease,
paraneoplastic syndromes)
Physiological (sleep myoclonus, hiccups)
Epileptic
Classification of myoclonus

38. Myoclonus

39. • clonazepam
• Valproat acid (depakin)
• Carbamazepin, hexamidin
• Nootropic drug (pyracetam) in high dosage
- 12 g i/v (in posthypoxic myoclonus)
Treatment of myoclonus

40. - are repetitive, rapid, usually brief
involuntary non-rhitmic stereotyped
movements, which involve the face,
axial muscles and proximal limbs.
Tics interrupt normal voluntary motor
activity
Tics

41. • Simple motor (blinking, twitching,
shrugging of the shoulders)
• Complex motor (handshaking,
scratching, kicking, toughing)
• Simple vocal (moaning, grunting,
hissing, clicking, shouting, throat
clearing, sniffing, coughing)
• Complex vocal (echolalia, coprolalia)
• Generalized (Tourette syndrome)
Classification of tics

42. Tics

43. • Clonazepam, baclofen
• Neuroleptics (sonopax, tiaprid)
• Haloperidol 0.25-10 mg daily
Treatment of tics

44. -sudden onset of violent involuntary flinging
movements of the limbs. Usually affects only one
side of the body (hemiballism).
The appearance is similar to a baseball pitcher’s
windup.
Caused by a lesion of the subthalamic nucleus,
usually as a result of stroke
Ballism

45. Ballism
Treatment: neuroleptic drugs