bordeaux approach movement disorders€¦ · atetosis. 16 ballism. dystonia. myoclonus. tics...
TRANSCRIPT
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AnApproachtoPatientswithMovementDisorders
JoaquimFerreira,MD,PhDLaboratoryofClinicalPharmacologyandTherapeutics
FacultyofMedicineUniversityofLisbon
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• MDSvideolibrary
• MDS-OwnedRatingScales• GlobalAssessmentScaleforWilson'sDisease |Scale• GlobalDystoniaScale |Scale• ModifiedBradykinesiaRatingScale |Scale• Non-MotorSymptomsScale(NMSS) +(IncludesNMSQ) |Scale• QualityofLifeEssentialTremorQuestionnaire |ScoreSheet• RatingScaleforPsychogenicMovementDisorders |Scale• RushDyskinesiaRatingScale* |Scale• RushVideobasedTicRatingScale |Scale• UFMGSydenham'sChoreaRatingScale(USCRS) |Scale• UnifiedDyskinesiaRatingScale(UDysRS) +*• UnifiedDystoniaRatingScale(UDRS) |Scale• UnifiedMultipleSystemAtrophyRatingScale(UMSARS) |Scale• UnifiedParkinson'sDiseaseRatingScale(MDS-UPDRS) +*|Scale
• UHDRStrainingvideos• …
EDUCATIONALTOOLS
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• Definition:Agroupofsymptomsorsyndromes
characterizedbyinvoluntaryorabnormal
movements
MOVEMENTDISORDERS
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• History–When(started…worsened…)– How(rest…movement…)–Whereinthebody–Why(trigger…facilitator…)
MDAPPROACH
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1. Localization1. whereinthebody?
2. Phenomenology1. whattypeof
movements?
3. Aetiology1. whatisthecause?
4. Pathophysiology1. Whichmechanismsare
involved?
5. Treatment1. Howcanwetreat?
6. Prognosis1. Howwillthedisease
progress?2. Shouldtherebe
geneticcounselingtopatient/offspring?
MDAPPROACH
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• Focal– Musclesofonelocalizedpartofthebody
• Segmental– Cranial/axial/scapula/arm/leg…
• Hemi-focal– Hemibodywithorwithoutheadandneck
• Multifocal– >1nonadjacentfocalbodyparts
• Generalized– Segmental+anyotherpartofbody
LOCALIZATION
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• Observepatient:– asheenterstheroomandwhileheisnotbeingquestioned–segmentbysegment(wheneverpossible)
LOCALIZATION
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• Lookfordiscretesymptoms– Slighttremor–Minordystonicmovement– …
• Lookformaskingmovements– Handinthepocketforrestingtremor– Handbehindbackforchorea– …
LOCALIZATION
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• Physiological– Tremor,myoclonus
• Primary,idiopathic,essential• Secondary,symptomatic,acquired• Psychogenic
AETIOLOGY
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• Classificationofmovements– Voluntary
• Intentionallyinitiatedorevokedasareactiontoexternalstimulus– Automatic
• Learnedmotorbehaviours,performedwithoutconsciousactivation(walking,cycling,speech)
– Unvoluntary(Semi-automatic)• Initiatedbyinternalstimulus(scratchingduetoitch),orbyunpleasantfeelingorcompulsion(Restlesslegs,tics,Akathisia);canbevoluntarilysuppressedforashortduration
– Involuntary• Involuntaryinitiationandprogression,(althoughsomevoluntarymodulationmayoccur)
PHENOMENOLOGY
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• Classificationofmovementdisorders
• Movementdisordersoccurwhenthereiseither– Toomuchmovement(Hyperkinesias)
or– Insufficientmovement(Hypokinesias)
PHENOMENOLOGY
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• Hyper/Hypokinesia• Rhythmic/Nonrhythmic• Simple/Complex– Simple:tremor,myoclonus;– complex:tics,stereotypies
• Resting/Inducedorincreasedwithaction/tasks(mental/motor)
• Spontaneous/Provoked
PHENOMENOLOGY
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Hyperkinesias• Akathisia• Ballism• Chorea• Dystonia• Myoclonus• Restlesslegs• Startlereflex• Tics• Tremor
Hypokinesias• Akinesia/Bradykinesia/
Hypokinesia• Catatonia/Catalepsy• Freezing• Rigidity• Stiffmuscles
PHENOMENOLOGY
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14
CHOREA
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15
ATETOSIS
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16
BALLISM
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DYSTONIA
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MYOCLONUS
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TICS
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• Gait• Wheelchair• Facialexpression• Neckposture• Upper-limbposture• Handshake• …
WALKINGIN
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WALKING
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WHEELCHAIR
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FACIALEXPRESSION
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NECKPOSTURE
Arq.Neuro-Psiquiatr.vol.68no.6SãoPauloDec.2010
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HANDPOSTURE
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HANDSHAKE
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• Firstcomplain– Tremor,bradykinesiavs.cognition,axialsigns
• Durationsofsymptoms– NotPD,PDvsessentialtremor
• Familyhistory• RedflagsforIPD
– Memory/cognitiveimpairment– Falls– OH/diziness– Urinarycomplains– Sexualdysfunction– Dysphagia– Dysarthria
CLINICALHISTORY
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• Eyemovements• Oromandibular movements
FACE
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EYEMOVEMENTS
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OROMANDIBULARMOVEMENTS
• Tardive• LD• HDlike• MSA
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• Bradykinesia• Tremor• Rigidity• Posturalinstability
CARDINALSIGNSPARKINSONISM
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BRADYKINESIA
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• Head• Chin• Voice• Upperlimbs• Lowerlimbs
• Stretchoutthearms– Re-emergenttremor– Polyminimyoclonus
TREMOR
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TREMOR
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TREMOR
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“Jerks”
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• Cogwheel!• Intensity0vs.1• Assimetry
RIGIDITY
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• Armswing– Hall– Dystonia
• Turning• Footdystonia• Orthostatichypotension
GAIT
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TURNING
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FOOTDYSTONIA
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• Edema• Livedo reticularis
LEGS
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OTHEREVALUATIONS
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OTHEREVALUATIONS
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• Bloodpressure– Orthostatichypotension– Bradycardia• Acetylcholinesterase inhibitors• Propranolol
OUTRASAVALIAÇÕES
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• Worstandbestmomentsoftheday• Mosttroublesomeproblems• RelationwithLDintake
– Earlymorning– Afterlunch
• Somnolence/driving• Mood
– Treatwhatistreatable!
• Familymembers/caregiver– Nocturnalsleep– Mood– Hallucinations/delusions– Shopping/eating/gambling/sex
OTHERQUESTIONS
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SLEEP
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• Homevideos–smartphone
• Spendsomehoursatthehospital(“close”tothedoctor)
STRATEGIES
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• Pharmacologicalhistory• Drug-inducedparkinsonism
NOTTOMISS
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49
NOTTOMISS