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Extra-pyramidal – Tutor Information

Extra-pyramidal – Tutor Information. PULSE: Preparation for Finals Tutor name. Resource summary. Common viva questions/topics Case-based additional information (Cases 1 – 5). Common questions. Things you might pick up and questions you will get asked….

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Extra-pyramidal – Tutor Information

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  1. Extra-pyramidal –Tutor Information PULSE: Preparation for Finals Tutor name

  2. Resource summary • Common viva questions/topics • Case-based additional information (Cases 1 – 5)

  3. Common questions • Things you might pick up and questions you will get asked…

  4. What is the function of the extrapyramidal system? Involuntary reflexes and movement, and co-ordination of movements

  5. What are the different patterns of increased tone? • ‘Clasp knife’ • ‘Lead pipe’ • Cogwheeling

  6. What are the different patterns of increased tone? • Spasticity = UMN. ‘Clasp knife’ • Rigidity = extrayramidal. ‘Lead pipe’ • Cogwheeling = increased tone with superimposed tremor

  7. What are the causes of Parkinsonism? • IPD - asymmetric tremor, good response to L-dopa • Vascular - Hx strokes, early falls, no tremor • PSP - failure of up gaze, early falls • MSA - cerebellar and pyramidal signs, postural drop, bladder dysfunction • DLB - hallucinations, cognitive decline • CBD - subcortical dementia, unilateral clumsiness/rigidity/bradykinesia • Wilsons - AR, liver disease, KF rings • Pugilistic - Hx head trauma e.g. boxing • Drugs - metoclopramide, domperidone, antipsychotics • Normal pressure hydrocephalus - urine incontinence, feet to floor gait, cognitive decline

  8. What are the essential features of Parkinsonism? • Tremor • Rigidity • Akinesia • Postural instability • TRAP!

  9. What are the other features of IPD? • Depression • Speech and swallow problems • Incontinence • REM sleep disturbance • Turning over in bed difficulty • Dementia • Anosmia • Handwriting - micrografia

  10. What are the indications and side effects of L-dopa therapy? • If <70yo first line is dopamine agonists, if >70yo start L-dopa • 75% develop motor complications at 5y • Given with peripheral decarboxylase inhibitor • Side effects: DOPAMINE - dyskinesia, on-off motor fluctuations, psychosis, ABP drop, mouth dryness, insomnia, N/V, excessive day time sleepiness

  11. What are the other treatments of IPD? • Physiotherapy, Occupational therapy support • Dopamine agonists (ropinirole, pramopexole) • COMT inhibitors (entacapone) • Apomorphine • Surgery (pallidotomy) • Deep brain stimulation

  12. DDx of a tremor?

  13. Case 1

  14. What are the causes of parkinsonism….? Idiopathic PD - Due to degeneration of dopaminergic neurons in the pars compacta of the substantianigra Secondary Parkinsonism - Drug induced - MPTD toxicity - Post-infective (Von Economo’s encephalitis, encephalitis lethargica Parkinsonian plus

  15. To complete my examination… • Cranial nerve examination • Full neurological Hx including drug history • Assess for and exclude parkinsonian-plus syndromes…

  16. Case 2

  17. Parkinson’s PLUS • Active stand reveals a postural drop Multi-system atrophy

  18. Case 3

  19. Parkinson’s PLUS • Visual fields – unable to look up Progressive Supra-nuclear palsy (PSP)

  20. Case 4

  21. Parkinson’s PLUS • Reduced score on MMSE; poor cognitive function Fronto-temporal or Lewy-body Dementia (FTD/LBD)

  22. Case 5

  23. Abdominal examination: • Dupytren’s contracture • Palmar erythema • LOSS of axillary hair • 8 spider naevi on anterior chest • Gynaecomastia Wilson’s Disease

  24. Special Tests for Parkinson’s • Gait – shuffling, poor initiation (hesitation), lack of normal arm swing, difficulty turning • Bradykinesia – decrease in speed and amplitude of complex movements • Tapping – ask pt to tap fingers in turn onto surface repeatedly, quickly and with both hands at once • Twiddling – rotating hands around each other in front of body • Tremor – resting, pill-rolling tremor (4-6 Hz); facilitated by distraction (e.g. serial 7s from 100, or moving the contralateral limb e.g. rapidly opposing contralateral thumb and fingers) • Tone – lead pipe rigidity (increased tone) or cogwheel (exaggerated stretch reflex interrupted by tremor) • Face • Absence of blinking • Lack of facial expression • Glabellar tap – keeping finger out of pt’s line of sight, tap middle of forehead (glabella) with middle finger – normal people blink a few times then stop; in PD blinking persists • Speech - Typically monotonous, soft and faint, lacking intonation; Palilalia sometimes present (repetition of end of word) • Writing - micrographia

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