Prof. A.V. SRINIVASAN, MD, DM, Ph.D, F.A.A.N, F.I.A.N, EMERITUS PROFESSOR TAMILNADU DR.M.G.R MEDICAL UNIVERSITY CHENNAI

FORMER PROFESSOR AND HEAD INSTITUTE OF NEUROLOGY MADRAS MEDICAL COLLEGE

17th MAY 2009

RECENT ADVANCES IN THE MANGEMENT OF EXTRA PYRAMIDAL- (BASAL GANGLIA) DISORDERS

Sir William OslerSir William Osler

To study the phenomenon of disease To study the phenomenon of disease without books is to sail an uncharted without books is to sail an uncharted sea, while to study books, without sea, while to study books, without patients is not to go to sea at all.patients is not to go to sea at all.

Sir William Osler AphorismsSir William Osler Aphorisms

DEFINITIONDEFINITION

Movement disorders can be defined as Movement disorders can be defined as neurologic syndromes in which there is neurologic syndromes in which there is either an excess of movement or either an excess of movement or paucity of voluntary and automatic paucity of voluntary and automatic movements, unrelated to weakness or movements, unrelated to weakness or spasticity.spasticity.

MOVEMENT DISORERS MOVEMENT DISORERS DESCRIBEDDESCRIBED

Started on 1567 to 2008 – 111 Started on 1567 to 2008 – 111 conditionsconditions

MovementMovement No. of No. of PercentPercentDisorder Disorder PatientsPatientsParkinsonismParkinsonism 7568 7568 32.932.9

DystoniaDystonia 67986798 31.331.3TremorTremor 30133013 13.913.9Tics Tics 10221022 4.74.7(Tourette Syndrome)(Tourette Syndrome)ChoreaChorea 658658 3.13.1Tardive SyndromeTardive Syndrome 583583 2.72.7MyoclonusMyoclonus 547547 2.52.5Hemifacial SpasmHemifacial Spasm 359359 1.71.7AtaxiaAtaxia 316316 1.51.5Paraxysmal dyskniesiasParaxysmal dyskniesias 169169 0.80.8StereotypiesStereotypies 163163 0.70.7Restless legs syndromeRestless legs syndrome 108108 0.50.5Stiff-person syndromeStiff-person syndrome 3232 0.10.1Psychogenic movement disorderPsychogenic movement disorder 43.443.4

2.02.0

Grand TotalGrand Total 21,76621,766 100100

CATEGORIES OF MOVEMENTSCATEGORIES OF MOVEMENTS

1.1. AutomaticAutomatic

2.2. VoluntaryVoluntary

3.3. SemivoluntarySemivoluntary

4.4. InvoluntaryInvoluntary

DEDICATED TO PROF DEDICATED TO PROF C.D.MARSDEN- A GENIUS IN C.D.MARSDEN- A GENIUS IN MOVEMENT DISORDERSMOVEMENT DISORDERS

•P- PARKINSONISM

•R- RESTLESS LEG SYNDROME

•O- OROFACIAL DYSKINESIA

•F- FIBRILLATION AND FASCICULATIONS

• C –CHOREA INCLUDING HEMIBALISM

• D- DYSTONIA

• M- MYOCLONUS,MYOKYMIA,MYORHYTHMIA,MTAF

• A-ATAXIA,AKATHESIA,ATHETOSIS,ABD.DYS

• R-RETT SYNDROME,

• S-STEREOTYPY,SPASM(HEMIFACIAL),JUMPY STUMPS

• D-DYSKINESIA(PAROXYSMAL)

• E-ESSENTIAL TREMOR, EKPLEXIA(HYPER)

• N-NEUROLEPTIC INDUCED -TARDIVE DYSKINESIA

CHOREACHOREARandom, quick Random, quick

unsustained unsustained purposeless purposeless movements that movements that have an have an unpredictable unpredictable flowing patternflowing pattern

Huntington diseaseHuntington disease NeurocanthocytosisNeurocanthocytosis Postinfectious Postinfectious

choreachorea Drug-induced Drug-induced

choreachoreaVascular choreaVascular choreaAutoimmune choreaAutoimmune choreaChorea gravidarumChorea gravidarum

Ballismus, Chorea, Athotosis Ballismus, Chorea, Athotosis and Dystoniaand Dystonia

These should NOT be thought of as These should NOT be thought of as separate entities amenable to specific separate entities amenable to specific definition but rather as a SPECTRUM definition but rather as a SPECTRUM of movements that blend into one-of movements that blend into one-anotheranother

WHY?WHY?

Because……..Because……..

• They often co-exist They often co-exist

• Even neurologists may often not Even neurologists may often not be be able to agree as to how a able to agree as to how a particular particular movement movement should be classified!should be classified!

• They often ( with some notable They often ( with some notable exceptions ) have the same exceptions ) have the same

significance in terms of aetiology. significance in terms of aetiology.

The spectrumThe spectrum

Ballismus DystoniaChorea Athetosis

Movements become - Less violent / explosive / jerky

- Smoother and more flowing

- More sustained

They differ from tics in that they cannot be suppressed by voluntary control

BallismusBallismus

• Violent “flinging” movement of entireViolent “flinging” movement of entirelimblimb

• Almost always unilateral and thereforeAlmost always unilateral and therefore

use term “ HEMIBALLISMUS”use term “ HEMIBALLISMUS”

• Involves proximal musculature and is Involves proximal musculature and is sometimes thought of as a sometimes thought of as a

“ “ proximal unilateral chorea ”proximal unilateral chorea ”

• Usually due to a CVA in contralateral Usually due to a CVA in contralateral subthalamic nucleussubthalamic nucleus

Causes of Chorea, Dystonia Causes of Chorea, Dystonia and athetosisand athetosis

• HereditaryHereditary

• Static Encephalopathy ( Cerebral Palsy )Static Encephalopathy ( Cerebral Palsy )

• DrugsDrugs

• Cerebrovascular ( ischaemia, haemorrhage )Cerebrovascular ( ischaemia, haemorrhage )

• Structural lesions ( subthalamic nucleus)Structural lesions ( subthalamic nucleus)

• Secondary to medical disordersSecondary to medical disorders

• MiscellaneousMiscellaneous - Sydenham’s chorea- Sydenham’s chorea

- Chorea Gravidarum- Chorea Gravidarum

- Sporadic idiopathic torsion - Sporadic idiopathic torsion dystonia dystonia

- Focal dystonias- Focal dystonias

HereditaryHereditary

• Huntington’s diseaseHuntington’s disease

• Wilson’s diseaseWilson’s disease

• NeuroacanthocytosisNeuroacanthocytosis

• Hereditary dystoniasHereditary dystonias - idiopathic torsion dystonia- idiopathic torsion dystonia

- dopa - - dopa - responsiveresponsive dystoniadystonia

• Anoxic brain damage ( post – CPR ) Anoxic brain damage ( post – CPR )

• Systemic lupus erythematosisSystemic lupus erythematosis

• Hepatic failureHepatic failure

• EndocrineEndocrine - Thyrotoxicosis- Thyrotoxicosis

- Addisons- Addisons

• ElectrolyteElectrolyte - Low Ca, Mg, - Low Ca, Mg,

- High Na- High Na

• Polycythemia rubra veraPolycythemia rubra vera

Secondary to medical Secondary to medical disordersdisorders(A SHEEP)(A SHEEP)

Chorea ( “dance” in Greek)Chorea ( “dance” in Greek)

• Rapid irregular muscle jerksRapid irregular muscle jerks• May affect limbs, head, face and tongueMay affect limbs, head, face and tongue

• In the limbs chorea refers more to distal In the limbs chorea refers more to distal movements ( as proximal movements movements ( as proximal movements usually called ballismus)usually called ballismus)

• Patients often attempt to conceal involuntary Patients often attempt to conceal involuntary movements by superimposing voluntary movements by superimposing voluntary movements onto them e.g. an involuntary movements onto them e.g. an involuntary movement of arm towards face may be movement of arm towards face may be adapted to look-like an attempt to look at adapted to look-like an attempt to look at watchwatch

Sydenham’s choreaSydenham’s chorea

• Mainly children / adolescentsMainly children / adolescents

• Complication of previous group A Complication of previous group A streptococcal infectionstreptococcal infection

• Usually no recent history of infectionUsually no recent history of infection

• Acute / subacute onsetAcute / subacute onset

• May have behavioural problems May have behavioural problems

• Usually remits spontaneouslyUsually remits spontaneously

Chorea gravidarumChorea gravidarum

• Chorea of any cause that begins in Chorea of any cause that begins in pregnancypregnancy

• May represent recurrence of May represent recurrence of Sydenham’s chorea.Sydenham’s chorea.

• Most commonly associated with Most commonly associated with anti-phospholipid syndrome +/- SLEanti-phospholipid syndrome +/- SLE

• Usually resolves spontaneouslyUsually resolves spontaneously

Athetosis “ changeable” in Athetosis “ changeable” in GreekGreek• Slow, flowing, often twisting Slow, flowing, often twisting

movementsmovements• Occurs mainly distally ( hands, Occurs mainly distally ( hands,

fingers)fingers)• Can also affect face and tongueCan also affect face and tongue• Often use term “ choreoathetosis ” Often use term “ choreoathetosis ”

due to overlap between syndromes due to overlap between syndromes ( chorea referring to less smooth , ( chorea referring to less smooth , more jerky movements)more jerky movements)

MYOCLONUSMYOCLONUS

Sudden, Shocklike Sudden, Shocklike movementsmovements

Physiologic myoclonus Physiologic myoclonus Essential myoclonus Essential myoclonusMetabolic Metabolic encephalopathyencephalopathyPostanoxic myoclonusPostanoxic myoclonusProgressive myoclonicProgressive myoclonic

epilepsyepilepsy

TREATMENT OF MYOCLONUSTREATMENT OF MYOCLONUS

DrugDrugClonazepamClonazepamLevetiracetamLevetiracetamPiracetamPiracetamPrimidonePrimidoneValporateValporate

Initial Adult DoseInitial Adult Dose0.5 mg / day0.5 mg / day250 mg / day250 mg / day400 mg 3 times a 400 mg 3 times a

dayday25 mg / day25 mg / day125 mg 2 times a 125 mg 2 times a

dayday

TREATMENT OF MYOCLONUSTREATMENT OF MYOCLONUS

Usual Effective DoseUsual Effective Dose 2 mg/day divided2 mg/day divided

3 times a day 3 times a day

1000-1500 mg/day1000-1500 mg/day

1200-16,000 mg/day 1200-16,000 mg/day divided 3 times a daydivided 3 times a day

500-750 mg/day500-750 mg/day

750-1000 mg/day divided 2 750-1000 mg/day divided 2 times a daytimes a day

IndicationIndication Posthypoxic myoclonus Spinal Posthypoxic myoclonus Spinal

myoclonus Progressive myoclonic myoclonus Progressive myoclonic epilepsy Essential myoclonus epilepsy Essential myoclonus

Posthypoxic myoclous Cortical Posthypoxic myoclous Cortical myoclonus Spinal myoclousmyoclonus Spinal myoclous

Posthypoxic myoclonus Cortical Posthypoxic myoclonus Cortical myoclonus Progressive myoclonic myoclonus Progressive myoclonic epilepsy Essential myoclonusepilepsy Essential myoclonus

Cortical myoclonusCortical myoclonus

Most forms of myoclonusMost forms of myoclonus

TREMORTREMOR

Repetitive Repetitive oscillation of a oscillation of a body partbody part

Essential tremorEssential tremorPhysiologic tremorPhysiologic tremorParkinson tremorParkinson tremorCrebellar tremorCrebellar tremor

TREATMENT OF ESSENTIAL TREMORTREATMENT OF ESSENTIAL TREMOR

DrugDrug Initial Adult Initial Adult Usual Usual EffectiveEffective

Dose Dose Dose DosePropranololPropranolol 20 mg/day20 mg/day 80-240 mg/day80-240 mg/day

PrimidonePrimidone 12.5-25mg 12.5-25mg 50-300 mg/day50-300 mg/day at bed timeat bed time divided Bio ordivided Bio or at bedtimeat bedtime

TopiramateTopiramate 12.5=25mg/day12.5=25mg/day 400 mg/day 400 mg/day maximum dosemaximum dose

divided Biodivided Bio

Class Class Drug Drug Usual EffectiveUsual Effective Dose (mg/day)Dose (mg/day)Antichlinergic Antichlinergic Trihexyphenidyl Trihexyphenidyl 6 – 80 6 – 80 agent agent Benztropine Benztropine 4 – 8 4 – 8

Ethopropazine Ethopropazine 100-400 100-400

Benzodiazepine ClonazepamBenzodiazepine Clonazepam 1 – 4 1 – 4 Diazepam Diazepam 10 – 60 10 – 60

Lorazepam Lorazepam 1 – 6 1 – 6

Dopamine-deple- Tetrabenzine Dopamine-deple- Tetrabenzine 50 – 200 50 – 200 ting agentting agent Reser[ome Reser[ome 1 – 3 1 – 3

GABA against GABA against Baclofen Baclofen 30 – 80 30 – 80

TREMOR CONTD..TREMOR CONTD..

TICTIC

Stereotyped, Stereotyped, automatic automatic purposeless purposeless movements and movements and vocalizationsvocalizations

Tourette syndromeTourette syndromeCelebral palsy or Celebral palsy or

developmental developmental delay syndromesdelay syndromes

AutismAutismHuntington diseaseHuntington disease

PRIMARY TIC DISORDERSPRIMARY TIC DISORDERS

DISORDERDISORDERTourette syndromeTourette syndrome

Transient tic disorderTransient tic disorder

DIAGNOSTIC CRITERIADIAGNOSTIC CRITERIAPresence of multiple motor Presence of multiple motor

and vocal ticsand vocal ticsAge at onset <21 yAge at onset <21 yTics must occur many times Tics must occur many times

daily, nearly every day, over daily, nearly every day, over a period of >1y a period of >1y

Disturbance causes marked Disturbance causes marked distress or significant distress or significant impairment in daily impairment in daily functioning functioning

Condition cannot be ascribed Condition cannot be ascribed to known neurological to known neurological disorder (symptomatic or disorder (symptomatic or secondary tic disorder)secondary tic disorder)

Duration of tic disorder <1 yDuration of tic disorder <1 y

Primary tic disordersPrimary tic disorders

DisorderDisorder

Chronic tic disorderChronic tic disorder

Chronic single tic Chronic single tic disorderdisorder

Adult-onset tic Adult-onset tic discorderdiscorder

Diagnostic CriteriaDiagnostic CriteriaChronic motor or chronic vocal Chronic motor or chronic vocal

tics (but not both of >1ytics (but not both of >1y

Chronic single motor or chronic Chronic single motor or chronic single vocal ticsingle vocal tic

Tic order that begins > age 21Tic order that begins > age 21Two temporal patterns:Two temporal patterns:- De novo adult-onset ticDe novo adult-onset tic- Recurrent childhood tic – a tic Recurrent childhood tic – a tic

disorder than goes into disorder than goes into remission and recurs during remission and recurs during adulthoodadulthood

DIFFERENTIAL DIANOSIS OF TICSDIFFERENTIAL DIANOSIS OF TICSCClassificationlassification Diffenential Diffenential DiagnosisDiagnosisSimple Motor TicsSimple Motor TicsClonicClonic MyoclonusMyoclonus ChoreaChorea SeizuresSeizuresDystonia Dystonia DystoniaDystonia AthetasisAthetasisTonicTonic Muscle spasms and Muscle spasms and crampscrampsComplex Motor TcsComplex Motor Tcs MannerismsMannerisms StereotypiesStereotypies Restless legs syndromeRestless legs syndrome SeizureSeizurePhenomenologyPhenomenologyAbruptAbrupt MyoclonusMyoclonus ChoreaChorea HyperekplexiaHyperekplexia Paraxysmal dyskinesiaParaxysmal dyskinesia

SeizuresSeizuresSensory phenomenon Sensory phenomenon Akathisia-stereotypyAkathisia-stereotypy(urge relief) (urge relief) Restless legs syndromeRestless legs syndrome DystoniaDystonia

Classification Classification

Diffenential Diffenential DiagnosisDiagnosis

Perceived as voluntaryPerceived as voluntary Akasthisia AkasthisiaSuppressibility Suppressibility All hyperkinesias but less than All hyperkinesias but less than

ticsticsDecrease with distractionDecrease with distraction Akasthisia Akasthisia Psychogenic movements Psychogenic movements Increase with stressIncrease with stress Most hyperkinesias Most hyperkinesiasIncrease with relaxationIncrease with relaxation Parkinsonian tremor Parkinsonian tremor (after a period of stressA)(after a period of stressA)Multifocal migrateMultifocal migrate Chorea Chorea MyoclonusMyoclonusFluctuate spontaneouslyFluctuate spontaneously Paraxysmal dykinesias Paraxysmal dykinesias SeizuresSeizuresPresent during sleepPresent during sleep Myoclonus (segmental) Myoclonus (segmental) Periodic movementsPeriodic movements Painfullegs / moving toesPainfullegs / moving toes Other hyperkinesiasOther hyperkinesias SEizuresSEizures

Treatment of tic disordersTreatment of tic disordersDrugDrug Usual Usual PotentialPotential EffectiveEffective

ClonideClonide 0.05-0.50.05-0.5 Drowsiness, hypotensionDrowsiness, hypotension

GuanfacineGuanfacine 0.5 – 4 0.5 – 4 Drowsiness, hypotensionDrowsiness, hypotension

ClonazepamClonazepam 0.25 – 2 0.25 – 2 Drowsiness, irritabilityDrowsiness, irritability

TetrabenazineTetrabenazine 12.5 – 10012.5 – 100 Drowsiness, hypotension, depression, Drowsiness, hypotension, depression, parkinsonismparkinsonism

ReserpineReserpine 0.25 – 3 0.25 – 3 Drowsiness, hypotension, depression Drowsiness, hypotension, depression parkinsonismparkinsonism

RisperidoneRisperidone 0.5 – 12 0.5 – 12 Parkinsonism, risk of tardive dyskinesiasParkinsonism, risk of tardive dyskinesias

OlanzapineOlanzapine 2.5 – 15 2.5 – 15 Parkinsonism, riks of tardive dyskinesiasParkinsonism, riks of tardive dyskinesias

Pimozide Pimozide 0.5 – 10 0.5 – 10 Parkinsonism, risk of tardive dyskinesias, Parkinsonism, risk of tardive dyskinesias, retinopathyretinopathy

HaloperidolHaloperidol 05 – 20 05 – 20 Parkinsonism, risk of tardive dyskinesiasParkinsonism, risk of tardive dyskinesias

Treatment of neuropsychiatric Treatment of neuropsychiatric symptoms associated with tic symptoms associated with tic disordersdisorders

NeuropsychiatricNeuropsychiatric Drug Drug Usual Usual EffectiveEffective

Obessive Obessive ClomipramineClomipramine 25 – 25025 – 250Compulsive Compulsive FluoxetineFluoxetine 10 – 60 10 – 60 Disorder (OCD)Disorder (OCD) SertralineSertraline 25 – 20025 – 200 FluvoxamineFluvoxamine 25 – 30025 – 300 VenlafaxineVenlafaxine 75 – 22575 – 225 CitalopramCitalopram 10 – 4010 – 40 Buspirone Buspirone 5 – 305 – 30 ClonazepamClonazepam 1.5 – 601.5 – 60

Attention-deficitAttention-deficit MethylphenidateMethylphenidate 2.5 – 60 2.5 – 60 Disorder (ADD) or Disorder (ADD) or Dextroamphetamine Dextroamphetamine 2.5 - 402.5 - 40Attention-deficit/ Attention-deficit/ Pemoline Pemoline 18.75 – 112.5 18.75 – 112.5 Hyperactivity Hyperactivity Modafinil Modafinil 100 – 400 100 – 400 Disorder (ADHD)Disorder (ADHD)

Dopamine receptor – blocking Dopamine receptor – blocking agentsagentsClassClassPhenothiazinePhenothiazine• AlphaticAlphatic

• PiperidinePiperidine• PiperidinePiperidine

ThioxantheneThioxanthene• AliphaticAliphatic• PiperazinePiperazineButyrophenoneButyrophenoneDiphenylbutylpiperidineDiphenylbutylpiperidineDibenzazepineDibenzazepineDibenzodiazepineDibenzodiazepineThienobenzodiazepineThienobenzodiazepineSubstituted benzamideSubstituted benzamide

DrugDrug

Chlorpromazine, Chlorpromazine, triflupromazinetriflupromazineThioridazine,mesoridazineThioridazine,mesoridazineTrifluoperazine, prochlor perazine, Trifluoperazine, prochlor perazine,

perphenazine fluphenazineperphenazine fluphenazine

ChlorprothixeneChlorprothixeneThiothixeneThiothixene

Haloperidol, droperidolHaloperidol, droperidolPimozidePimozideLoxapineLoxapineClozapine, quetiapineClozapine, quetiapineOlanzapineOlanzapine

Indalone Indalone PyrimidinonePyrimidinoneBenzothiazoleBenzothiazoleBenzisoxazoleBenzisoxazoleTricyclic antidepressantTricyclic antidepressantCalcum channel blockerCalcum channel blocker

Metoclopramide, tiapride, Metoclopramide, tiapride, Sulpiride, Clebopride, Sulpiride, Clebopride, remoxipride, veraliprideremoxipride, veraliprideMolindoneMolindoneRisperidoneRisperidoneZiprasidoeZiprasidoeIloperiodeIloperiodeAmoxapieAmoxapieFlunarizineCinnarizineFlunarizineCinnarizine

ClasClasss

DruDrugg

DopamineDopamine receptor – receptor – blocking agentsblocking agents

General guidelines for treating General guidelines for treating tardive syndromestardive syndromes• Taper and slowly eliminate causative medications, if clinically Taper and slowly eliminate causative medications, if clinically

possible. Avid sudden cessation of these drugs, which can exacerbate possible. Avid sudden cessation of these drugs, which can exacerbate symptomssymptoms

• If treatment of tardive movements is necessary, the drugs of first If treatment of tardive movements is necessary, the drugs of first choice are the dopamine-depleting drugs reserpine, tetrabenazine, choice are the dopamine-depleting drugs reserpine, tetrabenazine, and a-methylparatyrosine. Monitor for the development of and a-methylparatyrosine. Monitor for the development of depression, hypotension sedation, and parkinsonism.depression, hypotension sedation, and parkinsonism.

• If dopamine-depleting agents are ineffective, consider a trial of If dopamine-depleting agents are ineffective, consider a trial of clozpine or quetiapine.clozpine or quetiapine.

• Dopamine receptor-blocking agents can be used as medications of Dopamine receptor-blocking agents can be used as medications of last resort for patients with tardive syndromes despite the risk of last resort for patients with tardive syndromes despite the risk of worsening the syndrome over the long term.worsening the syndrome over the long term.

• Consider globus pallidus stimulation if pharmacotherapy is Consider globus pallidus stimulation if pharmacotherapy is ineffective.ineffective.

NEUROLEPTIC INDUCED NEUROLEPTIC INDUCED MOVEMENT DISORDERSMOVEMENT DISORDERS

1.1. Acute reactionAcute reaction a. Acute dystoniaa. Acute dystonia b. Acute (Subacute) akathisiab. Acute (Subacute) akathisia2. 2. Toxicity state (over dosage)Toxicity state (over dosage) a. Drug-induced parkinsonisma. Drug-induced parkinsonism3.3. Neuroleptic malignant syndrome (NMS)Neuroleptic malignant syndrome (NMS)4.4. Tardive stbdrinesTardive stbdrines a. Withdrawal emergent syndromea. Withdrawal emergent syndrome b.Classic fardive dyskinesiab.Classic fardive dyskinesia c. Tardive dystoniac. Tardive dystonia d. Tardive akathisiad. Tardive akathisia e. Tardive myoclonuse. Tardive myoclonus f. Tardive tremorf. Tardive tremor g. Tardive ticsg. Tardive tics h. Tardive Choreah. Tardive Chorea i. (?) Tardive parkinsonismi. (?) Tardive parkinsonism

TERMINOLOGY OF THE TARDIVE SYNDROMESTERMINOLOGY OF THE TARDIVE SYNDROMES

Description Description Equivalent Equivalent CommonNamesCommonNames

Tardive syndromes Tardive syndromes Tardive syndromeTardive syndromeas a group as a group Tardive dykinesiaTardive dykinesiaRepetitive, rhythmic Repetitive, rhythmic Classic tardive Classic tardive Movements, usually in Movements, usually in dyskinesiadyskinesiaThe oral-buccal-lingual The oral-buccal-lingual Tardive setreotypyTardive setreotypyRegion Region Rhythemic choreaRhythemic choreaDystonic movementsDystonic movementsand posturesand posturesrestlessness and therestlessness and the Tardive akasthisiaTardive akasthisiamovement that occurmovement that occuras resultas resultMyoclonusMyoclonus Tardive myoclonusTardive myoclonusTremor Tremor Tardive tremorTardive tremorTucs Tucs Tardive ticsTardive tics Tardive tourettismTardive tourettismChoreaChorea Withdrawal emergent syndromeWithdrawal emergent syndrome Tardive choreaTardive choreaOculogyriaOculogyria Tardive oculogyric crisisTardive oculogyric crisisParkinsonismParkinsonism Tardive Parkinsonism (if it exists)Tardive Parkinsonism (if it exists)

Adverse Adverse EffectEffect

HaloperidaHaloperidall

ClozapinClozapinee

QuetiapiQuetiapinene

LanzopineLanzopine RisperidoRisperidonene

ParkinsonisParkinsonismm

YesYes YesYes Not yetNot yet YesYes YesYes

Acute Acute akastisiaakastisia

YesYes YesYes YesYes YesYes YesYes

Acute Acute dystoniadystonia

YesYes YesYes YesYes YesYes YesYes

Neuroleptic Neuroleptic malignant malignant syndromesyndrome

YesYes YesYes Not yetNot yet YesYes YesYes

Tardive Tardive syndromesyndrome

YesYes YesYes YesYes YesYes YesYes

NATURE HISTORY OF NATURE HISTORY OF TOURETTE SYNDROMETOURETTE SYNDROME

• Excerbation Excerbation Remission ?Remission ?

• Obsessive-compulsive behaviorObsessive-compulsive behavior

• Vocal tics (simple complex)Vocal tics (simple complex)

• Motor tics (rostrocaudalprogession)Motor tics (rostrocaudalprogession)

• Attention deficit with hyperactivityAttention deficit with hyperactivity

SummarySummary

• Movement disorders are often difficult to define Movement disorders are often difficult to define precisely, but have similar differential diagnoses.precisely, but have similar differential diagnoses.

• They are often a manifestation of a more widespread They are often a manifestation of a more widespread neurological or internal medical problem.neurological or internal medical problem.

• Other than the specific treatments mentioned, most Other than the specific treatments mentioned, most details of therapy are beyond the scope of this course.details of therapy are beyond the scope of this course.

• In some cases treatment includes treatment of In some cases treatment includes treatment of underlying cause e.g. Wilson’s disease underlying cause e.g. Wilson’s disease

Dedicated to my family for Dedicated to my family for making everything worthwhile making everything worthwhile

My sincere thanks to Faculty of Madras Institute of Neurology and Madras Medical

College for giving this opportunity to speak in the CME Program

My sincere thanks to Faculty of Madras Institute of Neurology and Madras Medical

College for giving this opportunity to speak in the CME Program

READ not to contradict or confute

Nor to Believe and Take for Granted

but TO WEIGH AND CONSIDER

THANK YOU