Movement disorders
HYPOKINETIC
- Parkinsonism (akinetic-rigid)
ATAXIA
HYPERKINETIC
- Stereotypies
- Tremor: regular and rhythmic
- Dystonia: more sustained and patterned
- Tics: jerk-like and temporarily suppressible
- Chorea: brief and random (Sydenham's, Huntingtons, Wilsons, SLE, CP,
- Athetosis
- Myoclonus
- Ballism
- Restless legs syndrome
Consider Wilsons Disease in all paediatric movement disorders
Benign paroxysmal torticollis of infancy
alternating hemiplegia of childhood (AHC)
psychogenic movement disorders
DDx
Hyperactivity
Tic
a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization that is experienced as irresistible, but can be suppressed for varying lengths of time
usually markedly diminished during sleep
- 5-10% of early school age (TS: 1% prevelence)
- 4:1 M:F
- 65% resolve by onset of puberty
- Peak severity of complex tics is 10-12y
Motor: Simple or complex
Vocal:
- simple (throat clearing, grunting, sniffing, barking)
- Complex:
- Coprolalia: obscene words
- Palilalia: repeating their words
- Echolalia: repeating others words
Pathophysiology
- Noradrenergic, glutamatergic, serotoninergic, opioid, cholinergic, GABAergic, and dopaminergic systems have all been implicated
- Largely due to the success with atypical antipsychotics, dopamine is the generally favoured hypothesis.
Associations
›ADHD
- ›Hyperactivtiy
- ›distractibility
- ›impulsivity
- ›learning difficulties
›Compulsions
›Anxiety
›Depression
Dx for all below
- <18yo
- Tic: a sudden, rapid, recurrent, non-rhythmic motor movement or vocalisation
- Not explained by a drug/medical condition
- Either motor OR vocal tic for <12 months (no longer has to be present for 4 weeks)
- Never had a higher diagnosis (Persistent or Tourette)
- Either motor OR vocal tics present for >12months (Dx no longer withheld if tic free for 3m)
- Never had higher diagnosis (Tourette Syndrome)
- 2 motor AND 1 vocal tic
- Present for >12 months (Dx no longer withheld if tic free for 3m)
Education
Monitoring
Treat comorbid conditions
Non-pharm
- Habit reversal training
- Focuses on one tic at a time
- Functional analysis
- Relaxation technique
- Psychosocial support
- Exposure with response prevention
- Attacks all tics simultaneously
- Less evidence but greater effect found
Pharm if pain (Physical, emotional, educational)
- Alpha 2a agonists (strong evidence as per Canadian Guidelines)
- Clonidine 0.03-0.3mg/day
- if comorbidity ADHD > stimulants ok
- more often improve tic
- in the few were they worsen > they return to baseline on cessation of stimulant