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2004 SAE-P: rehabilitation of movement disorders
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2004 SAE-P: Rehabilitation of Movement Disorders Amy C. Phelan, MD, DVM 1. You are evaluating a 68-year-old patient with a severe resting tremor of approximately 4 to 6Hz affecting primarily the left distal upper extremity. On physical exam, you also note a flat facial affect and slow shuffling gait. If you were to prescribe medication to address this patient’s symptoms, which drug would be most appropriate? (a) Carbamazepine (b) Propranolol (c) Clonazepam (d) Levodopa Ref: (a) Charles PD, Esper GJ, Davis TL, Maciunas RJ, Robertson D. Classification of tremor and update on treatment. Am Fam Physician 1999;59:1565-72. (b) Cutson TM, Laub KC, Schenkman M. Pharmacological and nonpharmacological interventions in the treatment of Parkinson’s disease. Phys Ther 1995;75:363-73. 2. A 39-year-old man with a severe brain injury is 2 weeks out from his injury and still exhibiting significant agitation. The nursing staff reports that the patient is involuntarily turning his head consistently to the side of injury. After examining the patient, what would be your next step? (a) Prescribe clonazepam 0.5mg 3 times a day to address both the dystonia and the agitation (b) Place the patient in a cervical collar to decrease muscle tone and keep his head straight (c) Review the patient’s current medications for possible iatrogenic causes of dystonia (d) Administer botulinum toxin injections into the affected muscles to relieve the dystonia Ref: Friedman J, Standaert DG. Dystonia and its disorders. Neurol Clin 2001;19:681-705. 3. A 26-year-old woman presents for initial evaluation of gradually increasing tremors in her arms. You note that it is a postural tremor with a frequency of 4 to 11Hz affecting the proximal upper extremity more than the hands. She is otherwise healthy and cannot recall exactly when the tremors started, but remembers that her grandmother’s hands used to shake a lot. She is concerned about the possible cause and progression of her disorder. You inform her that (a) the typical course of her illness will be rapid worsening with onset of dementia and death, usually prior to the sixth decade of life. (b) her symptoms are consistent with a common type of tremor that may be hereditary in an autosomal dominant pattern with variable penetration. (c) you suspect that her symptoms are due to alcohol withdrawal and question her about her use of alcohol.
Arch Phys Med Rehabil Vol 85, Suppl 1, March 2004
(d) her symptoms are consistent with early Parkinson’s disease and recommend a trial of carbidopa and levodopa. Ref: (a) Anouti A, Koller WC. Tremor disorders: diagnosis and management. West J Med 1995;162:510-3. (b) Britton TC. Essential tremor and its variants. Curr Opin Neurol 1995;8:314-9. (c) Louis ED, Ottman R, Hauser WA. How common is the most common adult movement disorder? Estimates of the prevalence of essential tremor throughout the world. Mov Disord 1998;13:5-10. (d) Sandroni P, Young RR. Tremor: classification, diagnosis and management. Am Fam Physician 1994;50:1505-12. 4. Which statement best describes myoclonus? (a) Sudden, shock-like, brief, involuntary movements as a result of muscle contraction (b) Involuntary, rhythmic oscillation causing movement of a body part about a fixed plane in space (c) Sustained or intermittent muscle contractions that are exacerbated by particular movements or stress (d) Irregular, rapid, flowing, nonstereotyped, and random involuntary movements Ref: (a) Caviness JN. Myoclonus. Mayo Clin Proc 1996;71: 679-88. (b) Fahn S, Marsden CD, Van Woert MH. Definition and classification of myoclonus. Adv Neurol 1986;43:1-5. 5. A 12-year-old boy with a history of recent streptococcal pharyngitis develops rapid, irregular, purposeless, involuntary motor movements of his upper and lower extremities, and associated facial grimacing. His parents are understandably concerned and have many questions regarding their son’s condition. Among the information given to them, you would include (a) a recommendation for genetic counseling to rule out possible hereditary etiologies. (b) recommendations for medication management with neuroleptics. (c) reassurance that the condition is self-limiting and will subside without sequelae. (d) a recommendation for psychiatric evaluation to address his behavior. Ref: (a) Harel L, Zecharia A, Straussberg R, Volovitz B, Amir J. Successful treatment of rheumatic chorea with carbamazepine. Pediatr Neurol 2000;23:147-51. (b) Berkow R, Fletcher AJ, editors. The Merck manual of diagnosis and therapy. 17th ed. Rahway (NJ): Merck Sharp & Dohme Research Laboratories; 1992. p 2261-2.
2004 SAE-P: Rehabilitation of Movement Disorders Amy C. Phelan, MD, DVM 1. You are evaluating a 68-year-old patient with a severe resting tremor of approximately 4 to 6Hz affecting primarily the left distal upper extremity. On physical exam, you also note a flat facial affect and slow shuffling gait. If you were to prescribe medication to address this patient’s symptoms, which drug would be most appropriate? (a) Carbamazepine (b) Propranolol (c) Clonazepam (d) Levodopa Ref: (a) Charles PD, Esper GJ, Davis TL, Maciunas RJ, Robertson D. Classification of tremor and update on treatment. Am Fam Physician 1999;59:1565-72. (b) Cutson TM, Laub KC, Schenkman M. Pharmacological and nonpharmacological interventions in the treatment of Parkinson’s disease. Phys Ther 1995;75:363-73. 2. A 39-year-old man with a severe brain injury is 2 weeks out from his injury and still exhibiting significant agitation. The nursing staff reports that the patient is involuntarily turning his head consistently to the side of injury. After examining the patient, what would be your next step? (a) Prescribe clonazepam 0.5mg 3 times a day to address both the dystonia and the agitation (b) Place the patient in a cervical collar to decrease muscle tone and keep his head straight (c) Review the patient’s current medications for possible iatrogenic causes of dystonia (d) Administer botulinum toxin injections into the affected muscles to relieve the dystonia Ref: Friedman J, Standaert DG. Dystonia and its disorders. Neurol Clin 2001;19:681-705. 3. A 26-year-old woman presents for initial evaluation of gradually increasing tremors in her arms. You note that it is a postural tremor with a frequency of 4 to 11Hz affecting the proximal upper extremity more than the hands. She is otherwise healthy and cannot recall exactly when the tremors started, but remembers that her grandmother’s hands used to shake a lot. She is concerned about the possible cause and progression of her disorder. You inform her that (a) the typical course of her illness will be rapid worsening with onset of dementia and death, usually prior to the sixth decade of life. (b) her symptoms are consistent with a common type of tremor that may be hereditary in an autosomal dominant pattern with variable penetration. (c) you suspect that her symptoms are due to alcohol withdrawal and question her about her use of alcohol.
Arch Phys Med Rehabil Vol 85, Suppl 1, March 2004
(d) her symptoms are consistent with early Parkinson’s disease and recommend a trial of carbidopa and levodopa. Ref: (a) Anouti A, Koller WC. Tremor disorders: diagnosis and management. West J Med 1995;162:510-3. (b) Britton TC. Essential tremor and its variants. Curr Opin Neurol 1995;8:314-9. (c) Louis ED, Ottman R, Hauser WA. How common is the most common adult movement disorder? Estimates of the prevalence of essential tremor throughout the world. Mov Disord 1998;13:5-10. (d) Sandroni P, Young RR. Tremor: classification, diagnosis and management. Am Fam Physician 1994;50:1505-12. 4. Which statement best describes myoclonus? (a) Sudden, shock-like, brief, involuntary movements as a result of muscle contraction (b) Involuntary, rhythmic oscillation causing movement of a body part about a fixed plane in space (c) Sustained or intermittent muscle contractions that are exacerbated by particular movements or stress (d) Irregular, rapid, flowing, nonstereotyped, and random involuntary movements Ref: (a) Caviness JN. Myoclonus. Mayo Clin Proc 1996;71: 679-88. (b) Fahn S, Marsden CD, Van Woert MH. Definition and classification of myoclonus. Adv Neurol 1986;43:1-5. 5. A 12-year-old boy with a history of recent streptococcal pharyngitis develops rapid, irregular, purposeless, involuntary motor movements of his upper and lower extremities, and associated facial grimacing. His parents are understandably concerned and have many questions regarding their son’s condition. Among the information given to them, you would include (a) a recommendation for genetic counseling to rule out possible hereditary etiologies. (b) recommendations for medication management with neuroleptics. (c) reassurance that the condition is self-limiting and will subside without sequelae. (d) a recommendation for psychiatric evaluation to address his behavior. Ref: (a) Harel L, Zecharia A, Straussberg R, Volovitz B, Amir J. Successful treatment of rheumatic chorea with carbamazepine. Pediatr Neurol 2000;23:147-51. (b) Berkow R, Fletcher AJ, editors. The Merck manual of diagnosis and therapy. 17th ed. Rahway (NJ): Merck Sharp & Dohme Research Laboratories; 1992. p 2261-2.