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Motor System Examination Part-13 || Involuntary Movements || CNS Examination || Pediatrics — Transcript

by Learning Pediatrics · 3,160 words · 585 segments · language en · Watch on YouTube

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0:00hello everyone today in this video i am
0:03going to tell you the details of
0:05coordination and the abnormal moments
0:08this is the last part of the motor
0:10system examination i have already
0:12explained about the bulk posture tone
0:15power dtr superficial reflex and the
0:18gate in this v tube channel
0:22abnormal moments also known as the
0:24involuntary moments movement disorder or
0:27it is because of the lesion in the basal
0:29ganglia
0:31or extrapyramidal tract that's why known
0:33as the extrapyramidal
0:35disorders
0:37moments disorders are caused by lesion
0:40in the basal ganglia and the structure
0:42included in basal ganglia are coded
0:44putamen globus pallidus combinedly say
0:47as a stratum or corpus striatum with
0:50substantia and subthalamic nucleus
0:53and basal ganglia is the part of extra
0:55pyramidal system
0:58so other than the basal ganglia thalamus
1:01red nucleus and tegmentum of midbrain
1:03reticular formation inferior olivery
1:05nucleus and vestibular nucleus are also
1:08included in extra pyramidal system
1:10so broadly group a center and group b
1:14center are included in extra parameter
1:16system
1:18so in group a center
1:20there are structure of the basal ganglia
1:22are included while in the group b
1:25other is structure as red nucleus
1:28reticular formation olivary nucleus and
1:30vestibular nucleus there are various
1:31pathway which connect the
1:34either directly from the cortex to the
1:36group b sentence or the from cortex to
1:39the basal ganglia then from basal
1:41ganglia to the other structure in group
1:43b center
1:45so combinedly
1:47group a in group b center in which all
1:49these structure are included
1:51considered as a extra pyramidal system
1:56abnormal involuntary movement are
1:58categorized either hyperkinetic movement
2:00disorder or hypokinetic moment disorder
2:02so in hyperkinetic either korea
2:05ballistics dystonia there are various
2:07movement disorders in hypokinetic
2:10example resting tremor which is seen in
2:12the parkinson disease
2:14so today i am going to tell you the
2:16details of all these movement disorders
2:19in which athetosis ballismus
2:21dystonia myoclonus sticks and tumors
2:25are included so to remember all these
2:27movements
2:29there is a trick
2:31abcd my t
2:342
2:34so a4 athetosis b for ballismus c for
2:37chorea d for dystonia m4 myoclonus and
2:42t2 for ticks and tremors
2:47now the most important part of this
2:49presentation is how to differentiate all
2:51the involuntary moments
2:53so whenever we are seeing a patient with
2:56the abnormal movement we have to look
2:58which part of the body is involved so
3:00the location
3:02then the distribution
3:04is the proximal muscle or joint are
3:07involved or the distal muscles or joints
3:10are involved then we have to check the
3:12rhythmicity then rate the speed or
3:14frequency then amplitude and the force
3:17then relationship to the posture
3:19activity either during the sleep or not
3:21and then is it exaggerated with the
3:24emotions and the temperature
3:27so this will give us the clue about the
3:30which type of abnormal involuntary
3:32moment
3:33is this
3:35so now
3:36i will explain all the abnormal moments
3:38one by one so first treamers to define
3:42the dreamers we can say these are the
3:44purpose list involuntary movements these
3:46are rhythmic oscillatory moments
3:49and according to all these points
3:52we can say it involves the distal parts
3:54of the upper extremities generally
3:57but really it can also involve the
3:59armpit eyelids jaw or tongue
4:02but commonly it involves the hands and
4:05fingers
4:06there is a one example of fine eyelid
4:09streamers
4:10as seen in the hyperthyroid patient
4:13known as rosenberg sign
4:16according to distribution it involves
4:18the distal groups of the muscle and
4:20distal joints
4:22these are the rhythmic oscillatory
4:24moments and the frequency can vary from
4:27the slow to fast it can be between three
4:30to five hertz we label as a slow trimmer
4:33it can be fast between 10 to 20 hertz
4:37and force can also vary it can be fine
4:40trimmer as seen in the hypothyroid
4:42patient it can be coarse as seen in the
4:45wilson disease or it can be medium force
4:48and we have to check the relationship to
4:50the activity if it is during the resting
4:54we label as a resting trimmer as seen in
4:56the parkinson disease if it is
4:59associated with the activity we will
5:01label as a action treamer there are
5:04various other type of the action trimmer
5:07we will
5:08explain in next slide
5:12now how to examine for the dreamers
5:14so for the fine trimmer sometimes it is
5:17not visible with the
5:19resting position so we have to tell the
5:21child to out stretch the hands in this
5:24picture you can see
5:25if it is still not visible then we have
5:27to keep the piece of paper over the
5:30dorsum of both hands so the fine
5:32trimmers will be easily visible this is
5:35the way to demonstrate how to illicit
5:38for the dreamers
5:40now the types of trimmers it can be
5:43resting or aesthetic trimmer as i said
5:46previously or it can be action trimmer
5:49so the example of resting tremors is
5:52parkinson disease also known as a
5:55kinetic rigid syndrome
5:57in which patient will have the
5:58characteristic pill
6:00rolling movements
6:02and it is seen in the adults not in the
6:06pediatric patients because this is the
6:08disease of adults
6:12so now there are various subtypes of the
6:14action tremor it will be visible when
6:16the child will do the some kind of
6:18activity it will not be visible in
6:20resting state
6:22so what are the various subtypes of the
6:24action trimmer it can be intention or
6:26kinetic tremor as seen that in the
6:28cerebellar disease multiple sclerosis
6:31these are the low frequency tremor
6:33wing beating tremors seen in the western
6:36disease these are the core streamer
6:38and in this the proximal part of the
6:41upper extremities generally involved and
6:44these are the slow high
6:46amplitudes up and down movements and
6:50for illustrating the wing beating type
6:52of trimmer we have to tell the child to
6:55hold the arm
6:56with the shoulder abducted and elbow
6:59flexed and the characteristic wing
7:01beating type of the trimmers will be
7:03visible
7:04another is the essential tremors also
7:07known as physiological
7:09or exaggerated physiological it is seen
7:12in the old age label as a senile
7:14dreamers and rubral treamers are visible
7:19because of the lesion in cerebellar
7:21outflow or midbrain lesions
7:24orthostatic tumors will be visible when
7:26the child will stand
7:28also known as shaky leg syndromes it
7:32will not be visible in resting stage
7:35or when the child is sitting or lying
7:38down so these are the visible when the
7:41child will stand neuropathic tremors
7:43seen in the peripheral neuropathy and
7:46known organic or psychogenic tremors if
7:49you are not able to find out any
7:51etiology then you have to rule out
7:54any stress or any tension are associated
7:58with the trimmers
8:00so all these are the various subtypes of
8:03the action trimmers
8:06there are various drugs which can also
8:08lead to the trimmers if you are not able
8:10to find out any etiology then
8:12ask the detailed drug history example
8:15sometime patient is
8:17having the addiction with the alcohol
8:19nicotine caffeine amphetamine or
8:21aminophylline drugs can also lead to
8:23this
8:24antibiotic example aminoglycosides an
8:27anti-cholinergic anti-histaminic overuse
8:29can also lead to the tremor digepalm
8:32other antidepressants
8:34ssri lithium thyroxine
8:37even anti-convergent which we are
8:39generally using in the caesar disorder
8:41example phenytoin velproid can also lead
8:44to the
8:45dreamers
8:47now the another abnormal moment is the
8:49courier to define the korea it is the
8:51involuntary irregular known rhythmic
8:53purposeless and hyperkinetic it is rapid
8:57jerky unsustained moment
8:59so according to all these point it
9:02involves the one extremities generally
9:04if half of the body is involved we label
9:07as a hemi chorea and sometimes it is
9:09generalized also
9:11commonly involve the distal parts of the
9:13upper extremities really proximal parts
9:16lower limb face trunk lips tongue even
9:18the vocal cords can also be more it is
9:21known rhythmic
9:23and irregular moments
9:25while the dreamers are rhythmic
9:28regular
9:29and according to the read it is fast
9:32abrupt brief
9:34rapid jerky and unsustained moment
9:38and with the
9:40resting stage it can be present in rest
9:43or even during the action
9:45but it disappear with the sleep so
9:47whenever patient will be in sleeping
9:50stage korea will disappear
9:53there are various tests to elicit the
9:56korea example milk made grape spooning
9:59hyper pronation darting tongue piano
10:01playing movement so in this image you
10:03can see i am performing the milkmaid
10:05grip so for this we have to tell the
10:08child to hold the finger and child will
10:10have the constraint twitching movement
10:12of the hand
10:13and it is considered as a milkmaid grip
10:16other are spooning hyper pronation
10:19so for hyperpronation we have to tell
10:21the child to uh elevate the arms over
10:24the
10:26uh above the head
10:28and child will keep the position of hand
10:30in the hyperpronation
10:32you can see in this image and four is
10:34spooning
10:36we will tell the child to out stretch
10:38the hand and when child will do it
10:41hyper extension of the finger with
10:43flexion and dorsal arcing of the wrist
10:45occur in the shape of a spoon
10:48and the finger are separated and the
10:50thumb is abducted and drooped downward
10:53so considered as a spooning
10:56and for the darting tongue they will
10:58tell the child to protrude the tongue
11:00child will not be able to protrude the
11:02tongue and child will shoot out and jerk
11:05big quickly
11:06and also child will have the movements
11:08just like a piano playing
11:11so all these are the characteristic of
11:14the korea
11:16there are various etiology of the korea
11:18commonly we see the syndentum chorea due
11:21to the rheumatic fever
11:23also known as scent white dust dance
11:26other etiology it can be seen in some
11:28autoimmune disorder example sle
11:30antiphospholipid syndrome basic disease
11:33also in endocrine disorder example
11:35hyperthyroidis even in some infection
11:38neurosyphilis hiv
11:40even with the some inborn error of
11:42metabolism example known ketotic
11:44hyperglycemia
11:46it can be seen because of the basal
11:48ganglia lesion example in park trauma
11:51tumor
11:52and other
11:54causes can be some drugs can lead to the
11:57korea example levodopa phenytoin lithium
12:01even the isoniazide cocaine and ocp
12:04and other inborn error of metabolism in
12:06which the korea will be the finding
12:08example in pneumonic disease
12:11and
12:12neuroacanthosis lesk nihan syndrome so
12:15there are various other ideology
12:20now epithetosis
12:21to describe the eptosis we can say it is
12:24the slower more sustained large
12:26amplitude and irregular coarse moment
12:29so according to location it is generally
12:32unilateral but sometime bilateral we
12:34label as a double athatosis it
12:36distribution
12:37commonly involve the distal parts and
12:39fingers hands and toes generally
12:41involved but sometimes face naked rung
12:44can also be involved
12:45and it is somewhat rhythmic a regular
12:48movement riding an squaring character it
12:50is slower and sustained
12:53compared to the korea and amplitude it
12:56is large and coarse
12:58and generally we see the overflow
13:00phenomena that means it is intensified
13:03with the activity and also disappear
13:06with the
13:07sleep similar to the courier
13:10and whenever patient is having the
13:12athetosis we can label as a hemorrhoid
13:14disease
13:16and the moments of the athetosis there
13:18will be the combination of flexion
13:20extension adduction pronation supination
13:24and alternate degree of the movements
13:26will be there child will flow the
13:28body part in a very random manner
13:32direction will be changed randomly
13:35and affected limbs
13:37are in the uh constant motion so
13:40athetosis meaning means without any
13:43fixed position child will change the
13:44position of the
13:47extremities which are involved
13:51and sometimes there will be hyper
13:53extension of the finger and wrist sucker
13:56and pronation of the forearms and it
13:58will alternate with the full flexion of
14:00the finger rest and supination of
14:02forearm
14:04and sometimes child will also have the
14:06facial grimacing and it will be slower
14:09sustained than the coria
14:11and sometimes it may be
14:15associated with the other body parts
14:17movement
14:23now the etiology of athetosis generally
14:25it is conjunital
14:27seen due to the perinatal injury to the
14:29basal ganglia
14:30and
14:31athertotic cp is due to pathological
14:34changes in the coded and the putamen
14:36double athetos is associated with the
14:38status marmoratus of the basal ganglia
14:40due to anoxic birth injury
14:43we label the pseudoethosis or sensory
14:45athetosis whenever the patient is having
14:47the same type of the movement due to the
14:49loss of position sense
14:52as seen in the
14:53parietal lobe lesion or peripheral
14:56injuries
14:57example in the tabi's dorsal is in which
14:59the peripheral nerve disease is there in
15:02these condition abnormal movement will
15:04be more marked when the eyes will be
15:07close so
15:08patient will have the more abnormal
15:10movement when the
15:12having the no sense of
15:15position so we have to tell the child to
15:17close the eyes
15:20whenever child is having both
15:22characteristic pattern of the
15:25movements choreo and the athetosis we
15:28label as a choreoathetosis movement in
15:31this video you can see the child is
15:32having the
15:34abnormal movement of the distal
15:36extremities of the upper limb and the
15:38lower limb also having the twitching of
15:40the face child is having the combination
15:43of the choria and athetosis
15:46label as a choreoathertosis
15:50now dystonia to describe the dystonia
15:53these are the spontaneous involuntary
15:56sustained muscle contraction
15:58which will force the affected part of
16:00the body into the abnormal moment
16:02posture
16:04or spasm
16:06so according to the location it can be
16:08generalized focal or multifocal
16:10distribution generally affect the neck
16:13trunk and sometimes extremities space
16:16eyelids or even the vocal cord can be
16:18affected
16:19and
16:20according to the pattern involuntary
16:23muscle contraction will be there so the
16:25body part either will be in the abnormal
16:27moments or posture
16:30it is sustained slow cramp like moment
16:33if the duration is less than one second
16:36we will label as a dystonic is passed if
16:38between four to five seconds we will
16:40label as a dystonic moment if four
16:42minutes
16:43we will label as a dystonic posture
16:46and if it occur with the voluntary
16:49movements we will label as a action
16:51dystonia
16:55in this image you can see the child is
16:57having dystonia of the neck labeled as a
17:00retro collis
17:01extension moments are there and also
17:05having the
17:06facial dystonia and also the truncal
17:09dystonia
17:11there are various etiology of the
17:12dystonia it can be drug induced as seen
17:15in that cemented in anti-convergent
17:17calcium channel brokers
17:18and
17:20one condition dmd dystonia musculorum
17:23the form is it is a idiopathic condition
17:25labeled as a idiopathic tousan dystonia
17:28which is the rare progressive disease
17:31seen in the children's
17:32and patient of the wilson disease
17:35acquired hepatocerebellur degenerative
17:37disorder
17:39one inborn error of metabolism in which
17:41child will have the dopa responsive
17:43dystonia known as segawa disease
17:46it is characteristically have the
17:48diagonal variation in the severity and
17:51also patient will respond to the dose of
17:54levodopa
17:55if the patient is having the
17:58lesion in the striatum it will lead to
18:01the hemi dystonia of the contralateral
18:04site
18:06now the task is specific dystonia we
18:09label whenever patient is having the
18:11some particular
18:12activity and developing the dystonia
18:15example writers cram
18:17in which patient will have the focal
18:19dystonia of hand and the forearm
18:23and
18:24blepharospasm upper facial dystonia in
18:26which involuntary closure of both eyes
18:29occur
18:30bailly dancer dystonia it is because of
18:33the
18:35dance patient will have the abdominal
18:37musculature dystonia there are various
18:40other tasks specific dystonia
18:45now the ballistics
18:47it is
18:48characteristically
18:50wild flinging moments it involves the
18:53one side of the body then we label as a
18:55hemi ballistics if it involves the
18:58bilateral
18:59bibalismus or parabolic mass
19:01characteristically proximal portion of
19:03extremities will be involved it is spear
19:05the face and trunks
19:07it will not involve the face and trunk
19:10it is continuous swinging rolling
19:12throwing moments it is forceful it
19:15disappears with the deep sleep
19:18and it is such a forceful patient can
19:20throw the things whatever in
19:23that's why it is labeled as a throwing
19:26moment
19:27and etiology of the ballistics
19:30in parks or hemorrhage in the
19:32contralateral subthalamic nucleus will
19:34lead to the hemi ballistics
19:37and
19:38patient will have the
19:40such kind of violent movement during
19:43activity but it will disappear during
19:45the sleep so we can easily differentiate
19:48it
19:50another abnormal moment is sticks it is
19:53a very common condition in children to
19:55define the tick
19:57either we label as a simple motor tics
19:59if the patient is having simple movement
20:02example shoulder shrugging eye blinking
20:05facial twitching
20:07we label the complex sticks
20:09if the patient is having vocal tics
20:12having a
20:14some abnormal vocalization in the form
20:18of throat clearing or some bizarre
20:20vocalization
20:21it is repetitive and known rhythmic it
20:25can be sudden or fast
20:27and
20:28it disappear during the sleep
20:30voluntarily child can suppress it
20:33but whenever child will suppress it
20:36child will have the more anxiety more
20:38tension during this time and also will
20:40have the desire to elicit this moment
20:43but child can suppress so we can easily
20:46differentiate
20:47ticks can be suppressed by voluntary
20:51and other moments cannot be suppressed
20:54by the child it is exaggerated with the
20:57emotional strain and the tension
21:01now the last abnormal moment which i am
21:03going to describe is the myoclonus
21:08according to the location it commonly
21:10involves symmetrically
21:12extremities and the trunk symmetrically
21:15so the patient will have the bilateral
21:18abnormal movement it is not unilateral
21:20really phase your tongue pharynx larynx
21:23can also be involved
21:25and according to the distribution
21:28some portion or group of the muscle
21:30involved symmetrically on both sides of
21:32the body
21:34it is
21:35arrhythmic it is rapid abrupt reef jerky
21:39just like a shock like condition
21:41lightening movement
21:44and sometimes it is too weak on some
21:46time violent
21:47and relationship to the activity with
21:49resting or activity it can be present it
21:52is exaggerated by the some emotional
21:55visual tactile auditory stimuli and the
21:57one of the common example in pediatric
21:59patient is infantile spas before the
22:01myoclonus
22:03myoclonus can be epileptic or
22:05non-epileptic
22:06it can be simple complex
22:09so
22:10i'm not going into the detail of
22:12myoclonus movements right now
22:16in this video you can see the child is
22:18having the abnormal movement of the
22:20pellet pharynx and lips it is the
22:23palatal myoclonus due to central
22:25tegmentum lesion or inferior olivery
22:28nucleus lesion
22:31now the last part of the motor system
22:34examination is the coordination
22:36so coordination of the moments is the
22:38function of the cerebellum and we can
22:40assess all the tests whenever the age of
22:42the child is
22:44more than six year not possible in less
22:47than six years each group and
22:48coordination can
22:50can't be tested if the muscle power is
22:53less than
22:54grade three
22:55so what are the various uh coordination
22:58tests in upper limb finger no space
23:01rebound test this dido kinesia
23:03handwriting test
23:05in lower limb healing test cerebellar
23:08atexia rhomboxine tandem walking
23:11walkaround chair
23:13details of all these tests i will cover
23:15in cerebral function assessment
23:19thank you so much if you are having any
23:21query you can put into the comment box

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