Key learning points:
– The most common movement and balance disorders
– The primary care practitioner’s role in patient care
– Treatment options available
Movement, gait and balance disorders represent a major health problem, especially in the older population.1,2 Movement disorders, such as Parkinson’s disease (PD), tremor, tics and dystonia, are common and disabling conditions.3,4 According to Abdo et al, 2010 “the overall prevalence of PD is 1% in people aged 65-85 years, increasing to 4.3% above the age of 85 years. The prevalence of essential tremor – the most common form of tremor – is 4% in people aged over 40 years, increasing to 14% in people over 65 years of age. The prevalence of tics in school-age children and adolescents can be as high as 21%1 and dystonia 0.016%.”5 This article discusses these disorders and where cerebellar signs and movement disorder occur together, as well as their social and healthcare impact, with the aim of guiding primary care nurses in their approach to the care of these patients, their families and carers.
Movement disorders are a diverse group of neurologic conditions,6 but the unifying patho-physiology relates to dysfunction of the basal ganglia and its interconnected pathways.6 The basal ganglia is composed of the caudate and the putamen (striatum), globus pallidus, sub-thalamic nucleus (STN), substantia nigra pars compacta and substantia nigra pars reticulata (SNpc and SNpr).6 Basal ganglia output neurons inhibit the motor thalamus and the mid-brain extrapyramidal area and decreased activity in the cerebral cortex and brainstem.7 Dopamine (DA) is one of the major regulatory neurotransmitters of the basal ganglia, and dopaminergic system dysfunction can manifest in highly divergent clinical presentations8 such as tremor,6 gait and balance problems.2
The clinical presentation of movement disorders can be complex and variable.1 As a primary care nurse practitioner, a useful approach to a patient with a movement disorder is to determine if the issue is too little movement (hypokinetic) or too much (hyperkinectic) (see Table 1).
Some movement disorders can look similar,9 such as rhythmic myoclonus and tremor. Equally, some patients may present with more than one movement disorder9 such as chorea together with dystonia. In these cases, it is helpful to ask the question – “What is the predominant movement disorder?”10
The most common movement disorder a primary care nurse is likely to encounter is tremor.11 The diagnosis of some movement disorders can be difficult, and it is important that patients are referred to experienced neurologists who specialise in movement disorders.1 Even in instances where the diagnosis is straightforward, patients benefit from the counselling and advice on management provided by a specialist.1
Within this group of patients, some present with cerebellar syndromes (ataxia)12 – the presentation of this disorder is highly variable and can show a mixture of movements9 (see Table 2).
The majority of movement disorders are incurable and treatment is symptomatic.4 They can be progressive conditions. Occasionally, patients manifest the physical symptoms of common movement disorders that cannot be attributed to any known underlying organic disorder – these are termed psychogenic movement disorders.13 As with most conditions, there are limited treatment options, therefore trust and good communication between the healthcare professionals and the patient is vital.14
The type of treatments can be subdivided in three major groups: supportive, medical and surgical.
1. Supportive treatment– An initial referral to specialised services, such as a neurologist and nurse specialist, is vital to ensure a timely diagnosis and access to appropriate supportive treatment.15 In the more advanced stages of the disease process, a supportive coordinated multi-disciplinary approach involving physiotherapy, occupation therapy, speech and language therapy, and specialist nurse care14 is often required. Patient-centric charitable organisations such as Parkinson’s UK can also play an important role.16,13 Many patients find national and local associations an effective way of accessing good quality information. The needs of the patient’s support network should not be forgotten, as they will often also need support.14
2. Medical treatment –For the majority of movement disorders, with the exception of Parkinson’s disease, medical treatment options are limited.17 Table 3 shows the most common drugs that a primary care nurse should encounter when looking after these patients. Achieving the optimum medical regime can be a long process, in order to balance clinical benefit against potential side effects. It is important that patients understand that it can, to some degree, be a “trial and error approach”.9
3. Surgical treatment –can be effective for Parkinson’s, dystonia and tremor. The surgical lesioning of a target nucleus in the basal ganglia involves the permanent destruction through heating the target nucleus.18 However, lesional surgery has now largely been replaced by deep brain stimulation (DBS).19 With DBS, electrodes are placed in the nuclei of the basal ganglia in the brain and connected to an implantable pulse generator (IPG) that delivers high frequency electrical pulses. The advantage of DBS over lesionional surgery is that it is reversible, adjustable and adaptable. Due to the surgical risks and high cost treatment, patient selection is vital to maximise a successful outcome following surgery.10
1. Abdo WF, van de Warrenburg BPC, Burn DJ, Quinn NP, Bloem BR. The clinical approach to movement disorders. Nature Publishing Group 2010;6(1):29-37.
2. Snijders AH, van de Warrenburg BP, Giladi N, Bloem BR. Neurological gait disorders in elderly people: clinical approach and classification. The Lancet Neurology 2007;6(1):63-74.
3. Horsfall L, Petersen I, Walters K, Schrag A. Time trends in incidence of Parkinson’s disease diagnosis in UK primary care. Journal of Neurology 2013;260(5):1351-7.
4. World Health Organization. Neurological disorders: a public health approach. Neurological Disorders: Public Health Challenges 2006;41-176. who.int/mental_health/neurology/chapter_3_a_neuro_disorders_public_h_challenges.pdf?ua=1 (accessed 23 October 2015).
5. Steeves TD, Day L, Dykeman J, Jette N, Pringsheim T. The prevalence of primary dystonia: A systematic review and meta-analysis. Movement Disorders 2012;31:27(14):1789-96.
6. Mink JW. The Basal Ganglia and Involuntary Movements. Archives of Neurology 2003;60:1365-8.
7. Mink JW. The Basal Ganglia: Foused Selection and Inhibition of Competing Motor Programs. Progress in Neurobiology 1996;50(4):381-425. sciencedirect.com/science/article/pii/S0301008296000421 (accessed 23 October 2015).
8. Kaye AH. Movement Disorders – Neurosurgical Aspects. In: Kaye A, editor. Essential Neurosurgery. 3rd ed. Victoria: Blackwell; 2007:263-8.
9. Edwards MJ, Quinn NP, Bhatia K. Parkinson’s Disease and other movement disorders [Internet]. 1st ed. Schoenberg MR, Scott JG, editors. Oxford Specialist Handbooks. New York: Oxford University Press; 2011:336.
10. Breen DP, Evans JR, Farrell K, Brayne C, Barker R a. Determinants of delayed diagnosis in Parkinson’s disease. Journal of Neurology 2013;260:1978-81.
11. Schrag A, Horsfall L, Walters K, Noyce A, Petersen I. Prediagnostic presentations of Parkinson’s disease in primary care: a case-control study. The Lancet Neurology 2014;14(1):57-64.
12. Pedroso JL, Carvalho AA, Escorcio Bezerra ML, Braga-Neto P, Abrahão A, Albuquerque MVC, et al. Unusual movement disorders in spinocerebellar ataxias. Parkinsonism & Related Disorders 2013;19(9):834-5.
13. Ricciardi L, Edwards MJ. Treatment of functional (psychogenic) movement disorders. Neurotherapeutics 2014;11(1):201-7.
14. van der Marck MA, Munneke M, Mulleners W, Hoogerwaard EM, Borm GF, Overeem S, et al. Integrated multidisciplinary care in Parkinson’s disease: a non-randomised, controlled trial (IMPACT). The Lancet Neurology 2013;12(10):947-56.
15. Breen DP, Evans JR, Farrell K, Brayne C, Barker R a. Determinants of delayed diagnosis in Parkinson’s disease. Journal of Neurology 2013;260(8):1978-81.
16. Gratwicke J, Jahanshahi M, Foltynie T. Parkinson’s disease dementia: a neural networks perspective. Brain 2015;138(6):1454-76.
17. Yu H, Neimat JS. The Treatment of Movement Disorders by Deep Brain Stimulation. Neurotherapeutics 2008;5(1):26-36.
18. Dwarakanath S, Zafar A, Yadav R, Arivazhagan A, Netravathi M, Sampath S, et al. Does lesioning surgery have a role in the management of multietiological tremor in the era of Deep Brain Stimulation? Clinical Neurology and Neurosurgery 2014;125:131-6.
19. Eller T. Deep Brain Stimulation for Parkinson’s Disease, Essential Tremor, and Dystonia. Disease-a-Month 2011;57(10):638-46.