Medical College Movement Disorders Program:
“Our goal is to help patients maintain a normal life.”

For some people it starts with a barely noticeable tremor of the hand or head. For others it’s an involuntary spasm after a particularly stressful day or subtle difficulty getting out of the car or rolling over in bed. Movement disorders can run the gamut from mild to disabling, but they are all based in the delicate balance that exists between the complex mechanisms of the nervous system and the motor system it controls.

Residents of Southeastern Wisconsin are fortunate to have a nearby resource that’s renowned for its outstanding care of patients with movement disorders. The Movement Disorders Program (MDP) at the Medical College of Wisconsin provides comprehensive evaluation, diagnosis and continuing treatment for all types of neurological movement disorders.

Recently I spoke with Karen Blindauer, MD, Assistant Professor of Neurology and Director of the Movement Disorders Program, about advancements in the treatment of movement disorders and the work being done by the Medical College team.

Dr. Blindauer is part of the national Parkinson’s Study Group and has been co-principal investigator in two major Parkinson’s research studies; she also participates in ongoing research at the Medical College of Wisconsin. In addition Dr. Blindauer teaches the basic neurology/movement disorders lectures for Medical College students and residents and teaches hospital courses on the diagnosis and treatment of movement disorders.

Managing Treatment for Optimum Health
Because most movement disorders are chronic and progressive, the role of the patient care team is somewhat different than that of most treatment centers, where the ultimate goal is often to find a cure. According to Dr. Blindauer, the patients and the Movement Disorders Program medical team make mutual decisions at each step of the disease process about the treatments that will have the best possible outcome for the patient’s needs. While the patient’s initial workup is based on a thorough clinical exam and exact diagnosis of the problem, much of the work that’s done on a long-term basis consists of fine-tuning the timing and combinations of medications.

“There’s no one algorithm that works for every patient,” says Dr. Blindauer. “We base individual treatment on a variety of criteria, including age and how active the patients are. Are they still working or is their lifestyle more sedentary? What are their other medical issues? Do they have a co-existing condition such as dementia that would lead to different side effects of certain medications? What are their lifestyle expectations? All these factors help us determine our approach to treating the patient.”

Evaluation
Patients being evaluated by the MDP are given a neurological exam that includes a systematic array of tests to determine the type and extent of their disorders. Most of the tests are surprisingly low-tech, considering the complex issues they can reveal. Neurologists might ask a patient to perform a series of tasks that includes writing, drawing, other fine motor hand movements, speaking, walking or standing in specific positions. In addition they will likely test strength, reflexes, and sensory responses. Because neurologists are highly trained in the body’s sensory and motor mechanisms, they can gather an astonishing amount of information from these tests. In some cases blood tests, EMG (electromyography, to test muscle tone), EEG (electroencephalography, to test brain function), MRI (magnetic resonance imaging, to visualize the brain or spine) or even genetic testing might be considered necessary to augment physical studies.

Diagnosis
Movement disorders are defined both by clinical presentation – the symptoms of the patient – and by physical pathology, the study of changes in the brain’s structures and functions. Accurate and extremely specific diagnosis is the essential starting point of all future treatment. This process is further complicated by the fact that many times the same disturbances – such as tremors, gait (walking) disorders and dystonias – can show up either as primary disorders or as symptoms of other disorders.

Types of Movement Disorders
Dystonias are characterized by involuntary muscle contractions that cause twisting, repetitive movements or abnormal postures of a body part. Birth injury (particularly due to lack of oxygen), some infections, reactions to certain drugs, heavy-metal or carbon monoxide poisoning, trauma or stroke can cause dystonia. Early symptoms may include a deterioration in handwriting, foot cramps, and a tendency of one foot to pull up or drag after running or walking some distance. Other possible symptoms are neck spasms, tremor, or voice or speech difficulties. The initial symptoms can be very mild and may be noticeable only after prolonged exertion, stress or fatigue.

Over a period of time the symptoms may become more noticeable; sometimes, however, there is little or no progression. About half of dystonia cases have no connection to other diseases or injury and are called primary or idiopathic dystonia; many of these are likely inherited. Physicians use a variety of therapies (medications, botulinum toxin injections, surgery and other treatments such as physical therapy, splinting, stress management, and biofeedback), to reduce or eliminate muscle spasms and pain.

Tremor is a rhythmic, involuntary muscular contraction characterized by quivering or shaking of body parts such as the hands, head or legs. Essential tremor is tremor that exists outside of Parkinson’s disease or other known neurological causes; it is typically benign. When necessary, medication or teaching the patient to brace the affected limb during tremor can be useful. There are many other types of tremor and several ways in which tremors are classified.

Tremor is fairly common in older people; appropriate treatment depends on accurate diagnosis of the cause. Do all tremors need to be treated? “Not necessarily,” says Dr. Blindauer. “It depends on the individual’s perception of impairment, and of the impact of the symptoms on their lives.”

Huntington’s Disease (HD) results from degeneration of neurons in certain areas of the brain. The loss of these brain cells causes uncontrolled movements, loss of intellectual faculties, and emotional disturbance. HD is passed from parent to child through a mutation in a normal gene. Some early symptoms of HD are mood swings, depression or irritability, trouble with driving, learning new things, remembering facts or making decisions. As the disease progresses, concentration on intellectual tasks becomes increasingly difficult and motor control worsens where patients may have difficulty feeding themselves and swallowing. Physicians prescribe a number of medications to help control emotional and movement problems associated with HD. Many drugs used to treat HD symptoms can have side effects such as fatigue, restlessness or hyperexcitability. It is extremely important for people with HD to maintain physical fitness as much as possible, since those who exercise and keep active tend to do better than those who do not.

Parkinson’s Disease (PD) and related disorders are the result of the loss of dopamine-producing brain cells. Dopamine is a chemical messenger responsible for transmitting signals within the brain. Parkinson's disease occurs when the neurons that produce dopamine die or become impaired. This causes the nerve cells to fire out of control, leaving patients unable to direct or control their movement in a normal manner. The four primary symptoms of Parkinson's are tremor or trembling in hands, arms, legs, jaw, and face; rigidity or stiffness of the limbs and trunk; slowness of movement (bradykinesia); and impaired balance and coordination. Patients might have difficulty walking, talking or completing simple tasks. A variety of medications provide dramatic relief from the symptoms, but no drug can stop the progression of the disease. In some cases, surgery is an appropriate treatment.

Tourette’s Syndrome (TS) is an inherited neurological disorder characterized by repeated non-voluntary movements and vocal sounds called tics. In a few cases, such tics can include inappropriate words and phrases. Symptoms, which generally appear before 18 years of age, range from very mild to quite severe, with the majority of cases falling into the mild category. The first symptoms of TS are usually facial tics – commonly eye blinking. With time, other motor tics may appear, such as head jerking, neck stretching, foot stamping, or body twisting and bending. It is not uncommon for people with TS to continuously clear their throats, cough, sniff, grunt, yelp, bark or shout. They may also touch other people excessively or repeat actions obsessively.

A few TS patients demonstrate self-harming behaviors such as lip and cheek biting and head banging. People with TS can sometimes suppress their tics for a short time, but eventually tension mounts to the point where the tic escapes. Tics worsen in stressful situations and improve when the person relaxes or is absorbed in an activity. TS is diagnosed by observing symptoms and evaluating family history. Most people with TS require no medication, but it is available to help if symptoms interfere with functioning. There is no cure for TS, but the condition often improves as people mature. Individuals with TS can expect to live a normal life span.

Treatments
Due to the nature of most movement disorders, medication – which is symptomatic rather than disease-modifying – is the most common approach to treatment. But “physical therapy and speech therapy are useful adjuncts, predominantly with gait disorders or speech dysfunctions,” says Dr. Blindauer. During different stages of disease, and depending on the priorities of the patient, medications are added, reduced or changed as appropriate. This balancing act usually involves a trade-off, which is why patient input is so important. For instance, if a patient holds a job in which manual dexterity is required, medications to reduce tremor or dystonias might be the most important part of therapy. If a patient needs to maintain a very high level of mental acuity, any drugs that have side effects such as fatigue or excitability may have to be reduced, even if that means some symptoms are not well-controlled.

And, says Dr. Blindauer, “we also offer surgical treatment – primarily for the patient with Parkinson’s disease or essential tremor – for when medications no longer work.“ There are two types of surgical procedures used to alleviate movement disorder symptoms. The first involves placing a lesion or small hole in the overactive area of the brain. The second involves placing an electrode into the brain, attaching it to a pacemaker-type device implanted in the chest, and using a small current or electrical impulse to shut down the overactive areas of the brain. Patients remain awake during these surgeries while medical team members activate an area of the brain and record the resulting movement patterns.

Movement disorders are more prevalent among older adults, and we can expect to see the number of people with Parkinson’s disease, essential tremor and other movement disorders increase in the coming years as the US population continues to age. Are there specific signs and symptom for which we should be on the alert? In very general terms, says Dr. Blindauer, movement disorders are related to lack of coordination or precision of movement, not to impairment of strength. Loss of dexterity, impaired mobility and balance, or tremor in the hands, head or voice may be of neurological origin and should be discussed with a health care provider.

“Many people used to dismiss tremor as part of normal aging, or people with dystonias just thought they had arthritis of the neck or limb,” says Dr. Blindauer. Now the Medical College of Wisconsin Movement Disorders Program can treat the people who live with these disorders, even as its medical team continues to engage in the research that could help their patients live longer and more comfortably. “These are medical conditions that can be treated,” says Dr. Blindauer. “And our goal is to help patients maintain a normal life.”

Eileen Early, RN, BSN
HealthLink Editor
Office of Clinical Informatics
Medical College of Wisconsin

This article includes information from the Medical College of Wisconsin Department of Neurology and the National Institutes of Health.

The Medical College of Wisconsin Movement Disorders Program staff consists of :

• Karen Blindauer, MD, Assistant Professor of Neurology and Director of the Movement Disorders Program
• Wade M. Mueller, MD, Professor of Neurosurgery, Department of Neurosurgery
• Lynn Bartos, RN
  Article Created: 2002-02-08
  Article Updated: 2002-06-12

  
  MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.