Movement Disorders After Head Injury

Systematic Review of Post-Traumatic Parkinsonism, an Emerging Parkinsonian Disorder Among Survivors of Traumatic Brain Injury

This systematic review focuses on an increasing subset of traumatic brain injury (TBI) survivors who develop post-traumatic parkinsonism (PTP), characterized by slowness of movement (bradykinesia), rigidity (stiffness), postural instability, and resting tremors caused by obstruction or damage to deep brain structures of the basal ganglia. PTP is rare, and one hypothesis to explain PTP rarity is that TBIs severe enough to affect deep brain structures are often lethal; however, with increasing survivability of TBIs, these numbers are expected to increase. The goal of this review is to raise awareness of an expected global increase of a subgroup of TBI patients who are treatment responsive and report therapeutic results aiding providers in diagnosing, educating, and treating PTP patients. Literature over the past 100 years was considered, and 44,663 peer-reviewed articles were identified. Inclusion criteria required a clinical indication of parkinsonian signs and TBI. Twenty-six case reports were ultimately included from which 36 individual patient data points were extracted for this review. Between 1980 and 2010, there has been an increase in reporting of PTP decade after decade. Forty-seven percent of PTP cases have 1-6 months of latency to symptom onset, and 83% of cases were male. PTP can occur with or without presence of brain lesions, and the most common type of injuries that cause PTP are motor vehicle accidents followed by falls. PTP patients are responsive to surgery or medication treatments. Further detail on PTP symptomology, treatment responsiveness, and injury types is provided.

The effect of elastic and viscous force fields on bimanual coordination

Bimanual in-phase and anti-phase coordination modes represent two basic movement patterns with distinct characteristics-homologous muscle contraction and non-homologous muscle contraction, respectively. A method to understand the contribution of each limb to the overall coordination pattern involves detuning (Δω) the natural eigenfrequency of each limb. In the present experiment, we experimentally broke the symmetry between the two upper limbs by adding elastic and viscous force fields using a Kinarm robot exoskeleton. We measured the effect of this symmetry breaking on coordination stability as participants performed bimanual in-phase and anti-phase movements using their left and right hand in 1:1 frequency locking mode. Differences between uncoupled frequencies were manipulated via the application of viscous & elastic force fields and using fast and slow oscillation frequencies with a custom task developed using the Kinarm robotic exoskeleton. The effects of manipulating the asymmetry between the limbs were measured through the mean and variability of relative phase (ϕ) from the intended modes of 0 ° or 180 °. In general, participants deviated less from intended phase irrespective of coordination mode in all matched conditions, except for when elastic loads are applied to both arms in the anti-phase coordination. Second, we found that when force fields were mismatched participants exhibited a larger deviation from the intended phase. Overall, there was increased phase deviation during anti-phase coordination. Finally, participants exhibited higher variability in relative phase in mismatched force conditions compared to matched force conditions, with overall higher variability during anti-phase coordination mode. We extend previous research by demonstrating that symmetry breaking caused by force differences between the limbs disrupts stability in each coordination mode.

Mild traumatic brain injury and sports-related concussion

Mild traumatic brain injury (mTBI) and concussion are equivalent terms for the sequela of injury to the head that disrupts brain functioning. Various forces may be causative from seemingly innocuous bumps to the head resulting from sports-related injuries to more severe blows to the head. However, the postconcussive motor, cognitive, emotional, and psychosocial sequelae can be just as devastating and long lasting, leading to loss of independent function and safe performance of activities. Taken together, they pose a significant challenge to recovery, requiring a multifaceted dynamic rehabilitative strategy. The current systems of health care pose challenges to suboptimal management of sports-related concussion (SRC) that goes beyond the acute injury, and into the school setting, failing to be identified by school staff, and inconsistencies in communicating medical information regarding school modifications, follow-up health services, or concussion-related educational services. Children who sustain SRC at different ages face different challenges. Young children face increased vulnerability due to SRC that coincides with periods of brain motor maturation and development.

Bilateral chorea following severe traumatic brain injury treated with risperidone

A functionally independent man in his 20s with a history of intellectual disability and epilepsy and family history of Huntington's disease suffered a severe traumatic brain injury. Postinjury, bilateral chorea rendered him dependent for all activities of daily living. Risperidone provided a significant reduction of chorea, decreasing the overall burden of care. Movement disorders are a common sequela of brain injury. Currently, there are no best treatment guidelines for chorea in patients with brain injury. To the authors' knowledge there have been no case reports describing the effects of brain injury on patients with a primary movement disorder. Risperidone was an effective treatment in this case. Further research is needed to establish guidelines for treatment of movement disorders following brain injury and to better understand the effect of brain injuries on primary movement disorders.

Abnormal movements in critical care patients with brain injury: a diagnostic approach

Abnormal movements are frequently encountered in patients with brain injury hospitalized in intensive care units (ICUs), yet characterization of these movements and their underlying pathophysiology is difficult due to the comatose or uncooperative state of the patient. In addition, the available diagnostic approaches are largely derived from outpatients with neurodegenerative or developmental disorders frequently encountered in the outpatient setting, thereby limiting the applicability to inpatients with acute brain injuries. Thus, we reviewed the available literature regarding abnormal movements encountered in acutely ill patients with brain injuries. We classified the brain injury into the following categories: anoxic, vascular, infectious, inflammatory, traumatic, toxic-metabolic, tumor-related and seizures. Then, we identified the abnormal movements seen in each category as well as their epidemiologic, semiologic and clinicopathologic correlates. We propose a practical paradigm that can be applied at the bedside for diagnosing abnormal movements in the ICU. This model seeks to classify observed abnormal movements in light of various patient-specific factors. It begins with classifying the patient’s level of consciousness. Then, it integrates the frequency and type of each movement with the availability of ancillary diagnostic tests and the specific etiology of brain injury.

Posttraumatic focal dystonia of the shoulder

Focal posttraumatic shoulder dystonia is a rare and not easily identifiable entity. Its true pathophysiologic nature, predisposing factors, and disease course remain debatable.This article describes a rare case of a 40-year-old man with late symptoms of focal shoulder dystonia after peripheral trauma of his left shoulder girdle. The shoulder was indirectly injured from the impact of a fall off his motorbike 3 years earlier. He was referred to the authors' institution because remarkable reduction of arm abduction, muscle spasms, and circumscribed hypertrophy of the trapezius muscle were noted while his head and neck were in neutral position and had a full range of motion. The left shoulder had a fixed elevated posture compared with the contralateral shoulder. A continuous burning pain was localized over the area of the hypertrophied trapezius muscle, radiating to the ipsilateral side of the head and neck. Dystonic movements of the trapezius, rhomboid, and supraspinatus muscles were observed. The abduction of the shoulder was significantly decreased, and any repetitive effort for arm abduction induced an exaggeration of his movement disorder, leading to a more pronounced shoulder elevation.Plain radiographs and magnetic resonance imaging of the left shoulder revealed a suprascapular tendinitis with no other abnormalities. Repeated needle electromyography of the left trapezius muscle and neurography of the accessory nerve on both sides were normal. Injections of botulinum toxin A were effective in the resolution of muscle hypertrophy and abnormal posture.

Quetiapine Induced Acute Dystonia in a patient with History of severe Head Injury

A patient with a history of severe head injury 10 years ago regained ability to walk after years of being bound to a wheelchair. During the last psychiatric hospitalization, quetiapine was increased to therapeutic dose using a normal titration. As a result the patient developed dystonia of multiple muscle groups requiring 4 days of hospitalization for remittance of symptoms. In this paper, we take a close look at the literature concerning extrapiramidal symptoms (EPS) in this context, and we suggest that in patients with a history of head injury, it is warranted to consider a slower titration of antipsychotic medications, including ones that are considered having a lower risk of EPS such as quetiapine.

Increased c-fos expression in the central nucleus of the amygdala and enhancement of cued fear memory in Dyt1 DeltaGAG knock-in mice

DYT1 dystonia is caused by a trinucleotide deletion of GAG (DeltaGAG) in DYT1, which codes for torsinA. A previous epidemiologic study suggested an association of DYT1 DeltaGAG mutation with early-onset recurrent major depression. However, another study reported no significant association with depression, but instead showed an association with anxiety and dystonia. In this study, we analyzed these related behaviors in Dyt1 DeltaGAG heterozygous knock-in mice. The knock-in mice showed a subtle anxiety-like behavior but did not show depression-like behaviors. The mutant mice also displayed normal sensorimotor gating function in a prepulse inhibition test. While normal hippocampus-dependent contextual fear memory and hippocampal CA1 long-term potentiation (LTP) were observed, the knock-in mice exhibited an enhancement in the formation of cued fear memories. Anatomical analysis indicated that the number of c-fos positive cells was significantly increased while the size of the central nucleus of the amygdala (CE) was significantly reduced in the knock-in mice. These results suggest that the Dyt1 DeltaGAG mutation increased the activity of the CE and enhanced the acquisition of the cued fear memory.

Organisch bedingte psychische Störungen im Kindes- und Jugendalter - Vier Kasuistiken

Zusammenfassung: Die Aufgaben der Neuropsychologie im Rahmen der Diagnostik von psychischen Störungen im Kindes- und Jugendalter hat sich in den letzten Jahren sehr verändert. Während es früher häufig um die Frage ging, ob bei dem jungen Patienten eine Hirnschädigung vorliegt oder nicht, ist diese Aufgabe heute aufgrund der besseren Möglichkeiten der bildgebenden Verfahren eher in den Hintergrund gerückt. Anhand von vier Einzelfällen wird verdeutlicht, dass frühe Hirnschädigungen nicht nur unmittelbar, sondern auch mittelbar zu Beeinträchtigungen führen. Insbesondere die mittelbaren Folgen, wie z.B. Verhaltensauffälligkeiten und persistierende neuropsychologische Defizite im Entwicklungsverlauf, sind häufig der Grund für eine klinische Vorstellung. Die Besonderheiten von kinder- und jugendpsychiatrischen Patienten mit organisch bedingten psychischen Störungen hinsichtlich Diagnostik und Therapieverlauf werden anhand der ausgewählten Kasuistiken ausführlich diskutiert.