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