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In most cases, between the age of 2 and 4 oculomotor signals are present. Between the age of 2 and 8, telangiectasias appears. Usually by the age of 10 the child needs a wheel chair. Individuals with autosomal recessive cerebellum ataxia usually survive till their 20s; in some cases individuals have survived till their 40s or 50s.
Surgery, such as the denervation of selected muscles, may also provide some relief; however, the destruction of nerves in the limbs or brain is not reversible and should be considered only in the most extreme cases. Recently, the procedure of deep brain stimulation (DBS) has proven successful in a number of cases of severe generalised dystonia. DBS as treatment for medication-refractory dystonia, on the other hand, may increase the risk of suicide in patients. However, reference data of patients without DBS therapy are lacking.
The specific molecular mechanism that underpins this movement disorder is not well known. However, most researchers suggest that it follows an autosomal dominant genetic inheritance pattern in which mutations in certain genes give rise to structural abnormalities in nervous system networks responsible for voluntary skeletal muscle movement, which, in turn, result in the functional movement abnormalities seen in patients. Despite being autosomal dominant, it is important to note that the disease has variable expressivity. That is, patients who have inherited a mutated dominant allele, along with their genetically affected parent, can be symptomatic or asymptomatic for CMM disorder. The genes that currently have evidence to be associated with CMM disorder include "DCC" (deleted in colorectal carcinoma), "DNAL4" (dynein axonemal light chain 4), and "RAD51 (recombination protein A)".
"DCC" encodes a receptor for "NTN1" (netrin-1), a protein thought to be responsible for axon guidance and neuronal cell migration during development. A mutation of this gene (including nonsense, splice site mutation, insertions, frameshift) has been identified as a possible cause for CMM disorder. Experiments in mice also support the claim that CMM disorder is associated with genetic mutations in "DCC". "Kanga" mice, lacking the P3 intracellular domain of the "DCC" receptor, show a hopping gait, moving their hind legs in a strictly paired fashion, as do kangaroos.
"DNAL4" encodes a component of dynein motor complex in commissural neurons of the corpus callosum. In contrast to "DCC", "DNAL4" is thought to have a recessive inheritance pattern for the CMM disorder. In CMM disorder patients, researchers found splice site mutations on "DNAL4", which caused skipping of exon 3, and thereby omission of 28 amino acids from "DNAL4" protein. This mutant "DNAL4" protein, in turn, could lead to faulty cross-hemisphere wiring, resulting in CMM.
"RAD51" maintains genome integrity by repairing DNA double-strand breaks through homologous recombination. "RAD51" heterozygous mutations, specifically premature termination codons, have been found in many CMM disorder patients through genome-wide linkage analysis and exome sequencing. In a mouse model, researchers also found "RAD51" products in corticospinal tract axons at the pyramidal decussation. They therefore suggest that "RAD51" might be a gene that, when haploinsufficient, causes CMM disorder in humans.
Despite identification of three prospective genes, no genotype-phenotype correlations have yet been found. That is, the severity of clinical signs and symptoms does not correlate with the type of genetic variant. Mutations in the above genes account for a total of about 35 percent of cases. Mutations in other genes that have not been identified likely account for the other cases of this disorder.
CRPS can occur at any age with the average age at diagnosis being 42. It affects both men and women; however, CRPS is three times more frequent in females than males.
CRPS affects both adults and children, and the number of reported CRPS cases among adolescents and young adults has been increasing, with a recent observational study finding an incidence of 1.16/100,000 among children in Scotland.
One form of treatment that has produced a more integrated body awareness is mirror therapy, in which the individual who denies that the affected limb belongs to their body looks into a mirror at the limb. Patients looking into the mirror state that the limb does belong to them; however body ownership of the limb does not remain after the mirror is taken away.
Congenital mirror movement disorder (CMM disorder) is a rare genetic neurological disorder which is characterized by mirrored movement, sometimes referred to as associated or synkinetic movement, most often in the upper extremity of the body. These movements are voluntary intentional movements on one, ipsilateral, side of the body that are mirrored simultaneously by involuntary movements on the contralateral side.
The reproduction of involuntary movement usually happens along the head-tail axis, having a left-right symmetry. For example, if someone were to voluntarily make a fist with their left hand, their right hand would do the same. In most cases, the accompanying contralateral involuntary movements are much weaker than the ipsilateral voluntary ones, although the extent and magnitude of the mirrored movement vary across patients. This disorder has not yet been found to be associated with any other neurologic disease or cognitive disability, and currently, no cures nor means to improve signs or symptoms have been found.
The congenital mirror movements begin in infancy and persist throughout the patient’s life, often with very little improvement, or deterioration. Consequently, patients who do suffer from this movement disorder have serious difficulty carrying out tasks that require manual dexterity or precision, such as playing a two handed musical instrument or typing on a keyboard, for their whole lives. Patients also often experience discomfort or pain in the upper limbs due to prolonged use of the same muscles. Therefore, quality of life can be severely hampered.
CMM disorder’s prevalence in the world is thought to be less than 1 in 1 million people. Because of its rarity, researchers suggest that some mildly affected individuals may never be diagnosed. It is important not to confuse congenital mirror movement disorders, a rare genetically based neurologic disease, with acquired mirror movement disorders that present themselves during one’s lifetime due to other reasons (stroke for example).
Almost all cases of synkinesis develop as a sequel to nerve trauma (the exception is when it is congenitally acquired as in Duane-Retraction Syndrome and Marcus Gunn phenomenon). Trauma to the nerve can be induced in cases such as surgical procedures, nerve inflammation, neuroma
, and physical injury.
Good progress can be made in treating CRPS if treatment is begun early, ideally within three months of the first symptoms. If treatment is delayed, however, the disorder can quickly spread to the entire limb, and changes in bone, nerve, and muscle may become irreversible. The prognosis is not always good. Johns Hopkins Hospital reports that 77% of sufferers have spreads from the original site or flares in other parts of the body. The limb, or limbs, can experience muscle atrophy, loss of use, and functionally useless parameters that require amputation. RSD/CRPS will not "burn itself out", but if treated early, it is likely to go into remission. Once one is diagnosed with Complex Regional Pain Syndrome, the likelihood of it resurfacing after going into remission is significant. It is important to take precautions and seek immediate treatment upon any injury.
It has been suggested that damage to the posterior cerebral regions (temporoparietal junction) of the cortex may play a significant role in the development of somatoparaphrenia. However, more recent studies have shown that damage to deep cortical regions such as the posterior insula and subcortical structures such as the basal ganglia, the thalamus and the white matter connecting the thalamus to the cortex may also play a significant role in the development of somatoparaphrenia. It has also been suggested that involvement of deep cortical and subcortical grey structures of the temporal lobe may contribute to reduce the sense of familiarity experienced by somatoparaphrenic patients for their paralyzed limb.
Risk factors for Holmes tremor include excess exposure to heavy metals, such as mercury and lead, as well as an increased intake of various drugs and toxins. Researchers found that raising the dose of antidepressants or neuroleptics elevate the risk for developing Holmes tremor. Increasing intake of coffee, tea, or other stimulants can also cause for greater risk of development. Tremors depend on dosage and amount of exposure to these factors and will typically decrease dramatically if the intake is reduced. Hyperthyroidism and hyperglycemia also increase the likelihood of developing Holmes tremor.
Autosomal recessive cerebellar ataxia type 1 (ARCA1) is a condition characterized by progressive problems with movement. Signs and symptoms of the disorder first appear in early to mid-adulthood. People with this condition initially experience impaired speech (dysarthria), problems with coordination and balance (ataxia), or both. They may also have difficulty with movements that involve judging distance or scale (dysmetria). Other features of ARCA1 include abnormal eye movements (nystagmus) and problems following the movements of objects with their eyes. The movement problems are slowly progressive, often resulting in the need for a cane, walker, or wheelchair.
All PD associated subtypes have genetic contributions and are likely to run in a families genetic history due to dominant allele mutations. Mutations of identified genes have been leading areas of research in the study and treatment of paroxysmal dyskinesia. PKD, PNKD, and PED are classified as separate subtypes because they all have different presentations of symptoms, but also, because they are believed to have different pathologies.
Interestingly, studies on diseases that are similar in nature to PD have revealed insights into the causes of movement disorders. Hypnogenic paroxysmal dyskinesia is a form of epilepsy affecting the frontal lobe. Single genes have been identified on chromosomes 15, 20, and 21, which contribute to the pathology of these epilepsy disorders. Utilizing new knowledge about pathologies of related and similar disease can shed insight on the causal relationships in paroxysmal dyskinesia.
Because brainstem stroke and lesions are typically the causes of Holmes tremor, there is little research supporting a genetic factor to the disease. However, one could be more susceptible to developing Holmes tremor if there is a familial history of stroke, substance abuse, or other disorders that increase risk.
The direct cause and pathophysiological basis of RMD is still unknown and can occur in children and adults of perfect or non-perfect health. Rare cases of adult RMD have developed due to head trauma, stress, and herpes encephalitis. Familial cases have been reported suggesting there may be some genetic aspect to the disorder; however, to date, this explanation has not been directly tested. As familial incidence rate is still relatively low, it is believed that behavioral aspects may play a larger role in RMD than family history and genetics. Many sufferers report no family history of the disorder. Another theory suggests that RMD is a learned, self-stimulating behavior to alleviate tension and induce relaxation, similar to tic movements.
An alternative theory suggests that the rhythmic movements help develop the vestibular system in young children, which can partially explain the high prevalence of RMD in infants. It has been seen that children who have underdeveloped vestibular systems benefit from performing RMD-like movements which stimulate the vestibular system
Rhythmic Movement Disorder (or RMD) is a neurological disorder characterized by involuntary (however may sometimes be voluntary), repetitive movements of large muscle groups immediately before and during sleep often involving the head and neck. It was independently described first in 1905 by Zappert as jactatio capitis nocturna and by Cruchet as rhythmie du sommeil. The majority of RMD episodes occur during NREM sleep, although REM movements have been reported. RMD is often associated with other psychiatric conditions or mental retardation. The disorder often leads to bodily injury from unwanted movements. Because of these incessant muscle contractions, patients’ sleep patterns are often disrupted. It differs from Restless Legs Syndrome in that RMD involves involuntary muscle contractions before and during sleep while Restless Legs Syndrome is the urge to move before sleep. RMD occurs in both males and females, often during early childhood with symptoms diminishing with age. Many sufferers also have other sleep related disorders, like sleep apnea. The disorder can be differentially diagnosed into small subcategories, including sleep related bruxism, thumb sucking, hypnagonic foot tremor, and rhythmic sucking, to name a few. In order to be considered pathological, the ICSD-II requires that in the sleep-related rhythmic movements should “markedly interfere with normal sleep, cause significant impairment in daytime function, or result in self-inflicted bodily injury that requires medical treatment (or would result in injury if preventive measures were not used)”
Synkinesis is the result from miswiring of nerves after trauma. This result is manifested through involuntary muscular movements accompanying voluntary movements. For example, voluntary smiling will induce an involuntary contraction of the eye muscles causing the eye to squint when smiling. Most commonly involved are facial muscles and the extraocular muscles, rarely the hands are performing mirror movements.
Causes are diverse and include nerve trauma with improper healing, or nerve degeneration, as in the course of Parkinson´s disease. In congenital cases, mutations of genes involved in nerve growth, specifically axonal growth have been found. Rarely, it is part of syndromes with neuroendocrine problems such as Kallman syndrome.
The prognosis is usually good with normal intelligence and lifespan. Treatment depends on the cause, but is largely conservative with facial retraining or mime therapy, if needed, while Botox and surgery are used as last resort.
Numerous causes have been proposed for PKD, such as genetic mutations, multiple sclerosis, brain trauma, and endocrine dysfunction. This is not an exhaustive list; many other causes are being proposed and studied. Until causal genes can be identified, the pathology of PKD will not be fully understood. Researchers have identified specific loci in chromosomes 16 and 22, which have been reported to have a genotype-phenotype correlation.
Many other neurological conditions are associated with acanthocytosis but are not considered 'core' acanthocytosis syndromes. The commonest are:
- Pantothenate kinase-associated neurodegeneration, an autosomal recessive condition caused by mutations in "PANK2".
- Huntington's disease-like syndrome type 2, an autosomal dominant condition caused by mutations in "JPH3" that closely resembles Huntington's disease.
- Bassen-Kornzweig disease, or Bassen-Kornzweig Syndrome (see also History).
- Levine-Critchley syndrome (see History).
- Paroxysmal movement disorders associated with GLUT1 mutations.
- Familial acanthocytosis with paroxysmal exertion-induced dyskinesias and epilepsy (FAPED).
- Some cases of mitochondrial disease.
Dysdiadochokinesia is a feature of cerebellar ataxia and may be the result of lesions to either the cerebellar hemispheres or the frontal lobe (of the cerebrum), it can also be a combination of both. It is thought to be caused by the inability to switch on and switch off antagonising muscle groups in a coordinated fashion due to hypotonia, secondary to the central lesion.
Dysdiadochokinesia is also seen in Friedreich's ataxia and multiple sclerosis, as a cerebellar symptom (including ataxia, intention tremor and dysarthria). It is also a feature of ataxic dysarthria. Dysdiadochokinesia often presents in motor speech disorders (dysarthria), therefore testing for dysdiadochokinesia can be used for a differential diagnosis.
Dysdiadochokinesia has been linked to a mutation in "SLC18A2", which encodes vesicular monoamine transporter 2 (VMAT2).
Paroxysmal kinesigenic dyskinesia has been shown to be inherited in an autosomal dominant fashion. In 2011, the PRRT2 gene on chromosome 16 was identified as the cause of the disease. The researchers looked at the genetics of eight families with strong histories of PKD. They employed whole genome sequencing, along with Sanger sequencing to identify the gene that was mutated in these families. The mutations in this gene included a nonsense mutation identified in the genome of one family and an insertion mutation identified in the genome of another family. The researchers then confirmed this gene as the cause of PKD when it was not mutated in the genome of 1000 control patients. Researchers found PRRT2 mutations in 10 of 29 sporadic cases affected with PKD, thus suggests PRRT2 is the gene mutated in a subset of PKD and PKD is genetically heterogeneous. The mechanism of how PRRT2 causes PKD still requires further investigation. However, researchers suggest it may have to do with PRRT2's expression in the basal ganglia, and the expression of an associated protein, SNAP25, in the basal ganglia as well.
There is a group called myoclonic dystonia where some cases are hereditary and have been associated with a missense mutation in the dopamine-D2 receptor. Some of these cases have responded well to alcohol.
Other genes that have been associated with dystonia include CIZ1, GNAL, ATP1A3, and PRRT2. Another report has linked THAP1 and SLC20A2 to dystonia.
Mirror-touch synesthesia is a rare condition which causes individuals to experience the same sensation (such as touch) that another person feels. For example, if someone with this condition were to observe someone touching their cheek, they would feel the same sensation on their own cheek. Synesthesia, in general, is described as a condition in which a stimulus causes an individual to experience an additional sensation. Synesthesia is usually a developmental condition; however, recent research has shown that mirror touch synesthesia can be acquired after sensory loss following amputation.
Inverse Marcus Gunn phenomenon is a rare condition that causes the eyelid to fall upon opening of the mouth. In this case, trigeminal innervation to the pterygoid muscles of the jaw is associated with an inhibition of the branch of the oculomotor nerve to the levator palpebrae superioris, as opposed to stimulation in Marcus Gunn jaw-winking.
Paroxysmal kinesigenic choreathetosis (PKC) also called paroxysmal kinesigenic dyskinesia (PKD) is a hyperkinetic movement disorder characterized by attacks of involuntary movements, which are triggered by sudden voluntary movements. The number of attacks can increase during puberty and decrease in a person's 20s to 30s. Involuntary movements can take many forms such as ballism, chorea or dystonia and usually only affect one side of the body or one limb in particular. This rare disorder only affects about 1 in 150,000 people with PKD accounting for 86.8% of all the types of paroxysmal dyskinesias and occurs more often in males than females. There are two types of PKD, primary and secondary. Primary PKD can be further broken down into familial and sporadic. Familial PKD, which means the individual has a family history of the disorder, is more common, but sporadic cases are also seen. Secondary PKD can be caused by many other medical conditions such as multiple sclerosis (MS), stroke, pseudohypoparathyroidism, hypocalcemia, hypoglycemia, hyperglycemia, central nervous system trauma, or peripheral nervous system trauma. PKD has also been linked with infantile convulsions and choreoathetosis (ICCA) syndrome, in which patients have afebrile seizures during infancy (benign familial infantile epilepsy) and then develop paroxysmal choreoathetosis later in life. This phenomenon is actually quite common, with about 42% of individuals with PKD reporting a history of afebrile seizures as a child.
Hemiplegia is not a progressive disorder, except in progressive conditions like a growing brain tumour. Once the injury has occurred, the symptoms should not worsen. However, because of lack of mobility, other complications can occur. Complications may include muscle and joint stiffness, loss of aerobic fitness, muscle spasms, bed sores, pressure ulcers and blood clots.
Sudden recovery from hemiplegia is very rare. Many of the individuals will have limited recovery, but the majority will improve from intensive, specialised rehabilitation. Potential to progress may differ in cerebral palsy, compared to adult acquired brain injury. It is vital to integrate the hemiplegic child into society and encourage them in their daily living activities. With time, some individuals may make remarkable progress.