Michael Okun
@MichaelOkun • 39,726 subscribers
Author, The Parkinson’s Plan, a NY Times Bestseller and 14 other books, Medical Advisor Parkinson’s Foundation, Distinguished Professor UF Fixel Institute
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A person with Parkinson's disease can't walk because of severe freezing but put him on a bike and he is fine. Great case by Snijders and Bas Bloem Love the explanation: 'This striking kinesia paradoxica may be explained by the bicycle's rotating pedals, which may act as an external pacing cue. Alternatively, the motor-control mechanisms involved in gait as compared with other activities engaging the legs, such as cycling, could be affected differentially in Parkinson's disease. Cycling may offer a useful approach for exercise training in patients with Parkinson's who are “grounded” by severe freezing of gait.'
Michael Okun1,062,608 views • 2 years ago
Do you know how to teach your patients (persons w/disease) the simple home maneuver; the Semont Plus to alleviate their dizziness from benign positional vertigo. If we all learn this technique and teach it, we will save the healthcare system a bundle. JAMA Neurology trial
Michael Okun149,779 views • 3 years ago
Hoover's neurological sign. Do you know how to perform it. We have been in neurology consults this week and we find this sign useful beyond organic from functional differentiation. Remember to utilize your contralateral hand under the ankle to help you gauge and understand the examination of weakness. It is pretty darn easy to slip your hand under the contralateral ankle.
Michael Okun126,010 views • 3 years ago
Here is your humbling case of the day that was just published? ' Will you miss this 17 year old who comes in with a year and a half of behavioral change, loss of appetite, weight loss, and folks have suggested he has a functional movement disorder. Did you think PERM? Key Points: - It is actually progressive encephalomyelitis with rigidity and myoclonus (PERM) - Considered part of the large spectrum of stiff-person-syndrome - Think brainstem and autonomic involvement in addition to axial and limb rigidity, CNS hyperexcitability - Autoantibodies against glycine receptor in 70% of PERM cases - Other antibodies include glutamic acid decarboxylase (GAD), dipeptidyl peptidase-like-protein-6 (DPPX), and of course amphiphysin - This case was anti-DPPX-associated PERM My take: One word: humbling....
Michael Okun95,624 views • 2 years ago
Would you know myorhythmia if you saw it? Would you think paraneoplastic? Myorhythmia is so seldomly seen this is a great opportunity to share. Here are some adjectives to keep in mind: repetitive, rhythmic, slow (1-4 Hz). Locations: tend to be cranial and limb. This cool case by Gurram and colleagues is Anti-IgLON5 related. Slow, rhythmic, synchronous involuntary myorhythmic movements noted in chin, tongue and palate. Do you know the 5 phenotypes for IgLON5? 1- sleep disorder, 2- bulbar syndrome, 3- PSP like and 4- other movement disorders, 5- cognitive impairment possibly w/ chorea and neuromuscular issues. This cool case had facial-lingual-palatal myorhythmia, mild parkinsonism, and fasciculations.
Michael Okun53,807 views • 3 years ago
Do you know how to test all of the cranial nerves NEJM? There is a wonderful must read article for all trainees and also anyone who would like to brush up on their neurological examination skills. Here is a video teaser of the exam for cranial nerves III, IV and VI: Always check the eyes right! Nice demonstration of the swinging flashlight test: You are looking for a Marcus Gunn pupil right? NEJMres360 UF Movement Fellowship University of Florida Neurology Residency
Michael Okun44,764 views • 3 years ago
Do you know all the Parkinson's disease gait related compensation strategies folks have employed successfully? Bloem and colleagues nail it. I am sure there are more, however no better review video than this one. 1- Counting 2- Skating 3- Sliding sideways 4- Running 5- Cycling 6- Scooter 7- Tennis Ball 8- Staircase
Michael Okun36,244 views • 2 years ago
Can you name the 5 alien limb syndromes? This video shows one of the most famous: inter-manual conflict. Key points: - Did you know it is important to localize where the pathology is likely within the brain and whether you have a disconnection syndrome; anterior vs. posterior and involving or not involving the corpus callosum, parietal or frontal regions - I consider 5 categories though many papers refer to 4; the 5th in a movement disorders clinic is actually the most common; levitating. - 1) diagnostic dyspraxia/inter-manual conflict; one hand performs actions contrary to the other hand - 2) alien hand sign where there is a true feeling that the hand does not belong to the person - 3) Anarchic hand; performs goal-directed activity not desired or under the willfulness of the person - 4) supernumerary hand which is a person feeling like they have an extra limb - 5) levitating arm or leg; levitates without volitional action. Hint on this last one to consider corticobasal syndrome or PSP.
Michael Okun24,193 views • 2 years ago
Do you know how to perform the “whack-a-mole” or WAM sign on your neurological examination? Just like the arcade or fair game; reemergence of involuntary movement in different body part after suppression of movement by examiner. Original name Japan: mole buster or mole smash. Key points: - It is specific but not very sensitive for functional movement disorders. - Diagnosis of a functional movement disorder ideally supported by demonstrating positive signs during neurological examination. - Development and evaluation of new positive signs is an important to improving diagnostic certainty. - WAM sign was a highly specific (78%) and moderately sensitive (52%) test for the diagnosis of FMD. Tested across a variety of functional hyperkinetic movements. - Since stress or being under pressure may worsen abnormal movements during suppression of another body part and this makes it tough to be completely sensitive or specific. - Marked difference in the inter-observer agreement values for the WAM sign between FMD and organic movement disorder patients (0.77 vs. 0.28). - Greater than a third of persons tested, intra-person variability of the WAM sign. Translation: the test result depended on which part of the body was suppressed. - History lesson: Whac-A-Mole arcade game created in 1975 by the amusements manufacturer TOGO in Japan. - Original name Mogura Taiji モグラ退治, Mole Buster or Mogura Tataki モグラたたき, Mole Smash. - Criticized for teaching children to be cruel towards animals. - Used in rehabilitation to teaching auditory processing and attention. My take is that you should never diagnose a functional movement disorder based on one examination maneuver or one visit in the clinic or hospital setting.
Michael Okun23,006 views • 2 years ago
Ever seen a live worm removed from a brain? Check out this case in the Neurology Journal by Park and Paek. Headaches and vomiting in a defector from North Korea. The history included drinking pond water and eating raw snake. The brain mass on imaging migrated from the left occipital to the left parietal lobe. The diagnosis was sparganosis.
Michael Okun15,522 views • 1 year ago
The first 'timed up and go' TUG test in Parkinson's occurred in a garden just after 1900 and the person was asked to walk between two chairs? Do you appreciate the camptocormia and the excellent example of festination of gait in #parkinsons. Camptocormia: abnormal flexion of trunk in standing position increases w/walking; improves lying down. Festination: The tendency to speed up and chase center of gravity.
Michael Okun21,491 views • 2 years ago
This is PSP, right? Neurodegenerative and progressive, right? Wrong. This is autoimmune encephalitis associated with autoantibodies directed against the GABAB receptor. Great teaching case presented by Mustafa, Garg and colleagues Movement Disorders Clinical Practice Key Points: - Progressive recurrent backward falls for 3 months. - Slowness w/ unclear speech, body stiffness and a poker face. - Abnormal walking for one month (ataxic). - Vertical upgaze palsy w/ preserved vestibulo-ocular reflexes. My take: The clue was the subacute onset of atypical parkinsonism w/ a PSP-like phenotype accompanied by gait ataxia. Mark Hallett always says in Aspen, think about autoimmune ataxia when there is a subacute presentation. Be aware that the anti-GABAB receptor-mediated encephalitis can be observed in "drug refractory epilepsy, anterograde amnesia, limbic encephalitis and rapidly progressive dementia." Only half of cases will end up being associated with a hidden cancer. Docendo discimus – we learn by teaching – and we should be aware that PSP-like phenotypes can rarely be associated with autoimmune disorders. #PSP Parkinson's Foundation Norman Fixel Institute for Neurological Diseases
Michael Okun13,330 views • 1 year ago
What happened on Dec 14, 2023 (today) that was a historic bi-partisan success for Parkinson's disease? Today, in a vote of 407 to 9 a bill passed in the House of Representatives; the National Plan to End Parkinson’s Act HR2365. This bill will cover PSP and other parkinsonisms. It was named for Florida representative Gus Bilirakis brother Dr. Emmanuel Bilirakis and Virginia representative Jennifer Wexton living with CurePSP Also, Paul Tonko led the bipartisan effort. BRAVO for working together, and truly impacting lives. michaeljfox.org and 30 other PD related organizations like Parkinson's Foundation signed on to support this. On to the senate...and the president! Ending Parkinson's Disease: The Book
Michael Okun19,441 views • 2 years ago
Can a person have an alien leg? YES. Limb levitation in corticobasal syndrome is something we see commonly in an expert clinic. This video and report shows involuntary movements of the right leg “alien leg”. In order for the patient to stand up the doctor had to stand on his right foot to hold it in place. The ‘‘alien foot’’ is rarer and the authors point out that foot involvement can lead to erroneous localization of the clinical problem to the knee, hip, or back.''
Michael Okun19,509 views • 2 years ago
Check out the unusual gait pattern worsened by levodopa in this case of a PARKIN gene related Parkinson's. This is why we call it Parkinson's diseases plural as there are so many different manifestations, with or without known gene mutations. Nice case by Mehta and colleagues in Movement Disorders Clinical Practice. Key Points: - 26 year old Parkin gene-related early-onset Parkinson's. - Paradoxical response to levodopa, dopamine worsened dystonia. - Amantadine seemed to help. - Complaint was tightness of lower limbs when walking. - Had heterozygous PRKN mutations, w/ a 'missense pathogenic mutation in exon 7 (c.850G > C (p. Gly284Arg) and a deletion mutation in exon 3 (241 bp),' - 'Forward walking was characterized by bilateral hip flexion and abduction, flexed knees, ankle inversion and plantar flexion rebound during the stance phase on the left foot and reduced arm swing bilaterally.' My take: Some of these PARKIN and genetic PD cases may respond to anticholinergics or dopamine agonists, however in this case this was not helpful. The improvement w/ amantadine was humbling and unexpected. The authors suggest to us to try amantadine, if dopamine is worsening dystonia or gait in the setting of PARKIN. 'Parkinsons diseases, every day we learn something new.' A close look at the video suggests the amantadine helped however did not resolve the challenge. DBS may be a reasonable next step to consider. #Parkinsons
Michael Okun16,809 views • 2 years ago
Can you identify 'belly dancer dyskinesia?' Hint: look for undulating or circular abdominal contractions. Nice case by Cho, Hallett and colleagues in Movement Disorders Clinical Practice Key Points: - Spinal cord or basal ganglia lesions. - If spinal cord origin, the movements tend to continue during sleep. - An MRI may be helpful if a structural lesion is present. - Physiological studies can be helpful. My take: This case they present turned out to be a 'functional movement disorder' and the movements disappeared with sleep. There was no exposure to a dopamine blocking medication. There was no history of abdominal surgery. The authors remind us to uncover possible 'suggestibility, entrainability, and distractibility.' Physiologically the BP potential is actually present WITH functional myoclonus. Many propriospinal myoclonus cases have turned out to be functional movement disorders. HUMBLING even for the experts. … #dyskinesia #bellydancer #functionalmovementdisorder
Michael Okun12,686 views • 1 year ago
Can you identify an oculogyric crisis? @ChristosGanos and colleagues teach us about the intriguing possibility that the rolling eyes we frequently see after administration of a drug, may be localized to a brain lesion network associated with a brain dopaminergic transcriptomic signature. Read about it in a new paper Brain. Key Points: - Oculogyric crises what are they? Acute episodes sustained, typically upward, conjugate deviation of the eyes. - Common cause? Acute D2-dopamine receptor blockade by a drug. - The authors used data from 14 previously reported cases of lesion-induced oculogyric crises and employed' lesion network mapping' to search for shared connections. - What was the common network? Basal ganglia, thalamic, brainstem nuclei and cerebellum. - A look at the gene expression profiles showed spatial overlap specifically with the gene coding for dopamine receptor type 2 (DRD2). - The very cool part: spatial overlap with DRD2 and DRD3 gene expression seemed to be 'specific to brain lesions associated with oculogyric crises when contrasted to lesions that led to other movement disorders.' My take: I love the use of multiple modalities to chase down a common neural network for oculogyric crises. We should keep in mind that these were cases associated with brain lesions, and as we all contribute by reporting more cases and sharing their MRI scans we will likely further refine our understanding of the network. For clinicians when you see this, look down that medication list for the 'dopamine blocker' as your first step in diagnosis. This video by Elan Louis provides a nice illustration of oculogyric crisis to help you to identify them in your practice. #Parkinsons #oculogyric
Michael Okun15,398 views • 2 years ago