Michael Okun
@MichaelOkun • 39,931 subscribers
Neurologist, Author, The Parkinson’s Plan, Medical Advisor Parkinson’s Foundation, Distinguished Professor UF Fixel Institute
Shorts
Videos
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 Okun1,062,859 просмотров • 3 лет назад
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 Okun149,817 просмотров • 3 лет назад
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 просмотров • 3 лет назад
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 Okun95,682 просмотров • 2 лет назад
Teaser video for how to teach 'self treatment of BPPV' to your persons with dizziness. This is the recent positive randomized trial published in JAMA Neurology Check out article for full video. Self-treatment of Recurrent Benign Paroxysmal Positional Vertigo
Michael Okun65,691 просмотров • 3 лет назад
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 Okun53,867 просмотров • 3 лет назад
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 просмотров • 3 лет назад
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 просмотров • 3 лет назад
Measles is making a comeback as less people are getting vaccinated. Can you spot the neurological manifestations (SSPE)? Check out this great case by Garg and colleagues Movement Disorders Clinical Practice where in addition to myoclonus and other features you will observe a sensory trick. Key Points: - A late complication of measles is called subacute sclerosing panencephalitis (SSPE). - Sensory tricks are maneuvers that temporarily improve dystonic posture. - Another name is 'geste antagoniste' derived from the description of the 'phenomenon in cervical dystonia by Henry Meige and Eugene Feindel in 1902.' - The movement of a trick, as Dr. Hallett points out, 'does not always need to be antagonistic or in the opposing direction of the dystonia and the term antagonistic might be better thought of in terms of a trick reversing the dystonia.' - Patel et al. recently introduced the alternative term, alleviating maneuver. - In the current case, check out the video of a progressive cognitive decline, behavioral issues, myoclonus and abnormal posturing of the neck and upper limbs in a 15 year old. - Jerky movements of upper limbs are actually myoclonus. - Could touch chin on the right side with either hand, to reduce neck posturing and forward position of the head. - He could also occasionally insert a finger into the right side of the mouth for symptomatic relief. - This boy was not vaccinated. My take: It will be important for clinicians around the world to be on the lookout for measles and the late SSPE potential manifestations. The geste antagonist in this case was incredible, and I personally have never observed this dystonic manifestation in the setting of measles. Finem respice – consider the outcome of not vaccinating. Read about sensory tricks by Mark Hallett #Measles #vaccination #SSPE #dystonia #myoclonus
Michael Okun29,754 просмотров • 2 лет назад
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 просмотров • 2 лет назад
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 просмотров • 2 лет назад
0:28
Sensitive content
This media may contain sensitive content.
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 Okun15,546 просмотров • 1 год назад
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 просмотров • 3 лет назад
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 Okun19,456 просмотров • 2 лет назад
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 Okun19,519 просмотров • 2 лет назад
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 просмотров • 1 год назад
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 Okun16,865 просмотров • 2 лет назад
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 Okun12,768 просмотров • 1 год назад