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|Year : 2018 | Volume
| Issue : 7 | Page : 10-11
The rise of movement disorders
Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
|Date of Web Publication||1-Mar-2018|
Dr. Mark Hallett
Human Motor Control Section, NINDS, NIH, Building 10, Room 7D37, 10 Center Dr MSC 1428, Bethesda, MD 20892-1428
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Hallett M. The rise of movement disorders. Neurol India 2018;66, Suppl S1:10-1
Knowledge in medicine is constantly expanding, and, as it does, more subspecialties arise. This is certainly true in Neurology. The field of Movement Disorders was born just a little more than three decades ago. There had been interest in Parkinson disease (the British disease) and Huntington disease (the American disease), and since both were basal ganglia diseases, there was some focus on the basal ganglia and dopamine. Dr. Stan Fahn got interested in a broader range of disorders manifesting with hyper- and hypo-kinetic manifestations, and Dr. Lewis Rowland, his Chief, suggested that he call the field “Movement Disorders”. Dr. Fahn set up a Movement Disorder Clinic, first at the University of Pennsylvania, and then subsequently at the Columbia University in New York City, where it still functions. Dr. C. David Marsden developed a similar broad interest in London, and Dr. Fahn and Dr. Marsden became fast friends. Together they organized a case based discussion course centered around video presentations at the American Academy of Neurology that was very popular. They went on to found a society and journal, both called 'Movement Disorders'. Others found interest in this subspeciality of Neurology, the society grew, merged with another society (also founded in part by Marsden), fellowship programs emerged and more neurologists have identified with movement disorder specialty. The popularity of the field is now clear in India with neurologists having this focused interest, fellowship programs, and a new subspecialty society.
An appeal of Movement Disorders, as is true of much of Neurology, is that the history and physical examination are still critical to the diagnosis. For those of us really interested in people, it is a good field to work in. And, of course, the brain and neuroscience are at the cutting edge of science these days. The study of movement is a valuable way to study the brain since it is measurable. As with all of Neurology, there has been rapid growth of knowledge in Movement Disorders about disease, its diagnosis and treatment. The current issue of Neurology India has a series of papers dealing with some of those advancements.
Neurological disease does have geographical differences so it is valuable for there to be some emphasis on what is special for India. For example, the prevalence of Sydenham chorea and Wilson disease is higher than that in Europe or the United States. There is also a different frequency distribution of the dominant spinocerebellar ataxias (SCAs).
What are some of the new trends?
One general aspect is the recognition of how to label an individual patient's disorder. Each patient has a “phenotype,” the clinical and laboratory manifestations of his or her disease. Then, there would be the cause or etiology of that phenotype. It is now clear that almost every phenotype may have at least several etiologies, and that any etiology may produce different phenotypes. There is no simple one-to-one relationship. Hence, all patients need to be categorized by a two-axis system, for example, a phenotype of bradykinesia, rigidity and tremor due to SCA3. Of course, phenotypes can be complex and etiologies are often multiple, so this is often far from simple. The two-axis system, however, makes this easier to understand.
One of the first recognitions of this two-axis approach was the development of the idea of corticobasal syndrome as a phenotype that might be due several etiologies, of which one is corticobasal degeneration. This has been accepted now for dystonias, and very recently, also for tremor classification. In relation to tremor, one of the highlights of the new classification is to consider essential tremor a phenotype and not an etiology. The phenotype has been narrowed with the critical feature being bilateral upper extremity action tremor. The etiologies (and there will be many!) are still largely unknown, but it is hopeful that genetic causes will be uncovered. It has also been proposed as a way to consider progressive supranuclear palsy (PSP) – that is, to separate PSP as a syndrome as well as an etiology since there can be alternate etiologies.
The area of Parkinson disease continues to be one of the most active fields of Movement Disorders and it is covered in several articles in the current issue., In my view, it would be best to consider Parkinson disease as a phenotype with many etiologies, but there remains some confusion in this area with some authorities still thinking of it as an etiology. This will likely be resolved with time. In any event, Parkinson disease is now recognized to have many important non-motor features as well as motor features. Their treatment is as important as the motor manifestations. Thus, therapy of patients with Parkinson disease is getting to be very complex, clearly indicating that neurologists looking after these patients need to keep up with all the detailed advances.
One of the important advances in the treatment of Parkinson disease is deep brain stimulation,, and interestingly, this therapy has now been shown to be useful for many more movement disorders and other neurological and psychiatric disorders. This is an area for interaction between neurologists and neurosurgeons, both for appropriate referral and for post-surgical management, including programming the stimulators.
Another therapy covered in this issue is botulinum toxin treatment. Botulinum toxin has proven to be effective in many different movement disorders, and it is now another special skill that movement disorder specialists can learn. Even without developing the technique, it is critical to know when botulinum toxin might be used. First appreciated for treatment of dystonias, it is now frequently used for spasticity, and occasionally used for tremor, tics, myoclonus, hyperhidrosis, pain and miscellaneous spasms.
This issue of Neurology India indicates a step forward for Movement Disorders in India, and I am sure there will be many more.
Dr. Hallett is supported by the NINDS Intramural Program.
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