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With the latter condition, the tongue may undergo forceful involuntary protrusion; the throat and neck muscles may be thrown into violent spasm when the patient attempts to speak or the facial muscles may contract in a grimace; the laryngeal muscles may be involved, imparting a high-pitched, strained quality to the voice (spasmodic dysphonia) More often, spasmodic dysphonia occurs as an isolated phenomenon Of the large number of focal dystonias seen in the movement disorder clinic of Columbia Presbyterian Hospital, 44 percent were classi ed as torticollis, 26 percent as spasmodic dysphonia, 14 percent as blepharospasm, 10 percent as focal dystonia of the right hand and arm (writer s cramp), and 3 percent as oromandibular dystonia This re ects the distribution in our own and our colleagues practices These movement disorders are involuntary and cannot be inhibited, thereby differing from habit spasms or tics.

The rst contractions after rest are of near normal strength, but after 20 to 30 contractions, there occurs a deep ache and an increasing rmness and shortening of the contracting muscles The characteristics of these diseases are presented in the chapters on muscle disease Another such process acid maltase de ciency is at times associated with disproportionate weakness and fatigue of respiratory muscles, which leads to dyspnea and retention of carbon dioxide Fatigue in Neurologic Diseases Fatigue of varying degree is a regular feature of all diseases that are marked by denervation of muscle and loss of muscle ber Fatigue in these cases is due to the excessive work imposed on the intact muscle bers (overwork fatigue) This is most characteristic of amyotrophic lateral sclerosis and the postpolio syndrome, but it also occurs in patients who are recovering from Guillain-Barre syndrome and in those with chronic polyneuropathy.

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At one time torticollis was thought to be a type of neurosis, but psychiatrists and neurologists now agree that it is a localized form of dystonia As discussed in Chap 4, it is characteristic of these spasms and of similar focal dystonias that occur in the hands or feet to display a simultaneous activation of agonist and antagonist muscles (cocontraction), a tendency for the spasm to spread to adjacent muscle groups that are not normally activated in the movement (over ow), and sometimes to include an arrhythmic intermixed tremor; but these features tend not to be as prominent in most focal dystonias as in the generalized varieties (described in Chap 4) The tremor in particular may cause dif culty in diagnosis if the slight degree of dystonia is not appreciated except by careful observation and especially by palpation of the involved muscles.

Not surprisingly, many neurologic diseases that are characterized by incessant muscular activity (Parkinson disease, double athetosis, Huntington disease, hemiballismus) induce fatigue Also, muscles partially paralyzed by a stroke feel tired and may cause overall fatigue state (the distinguished neuroanatomist A Brodal has given an interesting account of his own stroke and its effects on muscle power) Fatigue is often a major complaint of patients with multiple sclerosis; its cause is unknown, although the effect of interleukins circulating in the cerebrospinal uid has been pos-.

The red pigment myoglobin, responsible for much of the color of muscle, is an iron-protein compound present in the sarcoplasm of striated skeletal and cardiac bers. Of the total body hematin com-

Any of the typical forms of restricted dystonia may represent a tardive dyskinesia; ie, they complicate treatment with neuroleptic drugs (see further on and pages 94 and 1327) The most common of these is a more or less constant movement of the tongue and lips, which may include lip smacking, tongue protrusion, and similar unnatural orolingual movements Also, restricted dystonias of the hand or foot often emerge as components of a number of degenerative diseases Parkinson disease, corticobasal ganglionic degeneration, and progressive supranuclear palsy (all described in Chap 39) These dystonias may also occur in metabolic diseases such as Wilson disease and nonwilsonian hepatolenticular degeneration Rarely, a focal dystonia emerges transiently after a stroke that involves the striatopallidal system, mainly the internal segment of the pallidum, or the thalamus, but the varied locations of these.

time nurses have the insurance, leave, and retirement bene ts in their designated category, teacher or administrator/supervisor. In 2001 02 the mean of average salaries for full-time school nurses was $38,221.

Answer 4-6

1. Press CTRL-F5. 2. Enter Bob into the first name text box and Smith into the last name text box (Figure 3-4) or use any name.

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