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Movement disorders

Movement disorders –Neurological syndromes in which there is either an excess of movement or paucity of voluntary and automatic movements unrelated to weakness or spasticity 

( Epidemiology and Classification of Movement Disorders Njideka U . Okubadejo Professor and Consultant Neurologist College of Medicine , University of Lagos & Lagos University Teaching Hospital , Nigeria )

Common neurological disorders Generalisation of prevalence is difficult- broad spectrum of conditions Most common hypokinetic disorder is Parkinsonism / Parkinsons disease
PD prevalence 1 % in people aged 65-85 yrs
↑ es to 4.3 % above 85 Essential tremor is the most common tremor
4 % in people aged over 40 yrs
↑ es to 14 % in people over 65 yrs Tics in school going children & adolescents can be up to 21 %

History and examination form the basis of diagnosis and management – establish phenomenology Usually synonymous with basal ganglia disease and extrapyramidal features but pathology may also arise from other structures ( e.g myoclonus ) or manifestation of a more widesprad neurological dis Presentation can be complex and diagnosis challenging even for experienced neurologists In early stages the diagnostic value of complex tests (as below , often expensive and time consuming ) is limited
eg CSF analysis , genetic tests , electrophysiological , structural and functional imaging studies or tissue biopsy Routine blood testing should be done ( also check for ceruloplasmin to r/o Wilson’s disease )

Insufficient movements -Akinetic, hypokinetic or bradykinetic syndromes. Akinesia could be described as an umbrella term for 
a symptom complex that can include
 Bradykinesia- slowness of movement Hypokinesia – poverty of movement and movements that are smaller than intended

 Idiopathic Parkinson’s Drug induced Parkinson’s Multi-system atrophy Progressive Supranuclear Palsy Corticobasal degeneration Dementia with Lewy bodies. Parkinsons disease is the most common hypokinetic
 movement disorder

Too much movement -Jerky Myoclonus , tic disorder Non-jerky- dystonia, tremor

Ataxia-Impaired motor co-ordination that is commonly related to disorders of the cerebellum or its connections with the brain and the spinal cord Symptoms include slurred speech , nystagmus , dysmetria , poor dexterity , wide based gait

athetosis-slow , writhing , continuous and involuntary movements usually affecting the distal limbs

Akathesia –Greek- not to sit Extrapyramidal movement disorder- difficulty in staying still and a subjective sense of restlessness Can happen acutely or as a late complication of neuroleptic medications Difficult to recognise and presents unexpectedly in variety of clinical settings

Ballismus-Large amplitude sometimes violent , proximal severe chorea. Usually on one side 
( hemiballismus- most common cause is stoke )

Chorea-Greek- dance Involuntary movement flowing and rhythmic in nature Movements generally generalised and purposeless ( can be difficult to differentiate from restlessness ) Happens due to dysfunction of a neuronal network between motor cortex and basal ganglia May involve face , tongue , neck , upper extremities and lower extremities Causes- genetic and non-genetic
Most common genetic cause is Huntington’s disease
Non-genetic- metabolic , infection and stroke Unilateral- hemichorea
Chorea + ballismus -> choreoballistic
Choreoathetosis -> slow and writhing movements

Dyskinesia –Abnormal involuntary movements which can manifest as jerking , twisting or writhing. Often used to describe drug-induced chorea and dystonia ( alone or in combination ) Can happen in patients on anti-psychotics or other agents with dopamine D2 blocking properties Tardive dyskinesia- choreodystonic movements 2ary to long-term use of neuroleptic or anti-emetic medications that have dopamine antagonist activity

Dystonia- Sustained involuntary muscle contractions generating twisting and repetitive movements or abnormal posture
( Fahn S et al Classification and investigation in dystonia 1987 ) Due to co-contractio of antagonist muscles Can be classified as
○ focal ,segmental , multifocal , generalised or hemidystonia
○ early ( < 26 yrs ) or late
○ primary , dystonia-plus , degenerative or secondary
○ persistent , action-specific , diurnal & paroxysmal
○ inherited , acquired or idiopathic

Myoclonus-Sudden , brief , shock-like involuntary movements which are usually positive 
( ie caused by muscle contraction ) but can also be negative ( due to a brief loss of inhibition of muscular tonus as in asterixis caused by hepatic or uraemic enkephalopathy ) Key word – is shock like movements

Parkinsons-Clinical syndrome with bradykinesia as the defining feature and almost always accompanied by rigidity and often tremor Covered separately

Stereotype-Purposeless voluntary movements carried out in a uniform fashion at the expense of other activity ( e.g hand wringing , clapping , mouthing )

Tic-Abrupt , jerky , non-rhythmic movement or sound that is temporarily suppressible by will power. Often preceded by rising discomfort or urge ( sensory tic ) that is relieved by the actual movement

Tremor-Rhythmical , involuntary , oscillatory movement of one or more body parts Key phenomena is rhythmicity- oscillations happen at a regular frequency Tremors can be classified in different ways ( dealt separately )

History and assessment- Onset Rate of progression Does it cause any functional disability ? Medical and drug history Infections ( e.g rheumatic fever ) Toxin exposure Response to alcohol and consumption Family history Neuro-psychiatric features Autonomic symptoms Sleep problems Any additional physical signs for e.g organomegaly , eye movement disorder , reflex changes Advice to get a video on smart phone

Distribution Relationship to voluntary movement Rhythmic or arrhythmic Relation to posture Sustained or non-sustained Slow or fast At rest or action Any sensory symptoms Suppressibility Aggravating factors Factors which improve the symptom

Observe during history taking- eg
○ any involuntary movements and their distribution
○ utterances and vocalisation
○ blink frequency
○ excessive sighing Cognitive assessment Cardiovascular ( e.g lyeing and standing BP ) Gait , postural reflexes and axial tone Eye movements Limb examination
○ tremors , dystonic posturing
○ tone
○ power , co-ordination
○ fine finger and rapid alternating
○ reflexes / plantars / primitive reflexes


  1. The clinical approach to movement disorders
    Wilson F. Abdo, Bart P. C. van de Warrenburg, David J. Burn, Niall P. Quinn and Bastiaan R. Bloem Abdo, W. F. et al. Nat. Rev. Neurol. 6, 29–37 (2010); doi:10.1038/nrneurol.2009.196
  2. Disorders of Movement Martin Harley Neurology Movement disorders : a brief practical approach to diagnosis and management DJ Burn J R Coll Physicians Edinb 2006 ;36 :331-335
  3. Akathesia : overlooked at a cost BMJ 2002 Jun 22 ; 324 ( 7352 ): 1506-1507
  4. Movement Disorders: Overview and Treatment Options Ali Samii, MD, and Bruce R. Ransom, MD, PhD 228 P&T® • April 2005 • Vol. 30 No. 4
  5. Review Article Chorea Sanjay Pandey  Journal of the association of physicians of India • july 2013 • VOL. 61
  6. Medscape CME The Clinical Approach to Movement Disorders
  7. Approach to the patient with a movement disorder David J Burn ACNR Volume 3 Number 2 May/ June 2003


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