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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
 movements
○ reflexes / plantars / primitive reflexes


References 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 Nature Reviews Neurology Volume 6 January 2010 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 Akathesia : overlooked at a cost BMJ 2002 Jun 22 ; 324 ( 7352 ): 1506-1507 Movement Disorders ; Overview and Treatment Options P&T April 2005 Vol30 No 4 Review Article Chorea Sanjay Pandey JAPI July 2013 Vol 61 Medscape CME The Clinical Approach to Movement Disorders Approach to the patient with a movement disorder David J Burn ACNR Volume 3 Number 2 May/ June 2003

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