Approach to abnormal movements

Question 1

Tremor

Answer 1

Involuntary rhythmic shaking or trembling movement

5-10 Hz - essential tremors
3-6 Hz (lower) - Parkinson’s disease

Question 2

Chorea

Answer 2

Irregular, rapid flowing, non-repetitive, non-rhythmic involuntary movements

Question 3

Athetosis

Answer 3

Slow, writhing, continuous, and involuntary movements, often blends with chorea (choreoathetosis)

Question 4

Dystonia

Answer 4

Sustained or intermittent muscle contractions causing abnormal, repetitive, movements and postures

Question 5

Myoclonus

Answer 5

Sudden, brief, shock-like, involuntary muscle jerks

Question 6

Tics

Answer 6

Abrupt, intermittent, stereotyped, non-rhythmic movements (motor tics) or sounds (phonic or vocal tics)

Preceded by an urge or premonitory sensation and can be temporarily suppressed.

Question 7

Akathisia

Answer 7

Subjective feeling of inner restlessness, causing inability to sit or stand still, leading to repetitive movements (pacing, shuffling, or rocking)

Question 8

Ataxia

Answer 8

Impaired coordination of voluntary muscle movements, resulting in unsteadiness, clumsiness, coarse and inaccurate movements

Question 9

Stereotypies

Answer 9

Repetitive, patterned/rhythmic, seemingly purposeful but non-goal-directed movements (or voice)

Question 10

Bradykinesia/Hypokinesia/Akinesia

Answer 10

Reduced amplitude or range of movement

Question 11

Differential diagnoses of abnormal movements

Answer 11

1. Cerebellar syndrome - ataxia and past pointing, unsteadiness
2. Parkinsonism - resting tremors, bradykinesia, postural instability
   - Idiopathic
   - Plus: MSA, PSP, CBD, DLB
   - Normal pressure hydrocephalus
   - Wilson’s disease
   - Drugs: antipsychotic, metoclopramide, prochlorperazine
3. Systemic condition - coarse tremors
   - Hyperthyroidism
   - Phaeochromocytoma
   - Hypoglycaemia
   - Drugs: lithium, antipsychotics, AED, sympathomimetics, caffeine
4. Choreoathetosis (CHOREAS-PRV)
   - C: Copper (Wilson’s)
   - H: Huntington’s disease
   - O: OCP
   - R: Rheumatic fever
   - E: Endocrine (hyperglycaemia, hyperthyroidism)
   - A: Antiphospholipid syndrome, autoimmune (SLE), neurosarcoidosis
   - S: Stroke / ICH / SOL in basal ganglia
   - PRV
5. Basal ganglia pathology - dystonia, dyskinesia, chorea
6. Focal seizure
7. Tics
   - Restless leg syndrome (anaemia)
   - Tourette’s syndrome