Abnormal Involuntary Movement History
Author – Karthikeyan Sivaganesh Editor – Dr James Mackintosh
Last updated 22/05/24
Introduction
Abnormal involuntary movement disorders also called dyskinesias can be categorised as hyperkinetic or hypokinetic although there is often an overlap. Parkinsonism is the main type of hypokinetic disorder while hyperkinetic disorders include tremor, dystonia, chorea, tics and myoclonus. Causes of dyskinesia can be categorised into primary (e.g. basal ganglia pathologies or secondary (e.g. antipsychotics, hyperthyroidism, anxiety, etc). It is important to gather collateral information from relatives or video evidence as this provides a better understanding of the problem and gives appropriate management.
Presenting Complaint
1. Tremor
Rhythmical oscillation due to alternating agonist-antagonist muscle contraction.
Features of common tremors:
| Site, characteristics | Associated Features | |
|---|---|---|
Parkinsonism | (Often) unilateral, low frequency (3-6 Hz) “pill-rolling” resting tremor e.g. when sitting | Rigidity, bradykinesia |
Cerebellar disease | Unilateral or bilateral, intentional tremor (i.e. worse on reaching finger when doing the finger-nose test) | Commonly caused by stroke |
Essential tremor | Bilateral, high frequency (8-10 Hz), prominent on movement (called action tremor) | Family history, improves on alcohol consumption (occurs in 50% of patients) |
Physiological or hyperthyroidism | Bilateral, high frequency, fine tremor, prominent on hands held straight (called postural tremor) or on movement | Worsened by anxiety, emotions → physiologicalWeight loss, palpitations → hyperthyroidism |
Functional/psychiatric | Variable | Distractible |
2. Chorea
Means “dance”. It is abrupt, brief, irregular involuntary movements. The person appears to be fidgety and clumsy. Often seen in Huntington’s disease or complication of levodopa treatment in Parkinson’s disease.
- A variant of chorea is ballism (or ballismus) which is violent, flinging movement of the limbs. It is most commonly caused by a stroke
3. Athetosis
Slow, writhing, “worm-like” movement of the limbs and often presents with chorea which is termed choreoathetosis. Causes include cerebral palsy and Huntington’s disease.
4. Tics
Sudden, repetitive, non-rhythmic movements or sounds which are briefly suppressible. Vocal phenomena include echolalia (repeating other’s phrases), palalia (repeating one’s own phrases) and coprolalia (swearing). It is commonly associated with Tourette syndrome.
5. Myoclonus
Shock-like muscle jerks. Causes include epilepsy and hypnic jerks.
6. Dystonia
Sustained muscle contractions causing abnormal posture and often repetitive movements without any rhythm. E.g. cervical dystonia. Initiated or worsened by voluntary action or can be task specific e.g. when writing, playing instrument, etc
7. Tardive Dyskinesia
Involuntary movement of the face and jaw typically caused by antipsychotics.
Site/Location
Tremor
- Unilateral → Idiopathic parkinson’s disease
- Bilateral → Essential tremor, drug-induced parkinsonism
- Variable → Functional e.g. depression
Myoclonus
- Bilateral → epilepsy or brain injury
- Unilateral → hypnic jerks, muscle strain
Face and jaw → Tardive dyskinesia, dystonia
Chorea → Presents bilaterally
Onset
Characteristics and Associated Features
Tremor
- Low frequency (3-6 Hz), bradykinesia, rigidity → Parkinsonism
- High frequency (8-10 Hz) → essential tremor, hyperthyroidism, physiological
- Coarse → lithium toxicity
- Fine → hyperthyroidism, physiological, chronic lithium use
- Intentional → cerebellar disease
- Postural → physiological
Chorea and …
- Athetosis → Huntington’s disease (more common), cerebral palsy
- Kayser Fleischer rings → Wilson’s disease
- Scissoring gait, learning disabilities → Cerebral palsy
- Ballism → subthalamic nucleus stroke
- Tardive dyskinesia → antipsychotic use, long-term levodopa use
Myoclonus and …
- Other seizures e.g. atonic, tonic-clonic → Epilepsy
Vocal tics e.g. coprolalia (swearing) → Tourette syndrome
Timing
Sudden onset:
- Cerebral trauma, birth injury
- Ischaemic or haemorrhagic stroke
- Medications e.g. antipsychotics, antiepileptics, levodopa
- Metabolic e.g. hypoglycaemia, electrolyte imbalances
Gradual and progressive:
- Neurodegeneration e.g. Idiopathic parkinson’s disease, Huntington’s disease
- Malignancy e.g. growing tumour
Gradual but non-progressive:
- Metabolic e.g. thyroid, parathyroid disorders, electrolyte imbalances
- Autoimmune e.g. systemic lupus erythematosus, antiphospholipid syndrome, post-streptococcal (Syndenham’s chorea)
Precipitating Factors
Tremor
- Worse on movement → essential tremor
- Worse at rest → Parkinsonism
Myoclonus
- Only in early morning or late evening → Juvenile myoclonic epilepsy
- Only during sleep → hypnic jerks
Red Flags
- Loss of consciousness, tongue biting → Epilepsy
- Bladder or bowel dysfunction → Late-stage Parkinson’s disease or Parkinson-plus syndromes
- Progressive neurological deficits → Neurodegeneration, growing cerebral tumour
- Acute, focal neurological deficits → Stroke
- Nocturnal headache, headache worse on lying down e.g. Space-occupying lesion
Past Medical History
- Throat infections → Post-streptococcal (Syndenham’s chorea)
- History of attention deficit hyperactivity disorder, obsessive compulsive disorder → Tourette syndrome
- Depression, schizophrenia → functional/psychiatric tremors/antipsychotic use
- Antipsychotic drugs → Parkinsonism, tardive dyskinesia, chorea
- Tremor and …
- Asthma → salbutamol overuse (causes palpitations as well)
- Bipolar disorder→ lithium toxicity or side effects of lithium
- Schizophrenia → side effects of antipsychotics
Social History
- Recreational drug use e.g nitrous oxide → subacute combined degeneration of spinal cord
- IV drug use → discitis, epidural or brain abscess
- Alcohol misuses → alcohol neuropathy, B12 deficiency
- Significant history of smoking tobacco → Lambert-Eaton syndrome
Family History
- Chorea → Huntington’s disease
- Tremor → essential tremor
Common Differentials in OSCE's
| Condition | Presentation |
|---|---|
Hyperthyroidism | Bilateral tremor prominent on hand held out straight
Features of hyperthyroidism in history e.g. weight loss, feeling hot, atrial fibrillation, eye problems (Graves’ specific)
Swelling in neck (thyroid adenoma) |
Parkinson's disease | Elderly person, unilateral resting tremor, shuffling gait, stooped posture, hypomimia (mask-like facies)
History of depression, Alzheimer (e.g. Lewy body dementia or Parkinson’s disease dementia)
If presence of autonomic disturbances e.g. incontinence, also consider Parkinson plus syndromes |
Essential tremor | Bilateral action tremor that may improve on drinking alcohol and positive family history |
Cerebellar disease | History of brain injury
Positive cerebellar signs on examination e.g. dysmetria, intentional tremor, dysdiadochokinesia, ataxia |
Anxiety | History of mental health condition e.g. PTSD, generalised anxiety disorder
Tremors only present in periods of stress rather than constant |
Drug induced | Use of antipsychotics or lithium for mental health conditions
Poorly controlled asthma with excessive salbutamol use |
Examination
Inspection
- Assess the surrounding e.g. wheelchair (for cerebral palsy), medication
- Consider age and assess for abnormal movements at rest.
- Localise the abnormal movement. If face and neck e.g. dystonia, if bilateral upper limbs e.g. essential tremor, etc
Palpation
- Assess tone, power and reflexes to distinguish if the cause is neurological, physiological or functional. Presence of any deficits suggests a neurological cause.
- Consider the differential stated above depending on the signs elicited
- Assess sensory modalities e.g. pin-prick, crude touch, vibration and proprioception
- A sensorimotor deficit suggests multiple nerves are affected e.g. radiculopathies, peripheral neuropathies, mononeuritis multiplex, multiple sclerosis, etc
MLA Tip 💡
Have a set of differentials prior to examining so you can rule in or out depending on the signs you elicit. Remember common is common! In OSCE’s, the commonest involuntary movement scenario is a tremor so know the types and common aetiologies. For tremors, a neurological and thyroid examination is appropriate.
References/further reading
- The Neurophile, Movement disorders (https://www.youtube.com/watch?v=LsK3vbY9C7I&t=680s) [accessed 25/4/24]
- Davidson’s principles and practice of medicine (2022)
- OSCEs for medical finals (2012)