Involuntary movements- dyskinesia are abnormal involuntary motor movements associated with many diseases Here I try to show some common movements in a simple way

1. INVOLUNTARY MOTOR MOVEMENTS
Prepared By : Khaled Hani Alkhodari
Supervisor: Dr. Iyad M Husain, PhD Neurology

2. INVOLUNTARY MOVEMENTS
 Imagine if parts of your body moved when you didn't want them to.
 Dyskinesia is abnormal uncontrolled movement and is a
common symptom of many movement disorders.

3. INVOLUNTARY MOVEMENTS
 Are neurological conditions that affect the speed, fluency, quality, and ease of
movement.
 Are clinically and pathologically heterogeneous ,and are characterized by
impairment of planning, control or execution of movement .
 Almost all movement disorders are worsened with stress, fatigue, anxiety or
concomitant illness (e.g. Pneumonia, UTI, etc.). As a rule, movement disorders
show significant or complete relief during sleep.

4. CLASSIFICATION

5. CLASSIFICATION OF HYPERKINESIA

7. TREMORS
PHYSIOLOGICAL
 Tremor is an unintentional, rhythmic muscle movement involving to-and-fro
movements (oscillations) of one or more parts of the body.
 Present in almost everyone and a normal finding that usually cannot be seen
unless worsened in certain situations that include:
 Anxiety, fear, physical exhaustion, hypoglycemia, hyperthyroidism, alcohol withdrawal

8. "ESSENTIAL" TREMOR (ET)- POSTURAL
 Most common involuntary movement disorder, typified by a rapid postural tremor most often
of the upper extremities.
 Progressive, may appear at anytime of life but most commonly >70 years.
 Mainly a postural tremor (i.e Tremor when skeletal muscle holding in on position against gravity.) but if
worsened, will occur at rest
 Commonly bilateral and symmetric.
 Classically affects head and/or speech.
 Classically, tremor decreases with EtOH, worsens with stress.
 Neurological exam is otherwise normal.
 Differentiate from Parkinson by noting absence of resting tremor, rigidity, bradykinesia, etc.

9. CEREBELLAR TREMOR (INTENTION TREMOR)
 Slow action tremor that most commonly occurs with purposeful movement
(such as in doing finger to nose test)
 Usually associated with other cerebellar findings
 Seen in any process that causes damage to the cerebrellum (stroke, tumor,
multiple sclerosis, chronic alcohol abuse, certain medications)
 Unlike the cerebrum, cerebellar disease causes problems on the SAME SIDE of
the body as the the cerebellar lesion
 Titubation refers to tremor of the head (and sometimes trunk) due to
cerebellar disease

10. PARKINSONIAN TREMOR
 Most common cause of a resting tremor that usually involves the distal muscles (e.g. pill
rolling tremor of the hand)
 May decrease with voluntary activity (e.g. raising arm) and increase with mental activity (e.g.
asking patient to do math) and increase with anxiety or emotional excitement
 causes:
 idiopathic parkinson's disease: usually starts in one hand then spreads to other limbs
 Drugs: antipsychotic agents, metoclopramide, prochloperazine
 Encephalitis (HIV/AIDS, neurosyphilis, PML, toxoplasmosis)
 Chronic head trauma.
 Other resting tremors include Wilson's Disease and severe essential tremor (ET is usually
postural but when servere can be seen at rest or even with movement)

11. TREMORS

12. TREMORS

13. TREMORS

14. CHOREA
 A state of excessive, spontaneous movements, irregularly timed, non-
repetitive, randomly distributed and abrupt in character.
 These movements may vary in severity from restlessness with mild
intermittent to unstable dance-like gait to a continuous flow of disabling,
violent movements.
 Chorea involves both proximal and distal muscles.

15. CAUSES OF CHOREA
 Hereditary: Huntington’s disease, benign chorea
 Drugs: Antiparkinsonian drugs, oral contraceptives
 Toxin: alcohol, carbon monoxide poisoning
 Infections: Sydenham’s chorea, encephalitis
 Metabolic: hyperthyroidism, hypocalcaemia
 Immunological: SLE, polyarteritis nodosa
 Vascular: Hemibalism

16. CHOREA
HUNTIGTON DISEASE
 Definition: is an autosomal dominant disease that characterized by
progressive chorea and dementia
 Etiology: pathology in gene called “huntingtin” located in chromosome 4p
16.3.
 Pathology: reduction in the striatum of γ-Aminobutyric acid-(GABA) and
acetylcholine
 Age: 30-40 years

17. CHOREA
HUNTIGTON DISEASE
 Symptoms and signs:
 motor impersistence.
 milkmaid's grip.
 harlequin's tongue.
 Patients often drop objects involuntarily.
 Trials to mask it by semipurposeful movements
 rigidity and dementia
 Diagnosis: MRI, PET scaning. Genetic testing is diagnostic
 Treatment: phenothiazine, haloperidole.

18. CHOREA
HUNTIGTON DISEASE

19. CHOREA
SYDENHAM CHOREA
 Its one of major criteria of rheumatic chorea, postinfective chorea
 Age: 5-15 years
 Movements are diffuse and often associated with behavioral changes
 Pathology: necrotising arteritis in thalamus, caudate nucleus and putamen
 Diagnosis: elevated ESR and ASOT (antistreptolysin titre)
 Treatment: aspirin, penicillin, sedation
 can occur in:
 A tumor or an infarct in the striatum (caudate or putamen) can cause acute unilateral chorea
(hemichorea).
 Sydenham chorea and chorea due to infarcts of the caudate nucleus often lessen over time
without treatment.

20. CHOREA
SYDENHAM CHOREA

21. CHOREA GRAVIDARUM
 Occurs during pregnancy, often in patients who have had rheumatic fever.
 Chorea usually begins during the 1st trimester and resolves spontaneously
at or after delivery.
 If treatment before delivery is necessary because chorea is severe,
barbiturates are indicated because they have fewer fetal risks than other
drugs used to manage chorea.
 Rarely, a similar disorder occurs in women taking oral contraceptive

22. OTHER CHOREAS
 Neuroacanthocytosis is a rare, recessive, relentlessly progressive disorder typified by chorea
coupled with erythrocyte abnormalities and possibly dystonia, tics, seizures, polyneuropathy,
and self mutilation. May present at any time in life.
 Similar presentation is noted in McLeod syndrome - an X-linked disorder associated with reactivity to
Kell antigens, typically older patients.
 Paroxysmal chorea has been described in hyper- and hypoglycemia, vascular diseases, and
infections.
 Benign senile chorea & benign inherited chorea of childhood have been described but are
controversial. It is important to rule out HD.
 SLE and less commonly other autoimmune disorders may cause chorea.

23. ATHETOSIS (SLOW CHOREA), CHOREOATHETOSIS
 Athetosis
 Is nonrhythmic, slow,
writhing (ie, squirming, twisting, or
snakelike), sinuous movements
 Predominantly in distal muscles.
 Often alternating with postures
of the proximal limbs.
 May be due to ↑ dopamine
 Choreoathetosis:
 Bit more rapid than the usual
athetosis, slower than the usual
chorea, or
 A mingling of chorea and
athetosis within the same
patient at different times or in
different limbs
The only difference between chorea, choreoathetosis, and athetosis is the
speed of movement

24. ATHETOSIS

25. HEMIBALLISMUS & BALLISMUS (SEVERE FORM OF CHOREA)
 Continuous, violent, coordinated involuntary activity involving the axial and
proximal appendicular musculature such that the limbs are flung about.
 Vascular type of chorea, due to stroke of corpus luisii in subthalamus
(posterior cerebral artery territory)
 Hemiballismus is unilateral
 Ballismus movement occurs bilaterally.

26. HEMIBALLISMUS & BALLISMUS

27. TIC
A “tic” is an involuntary movement or vocalization that is usually sudden onset,
brief, repetitive, stereotyped but non rhythmical in character, can be suppressed.

28. TIC
TYPES
 Motor tics are associated with movements. Categorized as simple or complex.
Simple motor tics involve only a few muscles usually restricted to a specific
body part.
 Examples of simple motor tics include: eye blinking, shoulder shrugging, facial
grimacing, neck stretching, mouth movements, jaw clenching and spitting.
 Vocal tics are associated with sound
 Simple vocal tics consist of sounds that do not form words, such as: throat clearing,
grunting, coughing, and sniffing

29. TICS
SUBTYPES
 Transient Simple: common in children
 Chronic: any age
 Persistent Simple or Multiple: onset before 15 yr age, resolve in
adults
 Chronic Multiple: Tourette’s syndrome

30. TIC

31. TICS
SOME DEFINITIONS
 Common complex vocal tics include:
 Repeating words or phrases out of context,
 Coprolalia : use of socially unacceptable words, frequently obscene.
 Palilalia : repeating one's own sounds or words.
 Echolalia : repeating the last-heard sound, word, or phrase.
 Echokinesis : imitation of someone else's movements.

32. TICS
GILLES DE LA / TOURETTE DISORDER
 Cause: unknown
 Common in male in
childhood or adolescence.
 Treatment: difficult but
patients may respond to
clonidine,
benzodiazepines, halidol,
risperdal, clozapine,
 Surgery for drug-resistant
tics, but not shown
effective in Tourette’s

33. TICS

34. TICS

35. MYOCLONUS
Definition: These are sudden, rabid,
involuntary, jerky, ‘shock-like’
movement of a single muscle or a
group of muscles.
 Epileptic myoclonus
 Seizures without significant
encephalopathy
 Cortical origin
 Benign essential myoclonus
 Nocturnal myoclonus
 Paramyoclonus multiplex
 Segmental myoclonus
 Brainstem
 Spinal

36. NON EPILEPTIC MYOCLONUS
ENCEPHALOPATHY WITHOUT SIGNIFICANT EPILEPSY
 Basal ganglia degenerations
 Wilson’s
 Huntingtons
 Dementias
 Alzheimer’s
 CJD
 Malabsorption
 Hypoxia
 Spinocerebellar degeneration
 Focal
 Tumour
 Stroke
 Trauma
 Metabolic
 Hepatic failure
 Renal failure
 Paraneoplastic
 Toxic

37. DYSTONIA (ALTERED MUSCLE TONE)
 Refers to a syndrome of
involuntary sustained or spasmodic
muscle contractions involving co-
contraction of the agonist and the
antagonist.
 The movements are usually slow
and sustained, and they often
occur in a repetitive and patterned
manner
 They can be unpredictable and
fluctuate.

38. DYSTONIA
TYPES
 Generalized:
 Dystonia muscularum deformans (idiopathic torsion dystonia):Dystonia affecting gait and
posture, common in childhood
 Dopamine responsive Dystonia: The disorder presents in childhood and generally
involves the legs only.
 Drug-induced dystonia (metoclopramide,phenothiazine, haloperidol, largactyl)
 Symptomatic dystonia (after encephalitis, Wilson’s disease)

39. DYSTONIA
TYPES
 Partial or focal:
 Spasmodic torticollis
 Blepharospasm
 Oromandibular dystonia
 Writer’s cramp
 Hemiplegic dystonia after stroke

40. SPASMODIC TORTICOLLIS
 Unilateral deviation of the head
 Dystonic contraction of left
sternomastoid muscle produces head
turning to the right
 Treatment: anticholinergics and
local botolinum toxin injection.

41. BLEPHAROSPASM & OROMANDIBULAR DYSTONIA
 Involuntary prolonged tight eye closure (blepharospasm) is associated with
dystonia of mouth, tongue or jaw muscles (jaw clenching and tongue
protrusion)

42. WRITER'S CRAMP = MOGIGRAPHIA = SCRIVENER'S PALSY
 Symptoms usually appear when a person is trying to do a task that requires fine motor
movements such as writing or playing a musical instrument.
 The symptoms may be isolated to only those tasks or affect the muscles in a more general
way and spread to affect many tasks.
 Common symptoms include, for example, excessive gripping of a pen or utensil, flexing of the
wrist, elevation of the elbow, and occasional extension of a finger or fingers causing the
utensil to fall from the hand.

43. WRITER'S CRAMP = MOGIGRAPHIA = SCRIVENER'S PALSY

44. MYOKYMIA
 Myokymia, a form of involuntary muscular movement, usually can be
visualized on the skin as vermicular or continuous rippling movements.
 The word myokymia was used first more than 100 years ago, when Schultze
described continuous, slow, undulating muscular contractions in small
muscles of hands and feet

45. MYOKYMIA

46. AKATHESIA
 Akathisia is a movement disorder characterized by a feeling of inner
restlessness and a compelling need to be in constant motion, as well as by
actions such as:
 rocking while standing or sitting.
 lifting the feet as if marching on the spot.
 crossing and uncrossing the legs while sitting.
 People with akathisia are unable to sit or keep still, complain of restlessness,
fidget, rock from foot to foot, and pace.
 Akathisia is frequently associated with the use of dopamine receptor
antagonist antipsychotic drugs

47. NEUROLEPTIC MALIGNANT SYNDROME
 Clinical features:
 Drowsiness, fever, tremor and rigidity
 Muscle necrosis (rhabdomyolisis), and
renal failure.
 Elevation of serum creatine kinase
activity and sometimes
 Myoglobinuria
Treatment:
 Dopamine receptor agonist
(Bromocriptine), Baclofen
 Muscle relaxants (Dantrolene)
Associated with prescribing dopamine antagonist and long acting neuroleptic therapy

48. AKATHESIA

49. RESTLESS LEGS SYNDROME
“EKBOM’S SYNDROME”
 Restless legs syndrome refers to
symptoms of spontaneous, continuous
leg movements associated with
paresthesia.
 These sensations occur only at the rest
and relieved by movement.
Causes:
 Familial
 Lumbar root disease
 Polyneuropathy
 Renal failure
 Iron deficiency
 Psychiatric
Treatment: Dopaminergic agent,
clonozepam, gabapentine.

50. ASSOCIATED MOVEMENTS “MIRROR MOVEMENTS”
 Mirror movements are
characterized by involuntary
movements on one side of the
body mirroring voluntary
movements of the other side.
 This mostly affects the top half
of the body but can also affect
the bottom half of the body.

51. ANY QUESTIONS?

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