Involuntary Movement

By Mustafa Abdul Sahib

What is an involuntary movement

It occurs when a body part moves in an uncontrolled and
unintended way
It could involve one part or multiple parts or even whole
body
It could be single movement or jerky movement
It could be a simple or a complex movement

Approach
Onset
Duration
Comorbid conditions

Recognize the pattern

Drugs, alcohol
Hx of trauma or neurosurgery
Associated cognitive or psychiatric problems

 When and how did the movements start?

What body parts are being affected?
What seems to make the movements worse or
better?
Does stress affect these movements?
How often are the movements taking place?
Are the movements getting worse over time?

Tremors
Defined as a rhythmic oscillating movement of a limb or part of
a limb, or of the head.

Rest tremor
This is pathognomonic of Parkinson's disease .
The tremor is characteristically 'pill-rolling' and usually
presents asymmetrically.

Action tremors
are more common than rest tremors and the potential
causes are more numerous

Causes of tremor on action

1)
2)
3)
4)
5)

Exaggerated physiological tremor.

Essential tremor (may be familial).
Parkinson's disease (rest tremor more usual).
Wilson's disease.
Postural ('Holmes' or 'rubral') tremor
A.
B.

Multiple sclerosis
Other lesions in cerebellar outflow/red nucleus

6) Intention tremor
.Cerebellar hemisphere disease

Psychogenic tremor
Usually on action, but can occur in all conditions
Comes suddenly and disappears spontaneously
Abnormal combination of multiple types of movement, Changes
in character
Since it is voluntary, asking patient to do repetitive movement
with other hand makes it disappear in the affected hand
Also disappears from a body part and appears in another while
examining the affected part.
Rare before age of 10 years old
Increase with attention
+ve placebo affect
Usually dominant hand
May be associated with other psychogenic movement
May have a +ve psychiatric history
EEG and EMG might help diagnose it
Organic causes should be excluded

Essential Tremor
higher in men than in women and in whites
Bilateral, largely symmetrical postural or kinetic tremor
in hands/forearms that is visible and persistent
Additional or isolated head tremor may occur two thirds
of patients give a positive family history of tremor .
Alcohol often suppresses it.

Flapping tremor(asterixis)
Typical of metabolic disturbances.

Primary orthostatic tremor

In patients older than 40 years.

Symptoms
a)

Sensation of unsteadiness, fear of falling. b) Discomfort in legs

when standing.
c) Difficulty initiating walking

e)

.d)

Symptoms attenuate by walking

Symptoms disappear by sitting .

Seizure
is a paroxysmal event due to abnormal excessive
or synchronous neuronal activity in the brain.

Chorea
Jerky, small-amplitude, purposeless involuntary
movements .
It can occur in face(grimaces) in limbs(fidgety
movements) due to caudate nucleus lesion.

Causes of chorea
A) Hereditary

D) Endocrine

1)
2)
3)
4)

Huntington's disease
Wilson's disease
Neuroacanthocytosis
Porphyria

5)

Paroxysmal choreoathetosis

1)Pregnancy
2)Oral contraceptive
3)Thyrotoxicosis
4)Hypoparathyroidism
5)Hypoglycaemia

B) Cerebral birth injury (includingE) Infective/inflammatory

kernicterus) Cerebral trauma6) Post-streptococcal (Sydenham's
chorea)
C) Drugs
6)
7)
8)
9)
10)

Levodopa
Dopamine agonists
Phenothiazines
Tricyclics
Oral contraceptive

7)
8)
9)
10)

Henoch-Schnlein purpura
Creutzfeldt-Jakob disease
Antiphospholipid antibody syndrome
Systemic lupus erythematosus (SLE)

F) Vascular
11)Lacunar infarction
12)Arteriovenous malformation

Tics
Tics are sudden, repetitive movements. Theyre classified as
simple or complex, depending on whether they involve a
smaller or larger number of muscle groups.
Excessively shrugging the shoulders or flexing a finger is an
example of a simple tic. Repetitively hopping and flapping
ones arms is an example of a complex tic.

Athetosis
This refers to slow, writhing movements.

Myoclonus
Myoclonus is characterized by quick, shock-like, jerking
movements. They may occur naturally during sleep or at
moments when youre startled. However, they can also be due
to serious underlying health conditions, such as epilepsy or
Alzheimers disease.
Myoclonus, especially of cortical origin, often responds to
clonazepam, sodium valproate or piracetam .

Dystonia
Sustained involuntary contraction that causes
abnormal posture or movement.
It may be generalized in various diseases of the
basal ganglia, or may be focal or segmental as
in spasmodic torticollis when the head involuntarily
turns to one side due to drugs or occupational.

Abnormal movement related to

drugs
Tardive dyskinesia
Abnormal repetitive involuntary and usually
stereotypical movement, and occur as a
result of prolong exposure to DPA

Diagnosis of Movement disorder

1. Which types of movement disorder
are present?
2. What is the dominant movement
disorder type?
3. What are the associated features?
4. What is the differential diagnosis?