This document discusses belly dancer's dyskinesia, a rare condition involving involuntary movements of the abdominal wall muscles. It was first described in 1723. The pathophysiology may involve dysfunction of inhibitory spinal neurons or structural changes in local neuronal circuits. Causes include prior abdominal surgery, vaginal delivery, neurological conditions, and functional disorders. Symptoms include fluttering of the abdomen that is rhythmic but not suppressed by breath holding. Diagnosis involves clinical exam, imaging, and electromyography. Treatment options with varying effectiveness include diazepam, botulinum toxin injections, and nerve blocks. The prognosis is variable and symptoms may persist for years.

1. Belly Dancer’s Dyskinesia
Ade WIJAYA, MD – May 2019

2. Introduction
• First described by Antonie van Leeuwenhoek in 1723 when he himself
experienced the symptoms
• Dyskinesia limited to the axial musculature is an extremely rare
phenomenon
• When such a dyskinesia involves the anterior abdominal wall, it is termed
as belly dancers dyskinesia
• Usually consists of involuntary, repetitive, sometimes painful and often
rhythmic movements of the anterior abdominal wall with the majority
being bilateral having slow writhing
• ~ Abdominal wall dyskinesia
• ~ Diaphragmatic flutter
Intermittent bursts of abdominal wall jerky movements: belly dancer’s syndrome? . Amin OSM, Abdulkarim QH, Shaikhani M. BMJ Case Reports. 2012
ASHUTOSH GUPTA SK. Belly Dancer's Dyskinesia: A Glimpse of a Rare Phenomenon. Cureus. 2017 Jul;9(7).
Larner AJ. Antony van Leeuwenhoek and the description of diaphragmatic flutter (respiratory myoclonus). Mov Disord 2005;20:917-8

3. Pathophysiology
• Dysfunction of inhibitory spinal interneurons
• Structural reorganization of local neuronal circuits
Diaphragmatic flutter, the moving umbilicus syndrome, and “belly dancer’s” dyskinesia. Iliceto G, Thompson PD, Day BL, et al. Mov Disord. 1990;5:15–22.

4. Etiology
• Post abdominal surgery
• Uncomplicated vaginal delivery
• Osmotic demyelination syndrome
• Intramedullary thoracic cord tumor
• Tardive syndromes
• Compressive thoracic radiculopathy
• Levodopa-induced movements
• Diaphragmatic flutter
• Basal Ganglia lesions
• Functional movement disorders
ASHUTOSH GUPTA SK. Belly Dancer's Dyskinesia: A Glimpse of a Rare Phenomenon. Cureus. 2017 Jul;9(7).
Rathore C, Prakash S, Bhalodiya D. Belly dancer's dyskinesia: A rare movement disorder. Neurology India. 2018 Mar 1;66(7):156.

5. Clinical Manifestation
• Fluttering or rolling of anterior abdominal wall
• Involuntary, repetitive, semi-continuous, sometimes painful, often
rhythmic and slow writhing
• Not suppressed on breath holding or distraction but may subside during
sleep.
• Patients may also present with shortness of breath, chest pain or fatigue
• Gradual onset
• The movements are due to the variable combination of contractions of the
rectus abdominis, oblique muscles, paraspinal, and perineal muscles
• The rate of diaphragmatic contractions varies from 35-480 per minute with
an average rate of 150 per minute
Diaphragmatic flutter presenting as inspiratory stridor. Cvietusa PJ, Nimmagadda SR, Wood R, et al. Chest. 1995;107:872–875.
ASHUTOSH GUPTA SK. Belly Dancer's Dyskinesia: A Glimpse of a Rare Phenomenon. Cureus. 2017 Jul;9(7).
Rigatto M, De Medeiros NP. Diaphragmatic flutter: Report of a case and review of the literature. Am J Med 1962;32:103-9.

6. Clinical Manifestation
• When the syndrome is caused by irritation of the phrenic nerve, the
heart is the most common source of irritation. Such cases result in
diaphragmatic flutter synchronous with the systole
• When diaphragmatic flutter is present bilaterally, a central origin is
more likely. A central origin are usually present during sleep whereas
the movements originating from peripheral or spinal origin invariably
would subside
• Psychogenic factors are also frequently suspected in such cases as
these symptoms only present while the patient is awaken.
Distractibility and breath holding may serve the purpose of diagnosis
in such a dilemma
A case of functional belly dancer's dyskinesia. Joo Cho H, Panyakaew P, Srivanitchapoom P, et al. Mov Disord. 2016;3:306–308.
Diaphragmatic flutter with a manifestation of high frequency ventilation. Tamaya S, Kondo T, Yamabayashi H. Jpn J Med. 1983;22:45–49.

7. Diagnosis
• Clinical
• Fluoroscopy
• Diaphragmatic Electromyography
• Abdominal ultrasound
• Brain and spinal cord imaging, in suspected cases be utilized to rule
out the secondary causes.
ASHUTOSH GUPTA SK. Belly Dancer's Dyskinesia: A Glimpse of a Rare Phenomenon. Cureus. 2017 Jul;9(7).
Patterson V. Belly dancer's syndrome: Causes, clinical presentations, and treatment. Available from: http://www.logan.edu/mm/files/LRC/Senior-Research/2011-Dec-31.pdf.
Ramírez JD, Gonzales M, Hoyos JA, Grisales L. Diaphragmatic flutter: A case report and literature review. Neurología 2015;30:249-51. Back to cited text no. 4
Chen R, Remtulla H, Bolton CF. Electrophysiological study of diaphragmatic myoclonus. J Neurol Neurosurg Psychiatry 1995;58:480-3.

8. Treatment
• Diazepam
• Clonazepam
• Haloperidol
• Aripiprazole
• Promethazine injection
• Phrenic nerve block or crushing
• USG –guided botox injection
Prognosis is variable in which some cases resolve spontaneously or with treatment
while many cases persist for years
Diaphragmatic flutter presenting as inspiratory stridor. Cvietusa PJ, Nimmagadda SR, Wood R, et al. Chest. 1995;107:872–875.
Diaphragmatic flutter with a manifestation of high frequency ventilation. Tamaya S, Kondo T, Yamabayashi H. Jpn J Med. 1983;22:45–49.
Spinal myoclonus resembling belly dance. Kono I, Ueda Y, Araki K, et al. Mov Disord. 1994;9:325–329.
Successful treatment of tardive diaphragmatic flutter in an elderly man with aripiprazole. Chen YH, Lee CS, Lin Y, et al. Int J Gerontol. 2013;7:127–128.
Ultrasound-guided botulinum toxin A injection in the treatment of belly dancer’s dyskinesia. Alshubaili A, Abou-Al- Shaar H, Santhamoorthy P, et al. BMC Neurol. 2016;16:226.

9. Summary
• Difficult to diagnose
• Exact mechanism is inconclusive
• Often refractory to medical therapy