This is to get an understanding of clinical aspects of the various kinds of Hyperkinetic movement disorder, with videos.

1. Hyperkinetic
Movement
Disorders

2. Movement Disorders
Movement disorders are classified
into two groups
Hypokinetic Movement Disorders
Hyperkinetic Movement Disorders

3. Examination
• Part of the body involved
• Exact Location
• Extent and Distribution
• Part of the muscle/ entire muscle/ muscle
groups/ joints/ complex
• Pattern, Rhythmicity, Uniformity/
Multiformity
• Recurrence regularity

4. Examination
• Course, Speed, Frequency of each movement
• Amplitude & Force of Movement
• Relationship with
• Posture/ Rest/ Voluntary activity/ Exertion/
Time of day/ Various stimuli/ Emotional
state/ Sleep
• Response to heat & cold

5. Examination
• Aggravating factors
• Stress/ Anxiety/ activity/ etc..
• Relieving factors
• sleep/ Rest/ etc..
• Differentiation from complex/ bizarre voluntary
movements
• Mannerisms/ Compulsions
• Palpation of Movements (for underlying fine and
clear movement)
• Videos

6. Clinical Classification of
Hyperkinetic Movement Disorders

7. Tremor
• Relatively rhythmic
• Purposeless
• Oscillatory
• Amplitude : Fine/ Coarse
• Involvement: Simple (Single muscle group)/
Compound (Multiple muscle groups)
• May involve: Agonists/ Antagonists/ Fixators/
Synergists
• Rate: Slow (3-5 Hz)/ Medium (6-9 Hz)/ Fast (10-
20 Hz)

8. Tremor
• Rhythmicity: Continuous/ Intermittent
• Types
• Resting(Static) Tremors: PD & other Parkinsonian
• Action Tremors:
• Postural: during antigravity posture (Physiologic &
ET)
• Kinetic: with voluntary movement, ↑ with precision
requirement (Cerebellar)
• Task-specific: along with a specific task (writing)
• Isometric: when in isometric contraction (Shaky leg
syndrome/ Orthostatic tremor)

10. Physiologic Tremor
• 8-10 Hz
• Young adults > anyone
• Distal extremities
• Fine
• At rest & with activity
• Disappear during Sleep
• ↑ with Emotion/ Stress/ Alcohol/ Nicotine/ Caffeine
• Seen in Ⓝ individuals & Hyperthyroidsm (Rosenbach’s
sign – closed eyelid tremor)
• Frequency is same at different sites for the same person

11. Essential Tremor
• 8-10 Hz
• Fine, Coarse (in severe)
• Postural/ Kinetic
• Hands, Head (yes-yes/ no-no), Voice
• ↑ with Anxiety
• Disappear during Sleep
• Slowly progressive
• Familial/ Non familial (Senile tremors)
• 20 – 60 yrs onset

12. Cerebellar abnormality in some pt (loss
of purkinjefibres, dendritic swellings)

13. Tremors In PD
• Slow, Coarse, Compound (pill rolling type)
• 2-6 Hz (4-5 Hz)
• Relatively Rhythmic
• At rest (temporarily suppressed by movement)
• Alternating tremor (Uniformly alternating
movements)
• U/l @ onset  B/l
• Disappear during Sleep
• ↑ with Emotion/ Fatigue

14. Basal ganglia involvement

15. Tremor in Parkinson’s Disease Essential Tremor
Low amplitude Medium Amplitude
Low rate Medium rate
↑ at rest ↑ with posture
Dampens with outstretch (at least
partially)
↑ with out stretch,
↑ more with precise action
Do not spills water while drinking Can’t drink from a cup
Rare involvement of Voice Usually involves
No effect with alcohol/ beta blockers Improves with alcohol/ beta blockers

16. Cerebellar Tremor
• 3-5 Hz
• Slow
• Postural & Kinetic
• Progressive towards the end of the movement
• Associated with cerebellar ataxia (past
pointing)
• Relieves with Rest
• Starts at Fingers, extremities

17. Ex: Vascular, Iatrogenic

18. Cerebellar Outflow Tremor
• Combined features of Tremors in PD along with
Cerebellar Tremor
• Tremor is
• Slow (2-5 Hz), Severe (sometimes throw the patient off
balance)
• Large amplitude (as Wing-beating movement)
• Often associated with cerebellar ataxia
• Predominantly unilateral  may progress B/L
• Usually Disappears during sleep  may seen if severe
• Develops within 4 weeks to 48 months of the insult, if
not familial
• Severely disabling
• Unpredictable course on long term

19. • Ex: vascular, tumor
Involvesdentato-rubro-thalamictract

20. Chorea
• Involuntary, irregular, purposeless, Random, non-
rhythmic
• Spontaneous, abrupt, brief, rapid, jerky,
unsustained
• Chaotic, multiform, constantly changing
movements that seem to flow from one body
part to another
• Seen at rest and action
• ↑ with activity/ Emotion/ Self consciousness
• May temporarily able to supress
• Disappear in sleep

21. Chorea
• Disturbs motor functions/ daily activities
• Associated with hypotonia, no paralysis,
Pendular DTR
• Distal parts of UL  anywhere
• Distribution: one limb/ one half (hemichorea)/
generalised
• Inability to sustain contraction
• Parakinesia: incorporate purpose to mask chorea
• Huntington’s disease, Sydenhams chorea, etc..

22. CaudateNucleus,Putamen, Cerebral cortex
involvement
Ex: Huntington’s,Sydenham

23. Athetosis (Hammond’s Ds)
• Slower, more sustained, large amplitude when
compared to chorea
• Involuntary, irregular, coarse, relatively rhythmic,
writhing/squirming in character
• Extremities, face, neck, trunk or combination
• Constant & continuous motion
• Over flow: ↑ with movement of other body part
• Difficulty for routine activities
• U/L; B/L (double athetosis)

24. • Caudate nucleus and Putamen involvement
• Ex: Cerebral Palsy, vascular, Vogt’s syndrome

25. Dystonia
• Spontaneous, involuntary, sustained muscle contractions (co-
contraction of agonist & antagonist)
• Constant/ intermittent
• Generalised/ segmental/ focal/ multifocal/ hemi-distribution
• patterned, recur in same location
• Sensory tricks can work
• Speed:
• <1 sec (dystonic spasm)
• Several sec (dystonic movements)
• Min-Hrs (dystonic posture)
• Rapid, rhythmic (dystonic tremor)
• During voluntary action (Action dystonia)

26. Ex: Dystonia Musculorum Deformans, Wilson’s,
Parkinson’s, Drugs, Segawa syndrome.

27. Hemiballismus
• Wild, flinging, incessant movement of one side
of body
• Resembles chorea but more pronounced
• Involuntary, purposeless, more rapid, forceful
• Proximal extremities (spares face & trunk)
• U/L; B/L (Bi-ballismus), single extremities (Mono-
ballismus)
• Disappears only with deep sleep

28. Subthalamic nuclei involvement
Ex: Vascular

29. Dyskinesia
• All hyperkinetic movements are technically
• Complex involuntary movements that do not
neatly fit with another category
• ↑ by movement (kinesigenic)/ stress/ heat/
fatigue (non-kinesigenic)/ sleep (hypnogenic)
• Paroxysmal: strike suddenly & unexpectedly
while engaging in normal motor activity

30. Ex: Drug related (Tardive dyskinesia), Rabbit
sydrome

31. Myoclonus
• Single/ repetitive, abrupt, brief, rapid, lightening
like, jerky, arrythmic, asynergic, involuntary
contractions
• Multifocal, diffuse, widespread compared to
chorea
• Extremities> trunk, face, jaw, tongue, pharynx
• Successive, simultaneous involvement of many
muscles
• Symmetric on both sides of the body
• At rest/ action
• ↑ with emotion/ auditory, tactile, visual stimuli

32. Myoclonus
• Positive / negative (asterixis)
• Physiological: hiccups, benign nocturnal
myoclonus
• With epilepsy (JME)
• Without seizures (metabolic encephalopathy,
SSPE, CJD, Wilson’s, etc)

33. Ex: CJD, Metabolic
Encephalopathy, Essential, JME

34. Palatal Myoclonus
• Involuntary, relatively rhythmic
• Soft palate, pharynx, larynx, eye muscles
• Not influenced by sleep
Tremor Palatal Myoclonus
Contraction of agonist &
antagonist
Only Agonist’s contraction &
relaxation
Disappears with sleep Do not disappear

35. • InvolvementofGullian-MollaretTriangleloop(at
midbrain)
Ex:Essential,Vascular,Tumor

36. Myorhythmia
• Slow, rhythmic alternating movements
• Resembles tremor ( but slow & wide spread)
• Intermittent/ continuous
• Synchronus/ Asynchronus (when multiple parts
involved)
• Absent during sleep

37. Ex: CNS Whipples (Occulo-
masticatory myorhythmia)

38. Unvoluntary Movements
• Patient will have some degree of awareness
• He must make the movement in response to the
urge of some compelling inner force
• Pt feels restless until he performs the action.
• Ex: Tics, Akathesia, Stereotypy

39. Tic (Habit spasms)
• Quick, irregular, repetitive (child > adults)
• Coordinated, seemingly purposeful, brief,
involves group of muscles in their normal
synergistic relations
• Suppressible temporarily
• ↑ by emotion & tension
• Disappear during sleep
• Any body part (repetitive blinking, shrugging,
throat clearing)

40. Ex: Tourette’s, Essential

41. Akathesia
• Continuous inner urge and restlessness to
move
• Remains almost in constant motion
• Mainly drug related/ PD

42. Ex: Drug related, PD

43. Stereotypy
• Repetitive, purposeless (seemingly purposeful),
involuntary, patterned motor activity
• Simple/ complex (in OCD)
• Compared to Tic
• Suppressible
• Less Variable
• Less tension/ compulsion

44. Ex: Autism, MR, Tourette’s, TD

45. Hyperekplexia
• Pathological startle
• Excessive startle in absence of neuro
disorder
• Sporadic/ hereditary

46. Ex: Tay sachs, lipidoses, CJD

47. Sleep related dyskinesia
• Primarily during sleep
• Restless leg syndrome:
• Unpleasant, difficult to describe sensation in
legs that are temporarily relieved by
movement
• Gets up and walks (Night-walkers)
• Diagnosed by Polysomnography

48. Central disturbance in dopa
metabolism

49. Fasiculations
• Fine, rapid, flickering/ vermicular twitching
movements
• Not extensive enough to cause joint movement
• Random, irregular
• At times abundant
• ↑ by cold, fatigue, mechanical stimulation of
muscle
• Difficult to see in women
• Usually unaware, persists during sleep
• Usually appear when not looking at

50. Ex: Hypercaffeinism, MND,
ALS, SMA

51. Myokimea
• Involuntary, spontaneous, localised,
transient/ persistent, quivering movement
• Involves few muscle bundles in single
muscle
• Not extensive to cause joint movements
• Coarse, slow, undulating (worm like)
• Not affected by motion/ position
• Persists during sleep

52. Ex: Demyelination, Toxins,
Hypocalcemia, Issac’s (generalised)

53. Psychogenic (Non-Organic)
• Can simulate any type
• Not corresponds to any of the organic
types
• Bizarre, change in type from time to time
• Influenced by emotion and suggestion
• Sudden onset
• Always a disease of Exclusion

54. Ex: Schizophrenia

55. Thank You