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Chapter 428: Tremor, Chorea, and Other Movement Disorders

C. Warren Olanow; Christine Klein; Jose A. Obeso

CONTENT UPDATE

July 2019

HYPERKINETIC MOVEMENT DISORDERS

Hyperkinetic movement disorders are characterized by involuntary movements unaccompanied by weakness (Table 428-1). This term is somewhat arbitrary and potentially misleading as hypokinetic disorders such as Parkinson’s disease (PD) are often accompanied by tremor which is a hyperkinetic feature, and hyperkinetic disorders such as dystonia may manifest slow movements because of the severe muscle contractions. Nonetheless, the terms continue to be used because of convention. The major hyperkinetic movement disorders and the diseases with which they are associated are considered in this section.

TABLE 428-1Hyperkinetic Movement Disorders
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TABLE 428-1 Hyperkinetic Movement Disorders
Tremor Rhythmic oscillation of a body part due to intermittent muscle contractions
Dystonia Involuntary, patterned, sustained, or repeated muscle contractions often associated with twisting movements and abnormal posture
Athetosis Slow, distal, writhing, involuntary movements with a propensity to affect the arms and hands (this represents a form of dystonia with increased mobility)
Chorea Rapid, semi-purposeful, graceful, dance-like nonpatterned involuntary movements involving distal or proximal muscle groups. When the movements are of large amplitude and predominant proximal distribution, the term ballism is used.
Myoclonus Sudden, brief (<100 ms), jerk-like, arrhythmic muscle twitches
Tic Brief, repeated, stereotyped muscle contractions that can often be suppressed for a short time. These can be simple and involve a single muscle group or complex and affect a range of motor activities.

TREMOR

CLINICAL FEATURES

Tremor consists of alternating contractions of agonist and antagonist muscles in an oscillating, rhythmic manner. It can be most prominent at rest (rest tremor), on assuming a posture (postural tremor), on actively reaching for a target (kinetic tremor), or on carrying out a movement (action tremor). Tremor may also be characterized based on distribution, frequency, amplitude, and related neurologic dysfunction.

PD (Chap. 427) is characterized by a resting tremor, essential tremor (ET) by a tremor that typically occurs while trying to sustain a posture coupled with an action tremor, and cerebellar dysfunction by a kinetic tremor and is usually associated with hypotonia and past pointing. Normal individuals can have a physiologic tremor that typically manifests as a mild, high-frequency (10–12 Hz), postural or action tremor typically affecting the upper extremities. This tremor is usually of no clinical consequence and often is only appreciated with an accelerometer or under stress. An enhanced physiologic tremor (EPT) can be seen in up to 10% of the population, and tends to occur in association with anxiety, fatigue, a metabolic disturbance (e.g., hyperthyroidism, electrolyte abnormalities), drugs (e.g., valproate, lithium), or toxins (e.g., caffeine, smoking, alcohol). Treatment is initially directed at control of any underlying disorder and, if necessary, can often be improved with a beta blocker.

ESSENTIAL TREMOR

ET is the most common movement disorder, affecting ~5% of the ...

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