What are the types of movement disorders and their respective treatments?

Types of Movement Disorders and Their Treatments

Movement disorders are classified into hypokinetic and hyperkinetic disorders, with specific treatment approaches for each type based on their underlying pathophysiology.

Classification of Movement Disorders

Hypokinetic Disorders

Characterized by reduced or slow movement:

• Parkinsonism: The most common hypokinetic disorder, featuring:
  • Resting tremor
  • Rigidity
  • Bradykinesia (slow movements)
  • Postural instability 1

Hyperkinetic Disorders

Characterized by excessive, involuntary movements:

1. Tremor: Rhythmic, oscillatory movements

   • Rest tremor (present when not voluntarily moving)
   • Action tremor (during voluntary movement)
   • Postural tremor (when maintaining a position against gravity)

2. Dystonia: Sustained muscle contractions causing abnormal postures or repetitive movements 1

   • Can affect specific body regions or be generalized
   • Often worsens with voluntary action

3. Chorea: Irregular, unpredictable, flowing movements

   • Random, dance-like movements
   • Associated with conditions like Huntington's disease and antiphospholipid syndrome 1

4. Ballism: Large amplitude, violent, flinging movements

   • Often affects proximal limbs
   • Usually unilateral (hemiballism)

5. Myoclonus: Brief, shock-like, jerky movements

   • Can be focal, multifocal, or generalized
   • May occur at rest or with action 1

6. Tics: Brief, repetitive movements or vocalizations

   • Simple or complex
   • Can be temporarily suppressed

7. Paroxysmal Dyskinesias: Episodic movement disorders 1

   • Paroxysmal kinesigenic dyskinesia (PKD): Triggered by sudden movements
   • Paroxysmal non-kinesigenic dyskinesia (PNKD): Not triggered by movement
   • Paroxysmal exercise-induced dyskinesia (PED): Triggered by prolonged exercise

8. Restless Legs Syndrome (RLS): Uncomfortable sensations in legs with urge to move 1

9. Periodic Limb Movement Disorder (PLMD): Repetitive limb movements during sleep 1

Treatment Approaches

Hypokinetic Disorders Treatment

Parkinson's Disease:

• First-line: Levodopa (with carbidopa) - improves symptoms by increasing dopamine in the brain 2
• Adjunctive therapies:
  • Dopamine agonists
  • MAO-B inhibitors
  • COMT inhibitors
  • Anticholinergics (for tremor)
• Advanced therapies:
  • Deep brain stimulation
  • Continuous intestinal levodopa infusion
  • Apomorphine pump

Hyperkinetic Disorders Treatment

1. Tremor:

• Essential tremor: Beta-blockers (propranolol), primidone, topiramate
• Parkinsonian tremor: Levodopa, anticholinergics
• Cerebellar tremor: Often resistant to medication; weighted devices may help

2. Dystonia: 1

• Focal dystonia: Botulinum toxin injections
• Generalized dystonia:
  • Anticholinergics (trihexyphenidyl)
  • Muscle relaxants (baclofen)
  • Benzodiazepines
• Specific interventions:
  • Encourage optimal posture and weight distribution
  • Avoid prolonged positioning of joints at end ranges
  • Address pain and hypersensitivity

3. Chorea: 1

• Symptomatic treatment: Dopamine antagonists (typical/atypical antipsychotics)
• For autoimmune causes (e.g., SLE): Glucocorticoids with immunosuppressants (azathioprine, cyclophosphamide)
• For antiphospholipid-positive patients: Antiplatelet and/or anticoagulation therapy

4. Myoclonus: 1

• Cortical myoclonus: Levetiracetam, valproate, clonazepam
• Subcortical myoclonus: Clonazepam
• Specific approaches:
  • Address pre-jerk anxiety and movement patterns
  • General relaxation techniques and diaphragmatic breathing
  • Sensory grounding techniques
  • Slow movement activities (yoga, tai chi)

5. Tics:

• Mild cases: Behavioral therapy (habit reversal training)
• Moderate-severe: Alpha-2 agonists (clonidine), antipsychotics (risperidone, aripiprazole)

6. Paroxysmal Dyskinesias: 1

• PKD: Anticonvulsants (carbamazepine, phenytoin)
• PNKD: Benzodiazepines, anticholinergics
• PED: Ketogenic diet, anticonvulsants

7. Restless Legs Syndrome/PLMD: 1

• First-line: Dopamine agonists (pramipexole, ropinirole)
• Second-line: Alpha-2-delta ligands (gabapentin, pregabalin)
• Refractory cases: Opioids, benzodiazepines

Special Considerations

Functional Movement Disorders

• Treatment approach: 1
  • Explain the diagnosis positively
  • Physical therapy focused on normal movement patterns
  • Cognitive behavioral therapy
  • Video recording to demonstrate changeability of symptoms

Movement Disorders in Children

• More likely to be genetic or developmental in origin
• Treatment must consider developmental stage and growth
• Some childhood movement disorders may resolve spontaneously

Acute Movement Disorder Emergencies 3

• Status dystonicus: Requires urgent treatment with benzodiazepines, propofol, or general anesthesia
• Serotonin syndrome: Discontinue offending agents, supportive care, benzodiazepines
• Neuroleptic malignant syndrome: Stop antipsychotics, supportive care, dantrolene, bromocriptine

Pitfalls to Avoid

• Misdiagnosis: Movement disorders can mimic each other; careful phenomenological assessment is crucial
• Overlooking secondary causes: Always consider metabolic, toxic, structural, or autoimmune causes
• Inappropriate use of splinting: May worsen symptoms in functional dystonia 1
• Polypharmacy: Multiple medications increase risk of adverse effects and interactions
• Delayed treatment: Early intervention often leads to better outcomes, especially in dystonia

Remember that accurate classification of the movement disorder type is essential for selecting the appropriate treatment strategy. Video recording of movements can be extremely helpful for diagnosis and monitoring treatment response.