How are involuntary movements managed?

Management of Involuntary Movements

The management of involuntary movements depends critically on identifying the specific movement disorder type, with treatment ranging from dopamine antagonists for chorea, to withdrawal of offending medications for drug-induced dyskinesias, to specialized rehabilitation techniques for functional movement disorders.

Initial Diagnostic Approach

The first step is accurate classification based on movement characteristics rather than laboratory data 1:

• Assess rhythmicity: Determine if movements are regular (tremor), mostly regular, or completely irregular (myoclonus) 1, 2
• Identify triggering conditions: Note whether movements occur at rest, with posture, during action, or with emotional stress 2
• Examine movement pattern: Observe distribution, stereotypy, and laterality 2

Critical caveat: Not every involuntary movement fits neatly into pre-existing categories; some may show features of multiple movement types or shift between categories, requiring flexible clinical judgment 1.

Drug-Induced Movement Disorders

Tardive Dyskinesia

If clinically feasible, gradually withdraw the offending antipsychotic medication 3:

• Tardive dyskinesia affects the orofacial region in 70% of patients, causing facial twitching, rigidity, and dysarthria 3
• When antipsychotic treatment must continue, switch to atypical antipsychotics with lower D2 affinity 3
• Baseline assessment before starting antipsychotics and regular monitoring using the Abnormal Involuntary Movement Scale (AIMS) every 3-6 months is essential 3, 4
• Early detection is crucial as tardive dyskinesia may persist even after medication discontinuation 3

Drug-Induced Parkinsonism

For bradykinesia and rigidity from antipsychotics 5:

• Use anticholinergic agents or mild dopaminergic agents such as amantadine 5
• Distinguish from other parkinsonian syndromes and negative symptoms in psychiatric disorders 5

Chorea and Related Disorders

Lupus-Associated Chorea

Symptomatic therapy with dopamine antagonists is usually effective 6:

• Most patients (55-65%) experience a single episode that subsides within days to months 6
• Glucocorticoids combined with immunosuppressive agents (azathioprine, cyclophosphamide) control active neuropsychiatric lupus disease 6
• In antiphospholipid-positive patients, administer antiplatelet and/or anticoagulation therapy, especially when other antiphospholipid syndrome manifestations are present 6
• Brain imaging should be considered when focal neurological signs are present or to exclude secondary causes 6

General Chorea Management

Chorea and ballismus belong to the same clinical and neuropharmacological category 1:

• Both respond to benzodiazepines and D2 receptor blockers 1

Functional Movement Disorders

Functional Tremor

Superimpose alternative voluntary rhythms on the existing tremor, gradually slowing all movement to complete rest 6:

• For unilateral tremor: use the unaffected limb to dictate a new rhythm (tapping/opening and closing the hand) to entrain the tremor to stillness 6
• Music can be introduced to dictate a rhythm to follow 6
• Assist the person to relax muscles in the limb to prevent cocontraction 6
• Control tremor at rest before moving to activity 6
• Use gross rather than fine movements (e.g., large lettering on whiteboard rather than normal handwriting) 6
• Discourage cocontraction or tensing of muscles to suppress tremor, as this is not a helpful long-term strategy 6

Functional Jerks

Address unhelpful pre-jerk cognitions and movements 6:

• Use general relaxation techniques: diaphragmatic breathing or progressive muscular relaxation 6
• Employ sensory grounding strategies to bring the person into the present moment (noticing environmental details, feeling textured items, counting backwards, singing) 6
• Encourage slow movement activities such as yoga or tai chi to regain movement control and redirect attention away from symptoms 6

Functional Dystonia

Encourage optimal postural alignment at rest and within function, using a 24-hour management approach 6:

• Encourage even weight distribution in sitting, transfers, standing, and walking to normalize movement patterns 6
• Grade activity to increase time the affected limb is used with normal movement techniques 6
• Avoid postures promoting prolonged positioning at end of range (full hip, knee, or ankle flexion while sitting) 6
• Discourage nursing of the affected limb but demonstrate therapeutic resting postures 6
• Use muscle relaxation strategies, support the affected limb at rest with pillows or furniture 6
• Address associated pain and hypersensitivity 6

Critical warning: Splinting may prevent restoration of normal movement by increasing attention to the area, increasing accessory muscle use, and promoting compensatory strategies 6.

Core Principles for Functional Movement Disorders

The rehabilitation approach focuses on accessing natural automatic movement patterns 6:

• Identify and explain symptomatic behaviors: Show how symptoms differ from normal movements and highlight unnecessary muscle efforts 6
• Facilitate automatic patterns: Conscious self-focused attention on movement mechanics negatively affects performance; instead, focus attention on the task target and desired outcomes 6
• Regain voluntary control: Trigger highly volitional utterances or movements that differ from abnormal patterns, then shape toward normal 6
• Extend into graded activities: Progress improved movements into meaningful, task-oriented activities 6

Video recording interventions (with consent) can demonstrate changeability, highlight successes, and serve as reference points for replicating strategies outside therapy 6.

Seizure-Related Movements

Anti-epileptic drug (AED) therapy is not necessary for single or infrequent seizures unless high-risk features are present 6:

• High-risk features include: two or more unprovoked seizures at least 24 hours apart, serious brain injury, structural MRI abnormalities causally linked to seizures, focal neurological signs, partial seizures, or epileptiform EEG 6
• Approximately 25% of lupus patients require a second AED to control seizure activity 6
• If seizures reflect acute inflammatory events or concurrent lupus flare, use glucocorticoids alone or combined with immunosuppressive therapy 6
• Pulse intravenous methylprednisolone combined with intravenous cyclophosphamide shows effectiveness in refractory seizures with generalized lupus activity 6

Assessment and Monitoring

Regular assessment using validated scales is essential 4:

• Use the Abnormal Involuntary Movement Scale (AIMS) to objectively evaluate and track movements over time 3, 4
• Comprehensive care must address physical manifestations as well as psychological, social, and functional impacts 4
• Regular follow-up assessments monitor treatment response, adjust medications when needed, and provide ongoing support 4