What is the best course of treatment for an adult or geriatric patient with a history of neurological conditions, such as Parkinson's disease, dystonia, or stroke, presenting with arm contraction and restlessness?

Management of Arm Contraction and Restlessness in Adults with Neurological Conditions

Immediate Diagnostic Clarification

The first critical step is distinguishing whether this represents functional dystonia, drug-induced dystonia, akathisia (restlessness), or restless legs syndrome affecting the upper extremities, as each requires fundamentally different management approaches. 1

Key Clinical Features to Identify:

• Functional dystonia: Fixed abnormal posturing, often with inconsistent patterns, may have associated tremor or jerks, typically improves with distraction 1
• Drug-induced dystonia: Sustained muscle contractions causing abnormal postures, particularly if patient is on antipsychotics, antiemetics, or dopaminergic agents 1, 2, 3
• Akathisia: Subjective inner restlessness with inability to sit still, occurs within days of starting antipsychotic medications 1
• Parkinson's-related dystonia: Painful sustained contractions, often worse during "off" periods in patients on chronic levodopa therapy 2, 4, 3

Treatment Algorithm Based on Etiology

For Functional Dystonia (Most Relevant to Primary Question)

Occupational therapy using movement retraining techniques is the cornerstone of treatment, NOT pharmacological intervention or splinting. 1

Specific Therapeutic Strategies:

• Encourage optimal postural alignment at rest and during function, considering 24-hour management with even weight distribution in sitting, standing, and transfers to normalize movement patterns 1
• Grade activities to increase time the affected limb is used with normal movement techniques within functional tasks, avoiding postures that promote prolonged positioning at end-range 1
• Discourage "nursing" the affected limb but demonstrate therapeutic resting postures—use pillows or furniture to support the limb when sitting or lying down to reduce muscle overactivity, pain, and fatigue 1
• Employ anxiety management and distraction techniques during tasks, as video recording interventions can demonstrate symptom changeability and build confidence 1

Critical Pitfall to Avoid:

Splinting should be avoided as it may worsen symptoms by increasing attention to the area, promoting accessory muscle use, causing muscle deconditioning, leading to learned non-use, and potentially triggering complex regional pain syndrome. 1 Only consider removable splints after exhausting strategies that encourage normal movement patterns, with regular monitoring and patient empowerment to discontinue if adverse effects occur 1

For Drug-Induced Dystonia or Akathisia

If the patient is on antipsychotic medications (including lurasidone, haloperidol, risperidone, or others), these agents are the likely culprit through dopamine D2 receptor antagonism. 1, 5

Immediate Management:

• For acute dystonia: Administer anticholinergic agents such as trihexyphenidyl 1-2 mg orally, which can be increased by 2 mg increments every 3-5 days until symptoms resolve (typical range 5-15 mg daily for drug-induced parkinsonism) 6
• For akathisia: Reduce or discontinue the offending antipsychotic if possible, or switch to an agent with less dopamine antagonism 1, 5
• Monitor for neuroleptic malignant syndrome: The tetrad of mental status changes, fever, rigidity, and autonomic dysfunction requires immediate discontinuation of all antipsychotics 1

For Parkinson's Disease-Related Dystonia

The management depends critically on whether dystonia occurs during "off" periods (dopamine deficiency) or "on" periods (dopamine excess). 2, 4, 3

"Off" Period Dystonia (Most Common):

• Optimize dopaminergic therapy first: Increase levodopa dosing, add dopamine agonists (bromocriptine, pergolide), or use subcutaneous apomorphine for rapid relief 4
• If dopaminergic optimization fails: Botulinum toxin injections into affected muscles (median 40 IU per muscle) can eliminate pain for 3-7 months, guided by electromyography to identify tibialis posterior, flexor digitorum longus, or other contracted muscles 4
• Adjunctive oral medications: Baclofen, anticholinergics (trihexyphenidyl), or benzodiazepines may provide additional benefit 2
• For refractory cases: Deep brain stimulation of the subthalamic nucleus is the most effective intervention 3

"On" Period or Peak-Dose Dystonia:

• Reduce levodopa dosing or redistribute throughout the day to avoid peak concentrations that trigger dystonia 3

For Restlessness Resembling Restless Legs Syndrome

If restlessness involves urge to move the arms with uncomfortable sensations that worsen at rest and improve with movement, treat as upper extremity RLS. 5

Treatment Algorithm:

1. Check morning fasting ferritin and transferrin saturation: Supplement with oral ferrous sulfate if ferritin ≤75 ng/mL or transferrin saturation <20% 5
2. First-line pharmacological treatment: Gabapentin 300 mg three times daily, titrating up to 1800-2400 mg/day divided three times daily, or pregabalin with twice-daily dosing 5
3. Avoid dopamine agonists (pramipexole, ropinirole, rotigotine) due to high risk of augmentation—paradoxical worsening of symptoms with long-term use 5
4. Address exacerbating factors: Eliminate alcohol, caffeine, antihistamines, SSRIs, and antipsychotics 5

Stroke Rehabilitation Context

For post-stroke patients with arm contractures and restlessness, intensive rehabilitation focused on the affected limb produces better functional outcomes than routine therapy. 1

• Engage in bilateral functional tasks using the upper limbs while standing with aid of a standing frame, promoting normal movement and even weight-bearing 1
• Avoid immobilization strategies that lead to learned non-use; instead, use the hand to stabilize objects during perch sitting in personal care or kitchen tasks 1
• Intensity matters: Studies show a dose-response relationship where 30-60 minutes of focused physiotherapy produces superior motor function and ADL performance compared to routine care 1

Medications to Avoid

Benzodiazepines (including diazepam and clonazepam) should be avoided during stroke recovery due to deleterious effects on neurological recovery and excessive sedation. 7 Valproic acid is not recommended for periodic limb movements 7, and long-term dopaminergic agents carry augmentation risk 5, 7.

Family/Caregiver Involvement

Involve family members in decision-making and treatment planning from the outset, as cognitive loss, personality changes, and physical disabilities create significant caregiver stress. 1 Provide up-to-date information on community resources and assistance in obtaining needed services 1.