Examination of the Patient With a Movement Disorder
GOAL
The main goal of the examination of the patient with a movement disorder is to characterize the disorder of increased or decreased movements to better understand the diagnosis and management of the patient’s symptoms.
PATHOPHYSIOLOGY OF MOVEMENT DISORDERS
Disorders of movement can be divided into those that cause diminished (hypokinetic) movement and those that cause abnormal (hyperkinetic) involuntary movements.
The hypokinetic movement disorders comprise mainly Parkinson’s disease and other parkinsonian syndromes. Parkinson’s disease occurs due to degeneration of substantia nigra neurons in the midbrain that project to the basal ganglia. Parkinsonism, on the other hand, is the generic name for any clinical syndrome that includes Parkinson’s disease-like symptoms.
The hyperkinetic movement disorders include tremors, dystonia, chorea, myoclonus, and tic disorders. Some of these symptoms occur due to disorders of basal ganglia (extrapyramidal) function (e.g., chorea, parkinsonian tremors, and, probably, dystonia), and some occur due to disorders of cortical or spinal cord function (e.g., myoclonus), but the pathophysiology of some of the hyperkinetic movement disorders (e.g., essential tremor and tic disorders) remains unclear.
TAKING THE HISTORY OF A PATIENT WITH A MOVEMENT DISORDER
More than any other neurologic disorder, the diagnosis of movement disorders depends primarily on observation of the findings on examination. Nonetheless, like any neurologic disorder, the history is integral to the diagnostic process.
In any patient with a movement disorder, take a good medication history because many medications can cause extrapyramidal symptoms of parkinsonism, dystonia, and chorea (e.g., neuroleptics and antiemetics), and many can cause or worsen postural tremor (e.g., valproic acid, amiodarone, and lithium). Make sure you ask about past medications and not just medicines the patient is currently taking.
The family history can give important clues for some of the movement disorders, such as Huntington’s disease and familial essential tremor.
Have the patient describe the abnormal movements, the age of onset (e.g., tic disorders usually begin in childhood), and the course of symptoms (e.g., worsening over time suggests a degenerative disorder).
Ask about any exacerbating or relieving factors (e.g., essential tremor may be worse with stress and improved with alcohol; patients with cervical dystonia may have found maneuvers to temporarily relieve the symptoms; patients with focal dystonias may only develop their symptoms during certain activities). Ask if there is any control over the movements (e.g., tic disorders).
Inquire about other associated symptoms that may provide diagnostic clues in the appropriate clinical situations, such as cognitive symptoms (e.g., Huntington’s disease and Wilson’s disease), autonomic symptoms (e.g., Shy-Drager syndrome), and systemic problems (e.g., liver dysfunction in Wilson’s disease or a recent streptococcal infection in Sydenham’s chorea).
EXAMINING THE PATIENT WITH A MOVEMENT DISORDER
Parkinsonism
Parkinson’s disease usually presents as asymmetric slowness (bradykinesia), rigidity, and tremors. Other parkinsonian syndromes are more likely to present symmetrically.
Observe for diminished facial expression consistent with masked facies and listen to the speech, which may be soft and even stuttering in some patients.
Observe the patient for a resting tremor in the hands, although not all patients have a tremor. The typical parkinsonian tremor is described as pill-rolling because of the characteristic oscillating movements between the thumb and the other fingers. It is often asymmetric, especially early in the course of Parkinson’s disease, and it tends to occur at rest and diminishes when the arm is performing a task. The tremor may be particularly prominent when the patient is preoccupied with another task, such as walking or manipulating the opposite hand. In some patients, a similar resting tremor may be seen in a foot as it dangles off the examining table.
Test for cogwheel rigidity as described in Chapter 27, Examination of Tone. The ability to perform fine movements and rapid alternating movements (see Chapter 34, Testing of Upper Extremity Cerebellar Function) may be impaired in parkinsonism due to slowness from basal ganglia dysfunction. Strength should be normal.Related posts:
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