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Movement disorder management for all specialties.

As medical providers for people interested in maintaining their optimal movement, it is more common for us to see manifestations of movement disorders in our patients. It is often the pain of movement or restriction of movement that prompts a person with a neurological problem to seek a solution from a primary care physician, orthopedist, pain specialist, physical therapist or even a psychiatrist before a correct diagnosis is made. Recognition of the movement disorders can save the person years of agony and promote timely initiation of proper treatment measures. The disorders most often missed or misdiagnosed by any discipline, even neurology, are early Parkinson's disease and focal dystonias including sports specific dystonia. It is also typical for the etiology of tremor disorders to be confused between Parkinson's, essential tremor, dystonic tremor or chorea. This, of course, leads to incorrect diagnosis and treatment.

Parkinson's Disease

Fully developed Parkinson's disease is seldom missed when manifesting a tremor that occurs at relative rest and includes slowness of movement (bradykinesia), cogwheeling type rigidity, and postural instability. Early in the course, however, especially in younger onset Parkinson's, symptoms can be more nonspecific to include extremity muscle pain, relative slowing of movements, decreased dexterity, sleep disturbance, constipation, and/or decreased smell acuity. These are symptoms that can easily be relegated to getting stiffer and slower with aging. It takes an ongoing awareness on our part to ask about Parkinson associations such as a one-sided intermittent tremor (may be of one finger initially) and to observe for masked facial appearance, decreased blink rate or underlying cogwheeling type of increased muscle tone. Now that research has documented the benefits of early treatment of Parkinson's in modifying long term progression of the disorder, it is imperative to establish early diagnosis. Patients should never be initially started on an L-dopa preparation (such as Sinemet) until seen by a neurologist due to the potential long-term detriment of its early use. It is acceptable for any provider to prescribe Rasageline (Azilect) 1mg daily for early treatment if familiar with this medication.

Essential Tremor

As opposed to the tremor that occurs with relative inaction as with Parkinson's disease, essential tremor occurs while the person is moving their extremity such as bringing a utensil or cup to the mouth or during writing or other purposeful movement of the upper extremities. It is a rapid regular tremor as opposed to the slower pill rolling tremor of Parkinson's. This commonly involves the upper extremities but also can cause head tremor or laryngeal tremor. It is distinguished from the tremor of dystonia by the rapid regular tremor movements of essential tremor, as opposed to the irregular directional preponderant or spasmodic nature of dystonic tremor. A new study called the DAT scan will be available to objectively distinguish a Parkinson tremor from essential tremor in questionable cases. Treatment options include Beta-blockers and Primidone.

Focal Dystonia

The focal dystonia are almost universally misdiagnosed initially and will present to multiple medical specialists or therapists, usually over years, before the clinician attuned to this disorder makes an instant diagnosis. These occur in otherwise normal people, most often in middle age, but can present as young as in the teens and through older age.

Focal dystonias arise from an abnormally high motor outflow from the brain to localized muscle groups and can produce painful dystonic postures involving the face, neck or hands. Although focal dystonia occur in hundreds of thousands of people throughout the world, they are typically vastly underrecognized. The disorders can be limited to one muscle group or a combination of areas but seldom progress to generalized dystonia as seen in inherited generalized dystonia of childhood.

Focal dystonia are grouped into categories and identified as follows:

Blepharospasm: This involuntary eye closure and spasm can be viewed as rapid blinking, and misdiagnosed as dry eyes or blepharitis.

Laryngeal dystonia (a.k.a. Spasmotic dysphonia): This involuntary contraction of the laryngeal muscles produces a halting and strained voice and can be misdiagnosed as essential tremor or persistent laryngitis.

Cervical dystonia (a.k.a. Spasmotic torticollis): This most common type of focal dystonia produces a spectrum of involuntary neck movements. These can range from a fixed or spasmodic rotation of the neck toward one direction to the more difficult to recognize painful tightness in one cervical-thoracic muscle group (that has not responded to traditional treatment for muscle spasm). Cervical dystonia usually begins spontaneously but can occur posttraumatically. Once the motor outflow abnormality starts, it is usually permanent. Any of the 52 muscles in the neck can be involved in combination to produce involuntary movements in a sustained or spasmodic nature in a combination of anterocollis, laterocollis, rotational torticollis or retrocollis. A neck tremor is very common with dystonia and, as a result, is commonly misdiagnosed even by neurologists as an essential tremor.

Sports specific dystonia: These can be associated with most sports that require precise movements that have been practiced innumerable times by those very skilled in the sport. The most commonly recognized sports dystonia is the Golfer's Yip. This is characterized by sudden involuntary movements that occur at precise moments of the golfer's putt or full swing. This, of course, greatly disrupts the golfer's accuracy. Unfortunately, some excellent golfers have had to give up the sport because of sports specific dystonia. Among these are Hank Haney (Tiger Woods previous swing coach), David Duval, and Ian Baker-Finch. Charles Barkley, who had been a scratch golfer, gave up the sport because of the dystonic activity that developed during his full swing. Some literature suggests, such as in the book The Brain has a Mind of its Own, that the motor cerebral cortex becomes overrepresented by a motion that has been extensively practiced by those very skilled at their sport that results in the sports specific dystonia or one of the occupational limb dystonias.

Occupational dystonia: This focal dystonia produces involuntary movements in specific muscle groups. It usually occurs in an upper extremity that has been performing a motor task countless times such as writing cramp dystonia, musician dystonia, and many other specific occupational movements. Individuals suffering from this condition can perform other functions with the muscles of their hands without impairment; however, when the brain is activated to perform a specific action such as write, play a specific instrument or press letters on a keyboard, the brain excessively activates the specific muscle group to produce a dystonic posture. This is far too often misdiagnosed as being psychogenic, overuse syndrome or carpal tunnel disorder.

Treatment of focal dystonia includes an exercise program for all patients, oral medications if needed, and injections of one of the botulinum toxins (Botox, Myobloc, Dysport or Xeomin) into the involved muscles. It is part of the art of treating these disorders to determine the precise location of the muscular injections and optimal dosage for each injection. Appropriate treatment can bring about dramatic results for patients who may have suffered for years with pain and involuntary movements.


These are rapid individual involuntary movements that can look purposeful such as bringing the hand toward the mouth or performing a leg movement. Although the movements can occur frequently, they are not rhythmical like a tremor. They are present in disorders such as Huntington's chorea and are associated with certain medications and neurological injury.

Kinesogenic Choreoathetosis

This is characterized as dramatic involuntary spasm twisting movements of the legs or arms that can occur suddenly in association with exertion such as running. Because of this, individuals may seek the advice of a sports medicine specialist. Fortunately, the disorder is rare but treatable if recognized.

Treatment of Movement Disorders

Movement disorder treatment should always include a well-designed diversified and challenging exercise program to promote adaptive changes in the brain. "Exercise as medicine" is the only way to produce long-lasting structural and neurochemical changes in the brain. It is a crucial adjunctive treatment to the symptomatic measures that medications offer. As I mentioned in my lectures, I have coined the brand name for this "medication" as Doesital because of its farreaching benefits for every person for prevention or treatment of every neurological, medical or psychiatric disorder.

Dr. Patrick Hogan is Director of the Puget Sound Regional Movement and Motility Disorder Clinic and Tacoma Neurological Headache Center in Tacoma, Washington. This article is a summary of his presentation given at the 2010 AMAA Sports Medicine Symposium at the Boston Marathon. Questions regarding this article can he sent to Dr. Hogan at

By Patrick J. Hogan III, DO
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Author:Hogan, Patrick J., III
Publication:AMAA Journal
Article Type:Disease/Disorder overview
Geographic Code:1USA
Date:Jan 1, 2011
Previous Article:Letter to the editor.
Next Article:Disuse and aging, 2009.

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