Diagnosis and management of acute movement disorders

Abstract

Most movement disorders, reflecting degenerative disorders, develop in a slowly progressive fashion. Some movement disorders, however, manifest with an acute onset. We wish to give an overview of the management and therapy of those acute-onset movement disorders.Drug-induced movement disorders are mainly caused by dopamine-receptor blockers (DRB) as used as antipsychotics (neuroleptics) and antiemetics. Acute dystonic reactions usually occur within the first four days of treatment. Typically, cranial pharyngeal and cervical muscles are affected. Anticholinergics produce a prompt relief. Akathisia is characterized by an often exceedingly bothersome feeling of restlessness and the inability to remain still. It is a common side effect of DRB and occurs within few days after their initiation. It subsides when DRB are ceased. Neuroleptic Malignant Syndrome is a rare, but life-threatening adverse reaction to DRB which may occur at any time during DRB application. It is characterised by hyperthermia, rigidity, reduced consciousness and autonomic failure. Therapeutically immediate DRB withdrawal is crucial. Additional dantrolene or bromocriptine application together with symptomatic treatment may be necessary. Paroxysmal dyskinesias are childhood onset disorders characterised by dystonic postures, chorea, athetosis and ballism occurring at irregular intervals. In Paroxysmal Kinesigenic Dyskinesia they are triggered by rapid movements, startle reactions or hyperventilation. They last up to 5 minutes, occur up to 100 times per day and are highly sensitive to anticonvulsants. In Paroxysmal Non-Kinesiogenic Dyskinesia they cannot be triggered, occur less frequently and last longer. Other paroxysmal dyskinesias include hypnogenic paroxysmal dyskinesias, paroxysmal exertional dyskinesia, infantile paroxysmal dystonias, Sandifer's syndrome and symptomatic paroxysmal dyskinesias. In Hereditary Episodic Ataxia Type 1 attacks of ataxia last for up to two minutes, may be accompanied by dysarthria and dystonia and usually respond to phenytoin. In Type 2 they can last for several hours, may be accompanied by vertigo, headache and malaise and usually respond to acetazolamide. Symptomatic episodic ataxias can occur in a number of metabolic disorders, but also in multiple sclerosis and Behcet's disease.

Enhanced Excitation-Coupled Calcium Entry in Myotubes Expressing Malignant Hyperthermia Mutation R163C Is Attenuated by Dantrolene

“…Heat stress has also been clearly shown to trigger fulminant MH in susceptible mice (Chelu et al, 2006;Yang et al, 2006), although its etiological role in human MH and MH in other species is debated (Robinson et al, 2003). Dantrolene is also clinically useful for the treatment of spasticity or muscle spasms associated with several clinical conditions, including spinal cord injuries, stroke, multiple sclerosis, and cerebral palsy (Chou et al, 2004;Dressler and Benecke, 2005;Saulino and Jacobs, 2006;Verrotti et al, 2006). Dantrolene has been used successfully to mitigate symptoms arising from neuroleptic malignant syndrome (Lappa et al, 2002;Strawn et al, 2007), but meta-analysis of 271 case reports has indicated an overall higher mortality rate when dantrolene monotherapy is used to treat neuroleptic malignant syndrome (Reulbach et al, 2007).…”

Clinical Reasoning: A 16-year-old girl with fixed unilateral grimace

“…We had chosen to treat her putative movement disorder with phenytoin due to its potency and efficacy in a variety of paroxysmal movement disorders. 6 Carbamazepine might also have been effective but lacks a readily available IV preparation. Her immediate and complete response to phenytoin, coupled with the MRI localization to the area of her motor cortex controlling the face, argued that these movements were in fact seizures.…”

Prevalence of Extrapyramidal Side Effects in Patients on Antipsychotics Drugs at a Tertiary Care Center5

“…Movements vary from fleeting disturbance to maintained abnormal postures [15]. It may occur in 25% to 40% of patients receiving typical antipsychotics.…”

“…It includes 50% of extrapyramidal symptoms and is considered one of the most common movement disorders caused by antipsychotics [18]. Akathisia may also be caused by antiemetics, serotonergic agents, serotonin reuptake inhibitors and cocaine [19]. The patients suffer from the feeling of restlessness and an irresistible urge to move.…”