A comprehensive guide to movement disorders

Parkinson’s disease is a progressive neurological condition that primarily affects movement. Slowness of movement, muscle stiffness, resting tremor, reduced arm swing and changes in balance may occur.

Non-motor symptoms such as sleep disturbance, constipation, reduced sense of smell, fatigue, mood changes and blood-pressure changes are also important in clinical assessment.

Diagnosis is not made from a single blood test or scan. Medical history, neurological examination, the course of symptoms and, when needed, investigations to exclude other causes are considered together.

Treatment is individualised according to symptoms, age, other medical conditions and daily-life needs. Medication timing or dosage should not be changed without medical advice.

Tremor is rhythmic, involuntary shaking that can occur at rest, while maintaining a posture or during movement. Not every tremor means Parkinson’s disease.

Assessment considers which body parts are affected, when shaking began, what makes it worse and how it affects daily life. Caffeine intake, stress, sleep patterns and medication are also taken into account.

Tremor can have different causes. Essential tremor is one of the common causes. Certain medications, thyroid disease and other neurological conditions can also cause shaking.

Treatment is planned according to the cause of the tremor and the degree of difficulty it creates in everyday life. Its effects on eating, writing, work and social life are considered when deciding on treatment.

Dystonia is a movement disorder in which involuntary muscle contractions cause repetitive movements or abnormal postures. It can affect the neck, eye area, jaw, vocal cords, hands or feet. Contractions may be continuous or intermittent.

Assessment considers when contractions began, which areas are affected, what makes them worse and how they have changed over time. Pain and effects on daily life are assessed alongside medication use, a family history of similar symptoms and accompanying symptoms. Further investigations are performed when necessary, guided by the neurological examination.

Treatment is planned according to the type of dystonia, the areas affected and the patient’s needs. Medication, botulinum toxin injections and rehabilitation may be used. Surgical options such as deep brain stimulation may also be considered in suitable patients.

Ataxia is a condition characterised by impaired balance and coordination of movement and can have different causes. It may affect walking, speech, eye movements and control of the arms and legs.

Assessment considers when symptoms began, how they developed and how they have changed over time. Associated symptoms such as falls, double vision and numbness are reviewed alongside family history, medication and alcohol use.

Depending on the neurological examination, blood tests, brain imaging, balance-system investigations or genetic assessment may be planned. Investigations are selected according to the patient’s findings and the suspected causes.

Treatment is planned according to the cause of ataxia and the difficulties the patient encounters in everyday life. Medication and rehabilitation aimed at improving balance and coordination may be used in suitable patients.

Parkinsonism is a clinical syndrome characterised by symptoms such as slowness of movement, muscle stiffness and tremor. Not every patient has all of these symptoms. Parkinson’s disease is its most common cause, but certain medications, cerebrovascular disease and other neurological conditions can also cause parkinsonism.

Assessment considers when symptoms began, how they have progressed and how they affect everyday life. Medication use, treatment response and associated symptoms help determine the cause.

Multiple system atrophy (MSA) is a progressive condition in which slowness and stiffness may be accompanied by impaired balance and coordination. Problems with automatic bodily functions, such as a drop in blood pressure on standing, difficulty urinating or urinary incontinence, may be prominent.

Progressive supranuclear palsy (PSP) may be notable for early loss of balance and backward falls. Difficulty moving the eyes up and down, stiffness of the trunk and neck, and speech and swallowing problems may occur. Changes in thinking, planning and behaviour may also be present.

Corticobasal degeneration may cause slowness, stiffness and involuntary contractions that are more pronounced on one side of the body. Despite adequate muscle strength, the patient may have difficulty using a hand or performing previously familiar movements.

Drug-induced parkinsonism can develop in association with certain medicines, particularly those used for psychiatric conditions and nausea. Medication use and the timing of symptom onset should be considered together. Symptoms may improve when the responsible medicine is reduced, changed or stopped by the treating physician; improvement may take time and symptoms can persist in some patients.

Vascular parkinsonism can occur in association with cerebrovascular disease. Slow walking, short steps, difficulty initiating walking and balance problems may be prominent. Examination findings and brain imaging are interpreted together; vascular changes on imaging alone do not establish the diagnosis.

No single finding is sufficient to distinguish these conditions. Diagnosis is based on the history and neurological examination, supported by imaging and other investigations when needed. Regular follow-up assesses changes in symptoms over time.

Treatment is planned according to the cause of parkinsonism and the patient’s needs. In addition to medication, care may include fall prevention, support for swallowing and speech, and rehabilitation to make everyday life easier.

Botulinum toxin temporarily reduces excessive contraction in the muscles into which it is injected. It can be used for cervical dystonia, involuntary eyelid contractions (blepharospasm), contractions on one side of the face (hemifacial spasm), dystonia affecting the jaw and mouth (oromandibular dystonia) and tongue dystonia (lingual dystonia). It may also be used to treat muscle stiffness and involuntary contractions after stroke (spasticity) and to reduce teeth-clenching symptoms in suitable patients.

Before treatment, the affected muscles, pain and impact on daily life are assessed. Target muscles and doses are determined through a detailed examination and any response to previous injections.

The effect usually begins within a few days and lasts for several months. Onset, duration and benefit can vary between individuals. Repeat treatment is planned according to the patient’s needs and response.

Pain, bruising or temporary muscle weakness may occur at the injection site. Depending on the area treated, drooping of the eyelid or difficulty swallowing may also occur. Expected benefits and possible adverse effects are discussed before treatment.

Deep brain stimulation (DBS) is a surgical treatment that aims to reduce symptoms through electrical stimulation delivered by electrodes placed in specific areas of the brain. It does not eliminate the disease and does not affect every symptom equally. In movement disorders, it is mainly used to treat Parkinson’s disease, essential tremor and dystonia.

DBS may also be considered for other types of tremor in selected patients. Outside movement disorders, it has applications in treatment-resistant epilepsy and obsessive-compulsive disorder. In Tourette syndrome it is considered only in limited, selected circumstances. Applications in areas such as ataxia and eating disorders remain investigational and should not be presented as routine uses.

Assessment for DBS considers the diagnosis, the nature of symptoms, benefit from medication and difficulties in daily life. In Parkinson’s disease, variation in medication benefit throughout the day and involuntary movements are specifically assessed. Memory and thinking, psychiatric status, brain imaging and surgical risks are also reviewed. The decision is made jointly by the relevant specialists, particularly neurology and neurosurgery.

After surgery, device programming, medication adjustment when needed and regular follow-up are required. Expected benefits and limitations are discussed with the patient and family so that realistic goals can be set.