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Chapter 17. Pharmacologic Management of Parkinson's Disease and Other Movement Disorders

The major movement disorders include Parkinson‘s disease, Huntington‘s disease, Wilson‘s disease, Tourette‘s syndrome. An outline of common movement disorders is given in Table 17–1.

Table 17–1. Types of Movement Disorders
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Table 17–1. Types of Movement Disorders
DisorderEtiologyManifestationsCommon SignsTherapy
Parkinson’s diseaseLoss of dopaminergic neurons in the basal gangliaTremor at restOscillatory movement, especially fine muscles (hands, face)Levodopa, dopamineagonists; antimuscarinics; brain stimulation
BradykinesiaDifficulty initiating movement (e.g., walking), flat facies
Rigidity“Cogwheel” effect
Familial tremor, essential tremor, physiologic postural tremorUnknownPostural tremorDifficulty eating, drinking; ataxiaβ blockers
Restless legs syndromeUnknown; (dopamine deficiency?)Subjective feeling of discomfort, especially at nightNoneDopamine agonists; e.g., ropinirole
Tourette’s syndromeUnknown; (dopamine excess?)Motor ticsInvoluntary twitches, vocalizationsClonidine; dopamine blockers; e.g., haloperidol
Wilson’s diseaseCongenital error in copper transport and binding Rest and postural tremor, chorea, ataxiaDeposit in cornea, elevated liver copper and liver function testsLow copper diet, copper-binding drugs
Huntington’s diseaseLoss of GABAergic neurons in the basal ganglia; strong genetic componentChoreaAbnormal movements and dementiaNone satisfactory. Dopamine blockers or depleting drugs may reduce abnormal movements

Several different types of abnormal movements or signs of these disorders are recognized, including athetosis, ballismus, chorea, dyskinesia, dystonia, tics and tremor as described in Table 17–2. These movements can be caused by a variety of general medical conditions and certain drugs, in addition to the neurologic disorders mentioned.

Table 17–2. Types of Abnormal Movements
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Table 17–2. Types of Abnormal Movements
MovementDescription
TremorOscillatory movement around a joint, e.g., fingers, wrist, jaw
Rest tremorOccurs in the absence of any intended movement
Postural tremorOccurs while maintaining a particular posture
Intention tremorOccurs during voluntary effort; e.g., picking up a pencil
ChoreaIrregular, involuntary movements occurring in any part of the body. May involve facial grimacing or tongue movements and abnormal speech
BallismusA form of chorea involving proximal muscles in which a limb may move violently
TicsSudden, involuntary, and repetitive coordinated movements; e.g., blinking, turning head, smacking lips
AthetosisInvoluntary slow, writhing movements
DystoniaProlonged, sustained athetosis that resembles abnormal posture
DyskinesiaAcute dystonia or muscle spasm, often caused by dopamine-blocking drugs
AkathisiaInability to sit or stand still, motor restlessness; usually caused by dopamine-blocking drugs
MyoclonusSudden, rapid, twitch-like movements; may be localized or generalized

To understand how the movement disorders are treated, it is important to understand their underlying pathogenesis. Many of the movement disorders have been attributed to disturbances of the basal ganglia, but the precise function of these anatomic structures is not yet fully understood, and it is not possible to relate individual symptoms to involvement at specific sites. Furthermore, individuals with the same disease, such as Parkinson’s disease, can present very differently in terms of symptoms and ...

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