Examination of the Patient With a Movement Disorder

Ovid: Field Guide to the Neurologic Examination

Authors: Lewis,
Steven L.

Title: Field
Guide to the Neurologic Examination, 1st Edition

> Table of Contents > Section 3 –
Neurologic Examination in Common Clinical Scenarios >Chapter 46 –
Examination of the Patient With a Movement Disorder

Chapter 46

Examination of the Patient With a Movement Disorder


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


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.


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

  • 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

  • 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

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  • 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



  • 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

  • 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
    , 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.

  • Ask the patient to write a sentence (not their signature);
    patients with Parkinson’s disease usually have small (micrographic), shaky
    handwriting. Also ask the patient to draw a spiral from the inside out (draw a
    sample of this for the patient, by drawing a loose spiral a few inches in
    diameter); patients with Parkinson’s disease usually draw a small, tightly
    packed spiral.

  • Examine the gait (see Chapter 39,
    Examination of Gait) for typical signs of parkinsonism, including diminished
    arm swing; multiple small, narrowbased, shuffling steps; and a stooped
    posture. The patient may have difficulty getting up out of a chair to initiate
    gait. Festination of gait refers to the tendency of
    parkinsonian patients to keep speeding up when walking, with difficulty
    stopping their forward progress. Make sure you observe the patient turn and
    walk back to you, because patients with parkinsonism may show typical en bloc turning, taking multiple extra steps as they
    attempt to change direction, rather than a normal pivot. There may also be a
    tendency to freeze at doorways and with turns.

  • In any patient with suspected parkinsonism, assess postural

    • Ask the patient to stand still. Inform the patient that you
      will be testing balance by pulling him or her backward and that the patient
      should maintain balance as best as he or she can and may take steps backward
      if necessary.

    • Stand directly behind the patient, so if the patient were to
      fall backward, you would be able catch him or her.

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    • Reach around and pull back quickly on the patient’s shoulders
      and observe the patient’s ability to retain his or her balance. Obviously,
      catch the patient if he or she begins to fall into you.

    • Impairment of postural reflexes would manifest as a series of
      backward steps or as the patient falling backward.

  • Patients with the parkinsonian syndrome of progressive
    supranuclear palsy may have difficulty with voluntary conjugate eye movements
    (see Chapter 14, Examination of Eye Movements) and
    especially may have difficulty looking down as the earliest eye sign of the
    disease. In these patients, the supranuclear (i.e.,
    above the cranial nerve nuclei in the brainstem) cause of the dysfunction can
    usually be detected by finding that the downward eye movements are intact when
    the patient’s head is passively tilted upward while the patient is asked to
    fixate his or her eyes forward on your face.

  • When the Shy-Drager syndrome (a form of multiple-system atrophy)
    is suspected, be certain to look for evidence of orthostatic hypotension (see
    Chapter 44, Examination of the Dizzy

Postural (Essential) Tremor

  • Unlike parkinsonian tremors, patients with essential tremor or
    other postural tremors have a tremor that is worse with activities that
    involve maintaining their arm in a specific posture or with action, rather
    than at rest. Holding a cup of coffee or a soup spoon may be difficult and
    embarrassing to the patient.

  • To assess for a postural tremor, have the patient hold his or her
    hands directly in front with the palms down and fingers spread (abducted), and
    observe the hands. Depending on the severity, there may be a subtle fine
    tremor of the fingers or more prominent, higher amplitude shakiness. Giving
    the patient a cup of water to hold can also be a good way for you to see the
    real-world severity of the tremor.

  • Watch the patient write a sentence of his or her choice. Patients
    with essential tremor usually have tremulous handwriting that, unlike
    parkinsonian writing, is not micrographic. Ask the patient to draw a spiral
    (draw a sample for the patient), which will be shaky but not micrographic as
    would occur in Parkinson’s disease.

  • Look for accentuation of essential tremor during the
    finger-to-nose maneuver (see Chapter 34, Testing of
    Upper Extremity Cerebellar Function) as an endpoint tremor. This usually
    manifests as a fine shakiness when the patient’s finger gets close to your
    finger or his or her nose but without the clumsiness (dysmetria) throughout
    the maneuver seen in cerebellar disorders.


  • Dystonic movements are abnormal, sustained muscle contractions
    that result in abnormal postures. Depending on the syndrome, these dystonic
    postures may be focal or generalized, and they may involve the limbs, neck,
    body, or face.

  • Patients with dystonia have abnormal postures of the involved
    body part evident simply by observation during the examination.

  • Patients with focal cervical dystonia (torticollis) show abnormal
    posturing of the neck, resulting in a combination of head turning, tilting,
    flexion, or extension. The patient may have the ability to prevent the posture
    by performing a self-learned simple maneuver such as touching the chin (called
    a geste antagoniste).

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  • Patients with symptoms suggestive of writer’s cramp or other
    focal or occupational dystonias should be observed in the act of performing
    the inciting activity (such as writing), so that you can observe the dystonic


  • Chorea manifests on examination as
    rapid, fidgety-appearing movements, primarily of the extremities, but it may
    also involve the face. These movements, which are often described as
    dance-like, are not stereotyped and move unpredictably from one area of the
    body to another (unlike myoclonus or tics).

  • Patients with generalized chorea (such as from Huntington’s
    disease) look fidgety and may be misdiagnosed as simply “nervous.” Patients
    with choreiform movements often, probably inadvertently, try to hide their
    choreiform movements by incorporating them into maneuvers such as brushing
    their hair with their hand.

  • Hemichorea is chorea involving only one side of the body.
    Hemichorea and hemiballismus (defined as flinging
    movements of the extremities on one side) are essentially clinically
    indistinguishable from each other.

Tic Disorders

  • Tics are rapid, stereotyped movements or vocalizations. Motor
    tics may involve the face (e.g., eye blinking), head (e.g., shaking), or
    extremities. Unlike chorea, tics are generally stereotyped for each patient
    (i.e., the patient usually manifests the same types of behavior
    intermittently). Vocal tics may be simple sounds (e.g., throat clearing) or
    more complex vocalizations, including obscenities (coprolalia).

  • Patients may be observed to be able to voluntarily suppress the
    tics at least to some extent, but they usually describe a build-up of tension
    that is released as they allow the tics to express themselves


The movements of myoclonus are rapid muscle jerks. Myoclonus may be
focal, involving a single extremity or part of an extremity, or generalized.
Generalized myoclonus is a common clinical finding, especially in patients with
metabolic encephalopathies.


  • The term athetosis is used to describe
    slow, writhing movements of the extremities. These movements can occur within
    the context of chorea (hence the common term choreoathetosis), but athetosis can also be seen in the
    setting of dystonia or even peripheral nerve disorders affecting position
    sense (pseudoathetosis), as described in Chapter 30,
    Examination of Vibration and Position Sensation.

  • Wilson’s disease is an important, treatable (but otherwise
    progressive) cause of a (hypokinetic or hyperkinetic) movement disorder. When
    this disorder is a consideration, the finding of copper deposition around the
    edge of the cornea (Kayser-Fleischer rings) needs to be sought on examination,
    but it requires slit-lamp examination by an ophthalmologist to be

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