Signs and symptoms

• Difficulty in getting out of chairs.
• Trouble turning over in bed.
• An overall reduced speed of activities (often misinterpreted).
• Patients may report trouble in starting to walk, or freezing or festination or tendency to run.
• Repeated falling is an important feature of movement disorders and all adults with unexplained falls should be neurologically evaluated.
• Dystonic movements often occur or increase with some activity such as writing, pouring liquids, buttoning and walking.
• Parkinson’s tremor occurs during rest, postural tremor during activity such as writing, pouring liquids, buttoning, and walking.
• Cerebellar tremor is worst when patients extend their arms maximally to complete a task with sloppiness due to dyssynergia.
• The onset of most movement disorders is quite insidious except for hemiballismus, which often begins suddenly.

Examination of hypokinesia and hyperkinesia
Patients are evaluated at rest during maintenance of a static posture and volitional activity. Study of speech and gait is also very helpful.

Patient at Rest: Sitting comfortably or lying supine. In hypokinetic disorders, one sees a lack of normal gesturing and spontaneous movements with a mask like face or rest tremor. Dystonias can be seen in positions which are seemingly at rest. Many other hyperkinesias are present at rest such as athetosis, Hemiballismus, chorea and tics. Patients with akathisia become restless and find it very difficult to sit quietly. Tics may be better seen when the patient feels he is not being observed. Myoclonus or a heightened startle reflex may be seen on suddenly clapping the hands.

Maintenance of a posture: Holding the hand outstretched may bring out a postural tremor or the sudden jerks of myoclonus. Dystonic patients also develop tremor (dystonic tremor) when they try to resist their dystonia. A hallmark of chorea is ‘Motor impersistence’ whereby patients are unable to maintain a posture without the superimposition of the random choric movements, eg. jack in the box tongue or milkmaid grip.

Execution of tasks
Many tasks are interrupted by hypokinesia and hyperkinesia.

Finger or foot tapping
Will be slow and cramped in hypokinesia and sloppy and overridden with additional movements in chorea or may precipitate a contorted spasm in dystonia.

Handwriting
Is useful since bradykinesia will cause a small and cramped Parkinsonian script (micrographia). Action tremor will cause a large, tremolos signature. Dystonia will induce irregular script and often the patient keep adjusting or even dropping the pen. Finger to nose task helps distinguish postural tremor from kinetic or end point tremor usually associated with cerebellar ataxia.

Speech
Allows the examiner to detect dysarthria, hypophonia and language and apraxic disorders, as well as mood and dementia. Talking often induces overflowing dystonic movements elsewhere in the body, apart from bringing out action, dystonia of the tongue, face or jaw muscles. On the other hand, patients with blepharospasm may have relief of their forced eyelid closure by talking. Those with hypokinetic disorders may exhibit monotonous speech with decreased amplitude (hypophonia) palilalia, transient speech arrests, or tachyphemia (rapid speech with no pausing between syllables). Hyperkinetic disorders like chorea, myoclonus and lingual dystonia can also impair speech.

Tone: Unlike spasticity, the increased tone of rigidity or cog wheeling, is seen in both flexor and extensor muscles during slow movements. Dystonic patients may have a fluctuating tone while chorea often has hypotonia.

Walking: Gait integrates and so tests numerous neuroanatomical systems. In hypokinesia, the patient has a hunched, flexed posture, with reduced arm swing. The steps are small and often the patient walks on the toes with a propulsive running gait. Alternatively, the patient may fall backwards, especially when pivoting.

The hyperkinesias may show a variety of gait abnormalities eg. a lilting stuttering dance like gait often accompanied by flail hypotonic limbs in chorea, foot and truck spasms in dystonias. Tics may abate during walking though.

Postural reflexes can be tested by the pull test, standing behind the patient and after a proper warning, giving a brisk pull on the shoulders. In the hypokinetic movement disorders they will take several steps backwards or even fall.