Hyperkinetic Disorders

Abnormal Movement	Causes	Description
Akathisia (motor restlessness)	Parkinson disease, traumatic brain injury, encephalitis Antipsychotic medications, some antiemetics, antidepressants, calcium channel blockers	Patients with akathisia cannot remain still; they have an urge to move continuously (eg, forward rocking, lateral swaying).
Athetosis	Huntington disease, encephalitis, hepatic encephalopathy	Movements are nonrhythmic, slow, writhing, and sinuous (snakelike), primarily in distal muscles; alternating postures of the proximal limbs often blend continuously to produce a flowing stream of movement.
Chorea	Huntington disease, hyperthyroidism, hypoparathyroidism, hyperglycemia and, less commonly, hypoglycemia, paraneoplastic syndromes, systemic lupus erythematosus (SLE) affecting the CNS, other autoimmune disorders, rheumatic fever, tumors or infarcts of the caudate nucleus or putamen Pregnancy, often in women who had rheumatic fever Medications that can cause tardive dyskinesia (eg, antipsychotics)	Movements are random, flowing, and nonsuppressible, going from one place to another, primarily in distal muscles or the face. Sometimes abnormal movements are incorporated into semipurposeful acts that mask the involuntary movements. Chorea often occurs with athetosis as choreoathetosis.
Dystonias	Primary (idiopathic) Degenerative or metabolic disorders (eg, Wilson disease, neurodegeneration with brain iron accumulation [NBIA] such as PKAN due to a PANK2 mutation [previously, Hallervorden-Spatz disease], various lipidoses, multiple sclerosis, cerebral palsy, stroke, brain hypoxia) Brain damage in the basal ganglia and their circuits due to any condition (eg, vascular, posttraumatic, postinfectious, or inflammatory causes; tumors)	Sustained or intermittent muscle contractions often distort body posture or cause twisting, repetitive movements.
Hemiballismus	Lesions (most often due to stroke) in the contralateral subthalamic nucleus or in connecting afferent or efferent pathways	Movements are nonrhythmic, rapid, nonsuppressible, violent, and flinging.
Myoclonus		Very rapid and jerky, nonsuppressible, shocklike twitches occur; they may be focal, segmental, or generalized.
Restless leg syndrome	Primary (idiopathic or familial) Secondary: Parkinson disease, uremia, iron deficiency, peripheral neuropathies	Legs feel uncomfortable, and patients have an irresistible urge to move the legs. Discomfort lessens significantly when the legs are moved; discomfort is worse at night (diurnal variability). Many patients also have periodic limb movement disorder (involuntary jerking of the legs and arms) during sleep.
Stereotypies (stereotypic movements)	Autism spectrum disorders, intellectual disability, limbic autoimmune or paraneoplastic encephalitis; can also occur in normal children	Repetitive rhythmic movements occur; they are usually bilateral (eg, hand flapping, waving) or behaviors (eg, sniffing, vocalizing, posturing) Preschool stereotypies occur in 3–4% of patients; they are benign and are typically stopped by distraction (eg, calling the child's name).
Tardive dyskinesia	Antipsychotics, some antiemetics	Movements are stereotypic and cannot be voluntarily suppressed; consciousness is preserved.
Tics	Primary: Tourette syndrome Secondary:	Movements are nonrhythmic, stereotypic, rapid, and repetitive; characteristically, patients have an urge to do them and feel brief relief after doing them. Tics can be suppressed only for brief periods and with conscious effort. Tics may be motor or phonatory; they may be simple (eg, eye blinking, growling, clearing the throat) or complex (eg, shoulder shrugging, arm swinging, shouting words or sentences, including obscenities).
Tremor	Essential tremor Parkinson disease Wilson disease Some Causes of Secondary and Atypical Parkinsonism) Cerebellar disorders Withdrawal syndromes (eg, from alcohol, opioids, or sedatives) Endocrine, metabolic, and toxic disorders (eg, anoxic encephalopathy, hepatic encephalopathy, hypoglycemia, hyperparathyroidism, hyperglycemia, hyperthyroidism, hypocalcemia, uremia, heavy metal toxicity) Physiologic	Movements are regular, mostly rhythmic, and oscillatory.
CNS = central nervous system; MAO = monoamine oxidase; PKAN = pantothenate kinase‒associated neurodegeneration; PANK2 = pantothenate kinase 2.

Abnormal Movement

Causes

Description

Akathisia (motor restlessness)

Parkinson disease, traumatic brain injury, encephalitis

Antipsychotic medications, some antiemetics, antidepressants, calcium channel blockers

Patients with akathisia cannot remain still; they have an urge to move continuously (eg, forward rocking, lateral swaying).

Athetosis

Huntington disease, encephalitis, hepatic encephalopathy

Movements are nonrhythmic, slow, writhing, and sinuous (snakelike), primarily in distal muscles; alternating postures of the proximal limbs often blend continuously to produce a flowing stream of movement.

Chorea

Huntington disease, hyperthyroidism, hypoparathyroidism, hyperglycemia and, less commonly, hypoglycemia, paraneoplastic syndromes, systemic lupus erythematosus (SLE) affecting the CNS, other autoimmune disorders, rheumatic fever, tumors or infarcts of the caudate nucleus or putamen

Pregnancy, often in women who had rheumatic fever

Medications that can cause tardive dyskinesia (eg, antipsychotics)

Movements are random, flowing, and nonsuppressible, going from one place to another, primarily in distal muscles or the face.

Sometimes abnormal movements are incorporated into semipurposeful acts that mask the involuntary movements.

Chorea often occurs with athetosis as choreoathetosis.

Dystonias

Primary (idiopathic)

Degenerative or metabolic disorders (eg, Wilson disease, neurodegeneration with brain iron accumulation [NBIA] such as PKAN due to a PANK2 mutation [previously, Hallervorden-Spatz disease], various lipidoses, multiple sclerosis, cerebral palsy, stroke, brain hypoxia)

Brain damage in the basal ganglia and their circuits due to any condition (eg, vascular, posttraumatic, postinfectious, or inflammatory causes; tumors)

Sustained or intermittent muscle contractions often distort body posture or cause twisting, repetitive movements.

Hemiballismus

Lesions (most often due to stroke) in the contralateral subthalamic nucleus or in connecting afferent or efferent pathways

Movements are nonrhythmic, rapid, nonsuppressible, violent, and flinging.

Myoclonus

Very rapid and jerky, nonsuppressible, shocklike twitches occur; they may be focal, segmental, or generalized.

Restless leg syndrome

Primary (idiopathic or familial)

Secondary: Parkinson disease, uremia, iron deficiency, peripheral neuropathies

Legs feel uncomfortable, and patients have an irresistible urge to move the legs. Discomfort lessens significantly when the legs are moved; discomfort is worse at night (diurnal variability).

Many patients also have periodic limb movement disorder (involuntary jerking of the legs and arms) during sleep.

Stereotypies (stereotypic movements)

Autism spectrum disorders, intellectual disability, limbic autoimmune or paraneoplastic encephalitis; can also occur in normal children

Repetitive rhythmic movements occur; they are usually bilateral (eg, hand flapping, waving) or behaviors (eg, sniffing, vocalizing, posturing)

Preschool stereotypies occur in 3–4% of patients; they are benign and are typically stopped by distraction (eg, calling the child's name).

Tardive dyskinesia

Antipsychotics, some antiemetics

Movements are stereotypic and cannot be voluntarily suppressed; consciousness is preserved.

Tics

Primary: Tourette syndrome

Secondary:

Movements are nonrhythmic, stereotypic, rapid, and repetitive; characteristically, patients have an urge to do them and feel brief relief after doing them.

Tics can be suppressed only for brief periods and with conscious effort.

Tics may be motor or phonatory; they may be simple (eg, eye blinking, growling, clearing the throat) or complex (eg, shoulder shrugging, arm swinging, shouting words or sentences, including obscenities).

Tremor

Essential tremor

Parkinson disease

Wilson disease

Some Causes of Secondary and Atypical Parkinsonism)

Cerebellar disorders

Withdrawal syndromes (eg, from alcohol, opioids, or sedatives)

Endocrine, metabolic, and toxic disorders (eg, anoxic encephalopathy, hepatic encephalopathy, hypoglycemia, hyperparathyroidism, hyperglycemia, hyperthyroidism, hypocalcemia, uremia, heavy metal toxicity)

Physiologic

Movements are regular, mostly rhythmic, and oscillatory.

CNS = central nervous system; MAO = monoamine oxidase; PKAN = pantothenate kinase‒associated neurodegeneration; PANK2 = pantothenate kinase 2.

In these topics

Overview of Movement and Cerebellar Disorders