Movement disorders, involuntary / tic disorders

Rationale

Movement disorders are classified as hyperkinetic (excessive or involuntary movements) or bradykinetic (reduced movements). Diagnosis relies primarily on careful observation of the clinical features.

Causal Conditions

(list not exhaustive)

1. Hyperkinetic
   1. Tics
      1. Primary
         1. Tourette syndrome
         2. Huntington disease
      2. Secondary
         1. Infections (e.g., encephalitis, Creutzfeldt-Jakob disease)
         2. Medications (e.g., stimulants, levodopa)
   2. Dystonia
      1. Primary (sporadic and inherited)
      2. Dystonia plus syndromes (e.g., medications)
   3. Stereotypies (typically with intellectual disability or autism spectrum disorder)
   4. Chorea, athetosis, ballism
   5. Essential tremor
   6. Myoclonus
2. Bradykinetic
   1. Parkinson disease
   2. Wilson disease
   3. Huntington disease
3. Tremor
   1. Resting (e.g., Parkinson, severe essential)
   2. Intention (e.g., cerebellar disease, multiple sclerosis)
   3. Action or postural (e.g., enhanced physiologic, essential)

Key Objectives

Given a patient with a movement disorder, such as a tic disorder or other involuntary movement disorder, the candidate will diagnose the cause, severity, and complications, and initiate an appropriate management plan.

Enabling Objectives

Given a patient with a movement disorder, the candidate will

1. list and interpret critical clinical findings, including those derived from
   1. careful observation (at rest and in action) to describe the abnormal movement accurately and differentiate between the types and causes of movement disorders,
   2. a history and physical examination to look for reversible causes (e.g., medications, Wilson disease), and
   3. identification of key physical findings characteristic of Parkinson disease (e.g., rigidity, akinesia);
2. list critical investigations and interpret the results of the investigations, including
   1. laboratory tests as indicated (e.g., electrolytes, copper level, iron studies), and;
   2. imaging studies and other tests as appropriate;
3. construct an effective initial management plan, including
   1. initiating medications for common conditions (e.g., essential tremor);
   2. recognizing adverse effects of medications (e.g., dystonia, on–off phenomenon) and modifying the patient’s regimen as necessary,
   3. determining if the patient requires specialized care for diagnosis or management (e.g., genetic testing), and
   4. counselling about the psychosocial impact of the disorder.