Identifying Common Movement Disorders in the Emergency Department

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Identifying movement disorders in the pediatric emergency department can be challenging. It is crucial to recognize which movements are true emergencies or require immediate attention in order to provide optimal care. The purpose of this article is to facilitate proper identification of the most common acute movement disorders in childhood. By reviewing the phenomenology and etiology, we aim to help emergency physicians formulate accurate differentials and, therefore, manage these appropriately.

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Initial Evaluation

A thorough history is one of the most valuable tools for formulating an accurate diagnosis for the child who presents with abnormal movements. If possible, history should be obtained both from family members as well as the child. Even young children can provide important information about their involuntary movements. Key features of the history include the age of onset and time course. An involuntary movement may be considered normal in an infant but abnormal in an older child due to changes

Chorea

Chorea, derived from a Greek word meaning dance, refers to ongoing, random, and discrete involuntary movements or fragments usually involving the face and proximal extremities.2, 5 The movements are continuous and nonrhythmic and cannot be controlled by the patient. Patients can seem restless and have motor impersistence, which is appreciable during certain postures or simple motor commands. Examples of examination maneuvers to evaluate for motor impersistence include the following. When the

Dystonia

Dystonia has been defined by the Task Force on Childhood Motor Disorders as involuntary, sustained, or intermittent muscle contractions causing twisting, abnormal postures, and/or repetitive movements.2, 10 Dystonia is classified as focal when it is localized to one part of the body. It may involve several parts of the body that are adjacent or unrelated, referred to as segmental or multifocal, respectively. Spasticity and dystonia can coexist but do not have to. Indeed, some patients with

Tremors

Tremors are defined as rhythmic, back-and-forth, or oscillating involuntary movements about a joint axis.2 Generally, there is contraction of both antagonist and agonist muscles resulting in the stereotyped and symmetric, alternating movements. Action tremors, those that occur during movement, are much more common in children than resting tremors, which are seen in parkinsonism.5

Postural, kinetic, and intention tremors are some of the most common action tremors in children. Postural tremors

Myoclonus

Myoclonus refers to a sequence of repeated, brief shock-like jerks due to sudden involuntary contraction (defined as positive myoclonus) or relaxation of one or more muscles (defined as negative myoclonus).2 Movements can be rhythmic or random. Different from chorea, movements are very fast and do not have a flowing appearance. Pathologic myoclonus can develop from injury at multiple levels in the neurologic axis, from the cerebral cortex to the spinal cord.6

Although myoclonus can be

Tics

Tics are repeated, individually recognizable, intermittent movements or movement fragments. Children are typically able to suppress the involuntary movement only for brief periods. They are usually aware of a premonitory urge to perform the movement.2 Movements are stereotyped and can be triggered by suggestion, excitement, or stress. Tics commonly resolve with sleep, but not always. They can be classified as simple, complex, motor, or vocal. Some examples of simple motor tics are excessive eye

Stereotypies

Stereotypies are simple, repetitive movements often involving the upper extremities.2 Children may rock their bodies, wave and flap their hands, or perform more complex movements. As the term suggests, movements are stereotyped. They can be predicted given that many times they are triggered by stressful situations or excitement. Stereotypies can be more continuous and prolonged than tics but should also be distractible by the examiner or family members. In contrast to tics, these movements tend

Summary

The key steps to the evaluation and diagnosis of hyperkinetic movement disorders in children include identifying the phenomenology, reviewing the time course, and obtaining a detailed history and neurologic examination. When correctly identified, patients with chorea, dystonia, and sometimes myoclonus or tremors should have initial diagnostic evaluations in the emergency setting. Treatment should also be instituted in the acute setting when indicated. Other more benign conditions such as tic

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