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  • Review Article
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The clinical approach to movement disorders

Nature Reviews Neurology volume 6, pages 29–37 (2010)Cite this article

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Abstract

Movement disorders are commonly encountered in the clinic. In this Review, aimed at trainees and general neurologists, we provide a practical step-by-step approach to help clinicians in their 'pattern recognition' of movement disorders, as part of a process that ultimately leads to the diagnosis. The key to success is establishing the phenomenology of the clinical syndrome, which is determined from the specific combination of the dominant movement disorder, other abnormal movements in patients presenting with a mixed movement disorder, and a set of associated neurological and non-neurological abnormalities. Definition of the clinical syndrome in this manner should, in turn, result in a differential diagnosis. Sometimes, simple pattern recognition will suffice and lead directly to the diagnosis, but often ancillary investigations, guided by the dominant movement disorder, are required. We illustrate this diagnostic process for the most common types of movement disorder, namely, akinetic–rigid syndromes and the various types of hyperkinetic disorders (myoclonus, chorea, tics, dystonia and tremor).

Key Points

  • The key to diagnosing movement disorders is establishing the phenomenology of the clinical syndrome

  • The phenomenology is determined from the specific combination of the dominant movement disorder, the presence of any additional abnormal movements, and any further neurological or non-neurological abnormalities

  • A range of conditions, both neurological and non-neurological, can mimic various movement disorders, and it is vital not to miss these lookalikes

  • A systematic approach is recommended when clinicians see patients who present with one or more types of movement disorder

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References

  1. de Rijk, M. C. et al. Prevalence of parkinsonism and Parkinson's disease in Europe: the EUROPARKINSON Collaborative Study. European Community Concerted Action on the Epidemiology of Parkinson's disease. J. Neurol. Neurosurg. Psychiatry 62, 10–15 (1997).

    Article  CAS  Google Scholar 

  2. Dogu, O. et al. Prevalence of essential tremor: door-to-door neurologic exams in Mersin Province, Turkey. Neurology 61, 1804–1806 (2003).

    Article  CAS  Google Scholar 

  3. Moghal, S., Rajput, A. H., D'Arcy, C. & Rajput, R. Prevalence of movement disorders in elderly community residents. Neuroepidemiology 13, 175–178 (1994).

    Article  CAS  Google Scholar 

  4. Kurlan, R. et al. The behavioral spectrum of tic disorders: a community-based study. Neurology 59, 414–420 (2002).

    Article  CAS  Google Scholar 

  5. Piccini, P. & Whone, A. Functional brain imaging in the differential diagnosis of Parkinson's disease. Lancet Neurol. 3, 284–290 (2004).

    Article  Google Scholar 

  6. Seppi, K. & Schocke, M. F. An update on conventional and advanced magnetic resonance imaging techniques in the differential diagnosis of neurodegenerative parkinsonism. Curr. Opin. Neurol. 18, 370–375 (2005).

    Article  Google Scholar 

  7. Litvan, I. et al. Movement Disorders Society Scientific Issues Committee report: SIC Task Force appraisal of clinical diagnostic criteria for parkinsonian disorders. Mov. Disord. 18, 467–486 (2003).

    Article  Google Scholar 

  8. Norlinah, I. M. et al. Primary lateral sclerosis mimicking atypical parkinsonism. Mov. Disord. 22, 2057–2062 (2007).

    Article  Google Scholar 

  9. Caviness, J. N. & Brown, P. Myoclonus: current concepts and recent advances. Lancet Neurol. 3, 598–607 (2004).

    Article  Google Scholar 

  10. Shibasaki, H. & Hallett, M. Electrophysiological studies of myoclonus. Muscle Nerve 31, 157–174 (2005).

    Article  Google Scholar 

  11. Roze, E. et al. Propriospinal myoclonus revisited: clinical, neurophysiologic, and neuroradiologic findings. Neurology 72, 1301–1309 (2009).

    Article  CAS  Google Scholar 

  12. Bakker, M. J., van Dijk, J. G., van den Maagdenberg, A. M. & Tijssen, M. A. Startle syndromes. Lancet Neurol. 5, 513–524 (2006).

    Article  Google Scholar 

  13. Hallett, M. & Kaufman, C. Physiological observations in Sydenham's chorea. J. Neurol. Neurosurg. Psychiatry 44, 829–832 (1981).

    Article  CAS  Google Scholar 

  14. Postuma, R. B. & Lang, A. E. Hemiballism: revisiting a classic disorder. Lancet Neurol. 2, 661–668 (2003).

    Article  Google Scholar 

  15. Muthugovindan, D. & Singer, H. Motor stereotypy disorders. Curr. Opin. Neurol. 22, 131–136 (2009).

    Article  Google Scholar 

  16. Shprecher, D. & Kurlan, R. The management of tics. Mov. Disord. 24, 15–24 (2009).

    Article  Google Scholar 

  17. Deuschl, G., Bain, P. & Brin, M. Consensus statement of the Movement Disorder Society on Tremor. Ad Hoc Scientific Committee. Mov. Disord. 13 (Suppl. 3), 2–23 (1998).

    PubMed  Google Scholar 

  18. Jankovic, J., Schwartz, K. S. & Ondo, W. Re-emergent tremor of Parkinson's disease. J. Neurol. Neurosurg. Psychiatry 67, 646–650 (1999).

    Article  CAS  Google Scholar 

  19. Bhatia, K. P. & Schneider, S. A. Psychogenic tremor and related disorders. J. Neurol. 254, 569–574 (2007).

    Article  Google Scholar 

  20. Gerschlager, W. et al. Natural history and syndromic associations of orthostatic tremor: a review of 41 patients. Mov. Disord. 19, 788–795 (2004).

    Article  Google Scholar 

  21. Britton, T. C. et al. Primary orthostatic tremor: further observations in six cases. J. Neurol. 239, 209–217 (1992).

    Article  CAS  Google Scholar 

  22. Munchau, A. et al. Arm tremor in cervical dystonia differs from essential tremor and can be classified by onset age and spread of symptoms. Brain 124, 1765–1776 (2001).

    Article  CAS  Google Scholar 

  23. Schneider, S. A. et al. Patients with adult-onset dystonic tremor resembling parkinsonian tremor have scans without evidence of dopaminergic deficit (SWEDDs). Mov. Disord. 22, 2210–2215 (2007).

    Article  Google Scholar 

  24. Jain, S., Lo, S. E. & Louis, E. D. Common misdiagnosis of a common neurological disorder: how are we misdiagnosing essential tremor? Arch. Neurol. 63, 1100–1104 (2006).

    Article  Google Scholar 

  25. Brown, P. New clinical sign for orthostatic tremor. Lancet 346, 306–307 (1995).

    Article  CAS  Google Scholar 

  26. Morris, J. G. et al. Athetosis II: the syndrome of mild athetoid cerebral palsy. Mov. Disord. 17, 1281–1287 (2002).

    Article  Google Scholar 

  27. Geyer, H. L. & Bressman, S. B. The diagnosis of dystonia. Lancet Neurol. 5, 780–790 (2006).

    Article  Google Scholar 

  28. Tanabe, L. M., Kim, C. E., Alagem, N. & Dauer, W. T. Primary dystonia: molecules and mechanisms. Nat. Rev. Neurol. 5, 598–609 (2009).

    Article  CAS  Google Scholar 

  29. van de Warrenburg, B. P. et al. The syndrome of (predominantly cervical) dystonia and cerebellar ataxia: new cases indicate a distinct but heterogeneous entity. J. Neurol. Neurosurg. Psychiatry 78, 774–775 (2007).

    Article  Google Scholar 

  30. Schrag, A., Trimble, M., Quinn, N. & Bhatia, K. The syndrome of fixed dystonia: an evaluation of 103 patients. Brain 127, 2360–2372 (2004).

    Article  Google Scholar 

  31. Nahab, F. B., Peckham, E. & Hallett, M. Essential tremor, deceptively simple. Pract. Neurol. 7, 222–233 (2007).

    Article  Google Scholar 

  32. Stolze, H., Petersen, G., Raethjen, J., Wenzelburger, R. & Deuschl, G. The gait disorder of advanced essential tremor. Brain 124, 2278–2286 (2001).

    Article  CAS  Google Scholar 

  33. Quinn, N. Multiple system atrophy—the nature of the beast. J. Neurol. Neurosurg. Psychiatry Jun. (Suppl.), 78–89 (1989).

    Article  Google Scholar 

  34. Wenning, G. K., Colosimo, C., Geser, F. & Poewe, W. Multiple system atrophy. Lancet Neurol. 3, 93–103 (2004).

    Article  Google Scholar 

  35. van Rootselaar, A. F., van Westrum, S. S., Velis, D. N. & Tijssen, M. A. The paroxysmal dyskinesias. Pract. Neurol. 9, 102–109 (2009).

    Article  Google Scholar 

  36. Bhatia, K. P. Familial (idiopathic) paroxysmal dyskinesias: an update. Semin. Neurol. 21, 69–74 (2001).

    Article  CAS  Google Scholar 

  37. Gerrits, M. C. et al. Phenotype–genotype correlation in Dutch patients with myoclonus–dystonia. Neurology 66, 759–761 (2006).

    Article  CAS  Google Scholar 

  38. Schmitz-Hubsch, T. & Klockgether, T. An update on inherited ataxias. Curr. Neurol. Neurosci. Rep. 8, 310–319 (2008).

    Article  Google Scholar 

  39. Cardoso, F., Seppi, K., Mair, K. J., Wenning, G. K. & Poewe, W. Seminar on choreas. Lancet Neurol. 5, 589–602 (2006).

    Article  Google Scholar 

  40. Dimutru, D., Amato, A. A. & Zwarts, M. J. Electrodiagnostic Medicine, 2nd edn (Hanley & Belfus, Philadelphia, 2002).

    Google Scholar 

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Acknowledgements

This clinical approach was handed down to us by the late Professor David Marsden. This work was supported by The Netherlands Organization for Scientific Research (NWO) Vidi research grant #016.076.352 to B. R. Bloem. W. F. Abdo was supported by a research grant from the Stichting Internationaal Parkinson Fonds.

Désirée Lie, University of California, Orange, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. Department of Neurology, Parkinson Centre Nijmegen (ParC), Radboud University Nijmegen Medical Centre, P. O. Box 9101, Nijmegen, 6500, HB, The Netherlands

    Wilson F. Abdo, Bart P. C. van de Warrenburg & Bastiaan R. Bloem

  2. Institute for Ageing and Health, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK

    David J. Burn

  3. UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK

    Niall P. Quinn

Authors
  1. Wilson F. Abdo
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  2. Bart P. C. van de Warrenburg
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  5. Bastiaan R. Bloem
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Corresponding author

Correspondence to Bastiaan R. Bloem.

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Supplementary information

Supplementary Table 1

Examples of clinical thinking in myoclonus (DOC 45 kb)

Supplementary Table 2

Examples of clinical thinking in chorea (DOC 43 kb)

Supplementary Table 3

Examples of clinical thinking in dystonia (DOC 54 kb)

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Abdo, W., van de Warrenburg, B., Burn, D. et al. The clinical approach to movement disorders. Nat Rev Neurol 6, 29–37 (2010). https://doi.org/10.1038/nrneurol.2009.196

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