Psychiatric disorders are frequently encountered in movement disorders. They may precede and obscure or often exacerbate neurological symptoms. Psychiatric interviewing can be daunting for many non-psychiatrists, who are accustomed to a more structured, less intuitive approach to the examination. It is critical for every clinician to have the basic skills to assess psychiatric symptoms in order to screen for and measure the severity of emotional distress. Longitudinal monitoring of psychiatric problems assists in the treatment of the underlying neurological condition. Some psychiatric symptoms may emerge alongside motor symptoms in the course of neurodegenerative diseases, such as Parkinson or Huntington disease. The Mental Status Examination is a comprehensive evaluation of the current state of psychiatric functioning, based on the examiner’s observations and responses directly elicited from the patient.

Patients with movement disorders can develop motor, cognitive, and behavioral impairments that can lead to a loss of functional ability and independence in activities of daily living resulting in decrease quality of life. Physical therapy can help to prevent and treat these symptoms. During the rehabilitation process, physical therapists assist patients to restore quality movement, functional mobility, and participation in work, family, and other social roles. The aim of therapy is to maximize independence and quality of life at the time of the diagnosis and throughout the course of the disorder. This chapter focuses on the role of physical therapists in the care and management of movement disorders. It first discusses the important role of exercise in the management of Parkinson disease. The chapter subsequently discusses the roles of physical therapists as part of a multidisciplinary team. Finally, it discusses the specific issue of falls in movement disorders.

The movement disorders community has spent a good portion of the last 30 years promoting and standardizing the language, definitions, phenomenology and dissemination of such knowledge to the neurological and medical community as a whole. Yes, technology provides a way to see or obtained data not before possible. However, in movement disorders, precision in terminology and careful astute observations of involuntary, semi-voluntary and voluntary movements remain pertinent. Clinicians interested in movement disorders are concerned with patients showing alterations of movement flow, pattern, and posture; patients who either move “too much or too little”. This chapter provides a brief description on basic pathophysiological concepts and prevalence of movement disorders. It then briefs on hypokinetic (Akinetic-Rigid Syndrome) and hyperkinetic disorders. The approach to a patient with a movement disorder is similar that of a patient with other conditions, beginning with history of illness followed by a careful neurological examination.

Spasticity is a pathological increase in muscle tone secondary to lesions affecting the pyramidal and parapyramidal tracts in the brain and/or the spinal cord. Initially the increase in muscle tone is velocity-dependent resulting in the classical clasp-knife tone quality but in more advanced stages, increased tone becomes persistent throughout the range of motion. Spasticity results in resistance to passive movements, hyperreflexia, tonic spasms, other involuntary movements, abnormal postures, spastic co-contractions, and may eventually lead to contractures and soft tissue changes. Pathophysiology includes loss of central inhibition of tonic stretch reflex leading to chronic hyperexcitability. Spasticity can also have some benefits which should be considered in each patient when implementing a spasticity management plan to avoid “over-treating”. The goals of spasticity management must be discussed thoroughly with the patient and family prior to implementing a management plan. Pharmacological treatment includes oral anti-spasticity agents; Botulinum toxin injections; and phenol nerve blocks.

Ablative procedures for the treatment of movement disorders dates back to the 1950’s, when Cooper first described ligation of the anterior choroidal artery for the treatment of Parkinson disease (PD). Movement disorders treatable with ablative procedures include PD, essential tremor, and dystonia. Deep brain stimulation has largely supplanted ablative techniques for most, but in some instances, ablative treatment is still preferable. The three most common ablative procedures used for movement disorders are high intensity focused ultrasound, radiofrequency ablation, and gamma knife radiosurgery. Shunting of continuous cerebrospinal fluid has even been reported to improve coexistent movement disorders in normal pressure hydrocephalus, including parkinsonism. Baclofen is a drug of choice for patients with spasticity. Spasticity is associated with the destruction or dysfunction of central nervous system tissue in the brain or spinal cord. Intrathecal delivery through a pump can lower systemic levels concentrating the drug solution around the spinal cord.

Psychiatric symptoms are to be expected in Parkinson disease (PD). They represent a special challenge to the practitioner because many of the psychiatric syndromes do not merely co-occur with PD but are predictable sequelae of the pathophysiology and/or treatment of this “quintessential neuropsychiatric disorder”. Cavalier treatment of psychiatric symptoms may result in not only lack of efficacy, but also worsening of motor symptoms, increased dysfunction, and decreased quality of life, particularly in late or burdensome disease. A proper evaluation includes a careful elucidation of psychiatric symptoms and a complete mental status examination. Systematic questioning about psychiatric symptoms and performance on the mental status examination will guide the diagnosis. This chapter discusses the following psychiatric issues in PD, and its treatment: depression and anxiety; apathy; cognitive impairment; psychosis; and impulse control disorders (ICDS) and other dysregulated behaviors. Tapering and/or discontinuing dopamine agonist agents will mitigate or eliminate ICDs and compulsive behaviors.

There has been growing recognition of the cognitive and neurobehavioral symptoms associated with movement disorders. The prevalence of cognitive and neurobehavioral symptoms makes intuitive sense given the functional neuroanatomy of the basal ganglia and the intimate connections between cognitive and limbic regions in the frontal lobes. This chapter discusses a neuroanatomical rationale for neuropsychological assessment in functional neurosurgery for movement disorders. It describes the role of a neuropsychologist on a movement disorders surgical team. There are four goals of a pre-surgical neuropsychological evaluation. These goals are directly related to some of the most common ethical questions that arise in the context of determining surgical candidacy: Assessment of cognitive status and potential risk for post-operative decline; neurobehavioral assessment and potential risk for interference with perioperative procedures and/or post-operative functioning; evaluation of level of support for the patient’s decision to consider surgery; and assessment of functional goals and expectations.

Ataxia is a Greek word that means “absence of order”; clinical syndrome of incoordination. A predominant clinical feature in a variety of disorders with impaired coordination of voluntary movement, affecting gait, swallowing, speech and fine motor skills. Cerebellar ataxia is characterized by rate, rhythm, amplitude and force irregularities of voluntary movements, evident at initiation and termination of motion, resulting in irregular trajectories, terminal tremor and overshoot of limbs (dysmetria). Vestibular ataxia is characterized by prominent vertigo, upper body or limb movement could be ataxic but does not affect speech. Sensory ataxia is characterized by gait incoordination worsened by diminution of visual cues, accompanied by decreased vibration and joint position sense, with no vertigo and speech impairment. This chapter provides a brief description on: etiology of ataxia; inherited ataxias; sporadic ataxia; acquired ataxia; clinical examination / neurological findings; ataxia work up and diagnosis; and treatment.

Motor speech, cognitive-linguistic, and swallowing abnormalities occur frequently in movement disorders. The evaluation and treatment of motor speech disorders (MSD), including the dysarthria types and apraxia of speech, cognitive-linguistic disorders, and oropharyngeal dysphagia are typically performed by Speech–Language Pathologists. These evaluations and treatments may accomplish the following: Identify the presence of MSD, cognitive-linguistic impairments, or oropharyngeal dysphagia; differentially diagnose the MSD type, cognitive-linguistic components, and dysphagia stages along with their association or disparity with the underlying neurological impairment; and determine the severity and the patient's prognosis for improvement under skilled intervention. This chapter summarizes the procedures that Speech–Language Pathologists use to evaluate motor speech, cognitive-linguistic skills, and swallowing. It introduces the Mayo classification system of MSD, with an emphasis on its relevance for physicians and other health care providers. Finally, the chapter discusses motor speech, cognitive-linguistic, and swallowing disorders and their treatment in a variety of movement disorders.

Dystonia is a movement disorder characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive, movements, postures, or both. Dystonic movements are typically patterned, twisting, and may be tremulous. Dystonia is often initiated or worsened by voluntary action and associated with overflow muscle activation. This chapter details the phenomenology of dystonic movements, and discusses the classification and treatment of dystonia. The phenomenology of dystonia combines abnormal movements and postures. The main features of dystonia include the following: voluntary action, dystonic tremor, overflow of movements, mirror dystonia, and alleviating maneuvers. Dystonia is usually worsened by fatigue and stress and is suppressed by sleep, hypnosis, or relaxation. Treatment is tailored by etiology. Management can be difficult and may require more than one modality of treatment and multiple strategies may be needed. Surgical therapies include: peripheral surgical procedures, central nervous system ablative procedures, and deep brain stimulation.