Movement is mediated through the pyramidal system, the basal ganglia and the

cerebellum in the brain.These are discrete parts of the brain which perform
specific but different functions, which are wired to each other for the
performance of normal movement. The movement disorders are a diverse group
of pathologic dysfunctions in the nervous system, giving rise to any of these: an
abnormal movement, a paucity of movement, an abnormality of muscle tone or a
disturbance in postural
reflex.

The common movement disorders are Tremors, Chorea, Parkinson's disease,

Dystonia and Writer's cramp.

The patient gives a detailed history of what has been occurring in terms of the
symptoms. The investigation is followed by a neurological physical examination.
Scales are used
(basically written proformas) to assess the severity and type of movement
disorder. Various movement sequences are recorded on video as a baseline
before any treatment, to later
compare the patient's performance in specific functions. This is followed by basic
bloods tests, a CT/ MRI brain scan and EEG or EMG along with some specific
teststhat may be needed, depending on the diagnostic possibilities that the
physician is thinking of.

1) Medications: Medications that either stimulate or inhibit the specific receptors

for central nervous system chemicals (neurotransmitters) are the mainstay of
management of
movement disorders.

2) Botulinum toxin injection: This toxin is injected into muscles to partially

paralyse them, and thereby control the abnormal movement.Several sites are
injected in one sitting, and several such sessions may be required at 4 week
intervals.

3) Stereotactic surgery: After detailed visualisation using CT/ MRI and mapping
the brain, ablation (destruction) of certain parts of the brain nuclei and/ or its
circuits will generally give relief from the abnormal movement.

4) Deep brain stimulation: The position of the basal ganglia nuclei are identified
using CT/ MRI brain scans. Electrodes are placed onto specific brain nuclei and
electrical signals are sent from a generator placed under the skin, in the chest.
The patient has the option of controlling the current from the generator, for
symptom relief.

The first task of the physician is to arrive at a diagnosis, or a highly probable

diagnosis, using variouslines of investigation.The best line of treatment: Each
patient would need to be tried on a specific combination of drugs which may vary
from 1 to 3 months, to assess the best outcome with drug management.

Following this minor adjustment in drug dosages may be required once every
three months.
Likely outcomes: It is usually expected that the abnormal movement decreases
to a remarkable extent. If the problem had been one of rigidity and paucity of
movement, then movements should be more easily performed. A small sub-set of
patients are not likely to improve on medications, for which deep brain
stimulation or Stereotactic surgery
should be considered to give optimal relief.

Movement disorders are generally progressive degenerative disorders, which

means that the pathological course cannot be greatly altered, though significant
improvement in function can be provided. However, the goal of management is
to provide optimal relief and restore normal functionality, with the least side
effects and thereby significantly improve the quality of life for the patients