2025 – PAGE 401 – NEUROLOGY
MOVEMENT DISORDERS
(DOUBLE TAKE) DYSTONIC REACTIONS
Dystonic reactions involve sudden muscle contractions and usually some odd postures. These can be related to clonidine, phenothiazine, metoclopramide, promethazine, and athetoid cerebral palsy. Treat medication-induced dystonic reactions with diphenhydramine.
TICS
Tics are specific movements that are seen in a child over and over again. Onset is usually after 3 years of age. The location of the tic(s) CAN CHANGE. Children often feel a strong need to do them, and older kids feel ashamed. They can be suppressed temporarily and rarely occur with purposeful voluntary movements or activities. Tics have no severe impact on daily living. They may be exacerbated by stress or excitement. They are sometimes treated with tricyclic antidepressants.
TOURETTE SYNDROME (AKA TOURETTE’S SYNDROME)
Tourette syndrome (AKA Tourette’s syndrome) may be diagnosed with TWO motor tics + ONE vocal tic. These will likely change over time. Tics may increase in stressful situation as well as when AT EASE (when AT HOME). Clonidine or guanfacine may be used for tics that cause significant impairment or pain (NOT SSRIs). Attention deficit disorder (ADD) is the most common concomitant condition.
PEARLS: ADD medications (especially methylphenidate) can unmask a tic or make tics worse. If such a scenario is presented on the exam, do “something.” You may stop treatment with stimulant medications, decrease the dose or change to another stimulant in order to get the tics back to baseline!
STEREOTYPY
A stereotypy is a pattern of movement or behavior that a child does not feel an urge to perform, but they do sometimes enjoy them (hand flapping, vocalizing portions of a video, head rocking). They usually start before 3 years of age and remain UNCHANGED. They can be suppressed by older children and have no severe impact on daily living.
CHOREA
Chorea refers to very random dance-like movements that suddenly occur. Age of onset depends on the cause, and these may or may not resolve depending on the cause. These CANNOT be suppressed and often worsen with focused activities. They are extremely disruptive to the child’s life.
SYDENHAM CHOREA (AKA SYDENHAM’S CHOREA)
Sydenham chorea (AKA Sydenham’s chorea) is specifically the finding of choreiform movements after a Streptococcal infection by Group A Streptococcus (GAS). Unlike tics, these are WORSE with purposeful movements. Can be associated with hypotonia, jerky movements and even emotional lability after a GAS infection. CSF findings are normal. The movements improve during sleep. Sydenham chorea does can be a stand-alone diagnosis OR it can be part of rheumatic fever (carditis, polyarthritis, erythema marginatum, subcutaneous nodules, etc.). Order an antistreptolysin titer (ASO titer) to look for recent streptococcal infection.
PEARLS: A negative ASO does NOT rule out a Group A Streptococcal (GAS) infection. The titer may have already come down if the chorea is presenting months after an infection. For the exam, if you see Sydenham Chorea in a patient, choose RHEUMATIC FEVER. In reality, though, a patient can get the chorea after a GAS infection, and that alone can be used to assign a diagnosis without any of the other findings of rheumatic fever. Please know the rheumatic fever section very well (see the Cardiology chapter for a very detailed discussion on RF).