An Overview of Dyskinesia

Dyskinesias are abnormal, involuntary muscle movements that can be mild or severe, and can even be painful in nature. Movement disorders characterized as dyskinesias can be caused by certain medications, by changes to the chemistry of the brain, or by brain injury or damage. Learn about the different types of dyskinesias, symptoms, risks, and treatment options. Also, learn about conditions similar to dyskinesias and some methods to manage life after diagnosis.

Defining Dyskinesia

Dyskinesia is characterized by involuntary or uncontrolled muscle movements that are abnormal in character and may make it difficult to coordinate normal movements.

There are several forms of dyskinesia that are associated with different symptoms and causes.

Dyskinesia is most commonly caused by medications, such as long term use of levodopa in Parkinson's disease and use of antipsychotic medications. Dyskinesia caused by brain injury such as vascular event ( stroke) or other brain damage is less common. Movement symptoms typically start as minor shakes, tics, or tremors. They can occur in just one body part like a person’s head or leg, or movements can affect the entire body. These symptoms can range from mild to severe, and some may be painful. 

There are different types of dyskinesias which lead to different symptoms as well as treatments. Common types of dyskinesias include:

• Athetosis: A form of dyskinesia associated with brain damage, mainly cerebral palsy. Movements in athetosis are slow and writhing
• Chorea: A form of dyskinesia often seen in Huntington's disease, structural damage of the brain, and caused by medications. Chorea refers to quick movements of the limbs and can resemble dancing.
• Levodopa-induced or Parkinson’s dyskinesia: A form of dyskinesia that may occur due to the long-term use of levodopa, a medication used to treat Parkinson’s disease.
• Tardive or delayed dyskinesia: A form of dyskinesia associated with the use of antipsychotic medications, often used to treat schizophrenia.
• Myoclonus dyskinesias: A form of dyskinesia seen in progressive myoclonic encephalopathy. Movements are severe and very disabling.

Oftentimes, related conditions like dystonias, stereotypies, and tics are included as dyskinesias. However, characterizing some of these other movement disorders as dyskinesias remains a topic of debate among medical professionals.

Symptoms

Symptoms can vary from person to person and might appear differently depending on the type of dyskinesia diagnosed. They may begin as fine movements called tremors, or even as tics, and then develop into the common symptoms characteristic of dyskinesia like:

• Body swaying 
• Fidgeting
• Head bobbing
• Restlessness
• Twitching
• Wriggling

It is notable that restlessness and twitching occur less often in levodopa-induced dyskinesia. 

Symptoms can worsen over time gradually or develop suddenly and intensify after a serious brain injury.

Patients with tardive dyskinesia have symptoms characterized by abnormal movements of the jaw, lips, and tongue. Rapid blinking and waving of the arms and hands, and in severe cases, symptoms of hip or waist swaying and difficulty breathing may also appear.

In myoclonus dyskinesias, movements are characterized by being sudden and repetitive muscle spasms and jerks. These movements can be so severe that they become painful and debilitating.

Chorea movements may be continuous, last a few seconds, or involve sudden, jerking behaviors. These movements most commonly affect the limbs, face, and head.

In cases of athetosis, movements may be slow turning, bending, or writhing and affect fingers, hands, and toes. Athetosis may affect the arms, legs, neck, and tongue of someone diagnosed with the disorder.

Causes

Dyskinesias are often related to medications, secondary to other diagnoses, or due to structural changes in the brain. There are times that dyskinesias can appear with no particular cause or known risk factor. 

Medications

The most common cause of dyskinesia is the long-term use of levodopa, causing levodopa-induced dyskinesia. Levodopa is the preferred method of treatment for Parkinson’s disease. However, about 50% of people with Parkinson’s disease who use levodopa will go on to develop dyskinesia within four to five years.

While scientists are still trying to understand why dyskinesia develops, in levodopa-induced dyskinesia, it is possible that the brain chemical that aids in cell communication, dopamine, plays a role in the development of the movement disorder.

People with Parkinson’s disease experience a loss in the brain cells that create dopamine, decreasing dopamine levels in the brain. Levodopa temporarily restores these dopamine levels. However, because the medication is rapidly metabolized and needs to be taken multiple times a day, dopamine levels remain unsteady and rise and fall. The fluctuation of dopamine and the continued loss of dopamine-producing brain cells makes it difficult to maintain normal levels, which possibly contributes to dyskinesia. People who are younger at the time of diagnosis of Parkinson’s disease, or those who are prescribed a high dose of levodopa, might be at greater risk for developing dyskinesia.  

Similarly, tardive dyskinesia is caused by the long-term use of neuroleptic drugs that treat neurological, gastrointestinal, and mental disorders like schizophrenia or bipolar disorder. These medications are dopamine-receptor blocking agents, and they impact the ability of cells to communicate. Gender, age, genetics, and mental and medical disorders, like diabetes, can be important risk factors for the development of tardive dyskinesia. Tardive dyskinesia tends to happen earlier in women than in men, for example.

Chorea can also be caused by the use of certain medications, like antipsychotic medications, antiepileptic medications, and other medications used to treat Parkinson’s disease. This specific dyskinesia can also develop through a variety of diseases, conditions, and deficiencies, from Lyme disease to Huntington's disease to hormone replacement therapy. 

Brain Injury and Damage

Altering chemistry through damage or injury to the brain’s tissues is another common cause of dyskinesia. People may develop athetosis due to a loss of blood supply or oxygen within the brain. Ballism, a form of chorea characterized by a wild and sometimes violent flinging of the arms and legs, may develop after cerebrovascular events, like after a stroke or suffocation.

Generally, if there is an injury to the basal ganglia, an area of the brain responsible for controlling voluntary movements and learned habits, dyskinesia could possibly develop. 

Diagnosis

The different abnormal movements that characterize the distinct types of dyskinesia will generally require the careful observation and clinical judgment of a neurologist or movement disorders specialist. It will be important to note the type of movements, and areas of the body affected when determining the proper diagnosis. Assessing the impact of the condition may require the use of an abnormal involuntary movement scale. 

Specifically for levodopa-induced dyskinesia, the control of symptoms associated with Parkinson’s disease (like tremor and stiffness) may be balanced against the gradual development of dyskinesia. Some affected people report preferring to deal with the symptoms of dyskinesia rather than those of Parkinson’s disease. 

Dystonias, stereotypies, and tics are additional motor disorders related to dyskinesias. Dystonias may cause muscles to tighten and form abnormal sustained or repetiive muscle spasm or abnormal fixed postures. For stereotypies and tics, those people experiencing these motor disorders may have some level of control over the movements, even the ability to reduce them. 

Treatment

Treatment can vary depending on the type of dyskinesia diagnosed and the individual and may include:

Medication Changes

For levodopa-induced dyskinesia, controlling the dose and the timing of taking levodopa may balance the levels of dopamine and decrease symptoms. Different forms of the medication, such as extended-release Rytary or the gel-infusion Duopa, may also be helpful. An extended-release form of amantadine, called Gocovri, may also help control levels of glutamate in the brain and reduce symptoms.

People with tardive dyskinesia may be prescribed Ingrezza or Austedo, which are both neuroleptic drugs approved by the FDA as treatment in 2017.

Deep Brain Stimulation

To control symptoms, deep brain stimulation (DBS) is a surgical procedure that is another treatment option, but it is not right for everyone. Minimum requirements include a diagnosis of Parkinson’s for at least four years, recurrent episodes of dyskinesia, and ongoing responsiveness to and benefit from the use of levodopa in most cases.

The DBS surgical procedure involves the placement of electrodes by a neurosurgeon into areas of the brain that control movement and posture, most commonly the subthalamic nucleus (STN) and globus pallidus interna (GPI). A wire travels from the electrodes to a pacemaker-like device that is implanted in the chest wall. After implantation, the clinician will set parameters that will determine the amount of electrical stimulation delivered.

Other Therapies

For dyskinesias that impact the facial, neck, and limb region, some patients try injections of botox, or botulinum toxin, to reduce movement.

There are several additional therapies that are currently undergoing clinical trials for the treatment of dyskinesias. Potential treatments for tardive dyskinesia include melatonin and estrogen, which modulate dopamine-controlled behavior and protect against cell damage from the long-term use of antipsychotic medications.

For the treatment of levodopa-induced dyskinesia, drugs that target different brain chemicals are being studied. In addition, under-the-skin levodopa pumps are also being studied to test if they can effectively maintain consistent dopamine levels.

Finally, researchers are investigating ways to best optimize deep brain stimulation and are testing a technique called focused ultrasound, a non-invasive, irreversible procedure to treat dyskinesia.

Coping 

Dealing with dyskinesias can be stressful and impact daily activities and social interactions. Exercise, like walking or swimming, may be recommended. Managing stress may also be crucial to control symptoms, as stress tends to exacerbate the uncontrolled movements.

Further information and resources may be sought from specialized organizations, like the Michael J. Fox Foundation for Parkinson’s Research or the Genetic and Rare Disease Information Center. Support groups may also be helpful to manage life with dyskinesia. 

A Word From Verywell

Dyskinesias can come in a variety of forms and may have significant impacts on your life. Talk to your practitioner if you believe you are developing symptoms of uncontrolled movements that may be associated with dyskinesia. Make note that while there are several treatment options available, it is important to work with your healthcare provider to determine what may be the best course for your long-term condition management and treatment.