Dystonia vs. Dyskinesia in Parkinson's Disease

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Dystonia and dyskinesia are movement problems that commonly occur in Parkinson’s disease (PD). You may experience one or both of them, particularly in late-stage PD. Dystonia is muscle stiffening caused by PD, while dyskinesia is a type of muscle twisting caused by some PD medications.

Dystonia and dyskinesia can both cause distress, and they are distinguished from each other based on their visible features. They can be managed with medication or surgery, typically with a moderate improvement of symptoms.

Symptoms

PD is characterized by four primary symptoms:

  • Resting tremor
  • Bradykinesia (slowness of movement)
  • Postural instability (being unstable and prone to falls)
  • Rigidity (muscle stiffness)

While they can fluctuate in severity, the primary symptoms of PD tend to be present most of the time.

Dystonia and dyskinesia are recurrent, abrupt, and short-lived muscle movements. Not everyone who has PD experiences dystonia and dyskinesia. If they do, the symptoms they experience can be telling.

Dystonia

  • Prolonged, involuntary muscle contractions

  • Affects a specific muscle or group of muscles

  • Causes abnormal posture or muscle spasm

  • Contorts part of the body

  • Causes pain (sometimes debilitating)

  • Tends to occur when effects of PD medication dip

Dyskinesia

  • Involuntary, continuous muscle movements

  • Affects large muscle groups (arms, head, trunk, legs)

  • Smooth, repetitive movement often described as a rolling or writing motion

  • Can begin suddenly and stop after several minutes

  • Not typically painful

  • More likely to occur when PD medication effects are at their peak

For example, dystonia can cause your toes to curl, making it difficult to walk. Or it may manifest primarily in your neck muscles, causing your head to turn painfully to one side.

With dyskinesia, you may experience a snakelike twisting of your arm or movements of your head and neck that appear like dancing in slow motion.

Being able to describe your symptoms to your medical team is important, especially when it comes to adjusting your medication dose. Consider keeping a symptom log to capture these important details.

Causes

PD is caused by decreased action of dopamine, a neurotransmitter that helps mediate voluntary muscle movements. PD is also associated with degeneration in the brain. These factors are believed to be the main cause of all of the symptoms of PD, including dystonia.

Medication Side Effects

Treatment of PD includes a number of medical and surgical approaches, including medications that replace the effects of dopamine, which are often described as dopaminergic medications.

Dyskinesia is considered to be a side effect of long-term use of dopamine replacement medications. The effect is often more prominent when dopaminergic medications like levodopa are at their peak concentration in the body.

Paradoxical Effects

The causes of dystonia and dyskinesia are not completely straightforward, however. Rarely, dystonia occurs as a medication side effect and dyskinesia occurs due to PD.

A phenomenon called diphasic dyskinesia can occur right before the next PD medication dose is due—when the body's concentration of PD medication is at its lowest.

Similarly, dystonia can occur as a side effect of dopaminergic medication. It is believed that long-term treatment can sometimes make the body less receptive to dopamine, possibly exacerbating the symptoms of PD.

Diagnosis

The diagnosis of dystonia and dyskinesia in PD is typically based on a visual assessment of the physical movements.

However, while some people who have PD can experience these effects several times per hour, you might not have them frequently, especially if they have just recently started. If this applies to you, you will have to describe your episodes in as much detail as possible to your medical team.

You may consider having a family member or friend videotape your episodes so that you can show them to your doctor.

Differential Diagnoses

There are several conditions that have features similar to those of dystonia and dyskinesia, and your medical team may mention them as possibilities. It is possible to experience another movement problem in addition to your dystonia or dyskinesia.

  • Tardive dyskinesia (TD): This is a type of involuntary movement that is typically characterized by repetitive mouth, tongue, eyelid, or face movements. It can occur as a side effect of antipsychotic medications. Antipsychotic medications generally reduce excess effects of dopamine in the brain. Ingrezza (valbenazine) is a medication approved for the treatment of TD, but it is not approved for the treatment of dystonia or dyskinesia .
  • Dystonic reaction: This is a sudden, prolonged muscle spasm that usually requires treatment with muscle relaxers. It may occur in response to Reglan (metoclopramide), a medication that counteracts the effects of dopamine and is used for the treatment of gastrointestinal illness.

Treatment

The management approaches used in the treatment of dystonia and dyskinesia are different. Because dystonia is usually considered an effect of PD, it is often treated with the same approaches that are usually used to reduce the other symptoms of the disease.

Treatment of dyskinesia is usually more complicated because the management of dyskinesia hinges on the very medications used to manage PD.

Often, and unfortunately, management of dystonia in PD worsens dyskinesia in PD.

Medications

Artane (trihexyphenidyl) is an anticholinergic medication that is commonly used to manage dystonia in PD. Muscle relaxers may be used as well, but they can result in side effects such as drowsiness, which should be considered.

Treatment of dyskinesia often relies on reducing the dose of the medications used to treat PD.

Surgery

Surgical approaches are often considered for the treatment of severe dystonia or dyskinesia that do not respond to medical therapy. Surgical options for both of these conditions include deep brain stimulation (DBS) with an implanted stimulator or lesional surgeries that physically cut a small area of the brain to reduce symptoms.

Surgical management of dyskinesia is aimed at reducing the need for dopaminergic medications or directly targeting the area of the brain believed to be responsible for the dyskinesia.

Surgical treatment of dystonia or dyskinesia requires extensive presurgical testing to ensure that implants and lesions will be effective and that they are placed optimally.

In addition to medical and surgical management of dystonia and dyskinesia, you may experience improved motor control and/or reduction of symptoms with physical therapy.

A Word From Verywell

Dystonia and dyskinesia in PD can be very troublesome. These involuntary movements are uncomfortable and may bring unwanted attention. Finding the right balance in the treatment of PD can be a trial-and-error process that requires delicate management. You may need to work closely with your medical team as the right approach for you is refined over time.

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Article Sources

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