Movement Disorders

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Click here to access the Adult Hospital Level Chapter 14: Neurological Disorders with Supporting NEMLC Report-2020-4-Review-Version-3.0-22-November-2025

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Description

Parkinsonism, Primary

Idiopathic Parkinson Disease

Parkinsonism, Secondary

Essential tremor

Chorea

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DESCRIPTION

Abnormalities of movement/initiation of movement, divided into those with reduction of movement (hypokinesia or bradykinesia), or those with excessive movements (hyperkinesia).

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PARKINSONISM, PRIMARY

IDIOPATHIC PARKINSON DISEASE

G20

DESCRIPTION

• Parkinsonism is a syndrome characterised by tremor, rigidity, bradykinesia and postural disturbances. 
• It may be primary, i.e. Parkinson’s disease, or secondary, i.e. drug-induced or due to uncommon disorders that may initially resemble Parkinson’s disease.

The objective of treatment is to:

• minimise disabling symptoms,
• prevent complications and avoid serious drug-induced side effects.

GENERAL MEASURES

• General supportive therapy and advice about lifestyle modification, physiotherapy and occupational therapy.

MEDICINE TREATMENT

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Note

Set therapeutic targets so that the patient is functioning as well as possible.

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Bradykinesia, rigidity and postural disturbance:

• Carbidopa/levodopa, 25/100 mg (1 tablet), oral, 8 hourly, increase gradually according to clinical response.
  • Maximum dose of 200/800 mg daily (8 tablets).
  • Increase dose in consultation with a specialist.

REFERRAL

• Alternative diagnosis suspected (e.g. secondary Parkinsonism).
• No improvement or poor control with treatment.
• Increasing on/off phenomenon.
• Dyskinesias.

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PARKINSONISM, SECONDARY

G21.0-4/G21.8-9/G24.0

DESCRIPTION

• Secondary parkinsonism is caused by certain medicines (typical and atypical antipsychotics, anti-emetics, anticonvulsants (phenytoin, sodium valproate) and SSRIs), nervous system disorders, or other systemic illnesses.

GENERAL MEASURES

• Primary approach in drug-induced parkinsonism should be to stop the offending medicine if possible.
• Refer to psychiatric services for review of antipsychotic treatment in patients requiring treatment for parkinsonism (see Schizophrenia spectrum disorders).

MEDICINE TREATMENT

Anticholinergics have a limited role in this setting and should be used with caution.

• Anticholinergic agent, e.g.:
  • Orphenadrine, oral, 50 mg 8 hourly, increase gradually according to clinical response.
    - Usual dose: 150-250 mg daily. 
    - Maximum dose: 400 mg daily.

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Note

Anticholinergic side effects are common and may be exacerbated by antipsychotics.

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OR

• Carbidopa/levodopa, 25/100 mg (1 tablet), oral, 8 hourly.

Acute dystonic reaction:

Usually follows administration of dopamine-antagonistic drug, e.g. metoclopramide and phenothiazines.

• Anticholinergic agent, e.g.:
  • Biperiden, IM/IV, 2 mg.
    - Repeat as necessary.

OR

• Promethazine, deep IM, 25-50 mg.
  - Decrease dose in the elderly to 25 mg.  

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ESSENTIAL TREMOR

G25.0

GENERAL MEASURES

• Exclude and manage alternate causes, such as drugs, thyrotoxicosis and hyperadrenergic states. 
• Occasionally a patient may present with essential tremor and an additional neurological condition, which may make the diagnosis difficult.

MEDICINE TREATMENT

If tremor is severe and interfering with normal daily activity:

• Propranolol, oral,
  • Start at 20 mg daily and titrate as needed up to 80 mg 8 hourly.
  • Monitor for symptomatic bradycardia and/or hypotension.

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CHOREA

G25.5

DESCRIPTION

Chorea is a hyperkinetic movement disorder characterized by involuntary brief, random, and irregular contractions conveying a feeling of restlessness to the observer. Chorea may be caused by hereditary neurodegenerative diseases; structural damage to deep brain structures; or be associated with autoimmune disorders, metabolic derangement, or certain drugs and hormones.
Aetiology is classified as:

• Rarer primary (idopathic or hereditary) – Huntington’s chorea,; or
• More common secondary (acquired) – Sydenham’s chorea, hemiballismus secondary to infarction, diabetes (hyperglycemia)

Symptoms include involuntary, random, irregular movements.

GENERAL MEASURES

• Exclude potential underlying causes initially.
• A careful history should include age of onset, time course (acute or insidious), past medical history, history of recent infection with group A beta-hemolytic streptococcus (GABHS), family history, and drug exposure.
• Neuroimaging should be performed for new-onset cases, especially when asymmetric.
• A variety of laboratory tests may be useful depending on the clinical context.

MEDICINE TREATMENT

Treat the underlying cause, if relevant.

First-generation antipsychotic agents (typical neuroleptics) may reduce chorea although there is little evidence to support their efficacy, and they are increasingly avoided due to increased risk of side effects.

• Haloperidol, oral, 0.75–5 mg 8-12 hourly (Specialist consultation).

REFERRAL

The need to refer may be based on the underlying cause and diagnostic workup. Refer primary choreas for genetic counselling.

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-4_Version 2.0_6 June 2025

Chapter 14 Neurological Disorders_14.9 Movement Disorders