Somewhere between the extremes of voluntary willed and involuntary, uncontrollable movement lies the gray area of unvoluntary movement. People with tics are thought to suffer from unvoluntary movements because they are able to consciously suppress urges to perform the motion. While restraining themselves, the desire to perform the action builds until they are unable to contain themselves and they release a flurry of tics.
A patient appeared in the movement disorder clinic, referred by his neurologist because the patient’s case was beyond his level of expertise. The patient reported an overwhelming need to move his legs or change position- something one would commonly hear from a person suffering from restless legs syndrome. Indeed, the patient had taken Mirapex, a drug prescribed for that disorder. Unfortunately, the medication did little his need to move, so that the odd movements he felt compelled to perform embarrassed him, and causing him to seek a doctor’s opinion. Movement disorders come in patterns. The patterns are based on physiological derangement of cells, in the case of Parkinson’s disease movements eventually arise when the population of dopamine producing neurons has diminished remarkably within the substantia nigra.
The patient’s movements were similar to those in Monty Python’s Ministry of Silly Walks, there were random and odd. The patient reported he didn’t know why he performed them, other than to calm a restless need he felt within his body. The loved one of the patient, who accompanied him to the appointment, stated he also moves oddly while sleeping.
The patient’s medical history included a clipped aneurysm; the bulging blood vessel had bled irregularly and given the patient tremendously painful headaches. He had been advised to have surgery, which he had done. He also suffers from diabetes, had undergone rotator cuff surgery and spinal surgery, in which a surgeon fused several levels of vertebra in his spine.
Diabetes invariably brings vascular disease, as the endothelial cells lining the smallest vessels in the brain and body degenerate because they are unable to utilize sugar. Neuropathies occur as a consequence of inadequate function of the blood vessels serving nerves and may present with decreased sensation in the feet and fingers. Diabetes may have contributed to the sensory changes in his limbs and could contribute in part to restless leg syndrome. But the extent of the unusual movements appeared much beyond the typical movements of the limbs seen in restless leg syndrome.
On physical examination, the clinician found no rigidity in the muscles of the arms. Reflexes were symmetrical and normal. The clinician documented the patient’s responses to fine motor testing as the medical student led the examination. Discussing his thoughts with the patient and significant other, the physician suggested the patient increase his level of antidepressant and add a small dose of the generic medication primozide, or the brand name equivalent Orap, given commonly to those suffering with tics. He also requested the patient obtain records of the neurosurgery performed nearly ten years ago, to ascertain if an MRI of the brain can be done. The practitioner requested the patient return in three months time, when a further discussion including past records can occur, and after gauging whether the current medications prove helpful.