BLEPHAROSPASM
Normal blink rate, when eyes open
Active forceful eye closure doesn't cause spasm
Tonic spasm
Resolves while speaking or moving tongue
HEMIFACIAL SPASM
Lower face at onset
Associated with pain
Lack of other Babinski sign
Forceful or longer spasms
Lower and upper face non-synchronised movements
Switching sides
Ipsilateral sensory symptoms or signs
Both sides involved
ORO-MANDIBULAR DYSTONIA
Unilateral downward or lateral jaw movement
TONGUE
Tonic tongue protrusion
Normal speech
Deep breathing normalized the movements
SPEECH
Whispering speech
Diplophonia
High pitch falsetto
Globus sensation
Speech with effortful facial or lip or neck movements
Normal phonation
Normal singing
CERVICAL
Varying semiology, may change when doing certain tasks
Fixed neck posture
Unusual, erratic and high amplitude associated tremor
Active range of movement not possible during examination but spontaneous normal head movement possible at other times
Resolution of posture while writing or performing tasks requiring concentration
Absence of typical sensory tricks
UPPER LIMB
Typical semiology of fisting posture and wrist flexion, elbow flexion or flexion of fingers at MCP or IP joints
Ring or Little fingers commonly affected. Thumb least affected
Posture resolves with contralateral Luria sequencing
Normal spontaneous movements in an affected limb (putting on glasses, swing while walking)
Pain in the affected limb
Involuntary jerks while testing range of movements
Effortful slow movement on affected side
LOWER LIMB
Typical semiology of plantar flexion and inversion with toe curling
Functional striatal toe
Persistence of abnormal posture when walking backward
Dragging leg behind and static abnormal posture throughout the gait cycle
The appearance of weakness on movement away from the dystonic direction
Paradoxical improvement with stress gait or walking in tandem
Excessive signs of effort in contrast to observed severity of gait disorder – the “huffing and puffing” sign
Sensory symptoms particularly anesthesia of the foot
Straightening out a posture or passively moving into a different posture can cause this to become a new resting fixed posture
LIMB GENERAL
Fixed dystonia early in the course (May be seen with CPRS)
Pain on attempted movement of the affected limb
Active resistance against the passive movement
Tremor or clonus-like movement when evaluating a range of motion or reflex testing of the limb.
Straightening out a posture or passively moving into a different posture can cause this to become a new resting fixed posture.
Sensory symptoms, particularly anesthesia of the affected limb
Ponderous and deliberate, slowed movements on the affected side can appear very effortful.
TRUNK/ GAIT
Inappropriate difficulties standing from sitting in comparison to gait
Fixed posturing when walking, either extension or flexion at the waist
Posture resolves when adjusting clothing or when doing a repetitive task (clicking fingers, tapping)
Associated knee bending or unusual dromedary gait in an adult patient
Posture does not improve when resting against a wall.
Episodic knee buckling
Unusual relieving maneuvers (e.g. standing on one leg)
Early use of crutches or other walking aid despite objective stability
Associated prominent back pain
Associated functional gait features (astasia abasia, unusual Romberg, unusual retropulsion pull testing), with apparently preserved balance when walking
Improves with backward walking or running
Tandem walk: excessive sway with no falls, stuck on first step
Romberg: Increased sway after few seconds with no fall
Frucht et al. Front Neurol 2020
