11/13/24, 7\:01 PM Guide | Extrapyramidal side effects (EPSE) examination

Extrapyramidal side e

Table of contents

Background

The extrapyramidal system plays a critical role in
and spontaneous motor activity.
1
Extrapyramidal side e
disorder.
They are most commonly associated with typical antipsychotics (e.g. haloperidol, risperidone). These medications often cause
EPSEs due to their antagonistic e
basal ganglia, which is integral to controlling movement and coordination.
2
However, it is crucial to recognise that other pharmaceutical agents, including certain antidepressants, lithium,
anticonvulsants, and antiemetics, can also precipitate these e
2,3
EPSEs may be divided into two broad categories\: hypokinetic (may resemble Parkinson's disease) and hyperkinetic (may
resemble Huntington's disease).
2
There are four common extrapyramidal side e
4
Acute Dystonia
Akathisia
Parkinsonism
Tardive dyskinesia
Parkinson's disease vs Huntington's disease
Parkinson’s disease and Huntington's disease are two motor pathologies that both a
Parkinson’s disease results from degenerations of neurons in the substantia nigra, resulting in a dopamine de
the basal ganglia. It is characterised by the mnemonic TRAP\:
5
Tremor (rest)
Rigidity (cogwheel)
Akinesia (or bradykinesia)
Postural instability
Huntington’s disease results from neuronal degeneration in the basal ganglia and cerebral cortex. It is characterised by
choreiform movements and cognitive decline.

Hypokinetic EPSEs

Acute dystonia
Acute dystonia is characterised by involuntary muscle contractions leading to abnormal postures or repetitive movements,
a
It typically presents within 1 - 5 days after drug exposure. It may a
(opisthotonos), neck (torticollis), jaw (trismus), eyes (oculogyric crisis), abdominal wall, pelvic muscles (tortipelvic crisis), facial,
and tongue muscles (buccolingual crisis).
2,4
https\://app.geekymedics.com/osce-guides/clinical-examination/extrapyramidal-side-effects-epse-examination/ 1/611/13/24, 7\:01 PM Guide | Extrapyramidal side effects (EPSE) examination
Intramuscular administration of antimuscarinic (e.g. benztropine) or diphenhydramine may relieve dystonia in minutes.
4
Parkinsonism
Parkinsonism is a clinical syndrome of resting tremor, cogwheel rigidity and general slowing of motor functions. Notable
characteristics include masked facies, a stooped posture, and a slow, shu2,4
Patients often experience gait imbalance
and di
Although the most common cause of parkinsonism is Parkinson's disease, antipsychotics (drug-induced parkinsonism) and
other conditions can also cause parkinsonism due to interfering with the dopaminergic pathway.
Management of drug-induced parkinsonism involves discontinuation or dose reduction of the causative medication. Patients
can be switched to an atypical antipsychotic. In some cases, medications used for Parkinson’s disease can be used, including
amantadine, antimuscarinic agents (e.g. benztropine), dopamine agonists and levodopa.
4

Hyperkinetic EPSEs

Akathisia
Akathisia is characterised by a subjective feeling of internal restlessness and a compelling urge to move, leading to the
objective observation of repetitive movements comprising leg crossing, swinging, or shifting from one foot to another.
2,4
It typically presents within four weeks of starting or increasing the dosage of the o
common due to its non-speci
anxiety or agitation, leading to inadvertent exacerbation of the condition when antidepressant or antipsychotic medications are
increased.
Withdrawal akathisia can also occur with the discontinuation or dose reduction of antipsychotic medications and is typically
self-limited, often resolving within six weeks.
2,4
Administration of antimuscarinic (e.g. benztropine) or diphenhydramine may relieve akathisia. If caused by a
antipsychotic, patients can be switched to an atypical antipsychotic. Additional therapeutic strategies speci
include beta-blocker (ex\: propranolol), amantadine, clonidine, benzodiazepines and mirtazapine.
4
Di
Akathisia, anxiety and agitation all cause restlessness. However, it is important to di
treatments. Confusing akathisia for agitation could lead to the inappropriate administration of antipsychotics, which
would further exacerbate the symptoms.
Anxiety is a feeling of worry or unease. It may present with physical signs such as nervousness, restlessness, tension,
tachycardia, sweating and gastrointestinal discomfort. However, anxiety primarily a
than directing a particular movement. The restlessness associated with anxiety is generally less intense than akathisia
and is less driven by an urge to move.
Agitation is a state of increased arousal or restlessness, which can manifest as both psychological and physical
symptoms. Individuals may present with irritability, anger or aggression that may include verbal outbursts. It does not
typically arise as a side e
disorder, depression, and psychosis. It is also associated with substance use.
In akathisia, the restlessness is largely driven by an internal sensation that is predominantly physical rather than
emotional.
Tardive dyskinesia
Tardive dyskinesia is characterised by involuntary, choreoathetoid movements that primarily a
muscles, extending to the trunk and extremities.
2,4
Symptoms are typically painless but may impede social interactions and impact daily functions such as chewing, swallowing,
and speaking. It is crucial to detect and treat early as there are cases where symptoms can become irreversible.
Tardive dyskinesia may improve temporarily with an increase in antipsychotic medication and temporarily worsen with a
decrease. Tardive dyskinesia is much less common with modern antipsychotics, and the incidence is less common today. It is
also important to note that it may be seen in other populations, such as patients with dementia.
https\://app.geekymedics.com/osce-guides/clinical-examination/extrapyramidal-side-effects-epse-examination/ 2/611/13/24, 7\:01 PM Guide | Extrapyramidal side effects (EPSE) examination
Treatment options include reducing the dose or discontinuing the causative medication and possibly switching to an atypical
antipsychotic. Other interventions include dopamine-depleting medications such as tetrabenazine.
4
Neuroleptic malignant syndrome (NMS)
NMS is a life-threatening reaction to medications with dopamine receptor-antagonist properties characterised by
altered mental status, fever, muscle rigidity and autonomic dysfunction.
6
Patients typically develop NMS within hours or days after exposure to causative drugs, with most cases falling between 2
weeks and 30 days. The clinical course typically begins with muscle rigidity followed by fever within several hours of
onset and mental status changes that can range from mild drowsiness, agitation or confusion to delirium or coma.
NMS is accompanied by autonomic instability, including labile blood pressure, tachypnoea, tachycardia, excessive
salivation (sialorrhea), sweating (diaphoresis),
6
Immediate management is critical. The causative medication should be discontinued. General management includes
aggressive hydration, cooling blankets to manage hyperthermia, and correcting metabolic abnormalities.
Bromocriptine (dopamine agonist) and dantrolene (muscle relaxant) can be used in severe cases.
6

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient, including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Ask the patient if they have any pain before proceeding with clinical examination.
Painful muscle spasms may occur in acute dystonia

General inspection

Most EPSEs can be observed through observation alone.
Perform a brief general inspection of the patient, looking for signs of EPSEs\:
Pain\: acute dystonia can be incredibly painful
Di
Posture\: abnormal posture, such as abnormal muscular contractions, twisted neck (torticollis), back (opisthotonus) or jaw
(trismus) that may be seen in acute dystonia
Facial expression\: look for blunted a
grimacing could manifest as involuntary contractions of facial muscles
Blink rate\: observe the patient’s blink rate, noting that less than ten blinks per minute could indicate a hypokinetic state,
while more than 30 could suggest a hyperkinetic condition. Vigorous blinking could be a sign of a Tic.
Motor restlessness (akathisia)\: akathisia presents as a subjective urge to move, coupled with observable excessive
movement. Patients may engage in excessive pacing or vocalise the need to move.
Abnormal involuntary movements\: these can be seen in tardive dyskinesia. Look for chorea (sudden, quick involuntary
movements in any skeletal muscle), athetosis (slow, writhing movements), and tics (sudden, quick, patterned movements).
While chorea could a
Common tics include throat clearing, vigorous blinking, sni
https\://app.geekymedics.com/osce-guides/clinical-examination/extrapyramidal-side-effects-epse-examination/ 3/611/13/24, 7\:01 PM Guide | Extrapyramidal side effects (EPSE) examination
Di
Mask-like facies and a
examination.
A
vocal in
positive and negative events may be severely limited or absent. A
psychiatric disorders such as schizophrenia and depression.
Mask-like facies (hypomimia) is a reduction in facial expressivity and is a motor symptom. Mask-like facies is more
common in patients with parkinsonism and is generally associated with other signs such as rigidity and bradykinesia.
Unlike a
responses in conversation.

Tremor

Observe for a resting tremor associated with parkinsonism, characterised by involuntary movements in a limb at rest, typically
slowing down at around 4 - 6 cycles per second. A prominent tremor in the second digit that causes it to rub against the
palmar surface of the thumb may be observed (“pill-rolling tremor”).
A resting tremor can be confused with a postural tremor and intention tremor\:
Postural tremors appear promptly with unsupported postures (such as in extended hands) and are more rapid than resting
tremors. It is the most common tremor seen in psychiatry and can be attributed to a range of causes, such as essential
tremor, anxiety, ca
benzodiazepines, or barbiturates.
Intention tremor is a broad, coarse, low-frequency tremor seen when a body part approaches a target. It consists of
rhythmic shifting from one side to the other of the target (dysmetria).

Gait

Sitting to standing

Ask the patient to stand from their seated position with their arms across their chest to screen for postural instability. Make
sure to stand close to the patient so that you can intervene if they lose their balance.
Imbalance and di

Observe gait

Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait\:
Parkinsonism gait will have short steps, diminished arm swinging, and rushed (festinating). When turning, several steps are
required.
Patients may appear unable to rotate at the waist (en bloc turning”). The patient may get stuck (freeze).

Tone

Assess tone in the muscle groups of the neck, upper limbs, and lower limbs, comparing each side. Looking for
rigidity (parkinsonism) and dystonia. Before beginning, it is important to explain to the patient what you will be doing and why.
Rigidity is a velocity-independent increase in muscle tone associated with parkinsonism. During the assessment, it is crucial to
move the limbs both quickly and slowly to observe any di
Cogwheel rigidity\: characterised by a ratcheting sensation, often due to an underlying tremor superimposed on hypertonia
Lead pipe rigidity\: a uniform increase in muscle tone throughout the movement, often associated with neuroleptic
malignant syndrome
https\://app.geekymedics.com/osce-guides/clinical-examination/extrapyramidal-side-effects-epse-examination/ 4/611/13/24, 7\:01 PM Guide | Extrapyramidal side effects (EPSE) examination
Dystonia may manifest as sustained muscle contractions or intermittent spasms. Pay attention to any unintended contractions
or abnormal postures. Dystonia more often a

Assessment

Neck
1. Support the patient’s head gently.
2. Ask the patient to relax and allow you to control the movement.
3. Passively rotate the head towards the shoulder, observing for rigidity or dystonia.
Upper limb
1. Support the patient’s arm.
2. Guide through circumduction of the shoulder,
3. Compare the tone on both sides, noting any asymmetry or unilateral abnormalities.
Lower limb
1. Roll each leg on the examination bed, observing for any resistance or abnormal postures.
2. Lift each knee briskly o
lifting o
3. Compare the tone on both sides, noting any asymmetry or unilateral abnormalities.

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
“ T o d a y I p e r f o r m e d a p h y s i c a l e x a m i n a t i o n o n a 2 9- y e a r-o l d m a n w h o i s t a k i n g a n t i p s y c h o t i c m e d i c a t i o n f o r
s c h i z o p h r e n i a t o a s s e s s c l i n i c a l f e a t u r e s o f E P S E . O n g e n e r a l i n s p e c t i o n , t h e p a t i e n t d e m o n s t r a t e d a b l u n t e d a
m a r k e d r e s t l e s s n e s s , g e t t i n g u p a n d p a c i n g b e f o r e a n d a f t e r t h e e x a m i n a t i o n . A t r e m o r w a s n o t e d i n h i s r i g h t h a n d t h a t
w a s p r e s e n t a t r e s t a n d r e s o l v e d w i t h m o v e m e n t . O b s e r v a t i o n o f ga i t w a s n o t a b l e f o r b r a d y k i n e s i a , r e d u c e d a r m
s w i n g i n g a n d h e s i t a t i o n w h e n t u r n i n g. A s s e s s m e n t o f T o n e r e v e a l e d r i g i d i t y i n t h e n e c k . T h e v i t a l s w e r e s t a b l e . T h e s e

F o r c o m p l e t e n e s s , I w o u l d l i k e t o p e r f o r m t h e f o l l o w i n g f u r t h e r a s s e s s m e n t s a n d i n v e s t i ga t i o n s .
”

Further assessments and investigations

Consider completing a movement disorder assessment scale. Several scales can be used to evaluate di
movement disorders\:
2,8
For assessing hypokinetic or parkinsonian signs, commonly used scales include the Uni
Scale motor exam section and the Simpson-Angus scale
The Uni and Abnormal Involuntary Movement Scale (AIMS) evaluate hyperkinetic or
tardive-like signs
The Barnes Akathisia Rating Scale (BARS) may be used to assess the presence and severity of akathisia
The Extrapyramidal Symptoms Rating Scale addresses both hyperkinetic and hypokinetic signs, providing a
comprehensive assessment tool for various movement disorders
https\://app.geekymedics.com/osce-guides/clinical-examination/extrapyramidal-side-effects-epse-examination/ 5/611/13/24, 7\:01 PM Guide | Extrapyramidal side effects (EPSE) examination
Perform a neurological and cerebellar examination if concerned about neurological pathology.
Assess the drug chart for neuroleptics, dopamine-blocking antiemetics and sodium valproate.

Reviewer

Dr Aisling Campbell
Consultant Psychiatrist
University College Cork

References

1. Lee, J., & Muzio, M. R. (2022). Neuroanatomy, Extrapyramidal System. In StatPearls. StatPearls Publishing. Available from\: [LINK]
2. Sanders, R. D., & Gillig, P. M. (2012). Extrapyramidal examinations in psychiatry. Innovations in clinical neuroscience, 9(7-8), 10–16.
Available from
3. Blair, D. T., & Dauner, A. (1992). Extrapyramidal symptoms are serious side-e
practitioner, 17(11), 56–67.
4. D'Souza, R. S., & Hooten, W. M. (2023). Extrapyramidal Symptoms. In StatPearls. StatPearls Publishing. Available from\: [LINK]
5. Jankovic J. (2008). Parkinson's disease\: clinical features and diagnosis. Journal of neurology, neurosurgery, and psychiatry, 79(4),
368–376.
6. Berman B. D. (2011). Neuroleptic malignant syndrome\: a review for neurohospitalists. The Neurohospitalist, 1(1), 41–47.
7. Oregon Health & Science University. Abnormal Involuntary Movement Scale (AIMS). Available from\: [LINK]
8. Barnes T. R. (2003). The Barnes Akathisia Rating Scale--revisited. Journal of psychopharmacology (Oxford, England), 17(4), 365–
370.
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/clinical-examination/extrapyramidal-side-effects-epse-examination/ 6/6