Dysdiadochokinesia (diadochokinesia) is the inability to perform rapid alternating muscle movements. These can be quick, synchronous, and can include pronation/supination, fast finger tapping, opening and closing of the fists, and foot tapping. It is an essential component to evaluate in patients suspected of having a cerebellar disease. These activities correlate well with numerous lifelong measures of disability. It is a form of ataxia that leads to the loss of coordination of speech and limbs. It is measurable by using the alternate motion rate (AMR). For example, speech AMR is measurable through verbal commands such as counting the number of syllable repetitions within a specific time (less than 1 minute).
Dysdiadochokinesia is present with cerebellar dysfunction. Cerebellar lesions producing dysdiadochokinesia include:
Dysdiadochokinesia is an important definition to understand cerebellar dysfunction in the context of clinical disease. It should be routinely assessed in patients who elicit deficits in the coordination of speech and movement, as it is a common finding. As it can be present or absent in cerebellar disease, no incidence or prevalence has been reported. Tapping performance showed a decline with increasing age, and male subjects were faster than females in forearm diadochokinesia.
Dysdiadochokinesia can be present in small children without other focalizing neurological deficits or mental retardation. Children under the age of 13 years can present dysdiadochokinesia in 8 to 20% of the cases if tested. It is highest in the 7-8 year range. This presentation could be due to decreased myelination at younger ages with improved corticocerebellar connections later in life.
The cerebellum is organized into:
The posterior vermis represents the limbic cerebellum. The corticopontocerebellar and cerebellothalamocortical loops connect the cerebellum to the motor and limbic tracts in the brain, any damage to these loops disrupts complex tasks involved in cognition, mood, and sensorimotor coordination. Complex white matter tracts involved include vestibulocerebellar, and vestibulospinal (cerebellar oculomotor systems).
The cerebellum coordinates the function of agonist and antagonist movements required for specific alternating movements. This altered coordination forms the basis for dysdiadochokinesia in cerebellar injury or dysfunction. The cerebellum also coordinates the acceleration and velocity of muscular activity.
Dysdiadochokinesia is one of the features of cerebellar dysfunction, but other clinical findings associated with cerebellar dysfunction can help you localize and narrow the differential diagnosis of the patient.
Typically affects the coordination of alternating movements and ambulation of the proximal and distal upper and lower extremity. It can also affect the laryngeal muscles that control speech. It is a form of dysmetria/ataxia, that can manifest as rigidity, bradykinesia, dysarthria, dysphagia, dysesthesias, or tremors. Ocular movements related to alignment, stability, and calibration also falls in the realm of cerebellar function.
It is relevant to include in the neurological exam other areas to increase the degree of certainty of the clinical findings and help with the diagnosis, which includes:
The underlying cause of the symptom will determine the evaluations needed.
Dysdiadochokinesia and cerebellar ataxia are challenging to treat, and the underlying etiology requires attention. Physical, speech, and occupational therapy, including strength training, balance exercises, treadmill, cycling, and Romberg exercises, can help improve functional outcomes in patients with cerebellar lesions. Home safety evaluation and durable medical equipment may be necessary to prevent falls.
It depends on the etiology of the slowed alternating movements. For example, acute traumatic, vascular, or fast progressing hereditary ataxias may have a poorer prognosis on elderly patients with multiple medical co-morbidities. Infectious, inflammatory, and metabolic etiologies can have a better prognosis if identified and diagnosed quickly and treated aggressively.
There are no known complications as dysdiadochokinesia is a clinical finding of cerebellar dysfunction.
Complications of cerebellar dysfunction include frequent falls, dysarthric speech, swallowing problems, visual-spacial coordination. Surgery for the cerebellum may become complicated by hemorrhage, edema, and hydrocephalus. As the posterior fossa is a small compartment, any complication that can potentially cause hydrocephalus or brainstem compression requires emergency treatment. Delay in the management can cause irreversible brainstem damage producing coma or death.
Patients with cerebellar dysfunction will often present signs that the patient will notice in the daily activities. Incoordination of hand or foot should prompt a patient to seek medical evaluation. Most cerebellar lesions are unpreventable, but those patients with arterial hypertension, hypercholesterolemia, and untreated or uncontrolled high blood triglycerides should seek medical treatment and normalize them. All of them are risk factors for vertebrobasilar atherosclerosis and strokes.
No evidence-based study is specific for dysdiadochokinesia, however depending on the etiology, an interdisciplinary team that consists of a neurologist, physical therapy, occupational therapy, speech therapy, social workers, nursing, mental health counselors, psychiatrist, and at times, geneticist should be consulted to provide the best quality of life for the patient. (Level V) To improve outcomes, prompt consultation with an interprofessional group of specialists is recommended. Collaboration, shared decision-making, and communication are crucial elements for a good outcome.
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