Non-parkinsonian Movement Disorders: Ballismus

00:01 Now let's talk about Ballismus or Ballism.

00:04 This is another hyperkinetic movement disorder.

00:07 So there's extra movement characterized by involuntary, irregular, wide-amplitude, flinging, violent, coarse and poorly patterned movements due to contraction of the proximal limb and associated axial muscles.

00:22 So the limbs move and they start proximally and move out.

00:27 And this is a large, wide, high-amplitude movement of a proximal limb.

00:34 When we think about ballism, we can classify it in a number of ways.

00:37 Monobalism is confined to one extremity.

00:40 Hemiballism is confined to one side of the body upper and lower extremity.

00:45 Paraballism is ballism in the lower extremities which is quite rare and bilateral ballism a ballism on both sides of the body, which is also extremely rare.

00:55 Typically when we're dealing with ballism, we will see hemiballism, problems affecting one side of the body with large movements of the arm or of the leg.

01:07 In terms of etiology, we think about structural lesions, and classically lesions affecting the subthalamic nucleus will contribute to hemiballism or ballism.

01:18 Ischemic lesions either ischemic strokes or hemorrhagic strokes can contribute to the sudden onset of hemiballism.

01:26 Vascular disorders, various infections that affect the subcortical basal ganglia, and then some metabolic disorders like nonketotic hyperglycemia.

01:36 This is a metabolic derangement that results in dysfunction of the neurons in the subcortical structures and in patients presenting with sudden onset of hyperglycemia, nonketotic hyperglycemia, we can see hemiballism.

01:50 And that improves and resolves with management of the hyperglycemia.

01:55 Other clinical features that we can see in these patients jerking, flinging, flailing, kicking of the ipsilateral leg and arm, it's mainly proximal, there's large proximal movement.

02:06 We can see large rotary displacement of the extremities, and in some cases, it can be so violent that the patients have damage of the limbs or dislocation, they can fall and injure themselves.

02:16 And this is absent during sleep.

02:19 And that's very important when patients sleep, the ballism goes away.

02:23 And when they're awake, the movement comes back and that's because the basal ganglia is involved in modulation of movement, not automatic movement or autonomous movement that would occur during sleep.

02:35 At sleep, the basal ganglia is shut down and we don't see these movements at sleep.

02:42 So here we can see an example of the types of movements that we see with ballism.

02:45 You can see it's proximal, can involve the upper and lower extremity and we see those large amplitude movements of a limb.

02:55 How is Hemiballism treated? Well this resolves typically over time and after a stroke we see improvement after a stroke.

03:02 After a metabolic derangement is corrected, we see improvement and sometimes no treatment is necessary.

03:08 But occasionally, movements are quite severe and debilitating for patients and we will attempt to neuroleptics or dopamine depleting agents for movement reduction.