ABSTRACT
While dystonia is rather painful, owing to the extensive involuntary flexion or extension of toes or other body parts, it is sometimes surprising how little patients are bothered by choreiform movements which may sometimes be very irritating to their relatives. While choreic movements are normally most pronounced in the upper part of the body, dystonia affects the distal extremities. Dystonia may herald the beginning of dyskinesias and, shortly thereafter, is followed by choreiform dyskinesia. Dystonia most often occurs in the morning or during the night when not enough levodopa or dopamine agonist were administered during the night. Patients mostly report painful foot cramps and painful toe distraction. It is important to distinguish between dystonia in off-periods, which is due to levodopa levels that are too low, or in onperiods, when it is due to levodopa levels that are too high. Myoclonus is also levodopa related and occurs both during the day or at night.9,10
The severity of dyskinesia seems to be dose dependent;11 thus patients with high dosages of levodopa present with more severe choreiform dyskinesia than patients with lower levodopa dosages. For this reason we will discuss later that lowering the levodopa dosage is an important tool in the treatment of dyskinesia. Subtle
observation of patients will reveal that akathisia is also quite common in parkinsonian patients.12
