Hemiballismus Literally means half ballistic Hemiballism both limbs

Hemiballismus Literally means “half ballistic” Hemiballism = both limbs one side (Monoballism = single side) 2019 Mary Griffiths

Mr B 78 yrs • History: MI 1996/ cardiac stents x 3 2005/ CHF secondary to cardiomyopathy 2016 • Assumed stroke before Xmas 2018 – didn’t come to hospital or notice anything at the time. • Admitted 12/02/19 with R)hemiballismus (likely secondary to a stroke) with increasing involuntary movements since late last year, but worsening over the 3 previous days. • Commenced Tetrabenazine. Could then walk, (but use of RUL difficult for ADLs especially as R)handed); therefore function compromised. • Symptoms aggravated with walking, disturbed coordination and relaxed with rest, but completely gone during sleep.

Video clip of Hemiballismus

Severity is measured by getting the patient to perform a sequence of pre determined tasks where the hemiballistic movements are counted in a set time session. The patient is then rated on a severity scale 0 – 4.

It can on rare occasions be due to certain metabolic abnormalities such as diabetic non-ketotic hyperglycaemia in children, traumatic brain injury, cancer in the basal ganglia area, vascular malformations, AIDS or toxoplasmosis where the lesions are also in the basal Ganglia.

Symptoms decrease during sleep. Can cause significant disability. U tube video

Treatment Dopamine blockers such as Haliperidol (interestingly, dopamine is not directly linked to Hemiballismus) seem to work. Anti-convulsants have limited use i. e. Topiramate Botox – only deals with muscular manifestations rather than the neurological cause. Atypical anti-psychotics such as Risperidone or Clozapine, have a reduced risk of extra pyramidal side effects. Tetrabenazine has a dramatic response, and works by depleting nerve endings of dopamine. However lowering the dose leads to a return of symptoms, so long time use is required. Only effective in a proportion of patients and use can be limited by development of depression or drowsiness. (Used also in Huntington’s and Tardive Dyskinesia)

Long Term Prognosis Occasionally there is spontaneous remission, but usually most cases are well controlled with medications Treatment resistance and the vigorous movements can potentially cause extreme exhaustion, acute MI (& possibly pulmonary oedema), or further strokes. The long term outlook is not so much down to clinical manifestations but has similar prognosis as for any other stroke patients. How to help hemiballismus in a non pharmacological way?

Correct movement patterns can be facilitated with application of proprioceptive i. e. safe environment/weighted spoons or utensils/optimising sleep; or reflexive inputs i. e. weighted blankets in the beginning of the recovery phase. Reinforcing successful sensorimotor experiences could expedite recovering from upper limb paralysis caused by the stroke i. e. manual stretches (Carey et al. , 1990), tactile stimulation such as rough/soft/textures against the extensor skin surfaces (Mark et al. , 1990) or joint compression – doesn’t always work and can cause shoulder subluxation, (Brouwer and Ambury, 1994) Once the external sensory inputs are helping, they are then replaced with strengthening against resistance exercises (Ada et al. , 2006) using designed patterns such as writing or repetitive actions. The Bobath methods?