Distonias: conceitos, classificação e fisiopatologia

Limongi, João Carlos Papaterra

doi:10.1590/S0004-282X1996000100024

Resumos

Pacientes portadores de movimentos distônicos têm sido relatados na literatura desde o fim do século passado. A conceituação clínica do movimento distônico tem sido debatida. Atualmente, é definida como uma síndrome de contrações musculares mantidas, frequentemente causando movimentos repetitivos ou de torção, ou posturas anormais. Distonias costumam ser classificadas segundo três critérios: distribuição, idade de início e etiologia. As formas generalizadas costumam iniciar-se na infância enquanto as formas focais quase sempre se iniciam na idade adulta. Movimentos e posturas distônicas podem ocorrer durante o repouso ou apenas durante o movimento voluntário. Geralmente pioram ou são desencadeados pela adoção de posturas específicas. Não se conhecem os mecanismos fisiopatológicos responsáveis pelo aparecimento da distonia. Evidências obtidas a partir do estudo das formas secundárias sugerem o envolvimento de algumas regiões dos núcleos da base, particularmente o putâmen e o globo pálido.

distonia; núcleos da base; síndromes distônicas

Since the last decades of the past century there have been several reports in the medical literature describing patients with dystonia. The clinical and phenomenological concepts of dystonic movements have been debated. Presently, dystonia is defined as a syndrome of sustained muscle contractions, frequently causing twisting and repetitive movements, or abnormal postures. Dystonia is usually classified according to three criteria: distribution, age of onset and etiology. The generalized forms often have their onset at childhood whereas the focal forms are most commonly seen in adults. Dystonic movements and postures can occur during resting or they can be precipitated by voluntary movements or by the adoption of specific posture patterns.The pathophysiologic mechanisms related to the appearance of dystonia are presently unknown. However, there are compelling evidences suggesting the involvement of some basal ganglia nuclei (e.g.putamen and globus palidus) in the development of dystonia.

dystonia; basal ganglia; dystonic syndromes

Distonias: conceitos, classificação e fisiopatologia

Dystonias: concepts, classification and pathophysiology

João Carlos Papaterra Limongi

Doutor em Medicina, Médico Assistente da Divisão de Neurologia do Hospial da Clínicas da Faculdade de Medicina da Universidade de São Paulo

RESUMO

Pacientes portadores de movimentos distônicos têm sido relatados na literatura desde o fim do século passado. A conceituação clínica do movimento distônico tem sido debatida. Atualmente, é definida como uma síndrome de contrações musculares mantidas, frequentemente causando movimentos repetitivos ou de torção, ou posturas anormais. Distonias costumam ser classificadas segundo três critérios: distribuição, idade de início e etiologia. As formas generalizadas costumam iniciar-se na infância enquanto as formas focais quase sempre se iniciam na idade adulta. Movimentos e posturas distônicas podem ocorrer durante o repouso ou apenas durante o movimento voluntário. Geralmente pioram ou são desencadeados pela adoção de posturas específicas. Não se conhecem os mecanismos fisiopatológicos responsáveis pelo aparecimento da distonia. Evidências obtidas a partir do estudo das formas secundárias sugerem o envolvimento de algumas regiões dos núcleos da base, particularmente o putâmen e o globo pálido.

Palavras-chave: distonia, núcleos da base, síndromes distônicas.

ABSTRACT

Since the last decades of the past century there have been several reports in the medical literature describing patients with dystonia. The clinical and phenomenological concepts of dystonic movements have been debated. Presently, dystonia is defined as a syndrome of sustained muscle contractions, frequently causing twisting and repetitive movements, or abnormal postures. Dystonia is usually classified according to three criteria: distribution, age of onset and etiology. The generalized forms often have their onset at childhood whereas the focal forms are most commonly seen in adults. Dystonic movements and postures can occur during resting or they can be precipitated by voluntary movements or by the adoption of specific posture patterns.The pathophysiologic mechanisms related to the appearance of dystonia are presently unknown. However, there are compelling evidences suggesting the involvement of some basal ganglia nuclei (e.g.putamen and globus palidus) in the development of dystonia.

Key-words: dystonia, basal ganglia, dystonic syndromes.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Aceite: 28-setembro-1995.

Dr João Carlos Papaterra Limongi - Rua Atlântica 460 - 01440-000 São Paulo SP - Brasil.

1. Berkovic SF, Karpati G, Carpenter S, Lang AE. Progressive dystonia with bilateral putaminal hypodensities. Arch Neurol 1987; 44:1184-7.
2. Blin O, Masson G, Serratrice G. Blepharospasm associated with pseudohypoparathyroidism and bilateral basal ganglia calcification. Mov Disord 1991 ;6: 379.
3. Boyce S, Clarke CE, Luquin R, Peggs D, Robertson RG, Mitchell IJ et al. Induction of chorea and dystonia in parkinsonian primates. Mov Disord 1990; 5:3-7.
4. Bressman SB, de Leon B, Brin MF, Risch N, Shale H, Burke RE et al. Inheritance of primary torsion dystonia among Ashkenazi Jews. In: Fahn S, Marsden CD, Calne D(eds). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:45-56.
5. Burguera JA, Catalá J, Casanova B Thalamic demyelination and paroxismal dystonia in multiple sclerosis. Mov Disord 1991; 6:379-83.
6. Burke RE, Fahn S, Jankovic J, Marsden CD, Lang AE, Gollomp S, Ilson J. Tardive dystonia: late-onset and persistent dystonia caused by antipsychotic drugs. Neurology 1982; 32:1335-46.
7. Calne DB, Lang AE - Secondary dystonia. In: Fahn S, Marsden CD, Calne DB (eds). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:9-33.
8. Chan J, Brin MF, Fahn S. Idiopathic cervical dystonia: clinical characteristics. Mov Disord 1991; 6:119-26.
9. Cooper IS, Cullinan T, Riklan M - The natural history of dystonia. Adv Neurol 1976; 14:157-69.
10. Couch JR. Dystonia and tremor in spasmodic torticollis. Adv Neurol 1976; 14:245-58.
11. Denny-Brown D. Clinical symptomatology of diseases of the basal ganglia. In: Vinken PJ, Bruyn GW. (ed). (Diseases of the basal ganglia). Handbook of clinical neurology. Amsterdam:North Holland, 1968, Vol 6:131 -172.
12. Duane DD. Spasmodic torticollis: clinical and biologic features and their implications for focal dystonia. Adv Neurol 1988; 50:473-92.
13. Dubinski AE, Gray CS, Koller WC - Essential tremor and dystonia. Neurology 1993; 43:2382-84.
14. Dürr A, Stevanin BS, Jedynak CP, Penet C, Agid Y, Brice A. Familial essencial tremor and idiopathic torsion dystonia are different genetic entities. Neurology 1993; 43:2212-4.
15. Dystonia Medical Research Foundation. Ad Hoc Committee of the Scientific Advisory Board , 1984.
16. Eldridge r, Gottlieb R - The primary hereditary dystonias: genetic classification of 768 families and revised estimate of gene frequency, autossomal recessive form, and selected bibliography. Adv Neurol 1976; 14:457-74.
17. Fahn S. The varied clinical expressions of dystonia. Neurol Clin 1984, 2:541-54.
18. Fahn S. Concept and classification of dystonia - In: Fahn S, Marsden CD, Calne DB, (eds). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:1-8.
19. Fahn S, Marsden C D, Calne D B - Classification and investigation of dystonia. In: Marsden CD, Fahn S (ed). Movement disorsders 2. London: Butterworths, 1987: 332-58.
20. Falk CT, Bressman SB, Allen FH, Moskowitz C, Fahn S, Brin M. Linkage studies in families with dystonia: linkage analysis as a tool to locate and characterize the gene(s) for dystonia. In: Fahn S, Marsden CD, Calne DB, (ed). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:67-72.
21. Ferraz HB, Andrade LAF, Silva SMCA, Borges V, Rocha MSG. Tremor postural e distonia: aspectos clínicos e considerações fisiopatológicas. Arq Neuropsiquiatr 1994, 52:466-70.
22. Forsgren L, Holmgren G, Almay BGL, Drugge U. Autossomal dominant torsion dystonia in a Swedish family. In: Fahn S, Marsden CD, Calne DB, (ed). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:83-92.
23. Jabbari B, Paul J, Scherokman B, Van Dam B - Posttraumatic segmental axial dystonia. Mov Disord 1992; 7:78-81.
24. Jankovic J, Fahn S - Dystonic Syndromes. In: Jankovic J, Tolosa E, (ed). Parkinson's disease and movement disorders. Baltimore: Urban-Scharzenberg, 1988:283-314.
25. Jankovic J, Fahn S. Dystonic syndromes. In: Jankovic J, Tolosa E (ed). Parkinson's disease and movement disorders. Baltimore: Williams and Wilkins, 1993.
26. Jankovic J, Leder S, Warner D.Schwartz K. Cervical dystonia: clinical findings and associated movements disorders. Neurology 1991; 41:1088-91.
27. Korczyn AD, Kahana E, Zilber N, Streiffer M, Karasso R, Alter M. Torsion dystonia in Israel. Ann Neurol 1980; 8:387-91.
28. Krauss JK, Mohadjer M, Noble F, Scheremet R. Hemidystonia due to a contralateral parieto-occipital metastasis: disappearance after removal of the mass lesion. Neurology 1991; 41:1519-20.
29. Larsen TA, Dunn HG, Jan JE, Calne DB - Dystonia and calcification of the basal ganglia. Neurology 1985; 35:533-7.
30. Lee LV, Pascasio FM, Fuentes FD, Viterbo GH - Torsion dystonia in Panay, Philippines. Adv Neurol 1976; 14:137-51.
31. Leiguarda R, Merello M, Sabe L, Starkstein S. Bromocriptine-induced dystonia in patients with aphasia and hemiparesis. Neurology 1993; 43:2319-22.
32. Limongi JCP. Utilização da toxina botulínica tipo A na terapêutica das distonias. Tese de Doutorado, Faculdade de Medicina da Universidade de São Paulo. São Paulo, 1994.
33. Markham CH. The dystonias. Curr Opin Neurol Neurosurg 1992; 5:301-7
34. Marsden CD. The dystonias. Br Med J 1990; 300:139-44.
35. Marsden CD, Harrison MJG, Bundey S. Natural history of idiopatic torsion dystonia. Adv Neurol 1976; 14:177-87.
36. Marsden CD. Obeso JA, Zarranz JJ Lang AE. The anatomical basis of symptomatic hemidystonia. Brain 1985; 108:463- 83.
37. Melamed E. Early-morning dystonia: a late side effect of long term levodopa therapy in Parkinson's disease. Arch Neurol 1979; 36:308-10.
38. Midgard R, Aarli JA, Julsrud OJ, Odegaard H. Symptomatic hemidystonia of delayed onset: magnetic resonance demonstration of pathology in the putamen and the caudate nucleus. Acta Neurol Scand 1989; 79:27-31.
39. Mitchell IJ, Crossman AR, Liminga U, Andren P, Gunne LM. Regional changes in 2-deoxiglucose uptake associated with neuroleptic-induced tardive dyskinesias in the Cebus monkey.Mov Disord 1992; 7:32-7.
40. Mitchell IJ, Luquin R, Boyce S, Clarke CE, Robertson RG, Sambrook MA et al. Neural mechanisms of dystonia: evidence from 2-deoxiglucose uptake study in a primate model of dopamine agonist-induced dystonia. Mov Disord 1990; 5:49-54.
41. Molho ES, Factor SA. Basal ganglia infarction as a possible cause of cervical dystonia. Mov Disord 1993; 8:213-6.
42. Morrison PJ, Patterson VH. Cranial dystonia (Meige syndrome) in postencephalitic parkinsonism. Mov Disord 1992; 7:90-1.
43. Nutt JG, Muenter MD, Melton J III, Aronson A, Kur-ind LT. Epidemiology of dystonia in Rochester, Minnesota. In: Fahn S, Marsden CD, Calne DB. (ed). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:361-365.
44. Nygaard TG, Duvoisan RC. Hereditary dystonia-parkinsonism syndrome of juvenile onset. Neurology 1986; 36:1424-8.
45. Obeso JA, Giménez-Roldán J. Clinicopathological correlation in symptomatic dystonia. In: Fahn S, Marsden CD, Calne DB. (ed). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:113-122.
46. Poewe WE, Lees AJ, Stern GM. Dystonia in Parkinson's disease: clinical and pharmacological features. Ann Neurol 1988; 23:73-78.
47. Rafai RD, Friedman JH. Limb dystonia in progressive supranuclear palsy. Neurology 1987; 37:1546-9.
48. Rivest J, Marsden CD. Trunk and head tremor as isolated manifestation of dystonia. Mov Disord 1990; 5:60-5.
49. Rivest J, Quin N, Marsden CD. Dystonia in Parkinson's disease, multiple system atrophy and progressive supranuclear palsy. Neurology 1990; 40:1571-78.
50. Rothwell JC, Day BL, Obeso JA, Berardelli A, Marsden CD - Reciprocal inhibition between muscles of the human forarm in normal subjects and in patients with idiopathic torsion dystonia. In: Fahn S, Marsden CD, Calne DB (ed). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:133-139.
51. Rothwell JC, Obeso J A. The anatomical and physiological basis of torsion dystonia. In: Marsden CD, Fahn S. (ed). Movement Disorders 2. London: Butterwoths, 1987:313-331.
52. Segawa M, Nomura Y, Kase M. Diurnally fluctuating hereditary progressive dystonia. In: Vinken J, Bruyn GW, Klawans HL. (ed). Handbook of clinical neurology. Elsevier: Amsterdan, 1986, Vol 49(Extrapyramidal disorders): 227-234.
53. Tolge CF, Factor SA. Focal dystonia secondary to cerebral toxoplasmosis in a patient with acquired immune deficiency syndrome. Mov Disord 1991; 6:69-72.
54. Wooten GF, Lopes MBS, Harris WO, Reagan TJ, Vandenberg SR. Pallidoluysian atrophy: dystonia and basal ganglia functional anatomy. Neurology 1993; 43:1764-8.

Datas de Publicação

Publicação nesta coleção
07 Dez 2010
Data do Fascículo
Mar 1996

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Berkovic SF, Karpati G, Carpenter S, Lang AE. Progressive dystonia with bilateral putaminal hypodensities. Arch Neurol 1987; 44:1184-7.

[2] 2. Blin O, Masson G, Serratrice G. Blepharospasm associated with pseudohypoparathyroidism and bilateral basal ganglia calcification. Mov Disord 1991 ;6: 379.

[3] 3. Boyce S, Clarke CE, Luquin R, Peggs D, Robertson RG, Mitchell IJ et al. Induction of chorea and dystonia in parkinsonian primates. Mov Disord 1990; 5:3-7.

[4] 4. Bressman SB, de Leon B, Brin MF, Risch N, Shale H, Burke RE et al. Inheritance of primary torsion dystonia among Ashkenazi Jews. In: Fahn S, Marsden CD, Calne D(eds). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:45-56.

[5] 5. Burguera JA, Catalá J, Casanova B Thalamic demyelination and paroxismal dystonia in multiple sclerosis. Mov Disord 1991; 6:379-83.

[6] 6. Burke RE, Fahn S, Jankovic J, Marsden CD, Lang AE, Gollomp S, Ilson J. Tardive dystonia: late-onset and persistent dystonia caused by antipsychotic drugs. Neurology 1982; 32:1335-46.

[7] 7. Calne DB, Lang AE - Secondary dystonia. In: Fahn S, Marsden CD, Calne DB (eds). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:9-33.

[8] 8. Chan J, Brin MF, Fahn S. Idiopathic cervical dystonia: clinical characteristics. Mov Disord 1991; 6:119-26.

[9] 9. Cooper IS, Cullinan T, Riklan M - The natural history of dystonia. Adv Neurol 1976; 14:157-69.

[10] 10. Couch JR. Dystonia and tremor in spasmodic torticollis. Adv Neurol 1976; 14:245-58.

[11] 11. Denny-Brown D. Clinical symptomatology of diseases of the basal ganglia. In: Vinken PJ, Bruyn GW. (ed). (Diseases of the basal ganglia). Handbook of clinical neurology. Amsterdam:North Holland, 1968, Vol 6:131 -172.

[12] 12. Duane DD. Spasmodic torticollis: clinical and biologic features and their implications for focal dystonia. Adv Neurol 1988; 50:473-92.

[13] 13. Dubinski AE, Gray CS, Koller WC - Essential tremor and dystonia. Neurology 1993; 43:2382-84.

[14] 14. Dürr A, Stevanin BS, Jedynak CP, Penet C, Agid Y, Brice A. Familial essencial tremor and idiopathic torsion dystonia are different genetic entities. Neurology 1993; 43:2212-4.

[15] 15. Dystonia Medical Research Foundation. Ad Hoc Committee of the Scientific Advisory Board , 1984.

[16] 16. Eldridge r, Gottlieb R - The primary hereditary dystonias: genetic classification of 768 families and revised estimate of gene frequency, autossomal recessive form, and selected bibliography. Adv Neurol 1976; 14:457-74.

[17] 17. Fahn S. The varied clinical expressions of dystonia. Neurol Clin 1984, 2:541-54.

[18] 18. Fahn S. Concept and classification of dystonia - In: Fahn S, Marsden CD, Calne DB, (eds). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:1-8.

[19] 19. Fahn S, Marsden C D, Calne D B - Classification and investigation of dystonia. In: Marsden CD, Fahn S (ed). Movement disorsders 2. London: Butterworths, 1987: 332-58.

[20] 20. Falk CT, Bressman SB, Allen FH, Moskowitz C, Fahn S, Brin M. Linkage studies in families with dystonia: linkage analysis as a tool to locate and characterize the gene(s) for dystonia. In: Fahn S, Marsden CD, Calne DB, (ed). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:67-72.

[21] 21. Ferraz HB, Andrade LAF, Silva SMCA, Borges V, Rocha MSG. Tremor postural e distonia: aspectos clínicos e considerações fisiopatológicas. Arq Neuropsiquiatr 1994, 52:466-70.

[22] 22. Forsgren L, Holmgren G, Almay BGL, Drugge U. Autossomal dominant torsion dystonia in a Swedish family. In: Fahn S, Marsden CD, Calne DB, (ed). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:83-92.

[23] 23. Jabbari B, Paul J, Scherokman B, Van Dam B - Posttraumatic segmental axial dystonia. Mov Disord 1992; 7:78-81.

[24] 24. Jankovic J, Fahn S - Dystonic Syndromes. In: Jankovic J, Tolosa E, (ed). Parkinson's disease and movement disorders. Baltimore: Urban-Scharzenberg, 1988:283-314.

[25] 25. Jankovic J, Fahn S. Dystonic syndromes. In: Jankovic J, Tolosa E (ed). Parkinson's disease and movement disorders. Baltimore: Williams and Wilkins, 1993.

[26] 26. Jankovic J, Leder S, Warner D.Schwartz K. Cervical dystonia: clinical findings and associated movements disorders. Neurology 1991; 41:1088-91.

[27] 27. Korczyn AD, Kahana E, Zilber N, Streiffer M, Karasso R, Alter M. Torsion dystonia in Israel. Ann Neurol 1980; 8:387-91.

[28] 28. Krauss JK, Mohadjer M, Noble F, Scheremet R. Hemidystonia due to a contralateral parieto-occipital metastasis: disappearance after removal of the mass lesion. Neurology 1991; 41:1519-20.

[29] 29. Larsen TA, Dunn HG, Jan JE, Calne DB - Dystonia and calcification of the basal ganglia. Neurology 1985; 35:533-7.

[30] 30. Lee LV, Pascasio FM, Fuentes FD, Viterbo GH - Torsion dystonia in Panay, Philippines. Adv Neurol 1976; 14:137-51.

[31] 31. Leiguarda R, Merello M, Sabe L, Starkstein S. Bromocriptine-induced dystonia in patients with aphasia and hemiparesis. Neurology 1993; 43:2319-22.

[32] 32. Limongi JCP. Utilização da toxina botulínica tipo A na terapêutica das distonias. Tese de Doutorado, Faculdade de Medicina da Universidade de São Paulo. São Paulo, 1994.

[33] 33. Markham CH. The dystonias. Curr Opin Neurol Neurosurg 1992; 5:301-7

[34] 34. Marsden CD. The dystonias. Br Med J 1990; 300:139-44.

[35] 35. Marsden CD, Harrison MJG, Bundey S. Natural history of idiopatic torsion dystonia. Adv Neurol 1976; 14:177-87.

[36] 36. Marsden CD. Obeso JA, Zarranz JJ Lang AE. The anatomical basis of symptomatic hemidystonia. Brain 1985; 108:463- 83.

[37] 37. Melamed E. Early-morning dystonia: a late side effect of long term levodopa therapy in Parkinson's disease. Arch Neurol 1979; 36:308-10.

[38] 38. Midgard R, Aarli JA, Julsrud OJ, Odegaard H. Symptomatic hemidystonia of delayed onset: magnetic resonance demonstration of pathology in the putamen and the caudate nucleus. Acta Neurol Scand 1989; 79:27-31.

[39] 39. Mitchell IJ, Crossman AR, Liminga U, Andren P, Gunne LM. Regional changes in 2-deoxiglucose uptake associated with neuroleptic-induced tardive dyskinesias in the Cebus monkey.Mov Disord 1992; 7:32-7.

[40] 40. Mitchell IJ, Luquin R, Boyce S, Clarke CE, Robertson RG, Sambrook MA et al. Neural mechanisms of dystonia: evidence from 2-deoxiglucose uptake study in a primate model of dopamine agonist-induced dystonia. Mov Disord 1990; 5:49-54.

[41] 41. Molho ES, Factor SA. Basal ganglia infarction as a possible cause of cervical dystonia. Mov Disord 1993; 8:213-6.

[42] 42. Morrison PJ, Patterson VH. Cranial dystonia (Meige syndrome) in postencephalitic parkinsonism. Mov Disord 1992; 7:90-1.

[43] 43. Nutt JG, Muenter MD, Melton J III, Aronson A, Kur-ind LT. Epidemiology of dystonia in Rochester, Minnesota. In: Fahn S, Marsden CD, Calne DB. (ed). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:361-365.

[44] 44. Nygaard TG, Duvoisan RC. Hereditary dystonia-parkinsonism syndrome of juvenile onset. Neurology 1986; 36:1424-8.

[45] 45. Obeso JA, Giménez-Roldán J. Clinicopathological correlation in symptomatic dystonia. In: Fahn S, Marsden CD, Calne DB. (ed). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:113-122.

[46] 46. Poewe WE, Lees AJ, Stern GM. Dystonia in Parkinson's disease: clinical and pharmacological features. Ann Neurol 1988; 23:73-78.

[47] 47. Rafai RD, Friedman JH. Limb dystonia in progressive supranuclear palsy. Neurology 1987; 37:1546-9.

[48] 48. Rivest J, Marsden CD. Trunk and head tremor as isolated manifestation of dystonia. Mov Disord 1990; 5:60-5.

[49] 49. Rivest J, Quin N, Marsden CD. Dystonia in Parkinson's disease, multiple system atrophy and progressive supranuclear palsy. Neurology 1990; 40:1571-78.

[50] 50. Rothwell JC, Day BL, Obeso JA, Berardelli A, Marsden CD - Reciprocal inhibition between muscles of the human forarm in normal subjects and in patients with idiopathic torsion dystonia. In: Fahn S, Marsden CD, Calne DB (ed). Dystonia 2. Advances in Neurology. New York: Raven Press, 1988, 50:133-139.

[51] 51. Rothwell JC, Obeso J A. The anatomical and physiological basis of torsion dystonia. In: Marsden CD, Fahn S. (ed). Movement Disorders 2. London: Butterwoths, 1987:313-331.

[52] 52. Segawa M, Nomura Y, Kase M. Diurnally fluctuating hereditary progressive dystonia. In: Vinken J, Bruyn GW, Klawans HL. (ed). Handbook of clinical neurology. Elsevier: Amsterdan, 1986, Vol 49(Extrapyramidal disorders): 227-234.

[53] 53. Tolge CF, Factor SA. Focal dystonia secondary to cerebral toxoplasmosis in a patient with acquired immune deficiency syndrome. Mov Disord 1991; 6:69-72.

[54] 54. Wooten GF, Lopes MBS, Harris WO, Reagan TJ, Vandenberg SR. Pallidoluysian atrophy: dystonia and basal ganglia functional anatomy. Neurology 1993; 43:1764-8.