TABLE 3.

Approach to dystonia

Thought-provoking questions	Elements to consider
Is this dystonia?	Completing a detailed history and physical examination is essential to: ○ Differentiate dystonia from spasticity and other movement disorders When in doubt, it is prudent to investigate as if dystonia is present and perhaps even trial a medication Sometimes it is only with improvement from a trial of medication that the presence of dystonia can be confirmed
What are the provoking factors?	Dystonia can worsen in response to pain, fever, infection and other causes of discomfort It is also important to consider anxiety, fear, and other forms of psychological stress, all of which can worsen dystonia
Are medications contributing?	Several common medications can induce and worsen dystonia, dopamine-receptor blocking agents such as anti-emetics and gastrointestinal promotility agents being common Dystonia has also been reported with selective serotonin reuptake inhibitors, opioids, methylphenidate, gabapentin, and general anesthesia using propofol or fentanyl (18) Medication interactions should also be thoroughly explored