The distribution of the movements is variable. They may involve one extremity, one half of the body (hemichorea), or be generalized. They occur most characteristically in the distal parts of the upper extremities, but may also involve the proximal parts, lower extremities, trunk, face, tongue, lips, and pharynx. Repeated twitching and grimacing movements of the face change constantly in character and location. When asked to hold the hands outstretched, characteristic constant random movements of individual fingers keep the fingers in perpetual motion (piano playing movements). If the patient holds the examiner’s finger in her fist, constant twitches of individual fingers cause variations in grip strength as individual fingers grip and relax randomly (milkmaid grip). The patient may try to incorporate a spontaneous, involuntary movement into a semi-purposeful movement in order to mask the chorea (parakinesia). If a choreic movement suddenly makes a hand fly upward, the patient may continue the movement and reach up and scratch her nose. Motor impersistence, the inability to sustain a contraction, frequently accompanies chorea. The patient is frequently unable to hold the tongue out for any length of time; when asked to do so, the tongue shoots out, then jerks back quickly (snake, darting, flycatcher, or trombone tongue). Choreic gait, the gait abnormality in chorea, is characterized by abundant extraneous movement and a dancing or prancing quality that may appear histrionic or nonorganic but is all too real (see http://neurosigns.org/wiki/Hyperkinetic_gait_disorders)
Video legend. Chorea with motor impersistence (trombone tongue)
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