Outpatient Billing

Outpatient Billing

Steps

Step 1: Is the patient NEW or ESTABLISHED?

Step 2: Calculate MDM

Step 3: Determine the Level

Step 4: Add G2211

Step 5: Use Time When Needed

Codes

E/M CPT: 99213, 99214, 99215, 99204, 99205

HCPCS (Add-on): G2211

Modifier: GC

❶ Is NEW or ESTABLISHED?

-CPT code

❷ MDM

-3 columns: problems addressed, data reviewed, and risk

❸ E/M Level

≥ 2 Low→ Low

≥ 2 Moderate→ Moderate

≥ 2 High→ High

*Not additive, so low+low+high is low

*Prescription drug management = moderate risk

❹ ⊕G2211

-HCPCS code (add-on code), cannot be billed by itself

-Always use, except:

>1x consultation only

>Independent medical examination

>Pre-op clearance visit

>You are not assuming ongoing responsibility for the condition

❺ Time

EPIC

Practical rules

-If fellow clinic, it is the same as resident

SHE (ADNFLE)

Sleep-Related Hypermotor Epilepsy (SHE)

"When epilepsy looks like a movement disorder"

Definition

"Brief focal motor szs w/ hyperkinetic or asymmetric tonic/dystonic features occurring predominantly from sleep"

Aka: ADNFLE, NFLE

*Exclude, if mainly awake

History

1981: Lugaresi and Cirignotta→ 1st report

Pathophysiology

-Paroxysmal network disorders

(szs, DTN, ATX, tremor, and DKN)

Epidemiology

-First 2 decades of life

-Male predominance

-ID/ behav issues, otherwise everything wnl

Genetics

-ACh receptor (CHRNA4 > CHRNB2 = CHRNA2)

-GATOR1 complex (DEPDC5, NPRL2 or NPRL3)

-Na-activated K channel (KCNT1)

>Most severe phenotype

-Rare: PRIMA1

Differentials

-Parasomnias (night terrors, sleepwalking)

-Psychiatric disorders

-Functional neurological disorders

-Paroxysmal dyskinesias

Secondary dystonia and pseudodystonia

Secondary Dystonia

C12c344 (Video 12.344): Secondary Dystonia Due to Mitochondrial Disease

Blepharospasm, eyelid-opening apraxia, jaw-opening dystonia, risor sardonicus, and upper-limb dystonia associated with mitochondrial dysfunction.

C12c345 (Video 12.345): Severe Generalized Secondary Dystonia

Generalized dystonia with intermittent dystonic spasms, spasticity, and bilateral pallidal and nigral lesions on MRI.

C12c346 (Video 12.346): Leigh Syndrome with Dystonia

Upper-limb dystonia and spastic gait associated with bilateral putaminal injury.

C12c347 (Video 12.347): Mitochondrial Encephalopathy with Hemidystonia

Blepharospasm, postural limb dystonia, and dystonic gait associated with bilateral striatal injury.

C12c348 (Video 12.348): Glutaric Aciduria Type I

Severe generalized dystonia with macrocephaly, torticollis, jaw-opening dystonia, and painful dystonic spasms.

C12c349 (Video 12.349): L-2-Hydroxyglutaric Aciduria

Writer's cramp and upper-limb dystonia associated with metabolic disease.

C12c350 (Video 12.350): Rasmussen Encephalitis with Hemidystonia

Persistent right-sided dystonia affecting arm posture and gait.

C12c351 (Video 12.351): Rasmussen Encephalitis with EPC and Hemidystonia

Progressive left hemidystonia associated with epilepsia partialis continua.

C12c352 (Video 12.352): Advanced Rasmussen Encephalitis

Severe fixed hemidystonia involving the arm and foot.

C12c353 (Video 12.353): Post-Thalamic Stroke Dystonia

The "dystonic-jerky hand" syndrome characterized by complex dystonic and cerebellar movements.

C12c354 (Video 12.354): Post-Thalamic Stroke Dystonia with Cerebellar Tremor

Mild dystonic hand posturing accompanied by cerebellar outflow tremor.

C12c355 (Video 12.355): Delayed-Onset Post-Stroke Dystonia

Painful thalamic syndrome accompanied by fixed upper-limb dystonia and mild cerebellar tremor.

C12c356 (Video 12.356): Pulvinar Stroke Presenting as Writer's Cramp

Apparent focal dystonia later recognized as secondary dystonia due to pulvinar infarction.

C12c357 (Video 12.357): Post-Traumatic Epilepsy with Foot Dystonia

Task-specific foot dystonia dramatically improved after temporal lobectomy.

C12c358 (Video 12.358): Delayed-Onset Childhood Stroke Hemidystonia

Fixed left hand dystonia developing years after childhood cerebrovascular injury.

C12c359 (Video 12.359): Childhood Stroke with Generalized Hemidystonia

Severe right hemidystonia involving both upper and lower extremities.

C12c360 (Video 12.360): Post-Stroke Cervical Dystonia

Cervical dystonia with adductor spasmodic dysphonia and upper-limb involvement.

C12c361 (Video 12.361): Dystonic Cerebral Palsy

Combined generalized dystonia and spasticity due to perinatal hypoxic injury.

Pseudodystonia

C12c362 (Video 12.362): Juvenile Cervical Inflammatory Arthropathy

Painful restriction of neck movement due to inflammatory C1-C2 disease mimicking cervical dystonia.

C12c363 (Video 12.363): Pseudotorticollis Due to Sternocleidomastoid Lymphoma

Neoplastic invasion of the sternocleidomastoid muscle producing apparent torticollis.

C12c364 (Video 12.364): Myasthenia Gravis Mimicking Cervical Dystonia

Head turning resulting from focal neck weakness rather than dystonic activation.

C12c365 (Video 12.365): Radiation-Induced Neck Fibrosis

Fixed neck posturing caused by radiation myopathy.

C12c366 (Video 12.366): Congenital Muscular Torticollis

Lifelong abnormal neck posture due to fibrotic sternocleidomastoid shortening.

C12c367 (Video 12.367): Congenital Torticollis Mimicking Dystonia

Persistent head tilt caused by structural neck abnormality rather than dystonia.

C12c368 (Video 12.368): Dropped Head Syndrome Misdiagnosed as Dystonia

Severe neck extensor weakness producing anterocollis-like posture.

C12c369 (Video 12.369): Atlantoaxial Rotatory Subluxation in a Child

Acute "cock-robin" posture resulting from C1-C2 subluxation.

C12c370 (Video 12.370): Chronic Atlantoaxial Rotatory Subluxation

Persistent torticollis caused by structural cervical instability.

C12c371 (Video 12.371): Fixed Head Tilt Pseudodystonia

Mechanical cervical deformity without evidence of dystonic muscle activation.

C12c372 (Video 12.372): Head Drop Due to Neck Extensor Myopathy

Marked neck extensor weakness producing severe dropped-head posture.

C12c373 (Video 12.373): Neck Extensor Myopathy

Progressive head drop resulting from isolated extensor muscle weakness.

Foot and Truncal Dystonia

Foot Dystonia

C12c314 (Video 12.314): Isolated Foot Dystonia

Walking-induced ankle flexion producing a “sticky foot” gait, absent during backward walking.

C12c315 (Video 12.315): Inversion Foot Dystonia

Walking-induced inversion and plantarflexion improving with running and imagined backward walking.

C12c316 (Video 12.316): Right Foot Inversion Dystonia

Marked inversion appearing only during walking and relieved by running.

C12c317 (Video 12.317): Foot Abduction Dystonia

Walking-triggered abduction of the foot with partial improvement during backward gait.

C12c318 (Video 12.318): Ankle Flexion Dystonia

Activation during stance phase causing apparent sticking of the foot to the floor.

C12c319 (Video 12.319): Subtle Distal Leg Dystonia

Mild stance-phase ankle flexion relieved by jogging and backward walking.

C12c320 (Video 12.320): Adduction-Inversion Foot Dystonia

Task-specific gait dystonia improved by imagined and actual backward walking.

C12c321 (Video 12.321): Stair-Descent Dystonia

Triple-flexion dystonia occurring only while descending stairs.

C12c322 (Video 12.322): Exercise-Induced Dystonia

Treadmill walking triggers external rotation and foot flexion.

C12c323 (Video 12.323): Severe Walking-Induced Foot Dystonia

Internal rotation, inversion, and toe flexion that disappear during running.

C12c324 (Video 12.324): Heel Adduction Dystonia

Heel adduction and toe abduction occurring with each step.

C12c325 (Video 12.325): Left Leg Task-Specific Dystonia

Marked ankle flexion relieved by backward and sideways walking.

C12c326 (Video 12.326): Painful Inversion Dystonia

Severe inversion and plantarflexion eliminated during backward gait.

C12c327 (Video 12.327): Complex Proximal Leg Dystonia

Hip abduction and knee flexion dystonia improved after botulinum toxin treatment.

C12c328 (Video 12.328): Severe Multi-Joint Leg Dystonia

Hip, knee, and ankle dystonia producing profound gait impairment.

C12c329 (Video 12.329): Proximal Lower Limb Dystonia

Hip and knee extension dystonia interfering with ambulation.

C12c330 (Video 12.330): Mild Foot Dystonia

Subtle inversion and ankle flexion during walking.

C12c331 (Video 12.331): Foot Dystonia Before and After Treatment

Marked improvement following ultrasound-guided botulinum toxin injections.

Truncal Dystonia

C12c332 (Video 12.332): Paradoxical Truncal Dystonia

Opisthotonic posturing present at rest and disappearing during walking.

C12c333 (Video 12.333): Camptocormia with Sensory Trick

Forward truncal flexion relieved by wall contact and abolished during running.

C12c334 (Video 12.334): Pisa Syndrome-Type Truncal Dystonia

Lateral trunk flexion improved by sensory gestures and backward walking.

C12c335 (Video 12.335): Isolated Truncal Tilt Dystonia

Walking-induced leftward torso deviation.

C12c336 (Video 12.336): Severe Flexion Truncal Dystonia

Marked camptocormia relieved by backward walking and jogging.

C12c337 (Video 12.337): Advanced Camptocormia

Severe truncal flexion persisting during rest and gait.

C12c338 (Video 12.338): Walking-Induced Truncal Flexion

Forward flexion improving with running and sideways walking.

C12c339 (Video 12.339): Truncal Dystonia with Back-Pocket Geste

Flexion dystonia alleviated by hooking the hands behind the back.

C12c340 (Video 12.340): Abdominal Dystonia

Forward truncal flexion improved by direct manual pressure.

C12c341 (Video 12.341): Running-Responsive Camptocormia

Flexion dystonia disappearing during running.

C12c342 (Video 12.342): Dynamic Truncal Dystonia

Complex standing dystonia abolished by walking, running, or marching in place.

C12c343 (Video 12.343): Focal Abdominal Wall Dystonia

Exercise-induced focal contraction of the abdominal wall producing visible bulging.

Plectrum, Woodwind Hand, Drummers' Dystonia

Plectrum Dystonia

C12c279 (Video 12.279): Banjo Dystonia with Writer's Cramp

Task-specific flexion dystonia of the thumb and index finger during banjo playing associated with writer's cramp and mirror dystonia.

C12c280 (Video 12.280): Banjo Picking Dystonia

Index-finger flexion dystonia disrupting rapid picking patterns, improved by abandoning use of the affected finger.

C12c281 (Video 12.281): Banjo Index Finger Dystonia

Task-specific index finger flexion causing rhythmic irregularity during performance.

C12c282 (Video 12.282): Third-Finger Banjo Dystonia

Dystonia affecting the third finger during rapid banjo passages, partially compensated by altered fingering strategies.

C12c283 (Video 12.283): Hybrid String Instrument Dystonia

Thumb extension and index finger flexion dystonia impairing performance on a custom string instrument.

C12c284 (Video 12.284): Jazz Guitar Dystonia Before and After Botulinum Toxin

Thumb extension and index finger flexion dystonia markedly improved following targeted treatment.

C12c285 (Video 12.285): Classical Guitar Tremolo Dystonia

Index extension and middle finger flexion disrupting tremolo technique, partially relieved by tactile stimulation.

C12c286 (Video 12.286): Third-Finger Classical Guitar Dystonia

Task-specific third-finger flexion impairing ascending scales.

C12c287 (Video 12.287): Guitar Dystonia with Ulnar Finger Involvement

Flexion dystonia of the fourth and fifth fingers during performance.

C12c288 (Video 12.288): Guitar Dystonia with Sensory Trick Pick

Finger flexion dystonia dramatically reduced by a modified thumb pick acting as a sensory trick.

C12c289 (Video 12.289): Koto Player's Dystonia

Finger and wrist flexion dystonia affecting traditional Japanese string instrument performance.

C12c290 (Video 12.290): Jazz Guitarist with Glove Effect

Complex middle-finger dystonia substantially improved by wearing a glove.

C12c291 (Video 12.291): Left-Hand Guitar Dystonia

Pinky flexion dystonia impairing fretboard control, improved after botulinum toxin treatment.

Woodwind Hand Dystonia

C12c292 (Video 12.292): Saxophonist's Third-Finger Extension Dystonia

Third-finger extension dystonia impairing scales and technical passages.

C12c293 (Video 12.293): Left-Hand Saxophone Dystonia

Task-specific flexion dystonia improved by mechanically opposing lumbrical activity.

C12c294 (Video 12.294): Flute and Saxophone Dystonia

Different dystonic patterns on flute and saxophone involving third and fourth fingers.

C12c295 (Video 12.295): Clarinet Fourth-Finger Dystonia

Subtle fourth-finger extension and release abnormalities producing professional disability.

C12c296 (Video 12.296): Flute MCP Extension Dystonia

Third- and fourth-finger extension at the metacarpophalangeal joints disrupting fingering.

C12c297 (Video 12.297): Fourth-Finger Flute Dystonia

Extension at the MCP joint with PIP flexion affecting key control.

C12c298 (Video 12.298): Flute Pinky Dystonia with Abduction

Abnormal extension and abduction of the fifth finger causing loss of key contact.

C12c299 (Video 12.299): Flute Pinky Flexion Dystonia

Fifth-finger flexion pulling the digit away from the key.

C12c300 (Video 12.300): Flutist with Instrument Modification

Mechanical changes to the flute compensate for persistent fourth-finger dystonia.

C12c301 (Video 12.301): Bilateral Flute Dystonia

Complex dystonic finger movements affecting both hands during performance.

C12c302 (Video 12.302): Bagpipe Dystonia

Fourth- and fifth-finger flexion dystonia impairing chanter control.

C12c303 (Video 12.303): Trumpeter with Hand Dystonia

Severe left-hand finger flexion dystonia triggered while operating trumpet valves.

C12c304 (Video 12.304): Clarinetist with Exquisitely Subtle Dystonia

Failure of the index finger to fully seal an open tone hole during rapid orchestral passages.

Drummers' Dystonia

C12c305 (Video 12.305): Tabla Player's Index Finger Dystonia

Task-specific flexion dystonia of the index finger dramatically improved by botulinum toxin.

C12c306 (Video 12.306): African Drum Dystonia with Spread to Rest

Fourth- and fifth-finger flexion dystonia present at rest but disappearing during drum strike.

C12c307 (Video 12.307): Percussionist's Hand Dystonia

Pinky extension, finger flexion, and wrist deviation affecting mallet control.

C12c308 (Video 12.308): Drumstick-Induced Wrist Dystonia

Wrist flexion, radial deviation, and finger flexion triggered during drumming.

C12c309 (Video 12.309): Timpanist's Wrist Extension Dystonia

Task-specific clonic wrist extension occurring with stick strikes.

C12c310 (Video 12.310): Position-Specific Drum Dystonia

Wrist dystonia activated only in a specific drumming posture.

C12c311 (Video 12.311): Drummer's FCU-Predominant Dystonia

Flexion and ulnar deviation improved following ultrasound-guided botulinum toxin injections.

C12c312 (Video 12.312): Severe Rock Drummer's Dystonia

Progressive widespread task-specific dystonia evolving to occur even at rest.

C12c313 (Video 12.313): Bass Drum Pedal Dystonia

Task-specific foot dystonia causing impaired rhythm and pedal control.

Pianists and Violinists Dystonia - Phenomenology Atlas

Pianists' Dystonia

C12c240 (Video 12.240): Pianist's Index Finger Flexion Dystonia

Task-specific index finger flexion during piano playing and writing, improved with botulinum toxin.

C12c241 (Video 12.241): Pianist's Index Finger Extension Dystonia

Left index finger extension disrupting scales, improved by a thumb sensory trick.

C12c242 (Video 12.242): Severe Index Finger Flexion Dystonia

Marked dystonic flexion during performance substantially improved after targeted injections.

C12c243 (Video 12.243): Concert Pianist's Index Finger Dystonia

Ascending scales trigger index finger flexion improved following botulinum toxin treatment.

C12c244 (Video 12.244): Mixed Index-Middle Finger Dystonia

Index finger extension and middle finger flexion disrupting scalar passages.

C12c245 (Video 12.245): Third-Finger Flexion Dystonia

Persistent third-finger flexion relieved by a positive sensory trick.

C12c246 (Video 12.246): Index Finger MCP Flexion Dystonia

Mechanical opposition identifies the primary dystonic movement pattern.

C12c247 (Video 12.247): Thumb and Index Finger Dystonia

Orthotic splints improve fluidity and reduce dystonic activation.

C12c248 (Video 12.248): Isolated Index Finger Dystonia

Selective dystonia of the right index finger during piano performance.

C12c249 (Video 12.249): Index Finger Extension Dystonia

Extension dystonia affecting passage work while octaves remain preserved.

C12c250 (Video 12.250): Multi-Finger Pianist's Dystonia

Complex finger flexion and extension abnormalities affecting scales.

C12c251 (Video 12.251): Index Finger Flexion with Compensatory Extension

Mechanical testing identifies primary flexion dystonia.

C12c252 (Video 12.252): Mirror Dystonia in Pianist

Mirror movements identify primary dystonic extension of the second and third digits.

C12c253 (Video 12.253): Accordion Dystonia

Middle-finger extension during rapid passages improved by finger splinting.

C12c254 (Video 12.254): Keyboard Contact-Induced Dystonia

Flexion dystonia triggered specifically by keyboard contact.

C12c255 (Video 12.255): Severe Left-Hand Dystonia

Flexion of multiple fingers with compensatory wrist rotation.

C12c256 (Video 12.256): Advanced Concert Pianist's Dystonia

Severe right-hand dystonia forcing transition to left-hand repertoire.

C12c257 (Video 12.257): Fourth and Fifth Finger Dystonia

Scale passages trigger finger flexion while arpeggios remain relatively preserved.

C12c258 (Video 12.258): Thumb and Index Finger Velocity-Dependent Dystonia

Subtle dystonia apparent only during rapid ascending scales.

C12c259 (Video 12.259): Complex Five-Finger Dystonia

Index finger acts as a principal trigger for multi-digit dystonia.

C12c260 (Video 12.260): Complex Concert Pianist's Dystonia

Multiple primary dystonic movements identified through biomechanical testing.

C12c261 (Video 12.261): Bilateral Pianist's Dystonia

Bilateral finger dystonia with mirror movements during writing.

C12c262 (Video 12.262): Complex Right-Hand Dystonia

Dystonic flexion of multiple fingers with postural activation.

C12c263 (Video 12.263): Fourth and Fifth Finger Predominant Dystonia

Flexion dystonia impairing hand balance during performance.

C12c264 (Video 12.264): Severe Left-Hand Flexion Dystonia

Keyboard contact provokes marked finger flexion.

C12c265 (Video 12.265): Wrist Extension Pianist's Dystonia

Severe wrist extension improved substantially after botulinum toxin treatment.

Violinists' Dystonia

C12c266 (Video 12.266): Bow Arm Dystonia

Loss of control during bow changes, especially transitioning into up-bows.

C12c267 (Video 12.267): Severe Bow-Hand Dystonia

Wrist and index finger dystonia relieved by sensory stabilization of the bow hand.

C12c268 (Video 12.268): Cellist's Bowing Dystonia

Task-specific wrist and hand tightening impairing bow reversals.

C12c269 (Video 12.269): Violin Bow Arm Adduction Dystonia

Upper-arm dystonia occurring during up-bow initiation.

C12c270 (Video 12.270): Fast-Bowing Dystonia

Task-specific tightening triggered only at concert tempo.

C12c271 (Video 12.271): Velocity-Dependent Bow Arm Dystonia

Upper-arm co-contraction impairing rapid bow strokes.

C12c272 (Video 12.272): Severe Bow Arm Task-Specific Dystonia

Professionally disabling bow-arm dystonia improved by targeted botulinum toxin treatment.

C12c273 (Video 12.273): Left-Hand Fingering Dystonia

Second-finger dystonia affecting scale performance.

C12c274 (Video 12.274): Third-Finger Violin Dystonia

Flexion and abduction of the third finger in higher positions.

C12c275 (Video 12.275): Multi-Finger Flexion Dystonia

Slow playing provokes dystonia more than fast playing.

C12c276 (Video 12.276): Pattern-Specific Violin Dystonia

Dystonia triggered only by specific fingering combinations.

C12c277 (Video 12.277): Fourth-Finger Adduction Dystonia

Biomechanical testing identifies adduction as the primary dystonic movement.

C12c278 (Video 12.278): Vibrato Dystonia

Impaired vibrato control causing professional disability despite otherwise preserved playing.

Writer's Cramp, Other Arm, and Sports Dystonias - Phenomenology Atlas

Writer's Cramp - Phenomenology Atlas

C12c204 (Video 12.204): Writer's Cramp with Abnormal Pen Grip

Thumb, index, and middle finger dystonia triggered specifically during writing.

C12c205 (Video 12.205): Writer's Cramp with Alternative Grip Strategy

Thumb-base dystonia improved by holding the pen between different fingers.

C12c206 (Video 12.206): Writer's Cramp with Proximal Arm Involvement

Writing induces dystonia extending into the forearm and shoulder.

C12c207 (Video 12.207): Writer's Cramp with Finger Extension

Writing triggers dystonic extension of digits three through five.

C12c208 (Video 12.208): Wrist Extension Writer's Cramp

Writing activates wrist extension with thumb and index finger flexion.

C12c209 (Video 12.209): Proximal Writer's Cramp

Internal shoulder rotation and proximal arm dystonia interfere with writing.

C12c210 (Video 12.210): Task-Specific Writer's Cramp

Clear loss of writing fluency attributable to dystonic activation.

C12c211 (Video 12.211): Thumb-Index Writer's Cramp

Task-specific flexion dystonia affecting thumb and index finger.

C12c212 (Video 12.212): Multi-Finger Writer's Cramp

Flexion dystonia involving thumb, index, and middle fingers.

C12c213 (Video 12.213): Writer's Cramp with Typing Dystonia

Writing and keyboard use trigger prominent finger flexion.

C12c214 (Video 12.214): Writer's Cramp Involving Thumb and Index Finger

Classic task-specific hand dystonia extending to typing tasks.

C12c215 (Video 12.215): Writer's Cramp with Mirror Dystonia

Writing-induced dystonia accompanied by dystonic movements in the opposite hand.

C12c216 (Video 12.216): Grip-Responsive Writer's Cramp

Alternative pen positioning partially relieves dystonic posturing.

C12c217 (Video 12.217): Extensor Writer's Cramp

Thumb extension dystonia disrupts pen control during writing.

C12c218 (Video 12.218): Writer's Cramp with Adaptive Techniques

Use of multiple compensatory pen grips to improve handwriting.

C12c219 (Video 12.219): Flexor Writer's Cramp

Thumb, index finger, and wrist flexion relieved by changing pen position.

C12c220 (Video 12.220): Mirror Dystonia Demonstration

Writing with the unaffected hand triggers dystonic movements of the affected limb.

C12c221 (Video 12.221): Writer's Cramp with Contralateral Overflow

Mirror flexion dystonia elicited by writing with the opposite hand.

C12c222 (Video 12.222): Writer's Cramp Clarified by Mirror Dystonia

Mirror overflow identifies the primary dystonic movement pattern.

C12c223 (Video 12.223): Severe Writer's Cramp with Glove Sensory Trick

Marked writing dystonia improved by wearing a glove.

C12c224 (Video 12.224): Mixed Flexion-Extension Writer's Cramp

Complex finger dystonia partially responsive to sensory tricks.

C12c225 (Video 12.225): Severe Writer's Cramp with Mirror Overflow

Pronounced mirror dystonia accompanying task-specific writing impairment.

C12c226 (Video 12.226): Severe Writer's Cramp with Temporary Improvement

Brief improvement after strenuous hand exercise.

C12c227 (Video 12.227): Writer's Cramp with Counter-Pressure Maneuver

Mechanical opposition of dystonic movement modestly improves handwriting.

C12c228 (Video 12.228): Writer's Cramp Before and After Botulinum Toxin

Ultrasound-guided treatment significantly improves writing and mirror dystonia.

C12c229 (Video 12.229): Complex Writer's Cramp Responding to Botulinum Toxin

Enhanced writing speed, fluidity, and reduction of dystonic posturing after treatment.

C12c230 (Video 12.230): Extension-Type Writer's Cramp

Improved writing performance following targeted botulinum toxin injections.

Other Arm and Sports Dystonias

C12c231 (Video 12.231): Texting and Typing Dystonia

Task-specific flexion of the index finger during texting and typing, improved by removing the index finger from the motor task ("fingerectomy maneuver").

C12c232 (Video 12.232): Archery Dystonia

Task-specific scapular dystonia impairing stabilization of the bow during archery.

C12c233 (Video 12.233): Table Tennis Dystonia

Complex dystonia involving elbow adduction, flexion, and forearm supination disrupting paddle control.

C12c234 (Video 12.234): Baseball Throwing Dystonia

Task-specific throwing dystonia causing loss of control during baseball throws from shortstop to first base.

C12c235 (Video 12.235): Finger Dystonia with Typing Impairment

Index finger extension dystonia improved after targeted lumbrical botulinum toxin injections.

C12c236 (Video 12.236): Upper Limb Dystonia with Mirror Overflow

Right hand dystonia affecting writing and typing, associated with mirror movements.

C12c237 (Video 12.237): Tennis Dystonia

Task-specific dystonia triggered while gripping and using a tennis racquet.

C12c238 (Video 12.238): Rest and Postural Hand Dystonia

Dystonic finger and wrist flexion most apparent during supination.

C12c239 (Video 12.239): Proximal Shoulder Girdle Dystonia

Complex dystonic movements involving the scapula and shoulder at rest.

Cervical Dystonia - Phenomenology Atlas

Cervical Dystonia - Phenomenology Atlas

C12c165 (Video 12.165): Cervical Dystonia, Predominantly Torticollis

Right torticollis activated by speaking, improved by touching the chin and demonstrating the "closing-the-loop" sensory trick phenomenon.

C12c166 (Video 12.166): Left Rotational Cervical Dystonia

Jerky left torticollis relieved by speech and by touching the forehead or cheek.

C12c167 (Video 12.167): Cervical Dystonia with State Function Behavior

Rightward torticollis improved by chin sensory geste and partially normalized while running.

C12c168 (Video 12.168): Severe Rotational Torticollis

Marked rightward torticollis improved by sensory tricks and significantly ameliorated during running.

C12c169 (Video 12.169): Torticollis with Laterocollis

Rightward torticollis and leftward tilt relieved by leaning the head against a wall or touching the chin.

C12c170 (Video 12.170): Cervical Dystonia with Sternocleidomastoid Hypertrophy

Left torticollis and right tilt accompanied by prominent hypertrophy of the right sternocleidomastoid muscle.

C12c171 (Video 12.171): Cervical Dystonia with Imagined Geste

Left turn and right tilt improved by both actual and imagined sensory tricks.

C12c172 (Video 12.172): Cervical Dystonia with Dystonic Tremor

Jerky head tremor with left torticollis and right tilt relieved by touching the posterior neck.

C12c173 (Video 12.173): Mixed Torticollis and Laterocollis

Leftward turn and right tilt improved by facial sensory tricks and support against a wall.

C12c174 (Video 12.174): Cervical Dystonia with Mild Dystonic Tremor

Combined torticollis, laterocollis, and head tremor responding to sensory gestes.

C12c175 (Video 12.175): Task-Activated Cervical Dystonia

Right torticollis and left tilt markedly worsened by texting and writing.

C12c176 (Video 12.176): Cervical Dystonia with Ponytail Geste

Left turn and right tilt relieved by touching the face or pulling a ponytail.

C12c177 (Video 12.177): Cervical Dystonia with Nasal Sensory Trick

Leftward turn and right tilt partially improved by pinching the nose.

C12c178 (Video 12.178): Fixed Cervical Dystonia

Right torticollis and left tilt with restricted range of motion and diminished response to prior sensory tricks.

C12c179 (Video 12.179): Cervical Dystonia with Marked Muscle Hypertrophy

Left torticollis and tilt associated with striking sternocleidomastoid enlargement.

C12c180 (Video 12.180): Severe Cervical Dystonia

Forceful leftward turn, right tilt, and shoulder elevation with marked improvement after botulinum toxin treatment.

C12c181 (Video 12.181): Evolving Cervical Dystonia Pattern

Initially left-sided torticollis evolving over time into right torticollis with dystonic tremor.

C12c182 (Video 12.182): Cervical Dystonia with Lateral Shift

Leftward torticollis associated with lateral head shift and mild retrocollis.

C12c183 (Video 12.183): Shift-Predominant Cervical Dystonia

Marked torticollis and lateral shift dramatically relieved by sensory tricks and running.

C12c184 (Video 12.184): Predominant Anterocollis

Forward neck flexion producing significant disability during standing and walking.

C12c185 (Video 12.185): Anterocollis with Sensory Gestes

Forward neck flexion improved by touching the forehead or chin.

C12c186 (Video 12.186): Progressive Anterocollis

Anterocollis associated with rotational and tilt components activated during gait.

C12c187 (Video 12.187): Complex Anterocollis

Anterocollis with torticollis and laterocollis demonstrating sensory tricks and improvement while running.

C12c188 (Video 12.188): Severe Retrocollis

Marked neck extension relieved by manually supporting the forehead.

C12c189 (Video 12.189): Walking-Induced Retrocollis

Jerky retrocollic movements becoming most apparent during ambulation.

C12c190 (Video 12.190): Retrocollis with Sensory Tricks

Retrocollis improved by chin touch, wall contact, and closing-the-loop maneuver.

C12c191 (Video 12.191): Mild Retrocollis with Torticollis

Retrocollis accompanied by leftward turn and left shoulder elevation.

C12c192 (Video 12.192): Retrocollis Activated by Writing

Retrocollis and torticollis worsened by writing and improved during walking.

C12c193 (Video 12.193): Retrocollis with Imagined Sensory Trick

Significant improvement using both real and imagined gestes.

C12c194 (Video 12.194): Retrocollis Controlled by External Supports

Retrocollis relieved by facial sensory tricks and a customized “sensory trick hat.”

C12c195 (Video 12.195): Shift-and-Turn Cervical Dystonia

Rightward torticollis associated with anterior head shift.

C12c196 (Video 12.196): Cervical Dystonia with Dystonic Tremor and Shift

Right torticollis and anterior shift normalized during running.

C12c197 (Video 12.197): Severe Shift Dystonia

Marked left torticollis and lateral shift improved by a mechanical support device.

C12c198 (Video 12.198): Anterior Head Shift Syndrome

Anterior translation with retrocollis demonstrating both positive and negative sensory tricks.

C12c199 (Video 12.199): Dystonic Head Tremor

Irregular multidirectional head tremor relieved by sensory gestures and null-point positioning.

C12c200 (Video 12.200): Dystonic Tremor with Torticollis

Jerky horizontal head tremor accompanying right torticollis.

C12c201 (Video 12.201): Severe Dystonic Head Tremor

Prominent head tremor partially controlled by manual stabilization.

C12c202 (Video 12.202): Complex Cervical Dystonic Tremor

Multidirectional jerky head oscillations markedly improved by sensory tricks.

C12c203 (Video 12.203): Closing-the-Loop Phenomenon

Demonstration of cervical dystonia sensory tricks requiring active patient-generated sensory feedback.

Spasmodic Dysphonia - Phenomenology Atlas

Spasmodic Dysphonia - Phenomenology Atlas

Abductor Spasmodic Dysphonia

C12c118 (Video 12.118): Mild Abductor Spasmodic Dysphonia

Breathy vocal breaks triggered by vowels and soft consonants.

C12c119 (Video 12.119): Sodium Oxybate-Responsive ABSD

Abductor vocal breaks significantly improved after sodium oxybate administration.

C12c120 (Video 12.120): Moderate Abductor Spasmodic Dysphonia

Breathy strained voice with partial response to sodium oxybate.

C12c121 (Video 12.121): ABSD with Sensory Feedback Maneuver

Improvement of vocal breaks by cupping hands behind the ears.

C12c122 (Video 12.122): ABSD with Writer's Cramp

Concurrent laryngeal and hand dystonia.

C12c123 (Video 12.123): Moderate ABSD

Frequent breathy vocal interruptions affecting connected speech.

C12c124 (Video 12.124): Classic ABSD

Task-specific breathy breaks reproduced by trigger sentences.

C12c125 (Video 12.125): Moderate-Severe ABSD

Telephone conversations markedly impaired while singing remains easier.

C12c126 (Video 12.126): Severe Abductor Dysphonia

Frequent vocal interruptions affecting nearly all speech.

C12c127 (Video 12.127): Near-Mute ABSD

Almost complete inability to generate fluent speech.

C12c128 (Video 12.128): Severe ABSD with Compensatory Strain

Abductor breaks partially compensated by excessive vocal effort.

C12c129 (Video 12.129): Advanced ABSD

Continuous vocal breaks significantly impairing communication.

C12c130 (Video 12.130): Severe Young-Onset ABSD

Frequent abductor vocal interruptions involving virtually every sentence.

C12c131 (Video 12.131): ABSD with Vocal Tremor

Breathy voice following botulinum toxin injections and superimposed vocal tremor.

C12c132 (Video 12.132): ABSD with Mild Vocal Tremor

Prominent abductor breaks with subtle oscillatory voice tremor.

C12c133 (Video 12.133): Abductor Dysphonia and Tremor

Speech improved by whispering or speaking in higher pitch.

C12c134 (Video 12.134): Vocal Tremor During Singing

ABSD associated with regular oscillatory tremor during singing.

C12c135 (Video 12.135): Severe ABSD with Tremor

Difficulty sustaining vowels due to combined tremor and vocal breaks.

C12c136 (Video 12.136): ABSD Improved with Sodium Oxybate

Modest improvement in both vocal tremor and vocal breaks.

C12c137 (Video 12.137): Singer with ABSD and Vocal Tremor

Task-specific dysphonia combined with prominent tremor during singing.

Adductor Spasmodic Dysphonia

C12c138 (Video 12.138): Mild Adductor Spasmodic Dysphonia

Subtle strangled vocal quality with intermittent adductor breaks.

C12c139 (Video 12.139): Sodium Oxybate-Responsive ADSD

Near-complete disappearance of adductor breaks after treatment.

C12c140 (Video 12.140): Moderate ADSD

Strangled voice quality and multiple adductor interruptions during phonation.

C12c141 (Video 12.141): Mild-Moderate ADSD

Relatively fluent speech interrupted by dystonic vocal strain.

C12c142 (Video 12.142): Raspy Adductor Dysphonia

Prominent vocal strain with relatively few overt breaks.

C12c143 (Video 12.143): Classic ADSD

Strained voice improving during whispering and singing.

C12c144 (Video 12.144): Moderate ADSD with Frequent Breaks

Speech disrupted by recurrent adductor interruptions.

C12c145 (Video 12.145): ADSD with Preserved Whispering

Characteristic vowel-triggered breaks with normal whispering.

C12c146 (Video 12.146): Moderate Adductor Dysphonia

Constricted, strained voice with significant vowel-induced spasms.

C12c147 (Video 12.147): ADSD with Compensatory Speech Strategies

Patient adapts to persistent vocal strain and voice interruptions.

C12c148 (Video 12.148): Moderate-Severe ADSD

Frequent adductor breaks and markedly strained speech.

C12c149 (Video 12.149): Severe Adductor Dysphonia

Near-continuous constricted phonation affecting all vocal output.

C12c150 (Video 12.150): Severe ADSD with Voice Dropout

Sustained adductor spasms causing periodic inability to phonate.

C12c151 (Video 12.151): Advanced Adductor Dysphonia

Voice perceived as trapped in the throat because of persistent spasms.

C12c152 (Video 12.152): Young Adult with Severe ADSD

Marked impact of dystonic voice disorder on everyday life.

C12c153 (Video 12.153): Singing-Induced Adductor Dysphonia

Task-specific dystonia triggered predominantly during singing.

C12c154 (Video 12.154): Singer's Dystonia

Adductor breaks occurring exclusively during sustained singing.

C12c155 (Video 12.155): Register-Specific Singer's Dystonia

Breaks occurring in middle register while high register remains preserved.

C12c156 (Video 12.156): Singing Dystonia with Compensation

Professional singer adapts technique to overcome dystonic interruptions.

C12c157 (Video 12.157): ADSD with Vocal Tremor

Combined adductor vocal breaks and oscillatory phonatory tremor.

C12c158 (Video 12.158): Severe ADSD with Tremor

Strangled speech accompanied by prominent vocal oscillations.

C12c159 (Video 12.159): ADSD with Reading-Induced Tremor

Vocal tremor emerging during connected speech.

C12c160 (Video 12.160): Adductor Dysphonia with Oscillatory Tremor

Regular phonatory oscillations combined with mild adductor spasms.

C12c161 (Video 12.161): ADSD with Fast Vocal Tremor

Fine rapid tremor superimposed on adductor voice breaks.

C12c162 (Video 12.162): Moderate-Severe ADSD and Vocal Tremor

Strangled voice accompanied by audible rhythmic oscillation.

C12c163 (Video 12.163): Mixed Tremor and Adductor Dysphonia

Vocal tremor interrupted intermittently by adductor spasms.

C12c164 (Video 12.164): Advanced ADSD with Vocal Tremor

Continuous vocal tremor and persistent dystonic voice breaks.

Embouchure Dystonia (Brass and Woodwind) - Phenomenology Atlas

Embouchure Dystonia (Brass and Woodwind)

C12c78 (Video 12.78): Trumpet Embouchure Tremor

Middle-register embouchure tremor consistent with tremor-variant embouchure dystonia.

C12c79 (Video 12.79): Trumpet Embouchure Tremor with Mentalis Activation

Visible and audible lip tremor involving lower facial musculature.

C12c80 (Video 12.80): Trumpet Lip-Pulling Embouchure Dystonia

Downward pulling of lip corners causing air leakage during performance.

C12c81 (Video 12.81): Severe Trumpet Lip-Pulling Dystonia

Loss of embouchure control affecting multiple playing registers.

C12c82 (Video 12.82): Task-Specific Meige Syndrome in a Trumpeter

Lower facial dystonia triggered simply by assuming playing position.

C12c83 (Video 12.83): Task-Specific Meige with Sensory Trick

Blepharospasm and facial dystonia abolished by self-generated facial touch.

C12c84 (Video 12.84): French Horn Embouchure Tremor

Task-specific embouchure tremor confined to a narrow register range.

C12c85 (Video 12.85): French Horn Embouchure Tremor

High-register tremor worsened after botulinum toxin treatment.

C12c86 (Video 12.86): French Horn Tremor Variant

Rapid visible embouchure tremor during performance.

C12c87 (Video 12.87): French Horn Task-Specific Tremor

Register-specific embouchure oscillations.

C12c88 (Video 12.88): French Horn Tremor Affecting Articulation

Greater impairment during separated attacks than slurred notes.

C12c89 (Video 12.89): Mouthpiece-Induced Embouchure Tremor

Visible tremor present both with mouthpiece and instrument.

C12c90 (Video 12.90): Essential Tremor Presenting as Embouchure Tremor

Jaw, facial, and vocal tremor affecting brass performance.

C12c91 (Video 12.91): French Horn Lip-Pulling Dystonia

Difficulty producing connected slurred notes.

C12c92 (Video 12.92): Articulation Failure Embouchure Dystonia

Loss of clarity at attack initiation in exposed orchestral passages.

C12c93 (Video 12.93): Advanced Horn Embouchure Dystonia

Difficulty initiating and sustaining tones in upper register.

C12c94 (Video 12.94): Jaw and Tongue Embouchure Dystonia

Jaw retraction and lingual tightening disrupting performance.

C12c95 (Video 12.95): Trombone Embouchure Tremor

Middle-register embouchure tremor causing difficulty sustaining pitch and tone production.

C12c96 (Video 12.96): Trombone Tremor Variant of Embouchure Dystonia

Visible and audible embouchure tremor most prominent in middle and low registers.

C12c97 (Video 12.97): Trombone Lip-Pulling Dystonia

Loss of articulation clarity during note initiation improved by mechanically pulling the lip corners laterally.

C12c98 (Video 12.98): Severe Trombone Lip-Pulling Dystonia

Lateral separation of the lips producing air leakage and impaired tone control.

C12c99 (Video 12.99): Trombone Embouchure Dystonia with Sensory Trick

Lip-pulling dystonia relieved by touching the cheek, improving note attacks.

C12c100 (Video 12.100): Trombone Lip-Lock Dystonia

Involuntary lip clamping causing delayed articulation and impaired note initiation.

C12c101 (Video 12.101): Lip-Lock Embouchure Dystonia

Failure of lip release during articulation resulting in delayed sound production.

C12c102 (Video 12.102): Sensory-Responsive Lip-Lock Dystonia

Improved articulation through facial sensory trick application.

C12c103 (Video 12.103): Lip-Lock Dystonia with Multiple Sensory Tricks

Improvement in attacks by touching the chin or jaw.

C12c104 (Video 12.104): Tuba Embouchure Tremor

Fine low-register embouchure tremor affecting sustained tone.

C12c105 (Video 12.105): Subtle Tuba Embouchure Dystonia

Selective impairment of highly exposed solo note attacks.

C12c106 (Video 12.106): Velocity-Dependent Lip-Lock Dystonia

Articulation failure occurring only during very slow note attacks.

C12c107 (Video 12.107): Didgeridoo Task-Induced Tremor

Jaw and facial tremor during didgeridoo performance, likely representing task-induced essential tremor.

C12c108 (Video 12.108): Alphorn Embouchure Tremor

Visible and audible tremor of embouchure control during performance.

Woodwind Embouchure Dystonia

C12c109 (Video 12.109): Flute Lip-Pulling Dystonia

Upper-lip protrusion misdirecting airflow, markedly improved by sensory tricks.

C12c110 (Video 12.110): Flute Embouchure Dystonia with Bilateral Sensory Gestes

Upper-lip dystonia improved by internal and external tactile cues.

C12c111 (Video 12.111): Instrument-Specific Jaw Dystonia

Normal flute playing but complete inability to control the saxophone embouchure.

C12c112 (Video 12.112): Jaw Embouchure Dystonia with Writer's Cramp

Combined flute, clarinet, and writing dystonia sharing a common dystonic mechanism.

C12c113 (Video 12.113): Flute Embouchure Dystonia with Mirror Writer's Cramp

Jaw dystonia during flute performance with coexisting hand dystonia.

C12c114 (Video 12.114): Laryngeal and Pharyngeal Embouchure Dystonia

Task-specific laryngeal and pharyngeal dystonia affecting saxophone tone production.

C12c115 (Video 12.115): Embouchure Dystonia with Spread to Rest

Jaw dystonia progressing beyond instrument playing to occur spontaneously.

C12c116 (Video 12.116): Tongue Embouchure Dystonia with Speech Spread

Tongue dystonia initially limited to flute playing, later affecting speech.

C12c117 (Video 12.117): Tongue Embouchure Dystonia

Persistent speech impairment after spread from task-specific flute dystonia.