Detection, Prevention, and Management of Extrapyramidal Symptoms

Tamra Jean Courey,MSN


Journal for Nurse Practitioners. 2007;3(7):464-469. 

In This Article

Clinical Manifestations and Onset of Symptoms


One of the most common EPSs is akathisia. This disturbing symptom of inner motor restlessness can have both a subjective and objective component.[1,2,3,9,10] Subjectively, clients may verbalize that they are unable to remain calm, have disturbed sleep patterns, or have impaired concentration. Symptoms are often described as "anxiety," which is concerning because it may prompt a clinician to administer an additional APM. Objectively, clients may demonstrate restlessness through actions such as pacing, marching, shuffling, foot-taping, rocking motion, or shifting body weight from leg to leg. Restlessness can be throughout the entire body or confined to a section of the extremities.[1,2,3] Akathisia can surface within a few days of administration of the APM or up to several weeks later.

Dystonic Reactions

Dystonic reactions are involuntary muscle contractions of the head, neck, trunk, and extremities. The neck and head muscles are the most commonly affected areas, including the tongue, throat, face, eyes, and jaw.[1,2,3] Symptoms affecting the tongue and throat muscles can affect the vocal cords, causing a hoarse voice, stiff or thick tongue, dysphagia, laryngeal or pharyngeal spasms, and potential obstruction, which becomes a medical emergency. Neck and trunk symptoms include torticollis, contorting or twisting of the cervical spine muscles, and opisthotonos, a severe form of back arching.[1,2,3] In addition, clients may experience oculogyric crisis which is rolling of the eyes in a locked upward position. This condition can easily be mistaken as delusional behavior.[3] Dystonic reactions can occur after a single dose of the APM or days after initiating treatment.


Pseudoparkinsonism, or neuroleptic-induced parkinsonism, includes slow pill-rolling finger tremors, masklike facial expression, weakened voice, absence of arm swing when walking, stiff stooped posture, and an impaired shuffling gait. Cogwheeling rigidity, assessed frequently in the arms, is a ratchet-like motion of the extremities during extension. Mentally, the client can display bradyphrenia, or a slowed ability to think through familiar situations. One unique manifestation after prolonged use of the APM is the rabbit syndrome which is tremors of the lips and a constant chewing motion.[2,11] Pseudoparkinsonism can develop after the first dose of medication is administered or weeks later; however, it is usually seen early in treatment or when the APM dosage is increased.


Dyskinesia is characterized by rapid, repetitive, involuntary movements of the face, trunk, respiratory muscles, and extremities. Facial movements, which often occur in the oral area, can include a protruding or rolling tongue, lip smacking, grimacing, frowning, sucking or kissing motions, and facial distortions. Stereotypic movements of the limbs can be irregular, rapid, purposeless motions or slow serpentine movements.[1,2,3] A client's trunk may rock, twist, jerk, or thrust forward. Unlike the other EPSs, dyskinesia is a late-appearing side effect that can emerge months to years after the APM has been administered, and it is identified as tardive dyskinesia. In some cases, about 6%, the symptoms are irreversible. However, if the antipsychotic agent is removed quickly, the tardive dyskinesia may be reversed.[2,3] The symptoms of tardive dyskinesia can be disfiguring and embarrassing for clients; therefore, potential for social isolation is a concern. Age, race, and sex appear to place some persons at a higher risk of tardive dyskinesia. Table 3 identifies potential risk factors contributing to this EPS.[12]

Screening instruments can assist in identifying the specific category of EPSs as well as the severity of symptoms. Examples of instruments are noted in Table 4 .[9,13,14,15]

From Table 4 , the 12-item Abnormal Involuntary Movement Scale (AIMS) is commonly used to screen for EPSs and can be easily accessed from the Internet at or This comprehensive tool measures the atypical movements as well as the intensity of symptoms. Completing the scale involves observing the client repeat specific actions and rating the movements. Directing the client to stick out his or her tongue, walk in a straight line, extend the arms with palms facing downward, and touch the index finger to the nose repeatedly are some of the examination procedures. These actions help identify irregular movements in seven different areas of the body, including the face, mouth, extremities, and trunk.[16] When an AIMS score is obtained, it provides quantitative assessment data for the NP to use in better management of symptoms.


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