Movement disorders involve either abnormal decrease in movement or increase in movement. Parkinson disease is a common disorder with decreased movement (hypokinetic), and Essential tremor is the most common disorder with excessive movement (hyperkinetic).
The term “movement disorders” refers to a group of nervous system (neurological) conditions that cause abnormal increased movements, which may be voluntary or involuntary. Movement disorders can also cause reduced or slow movements
Learn how our team approaches treatment of patients with the following movement disorders.
The term “parkinsonism” refers to the constellation of symptoms associated with decreased effect of dopamine in the brain, which results in slow movement, resting tremor, stiffness, postural instability, and slowed walking. These symptoms can be from various causes including exposure to medications, toxins, Parkinson disease, or “Parkinson-plus syndromes.”
Some antipsychotic and anti-nausea medications can cause medication induced parkinsonism. There are neuro-toxins that can rarely cause parkinsonism.
When there is no other clear cause and a person develops signs of parkinsonism that progress, Parkinson disease (PD) is diagnosed. When compared to other causes of parkinsonism, PD tends to have more asymmetry in presentation (one side of the body is more affected than the other) and tends to have a better response to medical treatments. It is not well understood what causes PD, but this is an area of current research.
PD is a clinical diagnosis, meaning that there is no specific blood test or MRI to state whether or not a person has PD. A Neurologist will be able to do a details evaluation and rule out other causes of symptoms, so as to allow an early diagnosis of PD, which can lead to beneficial treatment and improvement in quality of life.
Parkinson disease has prominent motor symptoms, but there are also less well publicized but important non-motor symptoms to note.
|Doctor Name||Dr. Barbara Pickut, MD|
|Subspecialty||Parkinson Disease, Movement Disorders|
There are a wide variety of medications when can be used to help with the symptoms of PD, particularly offering relief of the motor symptoms. Current medications available do not change the disease process or “cure” the PD, but instead help manage symptoms, which has been shown to improve quality of life and increase length of survival. The medications have varying side effect profiles and efficacy, so the Neurologist takes care to consider and discuss the options in detail.
Commonly used medications are discussed below:
Levodopa is the most effective medication for treating parkinsonism. It is a pill that is converted to dopamine in the brain. Many formulations of levodopa also contain carbidopa (such as Sinemet), which lowers the total dose of levodopa needed and therefore can decrease the amount of gastrointestinal side effects. There are short-acting and long-acting formulations available. More recently, for people who have dysphagia and cannot safely swallow pills due to PD, there is an option called Duopa where a pump can give an infusion of levodopa through a stomach tube.
Because levodopa is so reliably effective, a trial of this medication may be part of the diagnosis of PD
Some patients experience a “wearing off” phenomenon where the benefit goes away at the end of the dose cycle. This can be addressed by changing the dosing frequency.
It is possible to get dyskinesias, which can be painful stiffening or movement of muscles, due to excessive levodopa. This may result in a decrease in dosing.
COMT inhibitors such as Contain can be used to further increase the availability and duration of levodopa in the body, if needed.
Selective inhibitors of MAO-B, which is an enzyme that leads to breakdown of dopamine, can be used to increase the availability of dopamine in the brain. These may be used early in the PD disease process.
Amantadine is a medication that blocks NMDA receptors and increases dopamine availability in the brain, helping with the tremor of PD and levodopa-induced dyskinesias. This may be used in mild to moderate PD, especially in younger people. In older patients, amantadine can cause disorientation or hallucinations.
Dopamine receptor agonists directly activates the dopamine receptors in the brain, therefore helping with symptoms. There are pill and transdermal patch options. In comparison to levodopa, dopamine agonists are somewhat less effective at treating PD symptoms and have a higher risk of dyskinesias. These medications have been associated with difficulty with impulse control, such as increased gambling or risky behavior, and therefore a person’s behavior should be monitored closely.
In addition to medication therapies, there are now exciting surgical options available that can greatly improve parkinsonian symptoms in PD.
DBS involves surgically implanting stimulators into regions of the brain associated with PD – such as pallidal DBS, thalamic DBS, or subthalamic nucleus (STN) DBS. The DBS stimulator can be adjusted and tailored for symptom control. DBS is approximately as beneficial as levodopa, however it has the benefit of much less motor fluctuations and no dyskinesias.
There are other neurodegenerative conditions which involve parkinsonism but are distinct from PD due to the presence of other characteristics. It is important for the Neurologist to differentiate these conditions, as they are treated differently and have a different disease course.
Tics are brief purposeless movements, which are often repetitive. These are common, especially in children. In contrast to other conditions, these can be suppressed – or stopped – with concentration. Tics are considered to have partially voluntary control. These may occur more in times of stress.
Tics themselves do not require treatment, unless they are troublesome to the person experiencing them.
A wide variety of medications can be attempted for treating tics, each with differing side effect profiles.
Tourette’s syndrome is a neuropsychiatric disorder that starts in childhood and involves motor and phonic (or sound) tics. This tends to improve more in adulthood.
In addition to treating the tics, people with Tourette’s syndrome should be screened for Obsessive-compulsive disorder (OCD) and Attention deficit disorder (ADD), as these often are associated with each other.
Myoclonus is a brief large-amplitude involuntary jerking movement of a muscle group. There can be a wide variety of causes, including kidney problems, liver problems, brain injuries, or seizure activity.
The primary treatment for myoclonus is to address the underlying condition causing the myoclonus.
Tardive dyskinesia involves involuntary movements that are the result of exposure to dopamine receptor blocking drugs. The causative medications can include antispychotics or certain anti-nausea medications.
The most common form of TD with recurrent mouth, lip, or tongue movements. It can also occasionally involve movements of the extremities.
Care should be taken to avoid over-exposure to causative medications, but other medications may be considered to treat these movements once TD is present, such as tetrabenazine or clonazepam.
Dystonia involves sustained muscle contractions in portions of the body, which can result in abnormal postures. One example is cervical dystonia, where the neck may become bent and uncomfortable.
Medications such as trihexyphenidyl may be considered, but often Botox injections are the treatment of choice.
Chorea are a rare involuntary movement that involves non-rhythmic dance-like jerking movements. A variety of rare neurological conditions can result in this, such as Huntington’s disease, Wilson’s disease, or Sydenham’s chorea.
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