Symptoms of Parkinson's

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The symptoms of Parkinsons Disease are dyskinesias, anosmia, akinesia, gait freezing, “on-off” motor fluctuations, rigidity, tremor, bradykinesia, levodopa failure syndrome (LDFS), masked facies, parkinson’s plus syndrome, stooped posture, shuffling gait, and dystonia.

DYSKINESIA "Dyskinesia differs from tremor in that dyskinesias are larger non-purposeful movements involving several joints, where tremor is usually in the hands. Dyskinesia develops in normal onset Parkinson’s Disease patients usually after 5 to 8 years of taking L-dopa (Sinemet). This side effect can become more disabling than most other symptoms of Parkinson’s, and may cause the patient to reduce the amount of Sinemet that they take. These dyskinesias commonly occur when the level of L-dopa is maximum, usually beginning 30 minutes or so after ingestion of medicine. In some patients, dyskinesia occurs more than 75% of the day.

Fortunately, Pallidotomy completely eliminates dyskinesia in the vast majority of patients. If you have troublesome dyskinesia, you may be an excellent candidate for surgery."

ON-OFF MOTOR FLUCTUATIONS "One of the major disabling factors of advanced Parkinson’s is that medications, such as Sinemet, begin to promote erratic responses for both therapeutic and negative effects. During peak dose responses dyskinesia may occur and when the medication is low akinesia occurs. When the medication response becomes brittle, what is called “on-off” motor fluctuations take place and the patient may swing from a state of akinesia to dyskinesia. When a patient first begins taking their Parkinson’s medications, they are able to reduce their symptoms throughout the day. However, a wearing off period develops when the medicine stops working, and their symptoms get worse. Eventually this can reach a state where the patients go “off” even though they took the medication. The “off” periods can be quite severe and become manifest when a patient can no longer walk, develops a masked facies, is rigid, and has tremor. Falling may also occur during these states.

These side effects of Parkinson’s medication are reduced in most patients, and are eliminated in some patients following Pallidotomy. Overall, Pallidotomy smooths the effects of Parkinson’s medications, eliminating “on” dyskinesia and reducing the amount of fluctuations throughout the day. With concomittant medications, severe “off” periods are usually eliminated following Pallidotomy."

RIGIDITY "Resistance to movement of the arms and legs is called rigidity. The muscles are stiff, and difficult to move when the patient is attempting to relax the arms. Rigidity occurring in Parkinson’s Disease commonly has a “cogwheel” character. When the rigid arm is extended, for instance, the arm catches and releases as it is extended. Rigidity that feels like a “lead pipe” without any cogwheeling is indicative of a Parkinson’s Plus syndrome of Striatonigral degeneration. Also, in stroke patients there is “spasticity” in which a joint resists movement, then suddenly gives way. This is termed “clasped knife rigidity,” and is not seen in Parkinson’s Disease.

The Pallidotomy is very effective at eliminating rigidity on the opposite side of the operation.

TREMOR A large proportion of patients with Parkinson’s Disease have tremor. However, not all do, and some have very little. The presence of tremor does not mean that you have Parkinson’s Disease, since familial tremor can look like Parkinson’s. The tremor of Parkinson’s Disease is called “resting tremor”, meaning that it occurs when the hand or foot is not actively doing something, and dissipates with action. For example, a resting tremor is present when the patient is sitting and relaxing their hands on an armrest, and disappears when they pick up a glass of water. The resting tremor of Parkinson’s disease, especially if unilateral or the predominant symptom, is associated with a very favorable form of Parkinson’s within the spectrum of parkinsonism, and as such is a good prognostic indicator of long-term functional capabilities. Another form of tremor sometimes mistaken for Parkinson’s resting tremor occurs only when the patient tries to use their hand. This is called an “intentional tremor” and is associated with damage to the cerebellum. In advanced Parkinson’s Disease tremor becomes less apparent.

The Pallidotomy is effective at reducing the amount and severity of tremor on the side opposite the lesion. However, Pallidotomy does not eliminate all Parkinson’s tremor. The Thalamotomy, a similar operation, is 95% effective at permanently eliminating tremor. However, it is less effective at the other symptoms of Parkinson’s than is Pallidotomy. If your primary symptom is tremor, you may consider having both a Pallidotomy and Thalamotomy during the same operation. Deep brain stimulation for tremor is especially indicated for patients with severe bilateral tremor.

AKINESIA Many patients with advanced Parkinson’s Disease develop akinesia - the lack of initiation of movement. This is a serious consequence of medication failure and is often temporary during trough dosage levels, and is as such one of the “off” phenomena. Akinesia unrelated to medication fluctuations may be associated with structural degenerations linked to Parkinson’s Plus Syndromes.

Pallidotomy, Subthalamic nucleus stimulation, and Dopaminergic medications in general are often effective at eliminating disabling akinesia.

GAIT FREEZING This symptom may be distinct from akinesia and occasionally may not improve with medicine. This “stuttering” of steps at the time of gait initiation or passing through doorways can lead to falling and usually occurs during under-medicated states. Some medications such as L-Threo DOPS (from Japan) or Prozac have been reported to help. Deep brain stimulation in an area of the anterior globus pallidus can improve gait freezing in about half of the patients undergoing this procedure.

Pallidotomy can improve or eliminate “off” gait freezing, but may not affect “on” gait freezing.

ANOSMIA Most patients with idiopathic Parkinson’s Disease cannot smell. (This may be a good sign) A simple test to check your loved one’s smell is to ask them to close their eyes, place a strong smell (for instance, coffee grounds) under their nose, and ask them to tell you what they smell. Some patients, whose primary symptom is tremor for many years (more than 10 to 15 years) are still able to smell. And nearly all patients with Parkinson’s Plus syndromes can smell.

Unfortunately, smell is not improved by Pallidotomy, although appetite, appreciation for food, and normal body weight are improved.

BRADYKINESIA Slowness of movement is termed bradykinesia. This is common in Parkinson’s Disease. The slowness is apparent, and patients report taking longer to do simple things.

Pallidotomy significantly improves bradykinesia, although it rarely elimates it completely without the use of medication.

DYSTONIA Abnormal increased muscle tone or cramping, abnormal postures, especially of the ankle, foot, or toes which may persist for minutes or hours is referred to as dystonia. This problem is common in Parkinson’s Disease, especially among younger patients, or at trough levels of L-Dopa, for instance upon awakening the first thing in the morning.

LEVODOPA FAILURE SYNDROME (LDFS) This syndrome is defined by the disabling side effects of medication. LDFS is characterized by extended periods of akinetic “off” periods during the day, severe dyskinesia, or dystonia. Attempts to modulate these symptoms by well orchestrated combinations and refined dosages of medication eventually fail most patients. Levodopa was first introduced over 30 years ago. Many patients have been taking medications for more than the 12 to 15 year expected effective usefulness of these drugs. We estimate that over 200,000 patients of the 1,000,000 Parkinson’s patients suffer daily from the disappointment and disability of Levodopa Failure Syndrome.

Pallidotomy is recommended for patients suffering from Levodopa Failure Syndrome since it is capable of relieving all of the symptoms for 87% of patients. Moreover, Pallidotomy and Parkinson’s medications act in concert.

MASKED FACIES The characteristic expressionless face of a Parkinson’s patient is usually referred to by Doctors as a masked face. This is more common in under-medicated states and often is interpreted by the observer as a perception based on lack of the patient blinking his/her eyes. Eye blinking should occur about 20 to 30 times per minute. If the patient is under-medicated, eye blink rates can be as low as 2 to 5 times per minute. Generally speaking, beneficial medication doses and brain levels are associated with a normal blink rate.

Pallidotomy provides for consistency of medication effects, thereby eliminating the expressionless face.

PARKINSON’S PLUS SYNDROME These syndromes are severe Parkinsonian states not based solely on chemical imbalances, but along with structural degeneration in the brain. Patients may have early response to medication, but fail and become disabled to the point of being wheelchair bound within 5 years. This diagnosis can be made by MRI scanning which would then show atrophy of the brain stem, cerebellum, or basal ganglia. Thus olivo-ponto-cerebellar atrophy (OPCA) or striatonigral degeneration (SND) or both multiple system atrophy (MSA) can occur. Concomittant symptoms not usually found in Parkinson’s include swallowing difficulty, urinary incontinence, and very low blood pressure especially upon standing (Orthostatic hypotension). Unfortunately patients with these problems are not candidates for surgical intervention at this time.

SHUFFLING GATE This is a very common symptom of Parkinson’s associated with akinesia and an under-medicated state. This should be differentiated from gait-freezing, which occurs with initiation of walking.

Following Pallidotomy, shuffling is eliminated.

STOOPED POSTURE Another classic symptom of Parkinson’s disease, this sign is self explanatory. Other problems associated with stooped posture include depression and hypothryoidism. Adequate medications improve this symptom.

Pallidotomy eliminates this symptom. Most family members remark about the increased standing height and normal bearing following surgery.

All definitions from: http://www.pallidotomy.com/html/symptoms.html#Dyskinesia

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