Motor Symptoms Of Parkinson’s Disease

Clinical Evaluation Of Motor Symptoms

The motor stage of PD was evaluated according to the UPDRS scale during ON condition. UPDRS I assess mentation, behavior, and mood UPDRS II evaluates Activities of daily living , including speech, swallowing, handwriting, dressing, hygiene, falling, salivating, turning in bed, walking, and cutting food . UPDRS III is a score for motor examination . Each item of those scales scored on a scale from 0 to 4. UPDRS IV assesses the treatments complications in the week preceding the examination . UPDRS V is the Hoehn and Yahrs staging of severity of PD , and UPDRS VI is Schwab and England to assess independency on activity of daily living on OFF and on ON conditions .

The clinical type at onset of the disease was classified as tremor dominant, akinetic-rigid, or mixed form according to criteria used by Rajput et al. . Tremor dominant subtype referred to patients in whom the tremor was the dominant feature compared to bradykinesia and rigidity. Patients with prominent bradykinesia and rigidity with no visible tremor were classified as akinetic-rigid subtype and those who had comparable severity of bradykinesia, rigidity, and tremor were classified as mixed subtype. The first side and limb affected at the onset of the disease were also recorded. Levodopa equivalent daily dose was calculated based on Tomlinson et al. recommendations .

Motor System: Levels Of Description

Our concern is to address the relationship between motor symptoms and motor control. This is a distinct endeavor from reviewing the neurophysiology of motor symptoms, although the two are closely related. The distinction is perhaps best described in the language of David Marrs levels of description of an information processing system . The motor system can be considered such a system, in the sense that it receives information and produces outputs . Therefore, like all information processing systems, the motor system can be described at three levels: computational, algorithmic, and physical.

The other two levels of description are the algorithmic and implementation levels. Whereas the computational level describes what the motor system does and why, algorithms describe how the goals are accomplished. For a reaching movement, the motor system might first represent the desired trajectory in space and then activate muscles as needed in order to keep the hand on course along the desired path. The implementation level describes the operation of the physical structures that actually perform the computation. The motor systems hardware mainly consists of neurons and muscles, which communicate via electrical impulses and chemical substances and are connected together as circuits.

Weakening Sense Of Smell And Taste

This may be due to degeneration of the anterior olfactory nucleus and olfactory bulb, one of the first parts of the brain affected by Parkinsons. This can happen so gradually that youre not even aware of it.

Losing your sense of smell and taste can make you lose interest in food. You may miss out on important nutrients and lose weight.

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What Are The Primary Motor Symptoms Of Parkinsons Disease

There are four primary motor symptoms of Parkinsons disease: tremor, rigidity, bradykinesia and postural instability . Observing two or more of these symptoms is the main way that physicians diagnose Parkinsons.

It is important to know that not all of these symptoms must be present for a diagnosis of Parkinsons disease to be considered. In fact, younger people may only notice one or two of these motor symptoms, especially in the early stages of the disease. Not everyone with Parkinsons disease has a tremor, nor is a tremor proof of Parkinsons. If you suspect Parkinsons, see a neurologist or movement disorders specialist.

Tremors

Rigidity

Bradykinesia

Postural Instability

Walking or Gait Difficulties

Dystonia

Vocal Symptoms

Studies Of Patients With Non

The Parkinsons Associated Risk Study is an ongoing large study whose goal is to evaluate specific tests for their ability to predict an increased risk of PD. The ultimate goal is to find a set of tests that can predict the future development of PD. The study has evaluated smell tests, questionnaires that probe mood, bowel habits and sleep disorders, as well as the dopamine transporter imaging test, commonly referred to as DaTscan.

A DaTscan involves injecting a small amount of a radioactive tracer into the bloodstream. The tracer makes its way into the brain and binds to the dopamine transporters, which are molecules on the surface of the dopamine neurons. In PD, there are fewer of these neurons and therefore there is less uptake of the tracer in the brain. A brain scan then determines if the amount of uptake of the tracer is normal or decreased. Currently, this test is approved to distinguish between PD and a neurologic condition known as essential tremor, a tremor disorder which is not caused by an abnormality of the dopamine system.

DaTscan is not yet approved to determine if patients who are experiencing only the non-motor symptoms of PD, in fact have PD. However, it is known that a DaTscan can be abnormal even before motor symptoms are present. The PARS study is investigating whether in the future, a DaTscan can be part of an algorithm to determine who is at risk of developing PD.

Tips and takeaways

Dr. Rebecca Gilbert

APDA Vice President and Chief Scientific Officer

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The First Motor Symptoms Of Parkinsons Disease

When people ask what are the early signs and symptoms of PD? the answer they are typically expecting is one that involves motor symptoms. Early motor symptoms of PD can be a subtle rest tremor of one of the arms or hands . A rest tremor is one that occurs when the limb is completely at rest. If the tremor occurs when the limb is suspended against gravity or actively moving, this may still be a sign of PD, but may also be a sign of essential tremor.

The initial motor symptom of PD may be a sense of stiffness in one limb, sometimes interpreted as an orthopedic problem . This sense of stiffness may be noted when a person is trying to get on his/her coat for example. A person may also experience a sense of slowness of one hand or a subtle decrease in dexterity of one hand. For example, it may be hard to manipulate a credit card out of a wallet or perform a fast, repetitive motor task such as whisking an egg. A person may notice that one arm does not swing when he/she walks or that one arm is noticeably less active than the other when performing tasks. Another motor sign may be a stoop with walking or a slowing down of walking. A family member may notice that the person blinks infrequently or has less expression in his/her face and voice.

These motor symptoms may be very subtle. Bottom line if you are concerned that you may have an early motor or non-motor symptom of Parkinsons disease, make an appointment with a neurologist for a neurologic exam to discuss your concerns.

What Makes Pd Hard To Predict

Parkinsonâs comes with two main buckets of possible symptoms. One affects your ability to move and leads to motor issues like tremors and rigid muscles. The other bucket has non-motor symptoms, like pain, loss of smell, and dementia.

You may not get all the symptoms. And you canât predict how bad theyâll be, or how fast theyâll get worse. One person may have slight tremors but severe dementia. Another might have major tremors but no issues with thinking or memory. And someone else may have severe symptoms all around.

On top of that, the drugs that treat Parkinsonâs work better for some people than others. All that adds up to a disease thatâs very hard to predict.

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The Clinical Symptoms Of Parkinson’s Disease

Department of Neurology, Broomfield Hospital, Chelmsford, Essex, CM1 7ET UK

Queen Mary School of Medicine and Dentistry, University of London, London, UK

Department of Neurology, Broomfield Hospital, Chelmsford, Essex, CM1 7ET UK

Queen Mary School of Medicine and Dentistry, University of London, London, UK

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Information About Impulse Control Disorders

Quality statement

Rationale

Quality measures

Structure

Data source:Data source:

Process

Data source:Data source:Data source:

Outcome

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What the quality statement means for different audiences

Service providersHealthcare professionalsCommissionersAdults with Parkinsons disease

Definitions of terms used in this quality statement

Information about the risk of developing impulse control disorders

• the different types of impulse control disorders
• the increased risk of impulse control disorders developing with dopamine agonists
• the risk that impulse control disorders may be concealed by the person affected
• who to contact if impulse control disorders develop
• the possibility that if problematic impulse control disorders develop, dopamine agonist therapy will be reviewed and may be reduced or stopped.

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Box : Dementia In Parkinsons Disease

• Patients with Parkinsons disease are six times more likely to develop dementia as compared with the normal population.

• Dementia is the commonest cause of institutionalisation in Parkinsons disease.

• Depression can masquerade as dementia and should be excluded.

• Dementia is commoner in late onset and advanced Parkinsons disease.

• Dementia of Lewy body type can be differentiated by early onset, marked hallucinations, and high sensitivity to neuroleptics.

• Management of dementia in Parkinsons disease requires a multidisciplinary approach involving the nurse, psychiatrist, physician, carer, and social worker.

The anxiety disorders in Parkinsons disease patients can manifest as panic attacks, phobia, and/or as generalised anxiety disorder. As yet, there is no trial evidence as to the treatment of anxiety in patients with Parkinsons disease. Appropriate antidepressants should be used when anxiety is part of the depressive illness. Low dose benzodiazepines and sometimes low dose atypical neuroleptics may have to be used.

Depression And Parkinsons Disease

Depression is a common problem in patients with Parkinsons disease. Prevalence rates have been reported from 11% to 44% depending upon the presence of minor or major depressive symptoms and the assessment scales used. Prevalence of 31% was reported in a recent meta-analysis.

The manifestations include apathy, psychomotor retardation, memory impairment, pessimism, irrationality, and suicidal ideation without suicidal behaviour. Depression has been strongly related to the patients quality of life in Parkinsons disease.

The symptoms of depression in Parkinsons disease vary slightly from the typical symptom profile of primary depression. Depressed parkinsonian patients experience less guilt and self reproach and more irritability, sadness, and concern with health. Depression associated with agitation creates additional functional incapacity to which young onset parkinsonian patients appear particularly prone.

Mood fluctuations can accompany motor fluctuations of on-off states. Depression increases in the off state and improves in the on state. Completed suicide appears to be rare in the Parkinson population even though verbalised suicidal ideation is not uncommon. Younger onset patients appear to be more at risk for suicide and suicidal gestures than older patients. Severe depression in Parkinsons disease may anticipate the development of intellectual impairment. Depression may also present as pseudodementia that resolves with effective treatment of the depression.

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Anxiety In Idiopathic Parkinsons Disease

Symptoms of anxiety are common in Parkinsons disease. The prevalence of anxiety has been reported to be around 30% in some of the studies. Anxiety can be a part of depression and thus may respond to antidepressants with sedative effects. It can also be a manifestation of the cognitive impairment, a side effect of the dopaminergic medications, or a part of the mood swings noted in patients with on-off periods. It is, therefore, important to take a detailed history from the patient or the carer.

There Are Three Primary Categories Of Medications To Treat Motor Symptoms Of Parkinsons:

• Dopaminergic medications for movement
• Dopaminergic medications replace lost dopamine and can be used to treat tremor, stiffness, slowness and problems walking. These medications may also have a beneficial impact on non-motor symptoms of Parkinsons related to sleep, mood and cognition. Dopaminergic medications, such as carbidopa-levodopa , make up the majority of medicines used to treat Parkinsons and can sometimes be used in combination with each other because of how they impact the body. As Parkinsons progresses and more of these dopaminergic medications are needed to address symptoms, you may experience motor fluctuations and frustrating side effects of the added or increased medication, like dyskinesia. Dyskinesia is uncontrollable, jerky movements of the arms and legs caused long-term use of levodopa.

Muscle relaxants and pain medicines for painful spasms and rigidity

Anticholinergic medications for rest tremor

Anticholinergic medications are used to block the neurochemical acetylcholine, which can help reduce rest tremor. These medicines do not improve other motor symptoms such as rigidity, slowness or walking problems. Anticholinergic medications should be used cautiously as they can cause side effects such as dry mouth, blurred vision, dry eyes, constipation, memory problems and confusion, especially in people who are older.

Learn more about how medications and other therapies can help you live well.

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Box : Anxiety In Parkinsons Disease

• Anxiety can affect nearly third of the Parkinsons disease patients.

• Anxiety can be a part of off state.

• Treatment of anxiety in Parkinsons disease is not based on evidence, but antidepressants, benzodiazepines, and low dose neuroleptics have been used.

Confusion and paranoid delusions can also occur. The state of confusion and hallucinations is termed psychosis. Unfortunately, a delusional individual often directs his suspicions towards a spouse or other family member.

Pathogenesis of psychosis is not completely understood. Birkmayer and Riedere suggested that the interplay between two brain chemicals, dopamine and serotonin, is of major importance to occurrence of hallucinations. In support of this concept, improvement of psychosis in Parkinsons disease occurs not only with blockers of dopamine receptors, but also with the serotonin receptor antagonist, ondansetron.

Demographic Data And Motor Aspects

We enrolled into this study a total of 117 patients who fulfilled the inclusion and exclusion criteria of PD. The demographic features are reported in Table 1.

Table 1. Characteristics of Moroccan Parkinsons disease patients.

The overall mean age of this study population was 60.77 ± 11.36 years. The mean age at onset of the disease was 54.28 ± 12 years and the median of the disease duration was 6 years. The study cohort included 65 males and 52 females. 81 of our patients had low level of education.

Our patients presented different clinical forms with 40.2% of the mixed akinetic-rigid-tremoric form, 39.3% of the tremor-dominant form, and 20.5% of the akinetic-rigid form. The onset of the motor symptoms affected mainly the right side and in 2.5% of cases the onset was bilateral with asymmetry. The median LEDD was 325 mg per day .

The median UPDRS-III score was 13 . The median score of Hoehn and Yahr was 2 and 27.3% of cases had a score above 2. The median score of Schwab and England during ON condition was 90% .

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Managing Depression In Parkinsons Disease

People with Parkinsons, family members and caregivers may not always recognize the signs of depression and anxiety. If you are experiencing depression as a symptom of Parkinsons, it is important to know it can be treated.

Here are some suggestions:

• For information and support on living well with Parkinsons disease, contact our Information and Referral line.
• As much as possible, remain socially engaged and physically active. Resist the urge to isolate yourself.
• You may want to consult a psychologist and there are medications that help relieve depression in people with Parkinsons, including nortriptyline and citalopram .

Does Parkinsons Affect Voice

The voice is affected too, because the voice box is ultimately controlled by the basal ganglia as well. Thus the voice becomes soft, slurred and hushed. Others may comment that the patient is mumbling. The mumbling goes away temporarily once the patient becomes aware of it but soon returns to the soft, slurred state.

This temporary improvement when attention is paid is true of many of the motor symptoms of PD because the condition primarily affects subconscious movements, and does not directly affect nerve or muscle control at the most basic level. Thus, conscious awareness can override the slowness to a certain extent. This fact is one reason why physical therapy and physical activity are so useful and necessary in treating PD.

• Slowness of walking and other movements
• Trouble with dexterity
• Reduced arm swing or stride length
• Delayed reactions physically
• Reduced facial reactions
• Softer or slurred speech

• Tremor in one or both limbs with the limb at rest
• Sometimes also tremor with holding a posture or with actions
• Usually asymmetric

Imbalance, loss of balance reflexes

• May fall backwards

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Depression May Be An Early Symptom Of Parkinsons

Depression is one of the most common, and most disabling, non-motor symptoms of Parkinsons disease. As many as 50 per cent of people with Parkinsons experience the symptoms of clinical depression at some stage of the disease. Some people experience depression up to a decade or more before experiencing any motor symptoms of Parkinsons.

Clinical depression and anxiety are underdiagnosed symptoms of Parkinsons. Researchers believe that depression and anxiety in Parkinsons disease may be due to chemical and physical changes in the area of the brain that affect mood as well as movement. These changes are caused by the disease itself.

Here are some suggestions to help identify depression in Parkinsons:

• Mention changes in mood to your physician if they do not ask you about these conditions.
• Complete our Geriatric Depression Scale-15 to record your feelings so you can discuss symptoms with your doctor. Download the answer key and compare your responses.

• delusions and impulse control disorders

Treatment For Primary Motor Symptoms In Parkinsons Disease

Although there are currently no medications that can cure or slow the progression of PD, there are several treatments that can help relieve symptoms, including the primary motor symptoms of PD. Treatment approaches include medications, surgery , and complementary or alternative medicine.

Several medications are available that can help relieve the primary motor symptoms. Initial therapy is usually levodopa , dopamine agonists, and/or monoamine oxidase-B inhibitors. The combination of levodopa and carbidopa is the most effective treatment available for the management of motor symptoms of PD. However, it can cause a side effect known as dyskinesia, which are abnormal involuntary movements. Dopamine agonists are less effective on the motor symptoms of PD but have a lower rate of causing dyskinesia, although they have other side effects. MAO-B inhibitors are less effective than levodopa or dopamine agonists, however they have fewer side effects. Choice of therapy should be customized to the individual patient with an understanding of the risks and benefits of each class of medication.3

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