Muhammad Hamdan, dr.

, SpS(K)

Departemen of Neurology Faculty of Medicine,

Airlangga University,
Dr. Soetomo General Hospital Surabaya

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 Is a chronic, progressive neurodegenerative
disorder with a multifactorial etiology.
 It is superseded only by Alzheimer’s Disease
as the most common neurodegenerative
disorder

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 # per 100,000
Alzheimer’s disease 4,000,000 1,450
Parkinson’s disease 1,000,000 360
Frontotemporal dementia 40,000 14
Pick’s disease 5,000 2
Progressive supranuclear palsy 15,000 5
Amyotrophic lateral sclerosis 20,000 7
Huntington’s disease 30,000 11
Prion disease 400 <1

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• Prevalence of 0.3 % in the US population
• 1 – 2% of all persons > 65 yrs old
• 4 – 5% of all persons > 85 yrs old
• In US : > 1 million have diagnosis of Parkinsons – this is
greater than the combined number of MS, ALS, and
muscular dystrophy patients added together
• Usual age at onset – early 60s
• 10% of all those affected are < 45 yrs old – referred to as
young onset Parkinsons
• 40, 000 new cases of PD will diagnosed this year
• Lifetime risk of Parkinsons for men : 2.0%
• Lifetime risk for women : 1.3%
• Incidence of the disease is lower in African Americans
than in Caucasians in the USA

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1. Tremor at rest  Diagnostic Criteria :
Definite Parkinsons :
2. Rigidity at least two of these
3. Bradykinesia features must be
4. Loss of postural present, one of them
being # 1 or # 2
reflexes
 Probable : Feature #
5. Flexed Posture 1 or feature # 2 is
6. Freezing (Motor present
Block)  Possible : at least
two of features # 3 –
6 must be present

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 Freezing is also known as motor block
 Most often affects the legs when walking, but it
can also affect the arms and eyelids
 Freezing consists of a sudden, transient inability
to move
 It typically causes hesitation when initiating
walking & sudden inability to move feet when
turning or walking thru narrow passages – such as
doors or elevators – or when patients are about
to reach a target destination
 Freezing is thought to related to noradrenergic
deficiency related to degeneration of the locus
coeruleus
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 Determine when freezing occurs in
relationship to activity, the environment,
time of day & dosing of PD medications
 UPDRS assesses freezing when walking &
falling as related to freezing
0 = Normal
1 = Rare freezing when walking, may have
start hesitation
2 = Occasional freezing when walking
3 = Falls an average of once daily related to
freezing

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 Pharmacological
 Nonpharmacological

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 Pharmacological
 Sometimes when a patient is undermedicated,
increasing the dose of PD medications may
alleviate freezing
 “Off” phase, end – dose freezing responsds to
shortening the time between levodopa doses and
taking the next dose at earlier time, addition of
a COMT inhibitor or agonist
 If clinical response to levodopa is inadequate,
treatment is to increase the respective levodopa
dose
 Liquid levodopa as “rescue therapy” can be
effective given relatively short onset of
symptoms
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 Nonpharmacological
 Provide a referral to a physical therapist to
assesss freezing, provide gait training & instruct
the patient in how to use cueing & increase
safety with ambulation.
 Share tips with the patient & family on how to
break a freeze, as described in “Cueing Tips” in
the next section.

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 Cuing Tips – General Strategies
 First stop trying to continue the movement that
elicits the freezing. Then initiate a different
movement
 Auditory
 Use a metronome or music and walk to the beat.
Bigger steps may help reduce freezing occurs with
walking, first stop walking & then try marching or
reaching before resuming walking again
 Visual
 Look through, not directly at, doorways
 Step over a marked line or spot on the floor
 Use a device designed for gait freezing
 Verbal
 Count one, two, three, four, five, out loud
 March-left, right, left, right

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 Dyskinesia are involuntary movements, often
writhing or choreiform & are dance like in
nature
 Motor complications of long term levedopa
theraphy
 Can certainly appear earlier with use
dopaminergic medications.
 may affect any part of the body : the
extremities, trunk, neck & facial muscles


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 Pharmacological
 Nonpharmacological

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 Pharmacological
 Reduction of dose or frequency levodopa
 Dose reduction of dopamine agonists
 Amantadine (symmetrel) provides consistent
but only partial reductio of dyskinesia; dosing
often begins with 100 mg twice a day (BID), the
is increased to 100 mg three times a day (TID) as
needed
 Peak-dose dyskenesias : reduce amount of
levodopa IR and consider discontinuing
adjunctive selegiline or COMT inhibitors,
Consider addition of amantadine
 Rapid motor fluctuations with alternating
dyskinesias and “off” states, consider addition of
an agonist (use adequate dose and avoid rapid
titration of dose)
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 Nonpharmacological
 Patient/family education should include training on
how to assess & document the presence of dyskinesia.
Patients & family should be taught the difference
between dyskinesia & tremor so that symptoms can
be reported effectively
 Patient/family should be aware of the importance of
maintaining a safe environment when dyskinesia :
ambulation safety, driving limitation & modification
of activities of dailt living
 Individuals with moderate to severe dyskinesia often
have a significant decrease in dyskinesia followong
DBS surgery.
 Psychological support should be provided to assist the
patient/family in copig with the stigma associated
with dyskinesia.

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 Freezing
is the inability to initiate or continue a
movement.
it is usually a problem of gait in PD but can
be observed with other motor tasks
gait freezing strongly impacts a person’s
ability to move safely with ease &
confidence.
 Dyskenesia
Choreiform with without dystonia : usually
levodopa – induced
Ussually peak - dose (off-on-dyskinesia-on-
off) and rarely biphasic (off-dyskinesia-on-
dyskinesia-off) 16
 Dyskenesia

Choreiform with without dystonia : usually

levodopa – induced

Ussually peak - dose (off-on-dyskinesia-on-

off) and rarely biphasic (off-dyskinesia-on-
dyskinesia-off)

Dystonic in absence of chorea: usually

parkinsonian (most commonly,early morning
or nocturnal dystonia such as painful foot
cramps) 17
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