● Impaired dexterity and coordination: This may lead to micrographia (small writing). ● Fatigue. ● Muscle aches or cramps. ● Dysphagia (difficulty swallowing and chewing). ● Sleep disturbances. Clinical course and classification Primary Parkinsonism , also known as idiopathic PD , accounts for 78% of all cases of parkinsonism. The clinical course of idiopathic PD begins slowly and usually on one side of the body. It then progresses to involve the other side of the body. It typically has a slow, variable rate of progression, lasting between 20 to 30 years after onset. There are several recognized variants of primary PD, including postural instability gait disturbance (PIGD), which presents with dominant symptoms including postural instability and gait disturbances; tremor predominant, which presents with tremor as the main symptom and few problems with bradykinesia or postural instability; and Parkinson’s disease with dementia (PDD), which presents with early onset of dementia, bradykinesia, and rigidity. Prognosis for survival is longer for individuals with nondemented PD who present as tremor predominant and are treated with levodopa, especially if the drug is started early in the disease. The worst prognosis is for individuals with onset at an older age (57 years of age or older) who display rigidity and/or hypokinesia as a presenting symptom or those exhibiting PIGD. The most common causes of death are pulmonary complications, urinary tract infections, and complications from falls and fractures. The Hoehn and Yahr Classification of Disability is the most common method of classifying the stages of PD (Hoehn & Yahr, 1967). The original classification (Hoehn & Yahr, 1967) included five stages, ranging from stage I, indicating minimal disease involvement, to stage V, indicating severe involvement, but was subsequently expanded by Goetz and colleagues (2004) to provide more precise differentiation, as shown in Figure 3. Neurologists typically use a rating scale to monitor the longitudinal course of PD, and the Unified Parkinson’s Disease Rating Scale (UPDRS) was originally used for this purpose. However, the Movement Disorder Society (MDS; now called the International Parkinson and Movement Disorder Society ) published a revision of the UPDRS in 2007 that is now commonly in use. Known officially as the MDS-UPDRS, it is often still referred to as UPDRS in clinical settings. The MDS-UPDRS scale contains four subscales: Part I: nonmotor experiences of daily living; Part II: motor experiences of daily living; Part III:
● Depression. ● Feelings of fear and anxiety. ● Sialorrhea (drooling). ● Urinary problems. ● Constipation. ● Sexual dysfunction.
motor examination; and Part IV: motor complications. Each subscale contains multiple items that are scored from 0 to 4, with 0 indicating no impairment, and 4 indicating severe impairment. The first two scales are self-report measures based on information provided by the patient. The motor scale of the MDS-UPDRS is the most commonly used component of the MDS-UPDRS and is a performance-based measure of the motor features of PD, including tremor, rigidity, coordination, balance, and gait. Use of the MDS-UPDRS requires training. Any interested physical therapist can access video-based training at the MDS website: https://www.movementdisorders.org/ MDS/MDS-Rating-Scales/Training-Programs.htm. Copies of the MDS-UPDRS are available at https://www.movementdisorders. org/MDS/MDS-Rating-Scales/MDS-Unified-Parkinsons-Disease- Rating-Scale-MDS-UPDRS.htm. Figure 3: Modified Hoehn and Yahr Staging Stage 0 No signs of disease. Stage 1 Unilateral disease. Stage 1.5 Unilateral plus axial involvement. Stage 2 Bilateral disease, with no impairment of balance. Stage 2.5 Mild bilateral disease, with recovery on Pull Test. Stage 3 Mild to moderate bilateral disease; some postural instability; physically independent. Stage 4 Severe disability; still able to walk or stand unassisted. Stage 5 Wheelchair-bound or bedridden unless aided. Note . Adapted from “Movement Disorder Society Task Force on the Hoehn and Yahr Staging Scale: Status and Recommendations. Movement Disorder Society Task Force Report on Rating Scales for Parkinson’s Disease,” by C. G. Goetz, W. Poewe, O. Rascol, C. Sampaio, G. T. Stebbins, C. Counsell, N. Giladi, R. G. Holloway, C. G. Moore, G. K. Wenning, M. D. Yahr, L. Seidl, & Movement Disorder Society Task Force on Rating Scales for Parkinson's Disease, 2004, Movement Disorders Journal , 19 (9), pp. 1020-1028.Copyright 2004 by the Movement Disorders Journal .
DIAGNOSIS
Diagnosis of idiopathic PD is typically made by a physician when – in the absence of known causal factors such as drugs, brain injury, or metabolic disorder – an individual exhibits at least two of the four cardinal symptoms: bradykinesia, resting tremor, rigidity, or postural instability. In addition, a CT scan or MRI may be used to rule out other disorders. A definitive diagnosis of PD Differential diagnosis There is a group of neurodegenerative disorders that exhibit the same classic features as PD (bradykinesia, rigidity, tremor, and postural instability) but have additional features. It can be challenging to make a differential diagnosis early in the disease presentation. Diagnosis is typically made by observing the clinical course of the disease over time. Secondary parkinsonism When parkinsonism is caused by damage to the brain, it is known as secondary parkinsonism. This damage to the brain commonly results from strokes; toxins; traumatic brain injury (repetitive concussions in sport); infections (e.g., encephalitis, HIV); metabolic abnormalities (hypo- or hyperthyroidism or parathyroidism, liver failure); or drugs (e.g., antipsychotics and phenothiazines). Secondary parkinsonism is less responsive to medication than idiopathic PD. One of the more common
can be made only by autopsy. There are preclinical indicators of idiopathic PD that have been noted by clinicians and verified by several studies (Postuma et al., 2015). Symptoms for which the ability to predict conversion to PD is supported by the strongest evidence are olfactory loss, REM sleep behavior disorder, and constipation (Postuma et al., 2015). forms of secondary parkinsonism is vascular parkinsonism. In contrast to patients with idiopathic PD, patients with vascular parkinsonism are older with a shorter duration of illness; present with symmetrical gait difficulties; are less responsive to levodopa; and are more prone to postural instability, falls, and dementia (Benítez-Rivero et al., 2014). Pyramidal signs (spasticity, hyperreflexia, and difficulty moving); pseudobulbar palsy (difficulty with speech and swallowing); and incontinence are also more common in vascular parkinsonism. Additionally, tremor is typically not a main feature of vascular PD. Parkinson-plus syndromes Parkinson-plus syndromes are a group of neurodegenerative diseases displaying the typical features of idiopathic PD (akinesia/bradykinesia, tremor, rigidity, postural instability) with additional symptoms that distinguish them from idiopathic
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