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Movement Symptoms
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Movement Symptoms

Parkinson’s disease is called a movement disorder because of the tremors, slowing, and stiffening movements it can cause, and these are the most obvious symptoms of the disease. Parkinson’s affects many systems in the body. The symptoms are different from person to person and usually develop slowly over time.

There is no single test or scan for Parkinson’s disease but there are three telltale symptoms that help doctors make a diagnosis

  1. Bradykinesia
  2. Tremor
  3. Rigidity

Bradykinesia plus either tremor or rigidity must be present for a Parkinson’s Disease diagnosis to be considered. Another movement symptom that is often mentioned is postural instability (trouble with balance and falls) but it does not occur until later in the disease progression. In fact, problems with walking, balance, and turning around early in the disease are likely to be a sign of an atypical Parkinsonism.

Additional Movement Symptoms

  1. Cramping (dystonia): sustained or repetitive twisting or tightening of muscles.
  2. Drooling (sialorrhea): excessive saliva or drolling may result due to a decrease in normally automatic actions like swallowing.
  3. Dyskinesia: involuntary, erratic movements of face, arms, legs or trunk.
  4. Festination: short, rapid steps taken during walking.
  5. Freezing: gives the appearance of being stuck in place.
  6. Masked Face (hypomimia): results from the combination of bradykinesia and rigidity.
  7. Micrographia: small, untidy and cramped handwriting
  8. Shuffling Gait: accompanied by short steps and a stooped posture.
  9. Soft Speech (hypophonia): soft, sometimes hoarse voice.
Bradykinesia
Dizziness or Fainting
Dyskinesia
Facial Masking
Tremor

Bradykinesia

Bradykinesia means slowness of movement and it is one of the cardinal symptoms of Parkinson's Disease. You must have Bradykinesia alongside either tremor or rigidity for our Parkinson's Disease diagnosis to be considered.

In Parkinson's, this slowness happens in different ways:

  • Reduction of automatic movements such as blinking or swinging your arms when you walk
  • Difficulty initiating movements like getting up out of a chair
  • General slowness in physical actions
  • The appearance of abnormal stillness or a decrease in facial expression

This translates into difficulty performing everyday functions, such as buttoning a shirt, cutting food, or brushing your teeth. Bradykinesia can be particularly frustrating because it is often unpredictable. One moment you can be moving around easily while in another movement you may need help.

Managing slowness of movement

Levodopa is the medication most commonly given to control the movement symptoms of Parkinson's Disease. Dopamine Agonists, MAO-B inhabiters, and Amantadine can also be used alone or in combination with other medications to improve slowness as well as stiffness.

If you experience 'off periods', changes in your ability to move, usually related to medication timing; when Bradykinesia and other symptoms are worse, adjusting the dose or schedule of your medication could help. Talk to your health care provider before making any changes to your medications. In addition to medications exercise should be part of your treatment plan for all Parkinson's symptoms.

Dizziness or Fainting

Orthostatic hypotension is a drop in blood pressure that happens when you go from a seated position or lying down to standing. Certain medications; including those for high blood pressure; dehydration and conditions such as heart disease increase this risk.

When Orthostatic Hypotension is related to a neurologic disorder like Parkinson’s Disease, it’s called Neurogenic OH, or n OH. Damage caused by nervous system disorders, including Parkinson’s, can result in the nervous system not being able to make or release norepinephrine, a chemical that constricts blood vessels and raises blood pressure. This causes dizziness or lightheadedness.

NOH Symptoms
  • Light Headedness
  • Dizziness
  • Weakness
  • Difficulty Thinking
  • Headache
  • Blurred or Dimmed Vision

Neurogenic OH tends to be undiagnosed. It is usually identified because people get dizzy or start to black out when they stand up. Early in the Parkinson’s Disease progression, you might not notice the dizziness, but you may experience foggy thinking or memory problems.

Managing NOH

If you become lightheaded upon standing, report it to you doctor. In general, asking your doctor to screen you for NOH once a year is a good idea. This is done by taking your blood pressure while lying down and then standing. A drop of 20 points in the top number (systolic) or 10 points in the bottom number (diastolic) indicates NOH.

There are also several lifestyle strategies you can try:
  • Drink more fluids to keep hydrated
  • Consume more salt and caffeine
  • Monitor your blood pressure
  • Sleep with your head elevated between 10 and 30 degrees
  • Change positions slowly, especially when raising from a seated to a standing position. Pause for several seconds between each movement.

Dyskinesia

Dyskinesias are involuntary, erratic, writhing movements of the face, arms, legs or trunk. They are often fluid and dance-like, but they may also cause rapid jerky or slow and extended muscle spasms. They are not a symptoms of Parkinson's itself. Rather, they are a complication from some Parkinson's medications.

Dyskinesias usually begin after a few years of treatment with levodopa and can often be alleviated by adjusting dopaminergic medications. Younger people with Parkinson's are thought to develop earlier motor fluctuations ad dyskinesias in response to levodopa.

Dyskinesias may be mild and non-bothersome, or they can be severe. Most people with Parkinson's prefer to be "on" with some dyskinesias rather than "off" and unable to move well.

However, for some people, dyskinesias can be severe enough that they interfere with normal functioning.

Peak-Dose Dyskinesias

The most common kind of dyskinesias are "peak dose" These occur when the concentration of levodopa in the blood is at its highest - usually one to two hours after you take it. This typically matches up with when the medications are working best to control motor symptoms. In the earliest stages of Parkinson's, they are usually not bothersome, and you may not even notice these extra movements.

Didrasic Dyskinesia

Sometimes, instead of at peak dose, dyskinesias can occur as you are just beginning to turn "on" and again as you begin to turn "off*. This is known as diphasic dyskinesia, or the dyskinesia-improvement-dyskinesia (D-I-D) syndrome. Diphasic dyskinesias are associated with relatively low doses of levodopa and, unlike peak-dose dyskinesias, tend to improve with higher doses of levodopa.

Managing Dyskinesia

The "therapeutic window describes the period of time when a medication is effective. There is enough medication in your body to control your symptoms, but not too much so that side effects occur. Good medication response occurs within the window although outside the window, you might get motor fluctuations; not enough medication; or dyskinesia ;too much medication. Levodopa therapy is typically the cause of dyskinesias, but other drugs such as dopamine agonists, COMT (catechol-o-methyl transferase) inhibitors and MAO-B inhibitors can worsen dyskinesias.

Because they tend to occur at peak concentrations of levodopa, one management strategy is to reduce dopamine levels. This can be done with small decreases in levodopa dosage or by removing other dopaminergic medications. However, as Parkinson's progresses, if you reduce the levodopa dose, your Parkinson's symptoms will not be well controlled. There are currently two medications available to treat dyskinesia, and several in development.

Facial Masking

When we think of muscles that can be affected by stiffness and slowness, the muscles people work out in the gym are probably the first to come to mind, legs, arms, and maybe even abdominals! But the same stiffness and slowness that can impact your walking and other activities can have more subtle impacts as well. One of these is reduced facial expressions, also called hypomimia or facial masking.

When the muscles of the face are stiff or take longer to move, it can be hard to smile, raise your eyebrows, or otherwise express your feelings using your face, which is an important part of how we communicate. Combined with Parkinson's speech changes, such as low voice volume, facial masking can make it hard for others to interpret your mood and intentions. People might assume you're upset or depressed all the time, which can be frustrating if they constantly ask, "What's wrong?" when you are feeling fine. On the other hand, if you are experiencing symptoms of depression, talk to your doctor. Mood changes are common in Parkinson's Disease and treatable!

Managing Facial Masking

Medications to treat movement symptoms should help with facial masking, as they alleviate rigidity. It is also a good idea to ask your doctor about speech and language therapy. They will be able to teach you facial exercises that may help with the masking, as well as other issues you may be having, including speech and swallowing problems.

Finally, if you are having more frequent cases of people misinterpreting your mood or not believing you when you say how you are doing, try explaining the difficulty with muscle control and expression. This may help people to better understand how you are feeling, and also increase their awareness of Parkinson's Disease

Tremor

The typical Parkinson's Disease tremor occurs mostly at rest ("resting tremor*) and lessens during sleep and when the body part is actively in use. For example, your hand might shake while you're sitting, or even while you are walking, but when you reach out to shake hands with someone, the tremor is less noticeable or goes away entirely.

Tremor tends to occur in the hands and is often described as "pill-rolling", imagine you are holding a pill between your thumb and forefinger and continuously rolling it around. But it can also appear in other parts of the body, including the lower lip, jaw, or leg. These tremors can interfere with routine activities such as shaving, dressing, writing, and many other tasks that require fine motor coordination.

Some people report an internal tremor, a shaking sensation inside the chest, abdomen, or limbs that cannot be seen
Tremor usually affects only one side of the body, especially during the early stages of the disease. With disease progression, both sides may become affected. Fatigue, stress, or intense emotions can temporarily make tremors worse.

Who is Affected By Tremor?

About 70% of people with Parkinson's experience a tremor at some point in the disease. Tremor appears to be slightly less common in younger people with Parkinson's Disease, though it is still one of the most troublesome symptoms. People with resting tremor usually have a more slowly progressing course of illness than people without tremor.

Tremor In Other Conditions

While tremor is a common symptom of Parkinson's, it can also be a symptom of other conditions, most notably essential tremor. The main difference between a Parkinson's tremor and most other types of tremors is that in Parkinson's Disease, a resting tremor is most common. Other conditions are usually characterized by "action tremor", which tends to lessen at rest and increase when you're doing something, like trying to make a phone call or take a drink. Tremors of the head and voice are also common in essential tremor but rare in Parkinson's Disease.

Managing Tremor

Levodopa is the medication most commonly given to control the movement symptoms of Parkinson's, and tremor usually, though not always, responds to levodopa treatment.

If dopaminergic medications do not work to control tremor, other medications are sometimes used. For example, anticholinergics can be helpru for tremor. However, they can cause significant mental and physical side errects, so their use should be carefully considered. Anticholinergics are most useful in young people with tremor-predominant Parkinson's, when tremor is the main symptom that needs managing.

If medications are not effectve, deep brain stimulation (DBS) is generally successful in controlling tremor, even medication-unresponsive tremor. In addition to medication and surgical treatment, there are assistive devices that can help with various activities of daily living. Last but not least, exercise is as important as medication and other therapies for managing Parkinson's symptoms and leading your best possible life.