Research Insights

Diagnosis and initial management of Parkinson’s disease

Nutt, J. & Wooten, G. (2005) Diagnosis and initial management of Parkinson’s disease , 353, 1021-1027

This article began by reviewing the prevalence rates for PD in the US, how the disease affects the brain, and possible genetic links. The authors also mentioned the four common signs and symptoms that would lead to a diagnosis of PD ("tremor, weak and clumsy limb, a stiff and acing limb, and a gait disorder"). They stated that a resting tremor is a very common sign of PD but in approximately 20% of cases there is absence of tremor. The authors also discussed that essential tremors (ET) may be confused with early PD but there are patterns that differentiate the two diseases. They suggested that head tremor may be seen in ET but not as commonly in PD, instead tremor in PD often affects the tongue, jaw, and chin. Additionally, they noted that handwriting may differentiate the two as ET writing is large and tremulous and in PD it is very small. The authors also reported that rigidity and bradykinesia (slowed movements) are not commonly seen in ET. The authors stated that in approximately 75% of patients the slowed movements initially affect only one side of the body. Typically fine motor movements are affected first so patients notice difficulties in buttoning clothes or using small tools. They noted rigidity is initially seen as aching in a limb that may progress to freezing of that joint (e.g. frozen shoulder). Other early signs included slowed gait, dragging of the foot, decreased arm swing, difficulty rising from a chair, and a narrow based gait. The authors noted that a wide based shuffling gait with another cause was the "second most common misdiagnosis of PD." The authors noted that there is no one laboratory test that will confirm PD. Neuroimaging (MRI, PET, etc.) may be useful in some cases but it is not necessary in all cases. The authors then summarized the differential diagnoses of PD, including causes of parkinsonism. They listed toxins, infections, lesions in the brain, metabolic disorders, and other neurological conditions, most of all of these are very rare to see. They listed medications that can cause a reversible parkinsonism, which accounts for approximately 20% of cases of parkinsonism. They briefly discussed the parkinsonism-plus syndromes, which typically do not respond to medications and have different presenting symptoms. The authors then discussed medical and behavioral treatment of PD, including exercise, education about PD, and pharmacological therapy. They stated that medications are usually initiated because patients are finding the symptoms intolerable, versus automatically upon initial diagnosis of PD. The authors also briefly discussed the different pharmacological therapies but noted that decisions on medications need to be made with the patient and physician specifically in regards to that patient as PD can be a very individualized disease. They very briefly discussed surgical interventions for PD. They ended by discussing that there are clinical-practice guidelines for initial treatment in PD from the American Academy of Neurology and the Movement Disorder Society.

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