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Chapter 17. Pharmacologic Management of Parkinson's Disease and Other Movement Disorders

The major movement disorders include Parkinson‘s disease, Huntington‘s disease, Wilson‘s disease, Tourette‘s syndrome. An outline of common movement disorders is given in Table 17–1.

Table 17–1. Types of Movement Disorders

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Table 17–1. Types of Movement Disorders

Disorder

Etiology

Manifestations

Common Signs

Therapy

Parkinson’s disease

Loss of dopaminergic neurons in the basal ganglia

Tremor at rest

Oscillatory movement, especially fine muscles (hands, face)

Levodopa, dopamineagonists; antimuscarinics; brain stimulation

Bradykinesia

Difficulty initiating movement (e.g., walking), flat facies

Rigidity

“Cogwheel” effect

Familial tremor, essential tremor, physiologic postural tremor

Unknown

Postural tremor

Difficulty eating, drinking; ataxia

β blockers

Restless legs syndrome

Unknown; (dopamine deficiency?)

Subjective feeling of discomfort, especially at night

None

Dopamine agonists; e.g., ropinirole

Tourette’s syndrome

Unknown; (dopamine excess?)

Motor tics

Involuntary twitches, vocalizations

Clonidine; dopamine blockers; e.g., haloperidol

Wilson’s disease

Congenital error in copper transport and binding

Rest and postural tremor, chorea, ataxia

Deposit in cornea, elevated liver copper and liver function tests

Low copper diet, copper-binding drugs

Huntington’s disease

Loss of GABAergic neurons in the basal ganglia; strong genetic component

Chorea

Abnormal movements and dementia

None satisfactory. Dopamine blockers or depleting drugs may reduce abnormal movements

Several different types of abnormal movements or signs of these disorders are recognized, including athetosis, ballismus, chorea, dyskinesia, dystonia, tics and tremor as described in Table 17–2. These movements can be caused by a variety of general medical conditions and certain drugs, in addition to the neurologic disorders mentioned.

Table 17–2. Types of Abnormal Movements

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Table 17–2. Types of Abnormal Movements

Movement

Description

Tremor

Oscillatory movement around a joint, e.g., fingers, wrist, jaw

Rest tremor

Occurs in the absence of any intended movement

Postural tremor

Occurs while maintaining a particular posture

Intention tremor

Occurs during voluntary effort; e.g., picking up a pencil

Chorea

Irregular, involuntary movements occurring in any part of the body. May involve facial grimacing or tongue movements and abnormal speech

Ballismus

A form of chorea involving proximal muscles in which a limb may move violently

Tics

Sudden, involuntary, and repetitive coordinated movements; e.g., blinking, turning head, smacking lips

Athetosis

Involuntary slow, writhing movements

Dystonia

Prolonged, sustained athetosis that resembles abnormal posture

Dyskinesia

Acute dystonia or muscle spasm, often caused by dopamine-blocking drugs

Akathisia

Inability to sit or stand still, motor restlessness; usually caused by dopamine-blocking drugs

Myoclonus

Sudden, rapid, twitch-like movements; may be localized or generalized

To understand how the movement disorders are treated, it is important to understand their underlying pathogenesis. Many of the movement disorders have been attributed to disturbances of the basal ganglia, but the precise function of these anatomic structures is not yet fully understood, and it is not possible to relate individual symptoms to involvement at specific sites. Furthermore, individuals with the same disease, such as Parkinson’s disease, can present very differently in ...

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