Overview
Which major neurological findings are characteristic of Parkinson disease (PD)?
What are the initial clinical symptoms of Parkinson disease (PD)?
What are the initial motor signs of Parkinson disease (PD)?
What are the diagnostic criteria for Parkinson disease (PD)?
What is the goal of medical management of Parkinson disease (PD)?
Which medications are used to control symptoms of Parkinson disease (PD)?
Which medications are used to control the nonmotor symptoms of Parkinson disease (PD)?
What is deep brain stimulation for Parkinson disease (PD)?
What causes Parkinson disease (PD)?
What are the three motor signs of Parkinson disease (PD)?
What causes of tremor should be considered in the differential diagnoses of Parkinson disease (PD)?
How is a diagnosis confirmed in patients with a typical Parkinson disease (PD) presentation?
When are imaging studies considered in the diagnosis of Parkinson disease (PD)?
Which medications are used to control the motor symptoms of Parkinson disease (PD)?
What part of the brain is affected by Parkinson disease (PD)?
What are the neuropathologic findings of Parkinson disease (PD)?
How does Parkinson disease (PD) affect the basal ganglia motor circuit?
What is the etiology of Parkinson disease (PD)?
Which environmental risk factors may increase the risk of developing Parkinson disease (PD)?
Does high caffeine intake or smoking increase the risk of developing Parkinson disease (PD)?
Does 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) cause Parkinson disease (PD)?
What is the oxidation hypothesis of the etiology of Parkinson disease (PD)?
What is the role of genetic factors in the development of Parkinson disease (PD)?
Which gene mutations may be related to Parkinson disease (PD)?
Which genetic mechanisms are thought to cause Parkinson disease (PD)?
What is the role of alpha-synuclein in the pathogenesis of Parkinson disease (PD)?
What is the relationship between melanoma and Parkinson disease (PD)?
What is the incidence of Parkinson disease (PD)?
What factors are predictive of the rate of progression of Parkinson disease (PD)?
What educational information should be given to patients with Parkinson disease (PD)?
Presentation
What are the initial physical findings of Parkinson disease (PD)?
Which nonmotor symptoms precede the motor signs of Parkinson disease (PD)?
What are the initial clinical symptoms of Parkinson disease (PD)?
What is the typical presentation of tremors due to Parkinson disease (PD)?
What is bradykinesia in patients with Parkinson disease (PD)?
What are the characteristics of facial bradykinesia in patients with Parkinson disease (PD)?
What are the characteristics of truncal bradykinesia in patients with Parkinson disease (PD)?
How does bradykinesia manifest in activities of daily life in patients with Parkinson disease (PD)?
What is cogwheel rigidity in patients with Parkinson disease (PD)?
How does dystonia present in patients with Parkinson disease (PD)?
What are the cardinal signs of Parkinson disease (PD)?
How is resting tremor assessed in a physical exam in patients with Parkinson Disease (PD)?
How is rigidity assessed in a physical exam in patients with Parkinson disease (PD)?
How is bradykinesia assessed in a physical exam in patients with Parkinson disease (PD)?
How is postural instability assessed in patients with Parkinson disease (PD)?
Which speech tendencies should be assessed in patients with Parkinson disease (PD)?
What are manifestations of dysphagia in patients with Parkinson disease (PD)?
How is laryngeal dysfunction assessed in patients with Parkinson disease (PD)?
What are characterizations of the Parkinson disease (PD) larynx?
What is the prevalence of vocal tremor in patients with Parkinson disease (PD)?
Is autonomic dysfunction common in patients with Parkinson disease (PD)?
Does prominent autonomic dysfunction suggest an alternative diagnosis to Parkinson disease (PD)?
Which cardiopulmonary impairments may be caused by Parkinson disease (PD)?
How is Parkinson disease (PD) severity assessed and staged?
How is depression assessed in patients with Parkinson disease (PD)?
What is the prevalence of dementia in patients with Parkinson disease (PD)?
What are atypical parkinsonisms (Parkinson-plus syndromes)?
What is the prognosis of atypical parkinsonisms (Parkinson-plus syndromes)?
DDX
How is essential tremor differentiated from Parkinson disease (PD)?
Does Parkinson disease (PD) increase the risk of osteoporosis and osteopenia?
Does Parkinson disease (PD) increase the risk of bone fracture?
How is Lewy body disease characterized in patients with parkinsonism?
When should Wilson disease be considered in patients with parkinsonism?
What are the differential diagnoses for Parkinson Disease?
Workup
Which lab studies are useful in the diagnosis of Parkinson disease (PD)?
Are any lab tests or imaging studies required for the diagnosis of Parkinson disease (PD)?
What tests may be indicated in patients with an unusual presentation of Parkinson disease (PD)?
How is the clinical diagnosis of Parkinson disease (PD) confirmed?
When is MRI indicated in the evaluation of patients with suspected Parkinson disease (PD)?
What are the usual histologic findings in Parkinson disease (PD)?
What histologic findings i Lewy bodies in patients with Parkinson disease (PD)?
What were the results of the Parkinson's Progression Markers Initiative (PPMI)?
When should dopa-responsive dystonia be considered in the evaluation of Parkinson disease (PD)?
Treatment
What is the goal of medical management of Parkinson disease (PD)?
Are there neuroprotective (disease modifying) treatment options for Parkinson disease (PD)?
What is the role of levodopa in the management of Parkinson disease (PD)?
How long are medications effective in controlling the motor signs of Parkinson disease (PD)?
What is neuroprotective (disease modifying) therapy in the context of Parkinson disease (PD)?
How does the management of Parkinson disease (PD) differ in younger patients?
What are the indications for surgery in patients with Parkinson disease (PD)?
How are the nonmotor symptoms of Parkinson disease (PD) categorized?
Which medications are commonly used to control motor symptoms in early Parkinson disease (PD)?
What are the long-term risks of levodopa for the management of Parkinson disease (PD)?
What are the available preparations of levodopa/carbidopa?
When are selegiline and rasagiline indicated in the treatment of Parkinson disease (PD)?
How effective are dopamine agonists in the treatment of Parkinson disease (PD)?
What are the adverse effects of dopamine agonists?
When are anticholinergic medications indicated in the treatment of Parkinson disease (PD)?
How effective are anticholinergic agents in the treatment of Parkinson disease (PD)?
What is amantadine’s mechanism of action in controlling parkinsonian activity?
What is the recommended dosage for amantadine in the treatment of Parkinson disease (PD)?
What are the potential adverse effects of amantadine?
Which drugs reduce dyskinesis in patients with Parkinson disease (PD)?
Does the benefit of levodopa for the management of Parkinson disease (PD) decrease over time?
What is peak-dose dyskinesia in patients with Parkinson disease (PD)?
Is it safe to continue increasing dosage of levodopa if the patient develops dyskinesia?
What is the role of COMT inhibitors in the treatment of Parkinson disease (PD)?
What are the potential adverse effects of amantadine?
What are the treatment options for tremor in patients with Parkinson disease (PD)?
Are any neuroprotective therapies available for Parkinson disease (PD)?
Does rasagiline (Azilect) have neuroprotective effects in patients with Parkinson disease (PD)?
What are the potential neuroprotective effects of levodopa therapy in early Parkinson disease (PD)?
What are the potential neuroprotective effects of dopamine agonists in Parkinson disease (PD)?
Why is deep brain stimulation (DBS) the surgical procedure of choice for Parkinson disease (PD)?
How are patients with Parkinson disease (PD) selected for deep brain stimulation (DBS)?
Is thalamic deep brain stimulation (DBS) indicated for patients with Parkinson disease (PD)?
When are lesion surgeries indicated in the treatment of Parkinson disease (PD)?
Is thalamotomy effective in the treatment of Parkinson disease (PD)?
Is pallidotomy effective in the treatment of Parkinson disease (PD)?
What are the potential adverse effects of pallidotomy?
Is bilateral pallidotomy recommended in patients with Parkinson disease (PD)?
Is subthalamotomy effective in the treatment of Parkinson disease (PD)?
When is surgery indicated in the treatment of Parkinson disease (PD)?
How is neural transplantation used in the treatment of Parkinson disease (PD)?
What are the effects of neural transplantation in patients with Parkinson disease (PD)?
Is gene therapy safe and effective in the treatment of Parkinson disease (PD)?
How is dementia managed in patients with Parkinson disease (PD)?
What is the prevalence of depression in patients with Parkinson disease (PD)?
How is depression treated in patients with Parkinson disease (PD)?
Can medications for Parkinson disease (PD) trigger psychosis?
How is psychosis treated in patients with Parkinson disease (PD)?
How is anxiety treated in patients with Parkinson disease (PD)?
How are impulse behaviors treated in patients with Parkinson disease (PD)?
How are sleep disturbances treated in patients with Parkinson disease (PD)?
How effective is exercise and physical therapy in patients with Parkinson disease (PD)?
What is the prevalence of speech problems in patients with Parkinson disease (PD)?
What is the role of speech therapy in the treatment of Parkinson disease (PD)?
What is the Lee Silverman Voice Treatment (LSVT) program for Parkinson disease (PD)?
Are there effective alternative therapies to the Lee Silverman Voice Treatment (LSVT) program?
Are speech and language therapy effective in the treatment of Parkinson disease (PD)?
Why is dietary fiber recommended for patients with Parkinson disease (PD)?
What is the effect of dietary protein on levodopa in patients with Parkinson disease (PD)?
How is levodopa-induced nausea avoided in patients with Parkinson disease (PD)?
Are there dietary options that are beneficial in the management of Parkinson disease (PD)?
Do vitamin E and coenzyme Q10 have a neuroprotective effect in patients with Parkinson disease (PD)?
What consultations may be indicated for patients with Parkinson disease (PD)?
When is a neurosurgical consultation indicated in patients with Parkinson disease (PD)?
When is a psychiatric consultation indicated in patients with Parkinson disease (PD)?
When is consultation with a urologist indicated in patients with Parkinson disease (PD)?
What is the benefit of consultation with a nutritionist in patients with Parkinson disease (PD)?
What is the benefit of an otolaryngologist consultation for patients with Parkinson disease (PD)?
How often should patients with Parkinson disease (PD) be monitored?
What types of treatments may be available in the future for Parkinson disease (PD)?
Guidelines
What are the AAN treatment guidelines for nonmotor symptoms of Parkinson disease (PD)?
Medications
Which medications are used in the treatment of Parkinson disease (PD)?
Which medications in the drug class Anticholinergic are used in the treatment of Parkinson Disease?
Which medications in the drug class MAO-B inhibitors are used in the treatment of Parkinson Disease?
Which medications in the drug class NMDA Antagonists are used in the treatment of Parkinson Disease?
Which medications in the drug class COMT Inhibitors are used in the treatment of Parkinson Disease?
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Schematic representation of the basal ganglia - thalamocortical motor circuit and its neurotransmitters in the normal state. From Vitek J. Stereotaxic surgery and deep brain stimulation for Parkinson disease and movement disorders. In: Watts RL, Koller WC, eds. Movement Disorders: Neurologic Principles and Practice. New York: McGraw-Hill, 1997:240. Copyright, McGraw-Hill Companies, Inc. Used with permission.
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Schematic representation of the basal ganglia - thalamocortical motor circuit and the relative change in neuronal activity in Parkinson disease. From Vitek J. Stereotaxic surgery and deep brain stimulation for Parkinson disease and movement disorders. In: Watts RL, Koller WC, eds. Movement Disorders: Neurologic Principles and Practice. New York: McGraw-Hill, 1997:241. Used with kind permission. Copyright, McGraw-Hill Companies, Inc.
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Parkinson disease diary. The patient or caregiver should place 1 check mark in each half-hour time slot to indicate the patient's predominant response during most of that period. The goal of therapeutic management is to minimize off time and on time with troublesome dyskinesia. Copyright Robert Hauser, 1996. Used with permission.
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Stages in the development of Parkinson disease (PD)-related pathology (path.). Adapted from Braak H, Ghebremedhin E, Rub U, Bratzke H, Del Tredici K. Stages in the development of Parkinson's disease-related pathology. Cell Tissue Res. 2004 Oct;318(1):121-34.
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Schematic diagram of the basal ganglia circuitry. Represented are the following: inhibitory (red arrows) and excitatory (green arrows) projections between the motor cortex, the putamen, the globus pallidus pars externa (GPe) and globus pallidus pars interna (GPi), the subthalamic nucleus (STN), the substantia nigra pars reticulata (SNr) and substantia nigra pars compacta (SNc), and the ventrolateral thalamus (VL). D1 and D2 indicate the direct (regulated by dopamine D1 receptors) and indirect (regulated by dopamine D2 receptors) pathways, respectively.
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Sagittal section, 12 mm lateral of the midline, demonstrating the subthalamic nucleus (STN) (lavender). The STN is one of the preferred surgical targets for deep brain stimulation to treat symptoms of advanced Parkinson disease.
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The deep brain stimulating lead is equipped with 4 electrode contacts, each of which may be used, alone or in combination, for therapeutic stimulation.
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Axial, fast spin-echo inversion recovery magnetic resonance image at the level of the posterior commissure. The typical target for placing a thalamic stimulator is demonstrated (cross-hairs).
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Implantation of the deep brain stimulation (DBS) lead.
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Insertion of an electrode during deep brain stimulation for Parkinson disease.
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Postoperative coronal magnetic resonance image (MRI) demonstrating desired placement of bilateral subthalamic nuclei-deep brain stimulation (STN-DBS) leads.
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Radiograph of the skull depicting a deep brain stimulator and leads in a patient with Parkinson disease.
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Lewy bodies in the locus coeruleus from a patient with Parkinson disease.
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A: Schematic initial progression of Lewy body deposits in the first stages of Parkinson disease (PD), as proposed by Braak and colleagues. B: Localization of the cluster of significant volume reduction in PD compared with health control subjects. The significant cluster located in the medulla oblongata/pons is superimposed as a red blob on the mean normalized anatomic scan of all participants. The axial and sagittal sections are centered on the peak of significance (–1; –36; –49). This image using voxel-based morphometry (VBM), which searched for regional atrophy in idiopathic PD by comparing a group of subjects with the disease and a group of healthy controls. Jubault T, Brambati SM, Degroot C, et al. Regional brain stem atrophy in idiopathic Parkinson's disease detected by anatomical MRI. PLoS ONE. 2009;4(12):e8247.
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Gross comparison of the appearance of the substantia nigra between a normal brain and a brain affected by Parkinson disease. Note the well-pigmented substantia nigra in the normal brain specimen on the left. In the brain of a Parkinson disease patient on the right, loss of pigmented substantia nigra due to depopulation of pigmented neurons is observed.
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Lewy bodies are intracytoplasmic eosinophilic inclusions, often with halos, that are easily seen in pigmented neurons, as shown in this histologic slide. They contain polymerized alpha-synuclein; therefore, Parkinson disease is a synucleinopathy.
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Symptomatic Therapy, Early Disease
- Symptomatic Therapy, Advanced Disease
- Putative Neuroprotective Therapy
- Deep Brain Stimulation
- Neuroablative Lesion Surgeries
- Preoperative Evaluation
- Neural Transplantation
- Gene Therapy
- Management of Psychiatric Comorbidities
- Exercise and Physical Therapy
- Speech Therapy
- Dietary Considerations
- Consultations
- Long-Term Monitoring
- Future Treatments for Parkinson Disease
- Show All
- Guidelines
- Medication
- Questions & Answers
- Media Gallery
- References