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Types of Parkinsonisms

Parkinsonism is a term used to describe the collection of signs and symptoms found in Parkinson’s disease (PD). These include slowness (bradykinesia Slowness of movement.), stiffness (rigidity In Parkinson’s, stiffness of the arms or legs beyond what would result from normal aging or arthritis. Some people call it “tightness” in their limbs.), tremor Involuntary shaking of the hands, arms, legs, jaw or tongue. The typical Parkinson’s tremor is “pill-rolling” – it looks like holding a pill between thumb and forefinger and continuously rolling it around. Some people report an internal tremor, a shaking sensation inside the chest, abdomen or limbs that cannot be seen. Most Parkinson’s tremor is “resting tremor,” which lessens during sleep and when the body part is actively in use. and imbalance (postural instability Impaired balance and the tendency to fall without explanation, usually when pivoting; a common symptom in the later stages of Parkinson’s.). Conditions other than PD may have one or more of these symptoms, mimicking Parkinson’s.

Idiopathic Parkinson’s is the most common form of Parkinsonism. However, about 15 percent of those with symptoms suggesting PD have one of several diseases termed, atypical parkinsonism A group of brain disorders that initially look like Parkinson's disease, but differ in the course of the disease and response to antiparkinson medications. The term is used interchangeably with Parkinson-plus syndromes. disorders. These conditions are typically more difficult to treat than PD and include:

Multiple System Atrophy (MSA)

  • MSA is a term encompassing several  neurodegenerative disorders Diseases characterized by the loss of cells of the brain or spinal cord, which over time leads to dysfunction and disability; Parkinson’s disease, Alzheimer’s disease and Lou Gehrig’s disease (ALS) are all examples. in which one or more systems in the body deteriorates.
  • Similar syndromes include: Shy-Drager syndrome, striatonigral degeneration and olivopontocerebellar atrophy.
  • Average age of onset is in the mid-50’s.
  • In 2007, a new classification was proposed with two major subtypes:
    • MSA-P (similar to SND) in which parkinsonism dominates.
    • MSA-C  in which cerebellar ataxia Loss of control of bodily movements., (incoordination), dominates.
  • MSA symptoms include: incoordination (ataxia), dysfunction in the autonomic nervous system that automatically controls things such as blood pressure and bladder function. These are in addition to variable degrees of parkinsonism including symptoms such as slowness, stiffness and imbalance.
  • Initially, it may be difficult to distinguish MSA from Parkinson’s. More rapid progression, poor response to common PD medications and development of other symptoms in addition to parkinsonism may be clues.
  • The diagnosis of MSA is made based on clinical features. There is no specific test that provides a definitive diagnosis.
  • There is no specific treatment for MSA. Treatment focuses on alleviating symptoms.
  • People with MSA usually respond poorly to PD medications and may require higher doses than the typical person with PD, often with only modest benefit.

Progressive Supranuclear Palsy (PSP)

  • Most common degenerative type of atypical parkinsonism.
  • Average age of onset is in the mid-60’s.
  • Symptoms tend to progress more rapidly than PD. People with PSP may fall frequently early in the course of disease. Later symptoms include limitations in eye movements, particularly looking up and down, which also contributes to falls.
  • Those with PSP also often have problems with swallowing (dysphagiaDifficulty swallowing.), difficulty in producing speech (dysarthria A speech disorder (slurred or unclear speech) caused by problems with the strength or coordination of muscles that produce speech, as a result of damage to the brain or nerves.), sleep problems, memory and thinking problems (dementiaA term used to describe a group of brain disorders that cause a broad complex of symptoms such as disorientation, confusion, memory loss, impaired judgment and alterations in mood and personality.).
  • The diagnosis of PSP is made based on clinical features. There is no specific test that provides a definitive diagnosis.
  • There is no specific treatment for PSP. Treatment focuses on alleviating symptoms.

Corticobasal Syndrome (CBS)

  • CBS is the least common of the atypical causes of Parkinsonism.
  • Usually begins with symptoms affecting one limb. In addition to parkinsonism, other symptoms can include abnormal posturing of the affected limb (dystonia A disorder in which muscles contract uncontrollably, causing abnormal movements and postures; can be very painful.), fast, jerky movements ( myoclonus Abrupt, jerking movements of the arms or legs, commonly occurring when you are falling sleep.), difficulty with some motor tasks despite normal muscle strength (apraxia A neurological disorder in which you lose the ability to carry out common, purposeful movements when asked, even if you want to and are physically able to perform the movements. May affect speech or limb movement.), difficulty with language (aphasia) among others.
  • Typically begins after age 60.
  • Progresses more rapidly than PD.
  • No specific test for CBS. Treatment focuses on symptoms.
  • Supportive treatment such as botulinum toxin (Botox The brand name for botulinum toxin A, a neurotoxin that weakens muscles. In Parkinson’s it is sometimes used to decrease saliva production for people who have issues with drooling.®) for dystonia, antidepressants, speech and physical therapy may be helpful. LevodopaThe medication most commonly given to control the movement symptoms of Parkinson’s, usually with carbidopa. It is converted in the brain into dopamine. and dopamine A chemical messenger (neurotransmitter) that regulates movement and emotions. agonists (common PD medications) seldom help.

Dementia with Lewy bodies (DLB)

  • Dementia with Lewy bodies (DLB) A progressive, neurodegenerative disease that shares symptoms of both Alzheimer’s disease and Parkinson’s. Unlike Parkinson’s disease dementia, cognitive symptoms are present before or within one year of noticing movement symptoms. The central features of DLB include progressive cognitive decline, changes in alertness and attention, visual hallucinations and parkinsonian motor symptoms such as slowness of movement, difficulty walking or rigidity. is a progressive, neurodegenerative disorder in which abnormal deposits of a protein called alpha-synuclein A protein in the human brain that is associated with the development of Parkinson’s. It is the main component of Lewy bodies. build up in multiple areas of the brain.
  • Dementia with Lewy bodies is second to Alzheimer’s as the most common cause of degenerative dementedly first causes progressive problems with memory and fluctuations in thinking, as well as hallucinations. These symptoms are joined later in the course of the disease by parkinsonism with slowness, stiffness and other symptoms similar to PD.
  • While the same abnormal protein (alpha synuclein) is found in the brains of those with PD, when individuals with PD develop memory and thinking problems it tends to occur later in the course of the disease.
  • There are no specific treatments for DLB. Treatment focuses on symptoms.

Drug-induced Parkinsonism

  • This is the most common form of what is known as secondary parkinsonism.
  • Side effects of some drugs, especially those affecting brain dopamine levels (anti-psychotic or anti-depressant medication), can cause parkinsonism.
  • Although tremor and postural instability may be less severe, this condition may be difficult to distinguish from Parkinson’s. 
  • Medications that can cause the development of Parkinsonism include:
    • Antipsychotics
    • Certain antiemetics (anti-nausea medications)
    • Some antidepressants
    • Reserpine
    • Tetrabenazine
    • Some calcium channel blockers
    • Usually after stopping those medications parkinsonism gradually disappears over weeks to months, though symptoms may last for up to a year.

Vascular Parkinsonism (VP)

  • There is some evidence to suggest that multiple small strokes The sudden death of some brain cells due to a lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. in key areas of the brain may cause Parkinsonism.
  • No specific clinical features or diagnostic tests reliably differentiate PD and vascular parkinsonism, though some features may suggest VP.
  • A severe onset of parkinsonism immediately following (or progressively occurring within a year of) a stroke may indicate VP.
  • Other signs that can indicate VP include: evidence of vascular disease on an MRI (magnetic resonance imaging) A medical imaging technique that uses magnetic forces to obtain detailed images of the body. MRI is non-invasive and does not use radiation. of the brain in combination with varying levels of deterioration, prominent early cognitive problems and lower body issues, such as early gait and balance problems.
  • Dopaminergic medications (like levodopa) may possibly have modest benefit, depending on the location of vascular disease in the brain. 

Page reviewed by Dr. Ryan Barmore, Movement Disorders Fellow at the University of Florida, a Parkinson’s Foundation Center of Excellence.

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