Salsbury Family Movement Disorders Program

Parkinson’s disease (PD) is the most common movement disorder and the second most common neurodegenerative disorder, affecting over a million Americans. PD is a slowly progressive disorder and chronic neurological condition which primarily causes:

• Slowness of movement

• Stiffness

• Balance issues

• Tremor at rest

The exact cause of PD is unknown and there is no cure. A chemical called Dopamine is responsible for normal body movement. In Parkinson’s the brain produces less dopamine and it is not absorbed correctly. Symptoms of PD vary from one person to another. Other motor symptoms may include:

• Loss of arm swing when walking

• Difficulty walking

• Dystonia (abnormal limb spasms and position)

• Freezing of gait (feeling stuck in place)

• Difficulty swallowing

• Difficulty projecting the voice

• Small, cramped handwriting

• Loss of facial expression

Non-motor symptoms can include:

• Constipation

• Anxiety and depression

• Sleep disturbances and vivid dreams

• Loss of smell (anosmia)

• Urinary issues

• Drooling (sialorrhea)

• Blood pressure problems and dizziness when standing

The management of PD is a team approach that includes regular follow up with your movement disorder neurologist, therapy services who provide PT/OT and ST and a variety of additional supportive services. To assist with a diagnosis of PD, your movement disorder neurologist may order a daTscan which can be performed at Hoag Imaging Center.

Parkinson’s Disease Treatments:

• Medications: Medications are used to control symptoms of Parkinson’s disease. These medications are tailed to your individual symptoms.

• Botulinum (Botox™) injections are used to manage excessive drooling (sialorrhea) and is sometimes used to treat tremor. Botox™ is also used to treat dystonia.

• Parkinson’s Disease Neurorehabilitation: This includes Physical therapy, occupational and speech therapy, which is used to maintain and improve motor function, improve balance, and reduce falls. Physical exercise can slow the progression of PD and speech therapy can improve voice function and asses swallowing difficulties.

Surgical Options for Parkinson's Disease:

• Deep Brain Stimulation Surgery is a procedure that can be used to treat symptoms of PD in select individuals. The surgery involves placing an electrode into a specific location in the brain. The electrode is connected to a generator that interrupts the brain signals that cause tremor. The therapy can be adjusted to manage your symptoms and the surgery can be performed on both sides of the brain.

• Focused Ultrasound is an incisionless, anesthesia-free treatment option for those living with essential tremor or tremor-dominant Parkinson’s disease. With no incisions or implants, this safe and effective procedure uses thermal ablation under MR guidance to immediately improve tremor, quality of life, and functional disability.

Essential Tremor (ET) is a common neurological movement disorder. ET causes uncontrolled, involuntary shaking, usually in the hands, but can also occur in the head, voice, and arms. The shaking becomes worse with movement, stress, caffeine, illness, fatigue, and temperature extremes. Simple tasks are affected by ET, such as holding a cup or glass, or trying to execute smaller tasks like writing, shaving, or brushing ones’ teeth. Walking and posture are not affected. Expert consultation by a neurologist trained in movement disorders assists in proper diagnosis and management of ET. Medications and deep brain stimulation surgery are successful treatment options.

Multiple System Atrophy (MSA) is a rare, progressive neurodegenerative disorder. It affects involuntary body functions (autonomic) such as blood pressure and heart rate, as well as voluntary movements. MSA can cause many varied symptoms that may look like Parkinson’s disease. It is considered a Parkinsonism or Parkinson’s Plus syndrome. Symptoms include:

• Slowness

• Rigidity

• Balance difficulties

• Gait abnormalities

• Bowel, bladder, and sexual dysfunction

• Tremors

• Speech and swallowing difficulties

• Low blood pressure, fainting episodes

• Difficulty regulating body temperature

The symptoms and presentation of the disease vary from one person to another. The exact cause of MSA is unknown. Symptoms of MSA progress rapidly and there is no way to slow disease progression. Medications as well as physical, speech and occupational therapy can help manage the symptoms. Diagnosis and management by a movement disorders neurologist is highly recommended.

Progressive Supranuclear Palsy (PSP) is a rare disease that causes difficulties with movement. Symptoms include

• Slowness

• Rigidity and stiffness

• Balance and posture difficulties

• Falls

• Walking difficulty

• Difficulty moving eyes and controlling eye lids

• Difficulties with memory, problems solving and thinking

• Impulsive behavior, such as laughing or crying

• Sleep disturbances

• Swallowing and speech difficulties

• Tremor is rare

PSP results from damage to brain cells in the parts of the brain that control thinking, balance, and movement. PSP is also known as a Parkinson’s Plus disorder because they share some of the same symptoms, however PSP progresses more rapidly. The exact cause of PSP is unknown. Medications may help for a short period of time. The goal of treatment is to manage symptoms of the disease and offer supportive therapies through a multidisciplinary team approach.

Corticobasal Degeneration (CBD) is a rare, progressive neurological disorder that causes difficulties with movement and thinking. CBD is hard to diagnose as many symptoms overlap with those of other movement disorders. The cause of CBD is unknown. The symptoms may start on one side of the body and spread to both sides. The symptoms of CBD include

• New onset of “clumsiness” or difficulty executing tasks (apraxia)

• Abnormal muscle postures (dystonia)

• Muscle jerking (myoclonus)

• Stiffness and rigidity

• Swallowing and speech difficulties

• Tremor

• Poor balance and coordination

The goal of treatment is to manage symptoms of the disease and offer supportive therapies through a multidisciplinary team approach.

Dystonia causes involuntary and prolonged spasms and muscle contractions. This causes abnormal pulling, limb position and posture. For example, a foot curling inward or cervical dystonia, where the neck twists and pulls to one side. These abnormal movements can cause pain and difficulty in daily activities. Dystonia can be caused by brain injury, stroke, Parkinson’s disease, exposure to certain drugs or from unknown causes. Dystonia may occur on one side of the body or in multiple parts of the body. Dystonia can also occur in the jaw (oromandibular) tongue, eyelids (blepharospasm) and may even affect the voice. Effective treatments include medications and Botulinum injections. Deep brain Stimulation Surgery is another effective treatment option.

Restless Leg Syndrome (RLS) and the more severe Willis-Ekbom Syndrome is a common movement disorders characterized by an intense and irresistible urge to move. RLS worsens with age and can be triggered by dehydration, iron deficiency, caffeine, alcohol withdrawal and electrolyte imbalances. It occurs when lying down or sitting, especially for longer periods. RLS is not serious, however it causes an unpleasant sensation and is especially disruptive to sleep. RLS is effectively treated with medications and lifestyle modifications. RLS varies from person to person in severity and frequency.

Rapid Eye Movement Sleep Behavior Disorder (RBD) is a rare movement disorder that occurs during REM sleep. During normal REM sleep the body is temporarily paralyzed, however those with REM sleep behavior disorder will experience vivid dreams and act out their dreams with sudden body movements, thrashing or shouting. This disorder is disruptive to bed partners and increases the risk of injury to bed partners and those affected. RBD has been associated with Parkinson’s disease, Lewy body dementia and Multiple System Atrophy. It affects men more than women and those over the age of 50. Diagnosis is made by a movement disorders neurologist or sleep neurologist and is confirmed by conducting a sleep study. Visit Hoag's Sleep Program for more information.

Lewy Body Disease/Dementia (LBD) is a progressive neurological disease that causes problems with movement, thinking, behavior and mood. It is one of the most common causes of dementia affecting more than one million Americans. The exact cause is unknown and there is no cure, however abnormal alpha-synuclein protein misfolding and brain cell deposits have been associated with LBD. Damage to brain cells results in a loss of the important neurotransmitters Dopamine (responsible for movement, sleep, behavior, motivation) and Acetylcholine (responsible for memory, learning and other body functions). The cognitive changes that occur include hallucinations which often occur early in the disease. Symptoms include:

• Hallucinations (seeing, hearing, or smelling things that are not real or present)

• Memory loss

• Slow thinking and difficulty learning

• Disorganized thinking and changes in concentration and attention occur.

• Movement problems look like Parkinson’s Disease and include stiffness, shuffling gait, slowness, freezing, balance difficulties, loss of facial expression, quiet voice, and posture changes.

• Non-movement symptoms can occur and include problems with blood pressure, constipation, urinary incontinence, and changes in body temperature.

Early and accurate diagnosis by a movement disorders trained neurologist can ensure that the best supportive care and management can be offered. Mediations can help manage the cognitive symptoms.

Huntington’s Disease is an inherited, progressive neurological disorders that causes cognitive problems, emotional changes, and uncontrolled movements. It is caused by a genetic abnormality and results in slow deterioration of brain cells. Huntington’s disease can occur in children. Symptoms include:

• Irritability and obsessive-compulsive behavior

• Anxiety and depression

• Mood swings (emotional lability)

• Poor coordination

• Difficulty thinking (Cognitive difficulties)

• Difficulty moving

• Involuntary jerking movements (chorea)

There is no cure or way to slow down disease progression. Medications may help to manage emotional and movement symptoms. The goal of treatment is to manage symptoms of the disease and offer supportive therapies through a multidisciplinary team approach.

Cerebellar Ataxia results from damage to part of the brain known as the cerebellum. It can be caused by genetic mutation, brain or spinal cord injury, stroke, brain tumors, multiple sclerosis, and alcohol misuse. Symptoms include:

• Poor muscle control in the hands and legs

• Lack of coordination

• Balance difficulties

• Problem walking

• Swallowing and speech problems

• Vision and eye movement problems

Depending on the cause treatment may involve surgery or medication. Additional treatment includes physical, speech and occupational therapy.

Stiff Person Syndrome (SPS) is a progressive neurological disorder and autoimmune disease, where the person develops antibodies to glutamic acid decarboxylase (GAD). GAD is a protein that is involved in making gamma aminobutyric acid (GABA). GABA is an inhibitory neurotransmitter that helps control body movements. Stiff person syndrome results in less GABA. It is often associated with other autoimmune diseases. Symptoms include:

• Episodes of muscle stiffness and rigidity, especially in the body and limbs

• Painful severe muscle spasms

• Balance problems and falling

• Walking difficulty

• Hunched posture

• Heightened sensitivity to noise and touch which can trigger muscle spasms

• Risk of seizures

SPS is treated with medications such as steroids, muscle relaxants, IVIg, anticonvulsants and sedatives. A blood test can help diagnose SPS. Evaluation, diagnosis, and management by a movement disorder neurologist is recommended.

Tourette’s Syndrome (TS) is a disorder that causes uncontrollable, repetitive movements or “TICS”. The tics may include frequent blinking, sudden twitches, making sounds, shouting out, clearing the throat, or sniffing. The signs often begin in childhood and may improve or get worse in adulthood. TS is associated with certain psychological disorders. TS is treated with medications and behavioral therapy.

Chorea is an abnormal involuntary movement that can be characterized by irregular dance like movements of the body and limbs. These movements vary by the cause. Causes include genetic mutations, brain injury, medication side effects, uncontrolled diabetes, and illicit drug use.

Myoclonus describes sudden and quick involuntary movements. These movements can occur in all muscles of the body. Causes include brain injury, medication side effect, and severe illness.