How best to address these common movement disorders

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Applied Evidence

How best to address these common movement disorders

J Fam Pract. 2011 December;60(12):721-725

By

Aylin Yaman, MD

Melahat Akdeniz, MD

Hakan Yaman, MD, MS

This review describes how to manage everything from Parkinson’s disease and tic disorders to restless legs syndrome and ataxia.

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References

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3. Harris MK, Shneyder N, Borazanci A, et al. Movement disorders. Med Clin North Am. 2009;93:371-388.

4. Palhagen S, Heinonen E, Hagglund J, et al. Selegiline slows the progression of the symptoms of Parkinson disease. Neurology. 2006;66:1200-1206.

5. Olanow CW, Rascol O, Hauser R, et al. A double-blind, delayed-start trial of rasagiline in Parkinson’s disease. N Engl J Med. 2009;361:1268-1278.

6. Zesiewicz TA, Sullivan KL, Arnulf I, et al. Treatment of nonmotor symptoms of Parkinson disease. Neurology. 2010;74:924-931.

7. Suchowersky O, Reich S, Perlmutter J, et al. Practice parameter: diagnosis and prognosis of new onset Parkinson disease (an evidence-based review). Neurology. 2006;66:968-975.

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9. The National Collaborating Centre for Chronic Conditions Parkinson’s Disease. National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care. 2006. Available at: http://www.nice.org.uk/nicemedia/live/10984/30087/30087.pdf. Accessed May 12, 2010.

10. Jankovic J. Treatment of hyperkinetic movement disorders. Lancet Neurol. 2009;8:844-856.

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PRACTICE RECOMMENDATIONS

• Initiate neuroprotective therapy with a monoamine oxidase B inhibitor to slow the progression of Parkinson’s disease. With onset of functional impairment, give levodopa at the lowest effective dose. A

• Give propranolol for essential tremor causing a patient distress, starting at 20 to 40 mg twice daily and increasing the dose (to a maximum of 320 mg/d) until relief is achieved. B

• Consider giving a dopamine receptor blocker for Tourette syndrome or other tic disorder; alternative agents are clonidine or a newer agent, tetrabenazine. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Movement disorders often require consultation with a neurologist, and a working knowledge of established and novel treatments can set the stage for optimal long-term cooperative management.¹ In this article, we review therapeutic options for common movement disorders, including hypokinetic, hyperkinetic, and dyskinetic disturbances.

Parkinson’s disease treatment: MAO-B inhibitor, levodopa are mainstays

Parkinson’s disease, the most common hypokinetic movement disorder, is a chronic, progressive, neurodegenerative disease. It affects 1% of individuals older than 65 years and 4% to 5% of individuals older than 85 years. Its cardinal symptoms are resting tremor, bradykinesia, rigidity, a flexed posture, and loss of postural reflexes. Resting tremor, referred to as “pill rolling” tremor, is 4 to 6 Hz and usually begins unilaterally.^2,3 Associated symptoms can include dystonia, dementia, psychiatric disorders, sleep disorders, and autonomic symptoms.

Neuroprotective therapy is used to slow the progression of the disease, particularly in its early stage. The monoamine oxidase B (MAO-B) inhibitor selegiline has proven effective in this regard² (strength of recommendation [SOR]: A). In randomized controlled studies, selegiline has delayed the need for levodopa for 9 to 12 months⁴ (SOR: A). Another MAO-B inhibitor, rasagiline, has demonstrated neuroprotective effects as well⁵ (SOR: B). These medications may also be used with levodopa for symptom control and as adjuvant therapy in patients with motor fluctuations.² A conventional dose of selegiline is 10 mg/d (5 mg at breakfast; 5 mg at lunch). Rasagiline is given at 1 mg/d. Concomitant use of ciprofloxacin or other CYP1A2 inhibitors limits its effectiveness.^6,7

Symptomatic therapy is indicated at the onset of functional impairment. The dopamine precursor levodopa is the most widely used and effective drug for Parkinson’s disease symptoms, especially bradykinesia and rigidity. Use the lowest possible dose to control symptoms (eg, 100 mg twice daily) and protect against motor complications of the drug^7-9 (SOR: A). To prevent conversion of levodopa to dopamine outside the blood-brain barrier, combine it with the decarboxylase inhibitor carbidopa. Dietary restriction of proteins may be needed, because amino acids can interfere with the absorption of levodopa.

Especially with prolonged use, levodopa can cause disturbing adverse effects, such as nausea, vomiting, psychosis, cardiac arrhythmia, and orthostatic hypotension. Dyskinesias and motor fluctuations are complications of long-term treatment and are irreversible. Adding a cathecol-O-methyltransferase (COMT) inhibitor, such as entacapone, to increase levodopa’s effectiveness has been shown to reduce motor fluctuations^2,3,10 (SOR: B). Dopamine agonists such as bromocriptine, ropinirole, and pramipexole used in early Parkinson’s disease can also reduce dyskinesias and motor fluctuations. Dopamine agonists may be preferred to levodopa in early Parkinson’s disease because they are better tolerated and cause fewer adverse effects. Or they may be used as adjuncts for patients whose response to levodopa is deteriorating or fluctuating^3,7,8 (SOR: B). In advanced disease, motor complications can also be managed by augmenting levodopa therapy with a dopamine agonist, MAO-B inhibitor, or COMT inhibitor^7,8 (SOR: A).

Anticholinergics, mainly benztropine and trihexyphenidyl, may be used as symptomatic treatment, especially in young people with early Parkinson’s disease and severe tremor. However, they are not the first drugs of choice due to limited efficacy and the potential for neuropsychiatric side effects⁸ (SOR: C). Amantadine can reduce dyskinesia in people with advanced Parkinson’s disease⁸ (SOR: C). For patients who have Parkinson’s disease with severe motor complications, intermittent apomorphine injections can help reduce “off time” periods in the daily treatment cycle when the efficacy of drugs wanes⁹ (SOR: B).

Deep brain stimulation of the subthalamic nucleus has only SOR C support for reducing dyskinesias and off time.⁹

Treating nonmotor symptoms of Parkinson’s disease can be challenging. For dementia in these patients, consider cholinesterase inhibitors^6,8 (SOR: C). For depression, selective serotonin reuptake inhibitors are effective^6,8,9 (SOR: C). For psychosis, preferred agents are low-dose clozapine or quetiapine^6,8-10 (SOR: C). Plan for supportive and symptomatic management of constipation, dysphagia, sialorrhea, orthostatic hypotension, sleep disturbances, and urinary urgency.^2,3

Tremor

Tremor is a common form of hyperkinesia, presenting either as a primary disorder or as a symptom of another condition.¹¹ By definition, it is a rhythmical, involuntary, oscillatory movement of 1 or more body parts. Tremors are classified as rest or action tremors, with the latter being further categorized as postural (occurring while the patient maintains a position against gravity) or kinetic (occurring during voluntary movement).^2,10