In early stages, Parkinson disease typically begins with asymmetric or unilateral motor symptoms due to combinations of mild bradykinesia, rigidity, and tremor. In most cases, with progression, signs of more generalized bradykinesia appear, which include facial masking, reduced voice volume, and slowing of activities of daily living. In more advanced Parkinson disease, other disabling manifestations may follow, such as impaired balance, gait freezing, falls, speech disturbance, and cognitive impairment. Levodopa is the most effective medical treatment for Parkinson disease. However, motor complications uniquely related to levodopa treatment may emerge that may be difficult to manage. These include fluctuating levodopa responses and involuntary movements and postures known as dyskinesia and dystonia. Medication adjustments are usually effective, but in some cases surgical intervention with deep brain stimulation becomes necessary to alleviate motor complications. The case of Mr L, a man with an 11-year history of Parkinson disease, illustrates these emerging motor complications and the manner in which they may be managed both medically and surgically.
Deep brain stimulation (DBS) is executed by implanting a stimulating electrode containing 4 electrical contacts into a brain target and connecting it to a pulse generator placed subcutaneously in the upper chest to provide continuous stimulation. In Parkinson disease, 1 DBS strategy is to target the subthalamic nucleus or the internal segment of the globus pallidus. The electrical contacts are placed unilaterally or bilaterally depending on the patient’s needs.
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The Rational Clinical Examination
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