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Parkinson's disease

Background

Overview

Definition
PD is a chronic neurodegenerative disorder characterized by motor, cognitive and autonomic dysfunction, as well as mood and impulse control disorders.
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Pathophysiology
The exact cause of PD is unknown; however, a combination of genetic and environmental factors have been implicated. Advancing age (> 65 years), male gender, genetics (LRRK2, glucocerebrosidase, and Parkin mutation), industrial exposure, heavy metals (manganese, copper, and lead), pesticides (rotenone, paraquat), and obstructive sleep apnea increase the risk of PD.
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Epidemiology
The incidence of PD in the US is estimated at 9.5-10.3 cases per 100,000 person-years, while its prevalence is estimated at 81 persons per 100,000 population.
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Disease course
In patients with PD, premature selective loss of dopamine neurons and accumulation of Lewy bodies causes the classical motor manifestations of parkinsonism (tremor, rigidity, bradykinesia, and postural instability), as well as autonomic dysfunction, cognitive dysfunction, and mood and impulse control disorders.
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Prognosis and risk of recurrence
Patients with PD have 2.56-fold increased risk of mortality than similar age-matched individuals.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of Parkinson's disease are prepared by our editorial team based on guidelines from the American Physical Therapy Association (APTA 2022), the Movement Disorder Society-European Section (MDS-ES/EAN 2022), the American Academy of Neurology (AAN 2021), the American Academy of Sleep Medicine (AASM 2021), the Canadian Neurological Sciences Federation (CNSF 2019), the American ...
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Screening and diagnosis

Indications for screening: as per EFNS/ENS 2013 guidelines, insufficient evidence to recommend screening for premotor PD with olfactory testing, due to limited specificity.
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  • Diagnosis

Diagnostic investigations

Diagnostic imaging: as per CNSF 2019 guidelines, do not obtain routine functional imaging for the differential diagnosis of PD and Parkinson-plus disorders, such as progressive supranuclear palsy and multiple system atrophy.
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  • Olfactory testing

  • Genetic testing

  • Drug challenge tests

  • Screening for dementia and sleeping disorders

Medical management

General principles: as per CNSF 2019 guidelines, discuss the following before initiating treatment in patients with PD:
the patient's individual clinical circumstances, such as their symptoms, comorbidities and risks from polypharmacy
the patient's individual lifestyle circumstances, preferences, needs and goals
the potential benefits and harms of the different drug classes.
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  • Levodopa

  • Dopamine agonists

  • MAO-B inhibitors

  • COMT inhibitors

  • Amantadine

  • Other medications

  • Management of dementia

  • Management of sleep disorders

  • Management of depression

  • Management of psychosis

  • Management of autonomic dysfunction

  • Palliative care

Nonpharmacologic interventions

Physiotherapy: as per APTA 2022 guidelines, offer the following types of physical therapy interventions in patients with PD with corresponding purposes:
Situation
Guidance
Moderate-to-high-intensity aerobic exercises
Improve oxygen consumption, reduce motor disease severity, and improve functional outcomes
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Resistance training
Reduce motor disease severity and improve strength, power, non-motor symptoms, functional outcomes, and QoL
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Balance training
Reduce postural control impairments and improve balance and gait outcomes, mobility, balance confidence, and QoL
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Flexibility exercises
Improve ROM
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External cueing
Reduce motor disease severity and freezing of gait, improve gait outcomes
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Community-based exercises
Reduce motor disease severity and improve non-motor symptoms, functional outcomes, and QoL
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Gait training
Reduce motor disease severity and improve stride length, gait speed, mobility, and balance
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Task-specific training
Improve task-specific impairment levels and functional outcomes
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Behavior-change approaches
Improve physical activity and QoL
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  • Occupational therapy

  • Speech and language therapy

  • Augmentative and alternative communication devices

  • Dietary modifications

  • Vitamins and dietary supplements

Therapeutic procedures

Subcutaneous apomorphine infusion: as per EAN/MDS-ES 2022 guidelines, consider offering apomorphine pump infusion in patients with advanced PD if fluctuations are not satisfactorily controlled with medication.
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  • Levodopa-carbidopa intestinal gel

  • Deep brain stimulation

Surgical interventions

Indications for surgery: as per EAN/MDS-ES 2022 guidelines, consider offering unilateral pallidotomy with radiofrequency thermocoagulation in patients with advanced PD experiencing troublesome fluctuations, if deep brain stimulation and pump therapies are not treatment options.
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  • Radiofrequency thermocoagulation

  • Stereotactic radiosurgery

  • MRgFUS surgery

Patient education

General counseling: as per AAN 2021 guidelines, counsel patients with early PD on the benefits and risks of initial therapy with levodopa, dopamine agonists and MAO-B inhibitors based on the individual patient's disease characteristics to inform treatment decisions.
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Follow-up and surveillance

Monitoring for medication adverse effects, levodopa: as per AAN 2021 guidelines, monitor patients taking levodopa routinely for motor response to treatment and for the presence of dyskinesia, motor fluctuations, impulse control disorders, excessive daytime sleepiness, postural hypotension, nausea and hallucinations, to guide dosage titration over time.
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  • Monitoring for medication adverse effects (dopamine agonists)