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Post of the Week: Levodopa Worsens Gait in Some Patients


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#1 Dr. Okun

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Posted 22 January 2012 - 07:06 PM

Dear forum members,

In this weeks Neurology Dr. Espay and Bloem examine a rare PD manifestation when levodopa can actually worsen freezing and gait in a few patients. Over the years one trick I have learned is to ask patients if they are better with walking before their first dose of levodopa in the morning. If they are better before levodopa, this may be the clue that they are an "on" medication freezer, and they may need to ask their doc for a medication reduction. See below for the nice abstract of their paper.

Neurology. 2012 Jan 18. [Epub ahead of print]
"On" state freezing of gait in Parkinson disease: A paradoxical levodopa-induced complication.
Espay AJ, Fasano A, van Nuenen BF, Payne MM, Snijders AH, Bloem BR.
Source
From the UC Neuroscience Institute (A.J.E., M.M.P.), Department of Neurology, Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH; I.R.C.C.S. Neuromed (A.F.), Pozzilli (IS), Italy; and Department of Neurology (B.F.L.v.N., A.H.S., B.R.B.), Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical Center, the Netherlands.
Abstract
OBJECTIVE:
To describe the phenotype of levodopa-induced "on" freezing of gait (FOG) in Parkinson disease (PD).
METHODS:
We present a diagnostic approach to separate "on" FOG (deterioration during the "on state") from other FOG forms. Four patients with PD with suspected "on" FOG were examined in the "off state" (>12 hours after last medication intake), "on state" (peak effect of usual medication), and "supra-on" state (after intake of at least twice the usual dose).
RESULTS:
Patients showed clear "on" FOG, which worsened in a dose-dependent fashion from the "on" to the "supra-on" state. Two patients also demonstrated FOG during the "off state," of lesser magnitude than during "on." In addition, levodopa produced motor blocks in hand and feet movements, while other parkinsonian features improved. None of the patients had cognitive impairment or a predating "off" FOG.
CONCLUSIONS:
True "on" FOG exists as a rare phenotype in PD, unassociated with cognitive impairment or a predating "off" FOG. Distinguishing the different FOG subtypes requires a comprehensive motor assessment in at least 3 medication states.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#2 Emmie

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Posted 22 January 2012 - 10:05 PM

Dear forum members,

In this weeks Neurology Dr. Espay and Bloem examine a rare PD manifestation when levodopa can actually worsen freezing and gait in a few patients. Over the years one trick I have learned is to ask patients if they are better with walking before their first dose of levodopa in the morning. If they are better before levodopa, this may be the clue that they are an "on" medication freezer, and they may need to ask their doc for a medication reduction. See below for the nice abstract of their paper.

Neurology. 2012 Jan 18. [Epub ahead of print]
"On" state freezing of gait in Parkinson disease: A paradoxical levodopa-induced complication.
Espay AJ, Fasano A, van Nuenen BF, Payne MM, Snijders AH, Bloem BR.
Source
From the UC Neuroscience Institute (A.J.E., M.M.P.), Department of Neurology, Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH; I.R.C.C.S. Neuromed (A.F.), Pozzilli (IS), Italy; and Department of Neurology (B.F.L.v.N., A.H.S., B.R.B.), Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical Center, the Netherlands.
Abstract
OBJECTIVE:
To describe the phenotype of levodopa-induced "on" freezing of gait (FOG) in Parkinson disease (PD).
METHODS:
We present a diagnostic approach to separate "on" FOG (deterioration during the "on state") from other FOG forms. Four patients with PD with suspected "on" FOG were examined in the "off state" (>12 hours after last medication intake), "on state" (peak effect of usual medication), and "supra-on" state (after intake of at least twice the usual dose).
RESULTS:
Patients showed clear "on" FOG, which worsened in a dose-dependent fashion from the "on" to the "supra-on" state. Two patients also demonstrated FOG during the "off state," of lesser magnitude than during "on." In addition, levodopa produced motor blocks in hand and feet movements, while other parkinsonian features improved. None of the patients had cognitive impairment or a predating "off" FOG.
CONCLUSIONS:
True "on" FOG exists as a rare phenotype in PD, unassociated with cognitive impairment or a predating "off" FOG. Distinguishing the different FOG subtypes requires a comprehensive motor assessment in at least 3 medication states.



#3 Emmie

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Posted 22 January 2012 - 10:30 PM

Thank-you!

I started abruptly falling 7 weeks after I started Sinamet, changed to Carbidopa Levidopa ER and still fell. (with 4 ER visits last year due to broken ribs, stitches, goose eggs)

I ONLY fall after my 2nd dose of the day. I have fallen 11 times between the hours of 2pm-6:30 pm and at NO other time. My favorite time of day is before my 1st dose.

I never fall walking across ice, never fall tripping over anything, I don't lose consciesness, I just go down.

I thought it was the carbidopa-levidopa & my local neurologist suggested I space out my doses, which seemed to help a bit. He agreed to let me cut my dose in half in November. I have a trained service dog who alerts me before I fall, it is too early to say, but my SD has alerted me less often & I haven't fallen.

I have 2 questions:

1. If the medication causes freezing might it be causing damage? (I don't mind the tremor & tolerate Azilect well),

2. Did any of the subjects also have trouble with a Dopamine Agonist? Within 5 months of going on a Dopamine Agonist I was diagnosed with MSA. (Orthostatic Hypotension with a 40 pt drop on the tilt table, abnormal valsalva, Sudomotor dysfunction, dysphagia with deep penetration, periphrial neuropathy, vocal cord paralysis, Hypertensive Crisis, etc etc. 2 years later went off the Dopamine Agonist & one by one all the scary stuff improved to pre-medication levels.

I was still stuck with the MSA diagnosis, but no longer felt at risk of dying, so I had an FDG Petscan which confirmed I have Mild Ideopathic Parkinson's, NOT MSA! I also have Hypometabolism of unknown signfificance in my Frontal, Temporal-parietal & cerrebellar lobes.

Dear forum members,

In this weeks Neurology Dr. Espay and Bloem examine a rare PD manifestation when levodopa can actually worsen freezing and gait in a few patients. Over the years one trick I have learned is to ask patients if they are better with walking before their first dose of levodopa in the morning. If they are better before levodopa, this may be the clue that they are an "on" medication freezer, and they may need to ask their doc for a medication reduction. See below for the nice abstract of their paper.

Neurology. 2012 Jan 18. [Epub ahead of print]
"On" state freezing of gait in Parkinson disease: A paradoxical levodopa-induced complication.
Espay AJ, Fasano A, van Nuenen BF, Payne MM, Snijders AH, Bloem BR.
Source
From the UC Neuroscience Institute (A.J.E., M.M.P.), Department of Neurology, Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH; I.R.C.C.S. Neuromed (A.F.), Pozzilli (IS), Italy; and Department of Neurology (B.F.L.v.N., A.H.S., B.R.B.), Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical Center, the Netherlands.
Abstract
OBJECTIVE:
To describe the phenotype of levodopa-induced "on" freezing of gait (FOG) in Parkinson disease (PD).
METHODS:
We present a diagnostic approach to separate "on" FOG (deterioration during the "on state") from other FOG forms. Four patients with PD with suspected "on" FOG were examined in the "off state" (>12 hours after last medication intake), "on state" (peak effect of usual medication), and "supra-on" state (after intake of at least twice the usual dose).
RESULTS:
Patients showed clear "on" FOG, which worsened in a dose-dependent fashion from the "on" to the "supra-on" state. Two patients also demonstrated FOG during the "off state," of lesser magnitude than during "on." In addition, levodopa produced motor blocks in hand and feet movements, while other parkinsonian features improved. None of the patients had cognitive impairment or a predating "off" FOG.
CONCLUSIONS:
True "on" FOG exists as a rare phenotype in PD, unassociated with cognitive impairment or a predating "off" FOG. Distinguishing the different FOG subtypes requires a comprehensive motor assessment in at least 3 medication states.



#4 Dr. Okun

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Posted 23 January 2012 - 07:55 AM

I would suggest contacting the authors of the article. Dr. Espay is at University of Cincinnati.

I would caution that freezing that is relieved by dose reduction is relatively rare. Patients should NOT decrease medications without consulting their doc. One further point is that many patients who are freezing actually improve with increased doses.

Finally one of the most common long term issues with PD is axial resistant symptoms to levodopa----no matter how much you take you may develop freezing, balance and walking problems.

Thanks for the post as I want to be sure everyone understands these issues and doesn't jump to reduce meds.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#5 gmk

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Posted 27 May 2012 - 03:53 PM

I am grateful to Dr. Okun for bringing up the topic for discussion.
Previously, it was pointed out that individualization in dosage of L-DOPA (how much and how often) takes precedence to adding or changing
therapeutic agent/s. It was also noted that authoritative approach in the therapy should be replaced by partnership between the patient and
the physician treating him/her. Now, it appears that we should become aware how the dosage can result in the particular symptomatology
of him/her. The bottom line is that neither he/she should treat himself/herself alone and that cooperation between their family physician and
movement disorder specialist should be optimalised.
gmk

#6 Dr. Okun

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Posted 28 May 2012 - 09:06 AM

Very nice comment thank you!
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips




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