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| ==History== | | ==History== |
| The main clinical manifestations of Parkinson disease include tremor, rigidity and bradykinesia. Later in the course of the disease patient can have postural instability.(6 ta 10)
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| ==Common symptoms== | | ==Common symptoms== |
| Parkinson disease affects movement (motor symptoms). Typical other symptoms include disorders of mood, behavior, thinking, and sensation (non-motor symptoms). Individual patients' symptoms may be quite dissimilar and progression of the disease is also distinctly individual. | | The main clinical manifestations of Parkinson disease include [[tremor]], rigidity and [[bradykinesia]]. Later in the course of the disease patient can have [[postural instability]].(6 ta 10) Some studies suggest that there can be three clinical subtypes for Parkinson disease: [[Tremor]] dominant, akinetic-rigid and [[postural instability]] and [[gait]] difficulty(28 ta 30)but other studies demonstrate that clinical course of the disease can be variable and this subtypes can switch to each other through time.(37_38) |
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| ===Motor symptoms=== | | ==== Motor symptoms ==== |
| | Tremor: [[Tremor]] is the most common [[symptom]] in Parkinson disease and can be the presenting sign in 70 to 80 percent of patients.(16_17) This [[symptom]] starts unilaterally mostly in [[hand]] and then progress to the other side of the body. It can also involve [[Leg|legs]], [[jaw]], [[lips]] and [[tongue]].(22_15_23) [[Parkinson's disease|PD]] [[tremor]] frequency is 3 to 7 Hz.(15) There is a [[symptom]] called re-emergent tremor in some of the [[Parkinson's disease|PD]] patients. It manifests by postural tremor that starts after several seconds and can make it difficult to differentiate [[Parkinson's disease|PD]] from [[essential tremor]].(11_12_13) |
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| The [[cardinal symptom]]s are:
| | Rigidity: |
| * ''[[Tremor]]'': normally 4-7 Hz tremor, maximal when the limb is at rest, and decreased with voluntary movement. It is typically unilateral at onset. This is the most apparent and well-known symptom, though an estimated 30% of patients have little perceptible tremor; these are classified as akinetic-rigid.
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| * ''[[Spasticity|Rigidity]]'': stiffness; increased muscle tone. In combination with a resting tremor, this produces a ratchety, "cogwheel" rigidity when the limb is passively moved.
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| * ''[[Bradykinesia]]/[[Akinesia]]'': respectively, slowness or absence of movement. Rapid, repetitive movements produce a dysrhythmic and decremental loss of amplitude. Also "dysdiadokinesia", which is the loss of ability to perform rapid ''alternating'' movements
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| * ''[[Postural instability]]'': failure of postural [[reflexes]], which leads to impaired balance and falls.
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| Other motor symptoms include:
| | Bradykinesia: |
| * [[Gait]] and posture disturbances:
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| ** Shuffling: gait is characterized by short steps, with feet barely leaving the ground, producing an audible shuffling noise. Small obstacles tend to trip the patient
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| ** Decreased arm swing: a form of bradykinesia
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| ** Turning "en bloc": rather than the usual twisting of the neck and trunk and pivoting on the toes, PD patients keep their neck and trunk rigid, requiring multiple small steps to accomplish a turn.
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| ** Stooped, forward-flexed posture. In severe forms, the head and upper shoulders may be bent at a right angle relative to the trunk (camptocormia) <ref>{{cite journal |author=Lepoutre A, Devos D, Blanchard-Dauphin A, ''et al'' |title=A specific clinical pattern of camptocormia in Parkinson's disease |journal=J. Neurol. Neurosurg. Psychiatr. |volume=77 |issue=11 |pages=1229-34 |year=2006 |pmid=16735399}}</ref>.
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| ** Festination: a combination of stooped posture, imbalance, and short steps. It leads to a gait that gets progressively faster and faster, often ending in a fall.
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| ** Gait freezing: "freezing" is another word for akinesia, the inability to move. Gait freezing is characterized by inability to move the feet, especially in tight, cluttered spaces or when initiating gait.
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| ** [[Dystonia]] (in about 20% of cases): abnormal, sustained, painful twisting muscle contractions, usually affecting the foot and ankle, characterized by toe flexion and foot inversion, interfering with gait. However, dystonia can be quite generalized, involving a majority of skeletal muscles; such episodes are acutely painful and completely disabling.
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| * Speech and swallowing disturbances
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| ** Hypophonia: soft speech. Speech quality tends to be soft, hoarse, and monotonous. Some people with Parkinson's disease claim that their tongue is "heavy" or have [[cluttered speech]].<ref>{{cite book
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| | first=Michael
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| | middle=J
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| | last=Fox
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| | title= Lucky Man: A Memoir
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| | location =
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| | publisher= Hyperion
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| | isbn=0786888741
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| | pages=214
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| | year = 2003
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| }}</ref>.
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| ** Festinating speech: excessively rapid, soft, poorly-intelligible speech.
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| ** [[Drooling]]: most likely caused by a weak, infrequent swallow and stooped posture.
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| ** Non-motor causes of speech/language disturbance in both expressive and receptive language: these include decreased verbal fluency and cognitive disturbance especially related to comprehension of emotional content of speech and of facial expression<ref>{{cite journal | author = Pell M | title = On the receptive prosodic loss in Parkinson's disease. | journal = Cortex | volume = 32 | issue = 4 | pages = 693-704 | year = 1996 | pmid = 8954247}}</ref>
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| ** [[Dysphagia]]: impaired ability to swallow. Can lead to [[Pulmonary aspiration|aspiration]], [[pneumonia]].
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| * Other motor symptoms:
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| ** [[Fatigue (physical)|Fatigue]] (up to 50% of cases);
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| ** Masked faces (a mask-like face also known as [[hypomimia]]), with infrequent [[blinking]];<ref>{{cite journal |author=Deuschl G, Goddemeier C |title=Spontaneous and reflex activity of facial muscles in dystonia, Parkinson's disease, and in normal subjects |journal=J. Neurol. Neurosurg. Psychiatr. |volume=64 |issue=3 |pages=320-4 |year=1998 |pmid=9527141 |url=http://jnnp.bmjjournals.com/cgi/content/full/64/3/320}}</ref>
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| ** Difficulty rolling in bed or rising from a seated position;
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| ** [[Micrographia (handwriting)|Micrographia]] (small, cramped handwriting);
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| ** Impaired fine motor dexterity and [[motor coordination]];
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| ** Impaired gross motor coordination;
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| ** Poverty of movement: overall loss of accessory movements, such as decreased arm swing when walking, as well as spontaneous movement.
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| ===Non-motor symptoms===
| | Postural instability: |
| ====Mood disturbances====
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| *Estimated prevalence rates of depression vary widely according to the population sampled and methodology used. Reviews of [[clinical depression|depression]] estimate its occurrence in anywhere from 20-80% of cases.<ref>{{cite journal | author = Lieberman A | title = Depression in Parkinson's disease -- a review. | journal = Acta Neurol Scand | volume = 113 | issue = 1 | pages = 1-8 | year = 2006|pmid = 16367891}}</ref> Estimates from community samples tend to find lower rates than from specialist centres. Most studies use self-report questionnaires such as the [[Beck Depression Inventory]], which may overinflate scores due to physical symptoms. Studies using diagnostic interviews by trained psychiatrists also report lower rates of depression.
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| *More generally, there is an increased risk for any individual with depression to go on to develop Parkinson's disease at a later date.<ref>{{cite journal | author = Ishihara L, Brayne C | title = A systematic review of depression and mental illness preceding Parkinson's disease. | journal = Acta Neurol Scand | volume = 113 | issue = 4 | pages = 211-20 | year = 2006 | pmid = 16542159}}</ref>
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| *70% of individuals with Parkinson's disease diagnosed with pre-existing depression go on to develop anxiety. 90% of Parkinson's disease patients with pre-existing anxiety subsequently develop depression; [[apathy]] or [[abulia]].
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| <!--VERY STRONG evidence of pre-emergence of either depression (up to ten years prior) or (anxiety) up to 20 years prior; essentially a prodome? CAN DOCUMENT-->
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| ====Cognitive disturbances====
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| *slowed reaction time; both voluntary and involuntary motor responses are significantly slowed.
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| *[[executive dysfunction]], characterized by difficulties in: differential allocation of attention, impulse control, set shifting, prioritizing, evaluating the salience of ambient data, interpreting social cues, and subjective time awareness. This complex is present to some degree in most Parkinson's patients; it may progress to:
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| *[[dementia]]: a later development in approximately 20-40% of all patients, typically starting with slowing of thought and progressing to difficulties with abstract thought, memory, and behavioral regulation. [[Hallucinations]], [[delusions]] and [[paranoia]] may develop.
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| *short term [[memory loss]]; [[procedural memory]] is more impaired than [[declarative memory]]. Prompting elicits improved recall.
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| *medication effects: some of the above cognitive disturbances are improved by dopaminergic medications, while others are actually worsened.<ref>{{cite journal |author=Frank MJ |title=Dynamic dopamine modulation in the basal ganglia: a neurocomputational account of cognitive deficits in medicated and nonmedicated Parkinsonism |journal=Journal of cognitive neuroscience |volume=17 |issue=1 |pages=51-72 |year=2005 |pmid=15701239 |doi=10.1162/0898929052880093}}</ref>
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| ====Sleep disturbances====
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| *Excessive daytime [[somnolence]]
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| *Initial, intermediate, and terminal [[insomnia]]
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| *Disturbances in [[Rapid eye movement sleep|REM]] sleep: disturbingly vivid dreams, and [[Rapid eye movement sleep|REM]] Sleep Disorder, characterized by acting out of dream content - can occur years prior to diagnosis
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| ====Sensation disturbances====
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| *impaired visual [[contrast sensitivity]], spatial reasoning, [[color|colour]] discrimination, convergence insufficiency (characterized by [[double vision]]) and [[oculomotor control]]
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| *[[dizziness]] and fainting; usually attributable orthostatic hypotension, a failure of the autonomous nervous system to adjust blood pressure in response to changes in body position
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| *impaired [[proprioception]] (the awareness of bodily position in three-dimensional space)
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| *reduction or loss of sense of [[olfaction|smell]] (microsmia or [[anosmia]]) - can occur years prior to diagnosis,
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| *[[Pain and nociception|pain]]: neuropathic, muscle, joints, and tendons, attributable to tension, dystonia, rigidity, joint stiffness, and injuries associated with attempts at accommodation
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| ====Autonomic disturbances====
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| *oily skin and [[seborrheic dermatitis]]<ref>{{cite journal |author=Gupta A, Bluhm R |title=Seborrheic dermatitis |journal=Journal of the European Academy of Dermatology and Venereology : JEADV |volume=18 |issue=1 |pages=13-26; quiz 19-20 |year=2004 |pmid=14678527}}</ref>
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| *[[urinary incontinence]], typically in later disease progression
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| *[[nocturia]] (getting up in the night to pass urine) - up to 60% of cases
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| *[[constipation]] and [[gastric]] dysmotility that is severe enough to endanger comfort and even health
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| *altered sexual function: characterized by profound impairment of sexual arousal, behavior, orgasm, and drive is found in mid and late Parkinson disease. Current data addresses male sexual function almost exclusively
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| *[[weight loss]], which is significant over a period of ten years - 8% of body [[weight loss|weight lost]] compared with 1% in a control group.
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| == Less common symptoms == | | == Less common symptoms == |