1
|
Thongchuam Y, Panyakaew P, Bhidayasiri R. Orofacial dystonia and asssociated bulbar symptoms in multiple system atrophy: A blinded video analysis. J Neurol Sci 2020; 417:116992. [PMID: 32622521 DOI: 10.1016/j.jns.2020.116992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/08/2020] [Accepted: 06/15/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Orofacial dystonia (OFD) is considered a supporting feature for a diagnosis of Multiple System Atrophy (MSA). However, the association of OFD with other adjacent symptoms has not been explored. OBJECTIVES To identify clinical characteristics of OFD and associated bulbar symptoms in MSA patients. METHODS In this blinded trial, video clips of 24 MSA patients were reviewed by two movement disorder neurologists who rated the presence of OFD. Analysis was performed to determine correlations between the presence of OFD and clinical demographics as well as associated bulbar symptoms. RESULTS There were 14 patients with MSA-P and 10 patients with MSA-C. OFD was identified in seven patients (29.16%) and MSA-P as the majority (85.71%). Oromandibular dystonia (OMD) was hardly ever identified in isolation with the most frequent combination being OMD with upper facial dystonia, blepharospasm and platysma dystonia. All OMD patients had the jaw-closing subtype. Mean onset of OFD was 1.7 (SD = 0.5) years after the first symptom onset and 1.1 years (SD = 0.4) after the introduction of levodopa. Patients with OFD used significantly higher levodopa equivalent daily dosage (LEDD) than those without (p = 0.02). There were moderate correlations between the presence of OFD and LEDD (r = 0.458, p = 0.02), and dysarthria (r = 0.639, p = 0.001) while a strong correlation was demonstrated between the presence of OFD and dysphagia (r = 0.9, p < 0.001). CONCLUSION OFD is probably a manifestation of motor fluctuations in MSA and its presence is significantly associated with bulbar symptoms. Neurologists should inquire about dysphagia when encountering MSA patients with OFD for early recognition and appropriate management.
Collapse
Affiliation(s)
- Yuwadee Thongchuam
- Chulalongkorn Centre of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Pattamon Panyakaew
- Chulalongkorn Centre of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand.
| |
Collapse
|
2
|
Bhidayasiri R, Rattanachaisit W, Phokaewvarangkul O, Lim TT, Fernandez HH. Exploring bedside clinical features of parkinsonism: A focus on differential diagnosis. Parkinsonism Relat Disord 2018; 59:74-81. [PMID: 30502095 DOI: 10.1016/j.parkreldis.2018.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/29/2018] [Accepted: 11/04/2018] [Indexed: 12/12/2022]
Abstract
The proper diagnosis of parkinsonian disorders usually involves three steps: identifying core features of parkinsonism; excluding other causes; and collating supportive evidence based on clinical signs or investigations. While the recognition of cardinal parkinsonian features is usually straightforward, the appreciation of clinical features suggestive of specific parkinsonian disorders can be challenging, and often requires greater experience and skills. In this review, we outline the clinical features that are relevant to the differential diagnosis of common neurodegenerative parkinsonian disorders, including Parkinson's disease, multiple system atrophy, progressive supranuclear palsy, and corticobasal degeneration. We aim to make this process relatable to clinicians-in-practice, therefore, have categorised the list of clinical features into groups according to the typical sequence on how clinicians would elicit them during the examination, starting with observation of facial expression and clinical signs of the face, spotting eye movement abnormalities, examination of tremors and jerky limb movements, and finally, examination of posture and gait dysfunction. This review is not intended to be comprehensive. Rather, we have focused on the most common clinical signs that are potentially key to making the correct diagnosis and those that do not require special skills or training for interpretation. Evidence is also provided, where available, such as diagnostic criteria, consensus statements, clinicopathological studies or large multi-centre registries. Pitfalls are also discussed when relevant to the diagnosis. While no clinical signs are pathognomonic for certain parkinsonian disorders, certain clinical clues may assist in narrowing a differential diagnosis and tailoring focused investigations for the individual patient.
Collapse
Affiliation(s)
- Roongroj Bhidayasiri
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330, Thailand; Department of Neurology, Juntendo University, Tokyo, Japan.
| | - Watchara Rattanachaisit
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330, Thailand
| | - Onanong Phokaewvarangkul
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330, Thailand
| | | | - Hubert H Fernandez
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
3
|
Bhidayasiri R, Sringean J, Reich SG, Colosimo C. Red flags phenotyping: A systematic review on clinical features in atypical parkinsonian disorders. Parkinsonism Relat Disord 2018; 59:82-92. [PMID: 30409560 DOI: 10.1016/j.parkreldis.2018.10.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/28/2018] [Accepted: 10/04/2018] [Indexed: 12/18/2022]
Abstract
To establish a clinical diagnosis of a parkinsonian disorder, physicians rely on their ability to identify relevant red flags, in addition to cardinal features, to support or refute their working diagnosis in an individual patient. The term 'red flag', was originally coined in 1989 to define the presence of non-cardinal features that may raise a suspicion of multiple system atrophy (MSA), or at least suggest alternative diagnosis to Parkinson's disease (PD). Since then, the term 'red flag', has been consistently used in the literature to denote the clinical history or signs that may signal to physicians the possibility of an atypical parkinsonian disorder (APD). While most red flags were originally based on expert opinion, many have gained acceptance and are now included in validated clinical diagnostic criteria of PD and APDs. The clinical appreciation of red flags, in conjunction with standard criteria, may result in a more accurate and earlier diagnosis compared to standard criteria alone. However, red flags can be clinical signs that are non-neurological, making the systematic assessment for them a real challenge in clinical practice. Here, we have conducted a systematic review to identify red flags and their clinical evidence in the differential diagnosis of common degenerative parkinsonism, including PD, MSA, progressive supranuclear palsy (PSP), corticobasal degeneration (CBD), and dementia with Lewy body (DLB). Increasing awareness and appropriate use of red flags in clinical practice may benefit physicians in the diagnosis and management of their patients with parkinsonism.
Collapse
Affiliation(s)
- Roongroj Bhidayasiri
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330, Thailand; Department of Neurology, Juntendo University, Tokyo, Japan.
| | - Jirada Sringean
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330, Thailand
| | - Stephen G Reich
- Department of Neurology, University of Maryland School of Medicine, Baltimore, USA
| | - Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, Terni, Italy
| |
Collapse
|
4
|
Bologna M, Marsili L, Khan N, Parvez AK, Paparella G, Modugno N, Colosimo C, Fabbrini G, Berardelli A. Blinking in patients with clinically probable multiple system atrophy. Mov Disord 2014; 29:415-20. [DOI: 10.1002/mds.25830] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 11/12/2013] [Accepted: 01/06/2014] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Luca Marsili
- Department of Neurology and Psychiatry; Sapienza University of Rome; Rome Italy
| | - Nashaba Khan
- Department of Neurology and Psychiatry; Sapienza University of Rome; Rome Italy
| | | | - Giulia Paparella
- Department of Neurology and Psychiatry; Sapienza University of Rome; Rome Italy
| | | | - Carlo Colosimo
- Department of Neurology and Psychiatry; Sapienza University of Rome; Rome Italy
| | - Giovanni Fabbrini
- Neuromed Institute IRCCS; Pozzilli (IS)
- Department of Neurology and Psychiatry; Sapienza University of Rome; Rome Italy
| | - Alfredo Berardelli
- Neuromed Institute IRCCS; Pozzilli (IS)
- Department of Neurology and Psychiatry; Sapienza University of Rome; Rome Italy
| |
Collapse
|
5
|
Geser F, Egger KE, Wenning G. A face to remember …. Mov Disord 2008. [DOI: 10.3109/9780203008454-33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
6
|
Abstract
BACKGROUND It has been almost 4 decades since the descriptions of the 3 parts of multiple system atrophy (MSA) have taken place, characterized clinically by dysautonomia, parkinsonism, and cerebellar dysfunction. The discovery of a distinctive pathologic maker has finally provided the conceptual synthesis of these 3 entities into the universal designation of MSA as a distinct disease process with a complex combination of clinical presentations. Although advances have been made in terms of awareness and knowledge concerning the clinical features and pathophysiology of MSA, it remains challenging for neurologists who treat these patients to differentiate MSA from its mimics as well as providing them with effective treatment. REVIEW SUMMARY The aim of this review is to provide an overview of the advances in the knowledge of the disease, to highlight typical features useful for the recognition of its entity, and to enlist different treatment options. CONCLUSION Despite the fact that there is still no treatment modality that can alter the disease progression, a number of useful symptomatic treatment measures are available and should be offered to patients to ameliorate the nonmotor features of MSA and even the motor features that may at least transiently respond to treatment.
Collapse
|
7
|
Wenning GK, Geser F, Poewe W. Therapeutic strategies in multiple system atrophy. Mov Disord 2005; 20 Suppl 12:S67-76. [PMID: 16092094 DOI: 10.1002/mds.20543] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This review provides an update on therapeutic principles and their implications for practical management in multiple system atrophy (MSA), a sporadic neurodegenerative disorder characterized clinically by various combinations of dysautonomia, Parkinsonism, or cerebellar ataxia, often associated with other warning features (red flags), and pathologically by cell loss, gliosis, and glial cytoplasmic inclusions in selected multiple regions of the brain and spinal cord. Because of the small number of randomized controlled trials, the management of MSA is largely based on empirical or open-label evidence. Parkinsonism often shows a poor or unsustained response to chronic levodopa therapy, although more patients than previously recognized may experience an initial moderate-to-good dopaminergic response. There is no effective drug treatment for cerebellar ataxia. However, features of dysautonomia such as orthostatic hypotension, urinary retention or incontinence, constipation, and impotence, may often be relieved if recognized by the treating physician. Because no drug treatment consistently benefits patients with this disease in the long-term, palliative therapies are all the more important. Novel symptomatic and neuroprotective therapies are urgently required.
Collapse
Affiliation(s)
- Gregor K Wenning
- Innsbruck Medical University, Clinical Department of Neurology, Austria.
| | | | | |
Collapse
|
8
|
Abstract
We describe a 51-year-old man who developed awake bruxism during the course of multiple system atrophy. Electromyographic studies revealed side-to-side amplitude asymmetry of the bursts of motor activity. The bruxism responded favourably to low-dose levodopa-carbidopa therapy. Possible mechanisms of this rare association are discussed.
Collapse
Affiliation(s)
- Gurusidheshwar M Wali
- Jawaharlal Nehru Medical College, and Karnatak Lingayat Education Society's Hospital and Medical Research Centre, Belgaum, Karnataka State, India.
| |
Collapse
|
9
|
|
10
|
Riley DE, Chelimsky TC. Autonomic nervous system testing may not distinguish multiple system atrophy from Parkinson's disease. J Neurol Neurosurg Psychiatry 2003; 74:56-60. [PMID: 12486267 PMCID: PMC1738185 DOI: 10.1136/jnnp.74.1.56] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Formal laboratory testing of autonomic function is reported to distinguish between patients with Parkinson's disease and those with multiple system atrophy (MSA), but such studies segregate patients according to clinical criteria that select those with autonomic dysfunction for the MSA category. OBJECTIVE To characterise the profiles of autonomic disturbances in patients in whom the diagnosis of Parkinson's disease or MSA used criteria other than autonomic dysfunction. METHODS 47 patients with parkinsonism and autonomic symptoms who had undergone autonomic laboratory testing were identified and their case records reviewed for non-autonomic features. They were classified clinically into three diagnostic groups: Parkinson's disease (19), MSA (14), and uncertain (14). The performance of the patients with Parkinson's disease was compared with that of the MSA patients on five autonomic tests: RR variation on deep breathing, heart rate changes with the Valsalva manoeuvre, tilt table testing, the sudomotor axon reflex test, and thermoregulatory sweat testing. RESULTS None of the tests distinguished one group from the other with any statistical significance, alone or in combination. Parkinson's disease and MSA patients showed similar patterns of autonomic dysfunction on formal testing of cardiac sympathetic and parasympathetic, vasomotor, and central and peripheral sudomotor functions. CONCLUSIONS This study supports the clinical observation that Parkinson's disease is often indistinguishable from MSA when it involves the autonomic nervous system. The clinical combination of parkinsonism and dysautonomia is as likely to be caused by Parkinson's disease as by MSA. Current clinical criteria for Parkinson's disease and MSA that direct patients with dysautonomia into the MSA group may be inappropriate.
Collapse
Affiliation(s)
- D E Riley
- Department of Neurology, University Hospitals of Cleveland and Case Western Reserve University School of Medicine, 1100 Euclid Avenue, Cleveland, OH 44106, USA.
| | | |
Collapse
|
11
|
Tison F, Yekhlef F, Chrysostome V, Balestre E, Quinn NP, Poewe W, Wenning GK. Parkinsonism in multiple system atrophy: natural history, severity (UPDRS-III), and disability assessment compared with Parkinson's disease. Mov Disord 2002; 17:701-9. [PMID: 12210859 DOI: 10.1002/mds.10171] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
We analyzed parkinsonian features in multiple system atrophy (MSA) compared with age- and disease duration-matched Parkinson's disease (PD) patients, and assessed the applicability of the Unified Parkinson's Disease Rating Scale (UPDRS) -III motor scale as a means of rating their severity. Cross-sectional analysis of parkinsonism was done using UPDRS-III, International Cerebellar Atatia Rating Scale, and disability scales (Hoehn and Yahr [H&A], Schwab and England, Katz and Lawton) in 50 unselected MSA patients and in 50 matched PD patients. At symptom onset, falls occurred 10 times more frequently in MSA, whereas limb tremor was 10 times more common in PD. At first visit (10.2 months), hemiparkinsonism and pill-rolling rest tremor were less common in MSA. Hypomimia, atypical rest, postural or action tremor, as well as postural instability were more frequent in MSA. At study examination (62.4 months), parkinsonian signs in MSA patients were more frequently symmetrical and associated with axial rigidity, antecollis and postural instability. A levodopa response of >50% was seen in <10% of MSA patients. Modified H&Y stages (3.2 +/- 1.3 vs. 2.2 +/- 0.78) and UPDRS-III scores (48.14 +/- 19.5 vs. 31.74 +/- 12.9) were significantly (P = 0.0001) higher in MSA. The internal consistency of the UPDRS-III was fair in MSA patients (Cronbach's alpha >0.90), and correlated well with marked dependency on the Schwab and England and Katz and Lawton scales. Factor structure analysis of UPDRS-III in MSA showed five clinically distinct subscores accounting for 74% of the variance, differing from PD by the dependency of the face-speech and limb bradykinesia items and independence of the postural-action tremor from the rest tremor items. There was a significant correlation (R(2) = 0.70, P = 0.001) between ICARS ataxia and UPDRS-III scores in MSA patients. Results confirm a distinct profile of parkinsonism in MSA and greater severity and disability compared with PD. It also indicates that the UPDRS-III provides a useful severity measure of parkinsonism in MSA, albeit contaminated by additional cerebellar dysfunction.
Collapse
Affiliation(s)
- François Tison
- Fédération de Neurologie, Epidémiologie et Biostatistiques Centre Hospitalo-Universitaire de Bordeaux, Bordeaux, France.
| | | | | | | | | | | | | |
Collapse
|
12
|
Affiliation(s)
- M Miranda
- Parkinson's Disease Clinic, Chilean Parkinson's Disease Association, Santiago
| | | |
Collapse
|