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Pringsheim T, Day GS, Smith DB, Rae-Grant A, Licking N, Armstrong MJ, de Bie RMA, Roze E, Miyasaki JM, Hauser RA, Espay AJ, Martello JP, Gurwell JA, Billinghurst L, Sullivan K, Fitts MS, Cothros N, Hall DA, Rafferty M, Hagerbrant L, Hastings T, O'Brien MD, Silsbee H, Gronseth G, Lang AE. Dopaminergic Therapy for Motor Symptoms in Early Parkinson Disease Practice Guideline Summary: A Report of the AAN Guideline Subcommittee. Neurology 2021; 97:942-957. [PMID: 34782410 PMCID: PMC8672433 DOI: 10.1212/wnl.0000000000012868] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 09/11/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To review the current evidence on the options available for initiating dopaminergic treatment of motor symptoms in early-stage Parkinson disease and provide recommendations to clinicians. METHODS A multidisciplinary panel developed practice recommendations, integrating findings from a systematic review and following an Institute of Medicine-compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence. RESULTS Initial treatment with levodopa provides superior motor benefit compared to treatment with dopamine agonists, whereas levodopa is more likely than dopamine agonists to cause dyskinesia. The comparison of different formulations of dopamine agonists yielded little evidence that any one formulation or method of administration is superior. Long-acting forms of levodopa and levodopa with entacapone do not appear to differ in efficacy from immediate-release levodopa for motor symptoms in early disease. There is a higher risk of impulse control disorders associated with the use of dopamine agonists than levodopa. Recommendations on initial therapy for motor symptoms are provided to assist the clinician and patient in choosing between treatment options and to guide counseling, prescribing, and monitoring of efficacy and safety.
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Affiliation(s)
- Tamara Pringsheim
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Gregory S Day
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Don B Smith
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Alex Rae-Grant
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Nicole Licking
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Melissa J Armstrong
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Rob M A de Bie
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Emmanuel Roze
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Janis M Miyasaki
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Robert A Hauser
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Alberto J Espay
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Justin P Martello
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Julie A Gurwell
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Lori Billinghurst
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Kelly Sullivan
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Michael S Fitts
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Nicholas Cothros
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Deborah A Hall
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Miriam Rafferty
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Lynn Hagerbrant
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Tara Hastings
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Mary Dolan O'Brien
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Heather Silsbee
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Gary Gronseth
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
| | - Anthony E Lang
- From the Departments of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (T.P.), University of Calgary (N.C.), Alberta, Canada; Department of Neurology (G.S.D.), Mayo Clinic, Jacksonville, FL; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Cleveland Clinic Lerner College of Medicine (A.R.-G.), Case Western Reserve University, OH; New West Physicians (N.L.), Golden, CO; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology, Amsterdam University Medical Centers (R.M.A.d.B.), University of Amsterdam, the Netherlands; Department of Neurology (E.R.), Pitié-Salpêtrière Hospital, Sorbonne University and the Assistance Publique-Hôpitaux de Paris, France; Department of Medicine (J.M.M.), University of Alberta, Edmonton, Canada; Department of Neurology (R.A.H.), University of South Florida, Tampa; James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders and Department of Neurology (A.J.E.), University of Cincinnati, OH; Christiana Care Neurology Specialists (J.P.M.), Newark, DE; Department of Neurology (J.A.G.), University of Kentucky, Lexington; Department of Pediatrics, McMaster University (L.B.), Hamilton, Ontario, Canada; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; University of Alabama at Birmingham (M.S.F.); Department of Neurological Sciences (D.A.H.), Rush University Medical Center, Chicago, IL; Shirley Ryan Ability Lab and Department of Physical Medicine and Rehabilitation (M.R.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Michael J. Fox Foundation for Parkinson's Research (L.H., T.H.), New York, NY; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; Department of Neurology (G.G.), University of Kansas, Kansas City; The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (A.E.L.), Toronto Western Hospital and the University of Toronto, Canada
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Krumholz A, Wiebe S, Gronseth GS, Gloss DS, Sanchez AM, Kabir AA, Liferidge AT, Martello JP, Kanner AM, Shinnar S, Hopp JL, French JA. Evidence-based guideline: Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2015; 84:1705-13. [PMID: 25901057 DOI: 10.1212/wnl.0000000000001487] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To provide evidence-based recommendations for treatment of adults with an unprovoked first seizure. METHODS We defined relevant questions and systematically reviewed published studies according to the American Academy of Neurology's classification of evidence criteria; we based recommendations on evidence level. RESULTS AND RECOMMENDATIONS Adults with an unprovoked first seizure should be informed that their seizure recurrence risk is greatest early within the first 2 years (21%-45%) (Level A), and clinical variables associated with increased risk may include a prior brain insult (Level A), an EEG with epileptiform abnormalities (Level A), a significant brain-imaging abnormality (Level B), and a nocturnal seizure (Level B). Immediate antiepileptic drug (AED) therapy, as compared with delay of treatment pending a second seizure, is likely to reduce recurrence risk within the first 2 years (Level B) but may not improve quality of life (Level C). Over a longer term (>3 years), immediate AED treatment is unlikely to improve prognosis as measured by sustained seizure remission (Level B). Patients should be advised that risk of AED adverse events (AEs) may range from 7% to 31% (Level B) and that these AEs are likely predominantly mild and reversible. Clinicians' recommendations whether to initiate immediate AED treatment after a first seizure should be based on individualized assessments that weigh the risk of recurrence against the AEs of AED therapy, consider educated patient preferences, and advise that immediate treatment will not improve the long-term prognosis for seizure remission but will reduce seizure risk over the subsequent 2 years.
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Affiliation(s)
- Allan Krumholz
- From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Samuel Wiebe
- From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Gary S Gronseth
- From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - David S Gloss
- From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Ana M Sanchez
- From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Arif A Kabir
- From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Aisha T Liferidge
- From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Justin P Martello
- From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Andres M Kanner
- From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Shlomo Shinnar
- From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Jennifer L Hopp
- From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Jacqueline A French
- From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY
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