Dantrolene for muscle rigidity in progressive supranuclear palsy

Progressive supranuclear palsy is a degenerative neurological condition with a high level of associated motor symptom burden manifesting in poor postural reflexes, bradykinesia, dystonia and stiffness in the body core and neck. In the light of a paucity in literature exploring pain management in neurodegenerative diseases, the below case report describes the use of dantrolene to successfully relieve distressing widespread dystonia and muscle rigidity refractory to non-pharmacological and pharmacotherapy. To our knowledge, this is the first reported case of dantrolene use for the treatment of refractory muscle rigidity pain in neurodegenerative conditions.

Rigidity in Parkinson's disease: evidence from biomechanical and neurophysiological measures

Although rigidity is a cardinal motor sign in patients with Parkinson's disease (PD), the instrumental measurement of this clinical phenomenon is largely lacking, and its pathophysiological underpinning remains still unclear. Further advances in the field would require innovative methodological approaches able to measure parkinsonian rigidity objectively, discriminate the different biomechanical sources of muscle tone (neural or visco-elastic components), and finally clarify the contribution to 'objective rigidity' exerted by neurophysiological responses, which have previously been associated with this clinical sign (i.e. the long-latency stretch-induced reflex). Twenty patients with PD (67.3 ± 6.9 years) and 25 age- and sex-matched controls (66.9 ± 7.4 years) were recruited. Rigidity was measured clinically and through a robotic device. Participants underwent robot-assisted wrist extensions at seven different angular velocities randomly applied, when ON therapy. For each value of angular velocity, several biomechanical (i.e. elastic, viscous and neural components) and neurophysiological measures (i.e. short and long-latency reflex and shortening reaction) were synchronously assessed and correlated with the clinical score of rigidity (i.e. Unified Parkinson's Disease Rating Scale-part III, subitems for the upper limb). The biomechanical investigation allowed us to measure 'objective rigidity' in PD and estimate the neuronal source of this phenomenon. In patients, 'objective rigidity' progressively increased along with the rise of angular velocities during robot-assisted wrist extensions. The neurophysiological examination disclosed increased long-latency reflexes, but not short-latency reflexes nor shortening reaction, in PD compared with control subjects. Long-latency reflexes progressively increased according to angular velocities only in patients with PD. Lastly, specific biomechanical and neurophysiological abnormalities correlated with the clinical score of rigidity. 'Objective rigidity' in PD correlates with velocity-dependent abnormal neuronal activity. The observations overall (i.e. the velocity-dependent feature of biomechanical and neurophysiological measures of objective rigidity) would point to a putative subcortical network responsible for 'objective rigidity' in PD, which requires further investigation.

Neuroleptic malignant syndrome in a postoperative patient: A case report

Neuroleptic malignant syndrome is a rare medical emergency associated with the use of antipsychotics and other antidopaminergic drugs. There is no specific test, and diagnosis is based on high clinical suspicion and good differential diagnosis. A clinical picture consistent with hyperthermia, muscle rigidity, altered level of consciousness, together with signs of rhabdomyolysis in analytical studies and a history of taking neuroleptic drugs are the key elements in the detection of this entity. Due to its low incidence and potential mortality, it is essential to publish case reports of neuroleptic malignant syndrome in order to raise awareness of this entity and facilitate diagnostic suspicion when encountering a patient with compatible symptoms. The following is the case of a 79 year old patient with chronic alcohol consumption as the only history of interest, who was given a single dose of haloperidol after an episode of delirium in the postoperative period of conventional trauma surgery. She subsequently developed a picture of progressive deterioration of the level of consciousness, diaphoresis, generalized muscle rigidity, hyperthermia, together with severe metabolic acidosis, hyperlacticaemia, rhabdomyolysis, hypertransaminasemia and hypocalcemia. After ruling out other entities compatible with the clinical picture, neuroleptic malignant syndrome was given as the main diagnostic hypothesis. Diagnosis was confirmed after clinical and analytical improvement following treatment with dantrolene. The patient was discharged from hospital with no sequelae a few days after onset of the condition.

Efficacy of oral administration of licorice as an adjunct therapy on improving the symptoms of patients with Parkinson's disease, A randomized double blinded clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Licorice preparations are used as neuroprotective remedies in Persian ethnomedicine, in order to prevent from disabilities in neurodegenerative conditions like Parkinson's disease (PD).

AIM OF THE STUDY

This study was designed to determine the licorice (root of Glycyrrhiza glabra L.) effectiveness as an adjunct treatment in the PD management.

MATERIAL AND METHODS

In this double-blinded trial, 128 patients were assessed for eligibility criteria. Seventy-eight patients were ineligible and 11 of them refused from participating. Thirty-nine PD patients (YAHR staging ≤ 3) were divided into two groups by random. The patients received oral licorice or placebo syrups with a dose of 5 cc, twice a day for 6 months. High-performance liquid chromatography and spectrophotometric instruments determined licorice syrup constituents. The patients' situation for Unified Parkinson's rating scale (UPDRS) was assessed every 6 weeks for the duration of six months. In addition, patients' blood pressure, blood glucose, sodium and potassium levels, quality of life and dizziness were determined.

RESULTS

Six weeks after intervention, total UPDRS, daily activities and tremor were significantly improved with a considerable effect size. A significant better motor test and rigidity scores were observed 4 months after licorice intake (p > 0.05). No electrolyte abnormality, significant changes in blood pressure or blood glucose levels were observed during the study. Each 5cc of syrup contained 136 mg of licorice extract with 12.14 mg glycyrrhizic acid, and also 136 μg of polyphenols.

CONCLUSION

The licorice intake could improve the symptoms in PD patients without serious adverse events.

Electrophysiological resting state networks of predominantly akinetic-rigid Parkinson patients: Effects of dopamine therapy

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Analysis of whole-brain frequency-specific resting state networks with EEG.

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Comparison of dopamine medication ON and OFF state in Parkinson patients.

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Parkinson patients show distinct frequency-specific network alterations.

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Motor network at beta frequencies is re-instated after dopamine medication.

Parkinson's disease (PD) causes both motor and non-motor symptoms, which can partially be reversed by dopamine therapy. These symptoms as well as the effect of dopamine may be explained by distinct alterations in whole-brain architecture. We used functional connectivity (FC) and in particular resting state network (RSN) analysis to identify such whole-brain alterations in a frequency-specific manner. In addition, we hypothesized that standard dopaminergic medication would have a normalizing effect on these whole brain alterations. We recorded resting-state EEGs of 19 PD patients in the medical OFF and ON states, and of 12 healthy age-matched controls. The PD patients were either of akinetic-rigid or mixed subtype. We extracted RSNs with independent component analysis in the source space for five frequency bands. Within the sensorimotor network (SMN) the supplementary motor area (SMA) showed decreased FC in the OFF state compared to healthy controls. This finding was reversed after dopamine administration. Furthermore, in the OFF state no stable SMN beta component could be identified. The default mode network showed alterations due to PD independent of the medication state. The visual network was altered in the OFF state, and reinstated to a pattern similar to healthy controls by medication. In conclusion, PD causes distinct RSN alterations, which are partly reversed after levodopa administration. The changes within the SMN are of particular interest, because they broaden the pathophysiological understanding of PD. Our results identify the SMA as a central network hub affected in PD and a crucial effector of dopamine therapy.

The Use of Intravenous Glutathione for Symptom Management of Parkinson's Disease: A Case Report

Intravenous glutathione has been suggested empirically to improve Parkinson's disease (PD) symptoms of tremor and rigidity, but there is limited supporting research. This case report demonstrates both subjective and objective symptom improvement of a conventionally-treated patient suffering from PD when adjunctive intravenous glutathione was administered. In addition to suggesting clinical benefit, this case also suggests an effective therapeutic frequency of therapy and a minimal therapeutic dose. The consistent pattern of improvement following glutathione injections asserts that this therapy may improve symptoms common to PD patients and can offer additional quality of life that would be otherwise unattainable to these patients.

Degeneration of the corticofugal tract from the secondary motor area in a Parkinson's disease patient with limb-kinetic apraxia: A case report

RATIONALE

In this case report, we describe a Parkinson's disease (PD) patient with limb-kinetic apraxia (LKA) in whom degeneration of the corticofugal tract (CFT) from the supplementary motor area (SMA) was observed in diffusion tensor tractography (DTT).

PATIENT CONCERNS

A 63-year-old woman presented with a loss of dexterity in both upper extremities, which indicated LKA, and typical PD-related symptoms, including a gait disturbance with a short step, resting tremor in both upper extremities, and rigidity, and these symptoms had been present for 2 years. The F-florinated-N-3-fluoropropyl-2-β-carboxymethoxy-3-β-(4-lodophenyl) nortropane positron emission tomography scanning findings were consistent with PD. Based on the clinical symptoms and imaging findings, we diagnosed the patient with PD. In a coin-rotation test that was used to evaluate the severity of the LKA, the patient's results significantly decreased compared to the results of the normal controls.

DIAGNOSES

The DTT showed that the CFTs from the SMAs in both hemispheres were partially torn and thinned. The fractional anisotropy values and CFT volumes in both SMAs were >2 standard deviations lower than those of the normal controls.

INTERVENTIONS

The patient was treated with an initial dose of 150/37.5 mg/day of levodopa/benserazide, and the dose was gradually increased to 400/100 mg/day.

OUTCOMES

After treatment, although the bradykinesia, rigidity, and resting tremor of the patient significantly decreased, the dexterity of the patient's hands did not improve.

LESSONS

These observations indicated degeneration of the CFTs from the SMAs in both hemispheres in the patient. This degeneration might have, at least in part, contributed to the patient's LKA. The results of this study suggest that CFT degeneration could be one of the pathological mechanisms underlying LKA in patients with PD.

Cognitive impairment in Parkinson's disease

Parkinson's disease is the second most frequent neurodegenerative disorder. There is significantly elevated risk of cognitive decline and associated neuropsychiatric symptoms. Dementia may develop insidiously several years after manifestation of Parkinson motor symptoms (dementia associated with Parkinson's disease; Parkinson's disease dementia) or in close temporal relationship (within one year) after onset of motor symptoms (Dementia with Lewy bodies). There are clinical, pathophysiological and therapeutic similarities between these two conditions. Men are more frequently affected than women. Risk factor or indicators are advanced age at disease onset, disease duration, rigidity, akinesia and posture and gait impairment and falls as opposed to tremor dominance, and associated neuropsychiatric symptoms (depression, apathy, hallucinosis, delirium). Dementia is treatable with cholinesterase inhibitors (rivastigmine, donepezil), memantine, and adjustment of the pharmacological regimen of parkinsonian motor symptoms. Concomitant autonomic nervous system symptoms and neuropsychiatric complications warrant early clinical awareness and are accessible to pharmacological therapy.

Neuroleptic Malignant Syndrome: A Review from a Clinically Oriented Perspective

Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening side-effect that can occur in response to treatment with antipsychotic drugs. Symptoms commonly include hyperpyrexia, muscle rigidity, autonomic dysfunction and altered mental status. In the current review we provide an overview on past and current developments in understanding the causes and treatment of NMS. Studies on the epidemiological incidence of NMS are evaluated, and we provide new data from the Canada Vigilance Adverse Reaction Online database to elaborate on drug-specific and antipsychotic drug polypharmacy instances of NMS reported between 1965 and 2012. Established risk factors are summarized with an emphasis on pharmacological and environmental causes. Leading theories about the etiopathology of NMS are discussed, including the potential contribution of the impact of dopamine receptor blockade and musculoskeletal fiber toxicity. A clinical perspective is provided whereby the clinical presentation and phenomenology of NMS is detailed, while the diagnosis of NMS and its differential is expounded. Current therapeutic strategies are outlined and the role for both pharmacological and non-pharmacological treatment strategies in alleviating the symptoms of NMS are discussed.

Successful immune moderation treatment for progressive encephalomyelitis with rigidity and myoclonus

Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a rare disease. PERM consists of the same symptoms as stiff person syndrome, in addition to sensory, brainstem and autonomic features. We herein report a case of PERM in a 48-year-old woman who initially presented with spasticity of the lower limbs and subsequently developed upper limb spasticity, perioral myoclonus and restlessness after three months. The onset of potentially fatal dysautonomia was observed at the peak of the disease. Treatment with high-dose immunoglobulin (400 mg/kg, 5 days), levetiracetam and azathioprine resulted in a drastic and sustained improvement of these symptoms. This is an interesting case of PERM in which the patient showed a dramatic improvement following immune moderation.

Stiffness is more than just duration and severity: a qualitative exploration in people with rheumatoid arthritis

OBJECTIVE

Stiffness is internationally recognized as an important indicator of inflammatory activity in RA but is poorly understood and difficult to measure. The aim of this study was to explore the experience of stiffness from the patient perspective.

METHODS

Semi-structured interviews conducted with 16 RA patients were analysed independently by researchers and pat.ient partners using inductive thematic analysis.

RESULTS

Six themes were identified. Part of having RA identified stiffness as a normal consequence of RA, perceived as associated with disease-related aspects such as fluctuating disease activity, other RA symptoms and disease duration. Local and widespread highlighted stiffness occurring not only in joints, but also over the whole body, being more widespread during the morning or flare. Linked to behaviour and environment illustrated factors that influence stiffness, including movement, medications and weather. Highly variable captured the fluctuating nature of stiffness within and between patients and in relation to temporality, duration and intensity. Impacts on daily life emphasized the effect of stiffness on a range of domains, including physical function, quality of life, psychological well-being, activities of daily living and participation in work and leisure activities. Requires self-management detailed self-management strategies targeting both the symptom and its consequences.

CONCLUSION

Patients' experiences of stiffness were varied, complex and not exclusive to the morning period. Importantly, stiffness was reported in terms of impact rather than the traditional measurement concepts of severity or duration. Based on these findings, further research is needed to develop a patient-centred measure that adequately reflects inflammatory activity.

[Tyrosine hydroxylase deficiency: a case of autosomal recessive dopa-responsive dystonia]

OBJECTIVE

To analyze the clinical characteristics of the patient with tyrosine hydroxylase deficiency, and investigate it's molecular mechanism.

METHOD

The clinical characteristics of a patient with tyrosine hydroxylase deficiency were summarized and analyzed, his and his family's peripheral blood specimens were collected after informed consent was signed. All exons and the intron-exon boundaries of guanosine triphosphate hydroxylase I gene, tyrosine hydroxylase gene and sepiapterin reductase gene were examined by DNA-PCR, bi-directional sequencing.

RESULT

The patient was a 3-year-old boy, presented with unexplained dystonia for 3 years, without significant impairment of intelligence. Physical examination showed limb muscle strength grade V, rigidity of extremities, hypertonicity, brisk deep tendon reflexes in limbs, without obvious abnormalities in auxiliary examination, such as brain MRI, hepatic biochemical panel, creatine kinase, and ceruloplasmin. He dramatically responded to small doses of levodopa in the follow-up for half a year. A homozygous missense change in exon 5 of TH gene, c.605G > A (p.R202H), which was a known pathogenic mutation, was found in the patient. His parents were heterozygous for the R202H mutation.

CONCLUSION

The age of onset in tyrosine hydroxylase deficiency patients is usually within the first year of life. Unexplained dystonia and hypokinesia were the main clinical features of tyrosine hydroxylase deficiency. The dopa-responsive effects for some patients are so obvious that we should strengthen awareness of the disease. TH gene c.605G > A (p.R202H) may be a common type of causative mutations for the mild form at home and abroad.

Niacin improved rigidity and bradykinesia in a Parkinson's disease patient but also caused unacceptable nightmares and skin rash—A case report

A patient with Parkinson's disease taking levodopa/carbidopa, selegiline, buproprion, aspirin and niacin had decreased rigidity and bradykinesia when his niacin dose was steadily escalated for treatment of high triglycerides, but ultimately the patient could not tolerate niacin because of severe nightmares and skin rash. If further research can reproduce this patient's initial beneficial experience while avoiding the adverse effects, niacin could be a useful adjunctive agent for Parkinson's disease, either population-wide or in a pharmacogenomically defined set of responders.

Enhancement of parkinsonian rigidity with contralateral hand activation

OBJECTIVE

Quantify the enhancement of parkinsonian rigidity associated with a contralateral activation maneuver.

METHODS

Twelve subjects with PD and eight controls participated in the study protocol. Subjects' tested hand was displaced by a servo-motor throughout wrist flexion and extension motions of 60° without and with a concurrent gripping activation in the contralateral hand, referred to as Passive and Active conditions, respectively. Subjects with PD were tested in both OFF-MED and ON-MED states. Rigidity was quantified by integrating torque with position during both flexion and extension (torque resistance). ANOVA was performed to assess the effect of contralateral activation on rigidity.

RESULTS

PD patients had significantly (0.038) enhanced torque resistance in OFF-MED compared to healthy controls and ON-MED. In the Active condition, differences in torque resistance were magnified (p=0.002). Medication substantially reduced differences in torque resistance between controls and PD patients in the Passive and Active conditions.

CONCLUSIONS

A contralateral activation maneuver substantially increases rigidity in patients with PD, specifically the OFF-MED state. Rigidity is reduced with the application of dopaminergic medication, even with the presence of a contralateral activation maneuver.

SIGNIFICANCE

These data support the use of a contralateral activation maneuver as a tool in the diagnosis of PD.

Lipid therapy for serotonin syndrome after intoxication with venlafaxine, lamotrigine and diazepam

A 44-year-old woman developed coma and seizure activity after intentional ingestion of 200 mg diazepam, 20 g lamotrigine and 4.5 g venlafaxine. In our intensive care unit a distinct rigidity and hyperreflexia was observed. This status was not influenced by haemodialysis which was initiated directly after admission. Plasma concentrations of the ingested drugs were determined before hemodialysis was started (560 µg/L diazepam, 42.4 mg/L lamotrigine and 1254 µg/L venlafaxine). Eight hours after the start of haemodialysis a 150 mL (2.5 mL/kg) intravenous bolus of 20% lipid emulsion was given. Soon after administration of the lipid infusion the distinct rigidity and hyperreflexia disappeared. The further course was uneventful.

Efficacy and tolerability of eperisone in patients with spastic palsy: a cross-over, placebo-controlled dose-ranging trial

BACKGROUND AND OBJECTIVES

Central muscle relaxants are a clinical option in patients with spastic palsy. Eperisone is a central muscle relaxant used in several conditions, but its therapeutic potential in spastic palsy needs to be verified. This dose-ranging trial compares two doses of eperisone in patients with spastic palsy associated to cerebral or spinal diseases.

PATIENTS AND METHODS

In this randomized, placebo-controlled, double-blind, three-way cross-over study, patients (18-75 years) with spastic palsy received eperisone 150 mg/day, eperisone 300 mg/day, or placebo for 8 weeks. Treatment periods lasted for 14 days. Objective clinical parameters (intensity of spasticity and physiological reflexes) and functional parameters (walking capability, capability to climb stairs, rigidity) were measured. Tolerability was also evaluated.

RESULTS

Eighteen patients were enrolled. The reduction in the intensity of spasticity versus the beginning of each treatment cycle was significant with eperisone 300 mg/day (p = 0.004). Similar findings were observed in the evaluation of patellar reflex (p = 0.01), while the other reflexes were not significantly different. Walking capability was significantly improved with eperisone 300 mg/day (p < 0.05). No significant differences were observed in the capability to climb stairs and in rigidity. A trend towards a reduction in pain was noted with eperisone 300 mg/day versus placebo. The incidence of adverse events was similar in all groups.

DISCUSSION

Eperisone 300 mg/day might be an effective and well-tolerated treatment for spastic palsy. Larger studies are required to further characterize the efficacy of eperisone in this therapeutic area.

[Motor symptoms in Parkinson disease]

BACKGROUND

Early Parkinson's disease is dominated by a motor syndrome called parkinsonism, but as the disease develops motor complications and non-motor problems may occur as well. This paper describes how to diagnose Parkinson's disease and the various motor complications and gives recommendations on how to treat the symptoms in these patients.

MATERIAL AND METHODS

The paper builds on international evidence-based publications and the Norwegian guidelines for treatment of Parkinson's disease.

RESULTS AND INTERPRETATION

Motor symptoms such as tremor at rest, akinesia, rigidity and postural instability are the cardinal signs in Parkinson's disease. After diagnosing a patient with the disease we recommend to start with selegiline as a disease-modifying treatment strategy. When symptoms lead to functional impairment, symptomatic treatment should be started in addition. Dopamine agonists are primarily recommended in younger patients and levodopa in the older ones. When the patients develop motor complications it is important to first thoroughly evaluate the problems to arrive at the best possible treatment strategy. If a sufficient response is not obtained both deep brain stimulation and treatment with continuous delivery of medication should be considered.

Bilateral inguinal hernia repair in a child with hyperekplexia

This is a case report of anesthesia for a child with a rare congenital disease marked by hyperreactivity of the neuromuscular system; hyperekplexia. Unlike other reports, she experienced no untoward effects from general anesthesia using sevoflurane, rocuronium and a caudal block.

Axial hypertonicity in Parkinson's disease: direct measurements of trunk and hip torque

A cardinal feature of Parkinson's disease (PD) is muscle hypertonicity, i.e. rigidity. Little is known about the axial tone in PD or the relation of hypertonia to functional impairment. We quantified axial rigidity to assess its relation to motor symptoms as measured by UPDRS and determine whether rigidity is affected by levodopa treatment. Axial rigidity was measured in 12 PD and 14 age-matched controls by directly measuring torsional resistance of the longitudinal axis to twisting (+/-10 degrees ). Feet were rotated relative to fixed hips (Hip Tone) or feet and hips were rotated relative to fixed shoulders (Trunk Tone). To assess tonic activity only, low constant velocity rotation (1 degrees /s) and low acceleration (<12 degrees /s(2)) were used to avoid eliciting phasic sensorimotor responses. Subjects stood during testing without changing body orientation relative to gravity. Body parts fixed against rotation could translate laterally within the boundaries of normal postural sway, but could not rotate. PD OFF-medication had higher axial rigidity (p<0.05) in hips (5.07 N m) and trunk (5.30 N m) than controls (3.51 N m and 4.46 N m, respectively), which did not change with levodopa (p>0.10). Hip-to-trunk torque ratio was greater in PD than controls (p<0.05) and unchanged by levodopa (p=0.28). UPDRS scores were significantly correlated with hip rigidity for PD OFF-medication (r values=0.73, p<0.05). Torsional resistance to clockwise versus counter-clockwise axial rotation was more asymmetrical in PD than controls (p<0.05), however, there was no correspondence between direction of axial asymmetry and side of disease onset. In conclusion, these findings concerning hypertonicity may underlie functional impairments of posture and locomotion in PD. The absence of a levodopa effect on axial tone suggests that axial and appendicular tones are controlled by separate neural circuits.

Abdominal pain with rigidity secondary to the anti-emetic drug metoclopramide

We report a case of abdominal pain with rigidity, mimicking an acute abdomen, caused by metoclopramide, a common anti-emetic drug. Extrapyramidal symptoms are commonly reported side-effects of this medication. They generally include involuntary movements of limbs, torticollis, oculogyric crisis, rhythmic protrusion of tongue, trismus, or dystonic reactions resembling tetanus, etc. Abdominal rigidity due to this medication, resembling an acute abdomen, has not been reported previously. This case report illustrates the importance of considering medication side-effects when evaluating a patient with abdominal pain and rigidity.

Development of baclofen tolerance in a rat model of chronic spasticity and rigidity

Systemic or spinal treatment with baclofen has been associated with the development of tolerance in patients with chronic spasticity. In the present study, we used a rat model of spinal ischemia-induced spasticity to characterize the development of baclofen tolerance after chronic intrathecal (i.t.) baclofen infusion. Following the induction of spinal ischemia and the development of behavioral spasticity, animals were implanted with i.t. catheters connected to osmotic pumps to continuously infuse baclofen (1.0 microg/0.5 microl/h). Hindleg peripheral muscle resistance (PMR) was measured periodically after initiation of chronic infusion and after bolus i.t. baclofen injection (1.0 microg). Peripheral muscle resistance was significantly decreased at the onset of baclofen infusion, however, after 5-7 days of infusion a progressive return of spasticity was noted, where baseline PMR values returned to preinfusion levels. At the same time, the efficacy of bolus i.t. baclofen treatment also decreased, where after 5 days of baclofen infusion 1.0 microg (i.t.) baclofen only reduced PMR by 10% (compared to 40-50% preinfusion). Baclofen efficacy progressively returned once continuous infusion was stopped. These data demonstrate that transient spinal ischemia leads to the development of spasticity which is sensitive to spinal baclofen. Chronic i.t. infusion leads to a progressive development of tolerance. This model offers potential to study tolerance mechanisms after spinal injury, and aid in drug discovery for use in baclofen-tolerant patients.

Development of GABA-sensitive spasticity and rigidity in rats after transient spinal cord ischemia: a qualitative and quantitative electrophysiological and histopathological study

Transient spinal cord ischemia may lead to a progressive degeneration of spinal interneurons and subsequently to increased hind limb motor tone. In the present work we sought to characterize the rigidity and spasticity components of this altered motor function by: i) tonic electromyographic activity measured in gastrocnemius muscle before and after ischemia, ii) measurement of muscle resistance during the period of ankle flexion and corresponding changes in electromyographic activity, iii) changes in Hoffmann reflex, and, iv) motor evoked potentials. In addition the effect of intrathecal treatment with baclofen (GABAB receptor agonist; 1 microg), nipecotic acid (GABA uptake inhibitor; 300 microg) and dorsal L2-L5 rhizotomy on spasticity and rigidity was studied. Finally, the changes in spinal choline acetyltransferase (ChAT) and vesicular glutamate transporter 2 and 1 (VGLUT2 and VGLUT1) expression were characterized using immunofluorescence and confocal microscopy. At 3-7 days after ischemia an increase in tonic electromyographic activity with a variable degree of rigidity was seen. In animals with modest rigidity a velocity-dependent increase in muscle resistance and corresponding appearance in electromyographic activity (consistent with the presence of spasticity) was measured during ankle rotation (4-612 degrees /s rotation). Measurement of the H-reflex revealed a significant increase in Hmax/Mmax ratio and a significant loss of rate-dependent inhibition. In the same animals a potent increase in motor evoked potential amplitudes was measured and this change correlated positively with the increased H-reflex responses. Spasticity and rigidity were consistently present for a minimum of 3 months after ischemia. Intrathecal treatment with baclofen (GABA B receptor agonist) and nipecotic acid (GABA uptake inhibitor) provided a significant suppression of spasticity, rigidity, H-reflex or motor evoked potentials. Dorsal L2-L5 rhizotomy significantly decreased muscle resistance but had no effect on increased amplitudes of motor evoked potentials. Confocal analysis of spinal cord sections at 8 weeks-12 months after ischemia revealed a continuing presence of ChAT positive alpha-motoneurons, Ia afferents and VGLUT2 and VGLUT1-positive terminals but a selective loss of small presumably inhibitory interneurons between laminae V-VII. These data demonstrate that brief transient spinal cord ischemia in rat leads to a consistent development of spasticity and rigidity. The lack of significant suppressive effect of dorsal L2-L5 rhizotomy on motor evoked potentials response indicates that descending motor input into alpha-motoneurons is independent on Ia afferent couplings and can independently contribute to increased alpha-motoneuronal excitability. The pharmacology of this effect emphasizes the potent role of GABAergic type B receptors in regulating both the spasticity and rigidity.

Effect of complex phytoadaptogen on MPTP-induced parkinson's syndrome in mice

Oral administration of 10% solution of Phytomix-40 (multicomponent plant phytoadaptogen) to C57Bl/6 mice with MPTP-induced Parkinson's syndrome alleviated symptoms (oligokinesia and muscle rigidity), compensated for the deficiency of dopamine and its metabolites (DOPAC and homovanillic acid), and reduced the level of lipid peroxides in the striatum. In vitro Phytomix-40 in a concentration of 3.3 x 10(-2) g/liter exhibited a pronounced antioxidant effect (5-fold decreased MDA level in mouse brain homogenate in Fe(2+)-ascorbate-dependent LPO).

Identifying poor symptom control in Parkinson's disease

The range of drugs available to treat people with Parkinson's disease has never been greater. However, patients still encounter difficulties in non-specialist settings where there is often confusion over drug selection, dosage and the timing of dosages. Small adjustments to the type of drug used, dosage and timing can have a significant impact on the control of Parkinson's disease and with it the quality of life of patients, carers and their families. This article provides a brief overview of Parkinson's disease including how to identify poor symptom control.

Measurement of peripheral muscle resistance in rats with chronic ischemia-induced paraplegia or morphine-induced rigidity using a semi-automated computer-controlled muscle resistance meter

In experimental and clinical studies, an objective assessment of peripheral muscle resistance represents one of the key elements in determining the efficacy of therapeutic manipulations (e.g. pharmacological, surgical) aimed to ameliorate clinical signs of spasticity and/or rigidity. In the present study, we characterize a newly developed limb flexion resistance meter which permits a semi-automated, computer-controlled measurement of peripheral muscle resistance (PMR) in the lower extremities during a forced flexion of the ankle in the awake rat. Ischemic paraplegia was induced in Sprague-Dawley rats by transient aortic occlusion (10 min) in combination with systemic hypotension (40 mm Hg). After ischemia the presence of spasticity component was determined by the presence of an exaggerated EMG activity recorded from gastrocnemius muscle after nociceptive or proprioceptive afferent activation and by velocity-dependent increase in muscle resistance. Rigidity was induced by high dose (30 mg/kg, i.p.) of morphine. Animals with defined ischemic spasticity or morphine-induced rigidity were then placed into a plastic restrainer and a hind paw attached by a tape to a metal plate driven by a computer-controlled stepping motor equipped with a resistance transducer. The resistance of the ankle to rotation was measured under several testing paradigms: (i) variable degree of ankle flexion (40 degrees, 50 degrees, and 60 degrees), (ii) variable speed/rate of ankle flexion (2, 3, and 4 sec), (iii) the effect of inhalation anesthesia, (iv) the effect of intrathecal baclofen, (v) the effect of dorsal L2-L5 rhizotomy, or (vi) systemic naloxone treatment. In animals with ischemic paraplegia an increased EMG response after peripheral nociceptive or proprioceptive activation was measured. In control animals average muscle resistance was 78 mN and was significantly increased in animals with ischemic spasticity (981-7900 mN). In ischemic-spastic animals a significant increase in measured muscle resistance was seen after increased velocity (4 > 3 > 2 sec) and the angle (40 degrees > 50 degrees > 60 degrees) of the ankle rotation. In spastic animals, deep halothane anesthesia, intrathecal baclofen or dorsal rhizotomy decreased muscle resistance to 39-80% of pretreatment values. Systemic treatment with morphine induced muscle rigidity and corresponding increase in muscle resistance. Morphine-induced increase in muscle resistance was independent on the velocity of the ankle rotation and was reversed by naloxone. These data show that by using this system it is possible to objectively measure the degree of peripheral muscle resistance. The use of this system may represent a simple and effective experimental tool in screening new pharmacological compounds and/or surgical manipulations targeted to modulate spasticity and/or rigidity after a variety of neurological disorders such as spinal cord traumatic or ischemic injury, multiple sclerosis, cerebral palsy, or Parkinson's disease.

Paroxysmal sympathetic storm

INTRODUCTION

Paroxysmal sympathetic storm (PSS) is a rare syndrome characterized by episodic hypertension, hyperhydrosis, hyperthermia, tachycardia, tachypnea, and extensor posturing.

CASE REPORTS

This article describes two cases of PSS: one following traumatic brain injury and the other following cardiac arrest.

DISCUSSION

The first responded to labetalol, morphine, and codeine, whereas the second responded to labetalol.

CONCLUSION

These observations underscore the importance of central opioid receptors and nonselective beta-adrenergic antagonists in modulating catecholamine pathways.

Downbeating nystagmus and muscle spasms in a patient with glutamic-acid decarboxylase antibodies

PURPOSE

To report the ophthalmic findings and response to treatment in a patient with glutamic-acid decarboxylase antibodies.

DESIGN

Case report.

METHODS

A 55-year-old woman developed progressive, painful, low back muscle spasms, vertical diplopia, downbeating nystagmus, and asymmetric appendicular ataxia.

RESULTS

Downbeating nystagmus was present in primary gaze with an alternating skew deviation in lateral gaze. Serum and cerebrospinal fluid GAD antibodies were detected. Treatment with diazepam led to resolution of spasticity, whereas repeated courses of intravenous immunoglobulin improved cerebellar function, including appendicular ataxia and downbeating nystagmus.

CONCLUSIONS

Patients with GAD antibodies may have elements of both Stiff-person syndrome (muscle rigidity and spasms) and prominent cerebellar dysfunction. Treatment with diazepam rapidly improved Stiff-person symptoms, whereas IVIg was partially effective at the early stage of cerebellar dysfunction.

Hyperekplexie - eine behandelbare neuropädiatrische Erkrankung

Hyperekplexia (OMIM 138491) is primarily an autosomal dominant disease characterized by exaggerated startle reflex and neonatal hypertonia. If untreated it can be associated with sudden infant death from apnea or aspiration pneumonia and serious injuries. Different mutations of the alpha1-subunit of inhbitory glyzine receptor (GLRA1) could be found. Clonazepame, a gammaaminobutyric acid (GABA) receptor agonist is the therapy of choice. An early diagnose will lead to appropriate treatment and genetic counseling.

Long-term effects of bilateral subthalamic nucleus stimulation in advanced Parkinson disease: a four year follow-up study

In this study we aimed to investigate the effects of bilateral STN HFS in patients with advanced Parkinson disease (PD) at long-term, with a minimum follow-up of 4 years. Twenty patients (15 men, five women) were included, with a mean age of 60.9+/-8.1 years. Surgery was performed under local anesthesia. The target was defined on computerized tomography (CT). At 3 months, significant improvements were found on the total Unified Parkinson disease rating scale (UPDRS) III (motor) score, in the medication. off (from 42.3+/-9.3 to 19.5+/-6.4), as well as the medication on (from 18.6+/-12.1 to 10.1+/-5.9) phase. The UPDRS IVa (dyskinesias) and IVb (motor fluctuations) scores decreased significantly. At long-term follow-up, there were still significant improvements on the total UPDRS III motor score (from 42.3+/-9.3 to 24.2+/-13.2), as well as in all motor subscores, in the off phase, during stimulation. In the on phase, the only significant improvement was seen for rigidity. Complications included hypomania to mania in four patients. Our results indicate that HFS STN results in long-lasting improvement of the motor symptoms, ADL activities and functional performance in patients suffering from advanced PD. The stimulation induced behavioural changes need special consideration.

Postural stability of Parkinson's disease patients is improved by decreasing rigidity

Postural instability has a big impact on the quality of life of patients with Parkinson's disease (PD) as it often leads to an insecure stance and fall. We investigated if postural stability in these patients improves by decreasing rigidity with a dopaminergic agonist. In our study, we tested eight PD patients with no concomitant diseases. Their age was 61 +/- 2 years (mean +/- SE) and their Hoehn-Yahr score was 3 +/- 0.1. The patients were evaluated according to the Unified Parkinson's Disease Rating Scale for motor function (mUPDRS) and with stabilometric measurements of forward-backward and side-to-side body oscillations during free stance with eyes open. Both evaluations were performed in an "off "state and in an apomorphine-induced "on" state. As expected, the mUPDRS score was significantly decreased in the "on" state with posture being improved in six patients, gait in eight patients and postural stability in seven of eight patients. In addition, apomorphine caused a significant reduction of the relative amplitude of lower frequencies and an increase of the relative amplitude of higher frequencies of forward-backward body oscillations. The results of stabilometry and mUPDRS evaluations are in agreement with the effect of apomorphine on rigidity, indicating that postural stability of PD patients is improved by decreasing rigidity.

Progressive encephalomyelitis with rigidity: a paraneoplastic presentation of oat cell carcinoma of the lung. Case report

Progressive encephalomyelitis with rigidity and myoclonus (PEWR) is a rare neurological disorder, characterised by muscular rigidity, painful spasms, myoclonus, and evidence of brain stem and spinal cord involvement. A 73-year-old white man was admitted with a 10-day history of painful muscle spasms and continuous muscle rigidity on his left lower limb. He had involuntary spasms on his legs and developed encephalopathy with cranial nerves signs and long tract spinal cord symptomatology. Brain CT scan and spinal MRI were normal. The CSF showed lymphocytic pleocytosis and no other abnormalities. EMG showed involuntary muscle activity with 2-6 seconds of duration, interval of 30-50 ms and a frequency of 2/second in the left lower limb. Anti-GAD antibodies were detected in the blood. We detected radiological signs of lung cancer during the follow-up, which proved to be an oat cell carcinoma. The patient died two weeks after the diagnosis of the cancer.

The role of shortening reaction in mediating rigidity in Parkinson's disease

Rigidity in Parkinson's disease (PD) is defined as an increased resistance to passive movement of a joint. The plastic-type rigidity is uniform and constant throughout the entire range of motion, whereas the cogwheel-type rigidity is accompanied by tremor. Rigidity in PD has been understudied. Thus, its pathophysiological basis remains unclear. The purpose of the study is to examine neuromuscular/biomechanical properties of PD rigidity and to provide its physiological characteristics. We hypothesize that PD rigidity presents as a flattened trace of joint torque vs. angular position (torque-angle relation) of the wrist, because the forces generated by lengthening muscles are offset by activation of the antagonist, i.e. show "shortening reaction" (SR). Experiments were conducted on six PD subjects medication OFF and ON. PD severity was assessed based on the unified Parkinson's disease rating scale. Each subject sat on a chair and was instructed to relax, with the wrist coupled to the device. The servomotor applied constant velocity displacement to create wrist flexion/extension. Electromyographic (EMG) responses were monitored from wrist muscles, along with position, velocity and torque. EMG magnitudes were computed over the movement period. Slopes were derived from the torque-angle trace. Results showed that SRs were routinely recorded OFF medication, but substantially reduced ON medication. Due to the interaction of SR, torque-angle relation was flatter OFF medication and became steeper ON medication. Correlation analyses showed that a strong correlation (R=0.65) existed between SR and torque-angle slope OFF medication, exclusively. We suggest that SR may play an important role in mediating the mechanical features of PD rigidity.

[The effectiveness and tolerance of piribedil as adjunct therapy to levodopa in patients with Parkinson's disease: a nine month follow up]

INTRODUCTION

Piribedil is a D2 D3 dopamine agonist, which has been shown to be well tolerated and to improve Parkinsonian symptoms, particularly tremor. However, few studies have been published about this Dopamine Agonist as an adjunct to levodopa therapy in patients with Parkinson's disease (PD). This placebo controlled, parallel group study was undertaken to investigate the effects of piribedil in PD patients insufficiently controlled with levodopa in a nine months follow up.

PATIENTS AND METHODS

We included 62 PD patients insufficiently controlled with levodopa and needed an increase in dopamine stimulation. Patients were randomized in two similar groups, one of them taking Piribedil and levodopa and the other group taking a placebo and levodopa. The primary efficacy measures were the items II and III of the UPDRS. The patients were evaluated prior to the start of therapy, and 3, 6 and 9 months after the start of the study.

RESULTS

Patients taking Piribedil showed an average of improvement of 37,8% (p < 0.01) in the part II and 63,2% (p < 0.01) in the part III of the UPDRS at the end of the study. At 9 month evaluation, tremor at rest showed an average improvement of 68,6%, rigidity, fingers taps and legs agility improved substantially in their respective items of the UPDRS at the end of the study.

CONCLUSIONS

We concluded that PD patients with functional worsening while on stable levodopa doses exhibit a steady improvement of the UPDRS part II and III with the adjunction of Piribedil 150 mg mean daily dose for 9 months.

[Masseter muscle rigidity after suxamethonium during induction and postoperative abortive malignant hyperthermia in a patient with esophageal achalasia]

A 38-year-old man diagnosed as esophageal achalasia developed masseter muscle rigidity after intravenous suxamethonium during anesthetic induction. Anesthesia was maintained with intravenous agents and epidural blockade, while the masseter muscle rigidity continued. After the surgery, his body temperature increased to 38.8 degrees C concomitantly with the appearance of myoglobinuria suggesting the occurrence of abortive malignant hyperthermia. These symptoms were dissolved by dantrolene administration. He was later proved to be negative with CICR test.

Alpha-dihydroergocryptine in the long-term therapy of Parkinson's disease

The trial was designed as an open-label, post-authorisation safety study, aimed to complete the available information on adverse events and drug reactions to alpha-dihydroergocryptine (CAS 14271-05-7, alpha-DHEC). The study included 294 patients with idiopathic Parkinson's disease who received levodopa (CAS 59-92-7, L-DOPA) and started taking alpha-DHEC (Cripar). Adverse events were analysed descriptively, Parkinson's disease symptoms were documented using a questionnaire applied by the physicians. Patients were evaluated at study start and three and six months later, respectively. In 31 patients, 32 adverse events were observed, gastrointestinal and nervous system disorders being the most frequent. Dyskinesias, psychoses/hallucinations, sleep disturbances, and cardiovascular disorders were uncommon (< or = 1%). in total, 21 adverse events were classified as adverse drug reactions. In nearly 80 % of the cases, Parkinson symptoms had improved or completely vanished. Symptoms were unchanged in 16.7 % of patients and had worsened in 3.1%. The results confirm that the use of alpha-DHEC in combination therapy with levodopa in patients with Parkinson's disease is a well-tolerated and efficacious treatment option.

Pramipexole in routine clinical practice: a prospective observational trial in Parkinson's disease

OBJECTIVE

The mixed dopamine D2/D3 receptor agonist pramipexole is effective as monotherapy in early Parkinson's disease and as adjunctive therapy in advanced disease. Clinical trials suggest that the benefits of pramipexole may extend beyond the relief of motor symptoms (akinesia, rigidity and tremor at rest) to amelioration of depressive symptoms in Parkinson's disease. The aim of this study was to confirm the beneficial effects of pramipexole on the core symptoms of Parkinson's disease (with a focus on tremor), as well as to assess its antidepressant activity, during routine clinical practice. The study also aimed to demonstrate the practicability of the Snaith-Hamilton Pleasure Scale (SHAPS-D), the Tremor Impact Scale (TIS) and the Short Parkinson's Evaluation Scale (SPES) under conditions of routine clinical practice.

STUDY DESIGN

This was a prospective observational study.

PATIENTS

Data for 657 outpatients with Parkinson's disease were collected from German hospitals and specialist practices. The majority of patients were in Hoehn & Yahr stage II or III and were receiving levodopa.

METHODS

Pramipexole (Sifrol) was initiated at a dosage of 0.375 mg/day (using a three-times-daily schedule) and titrated upwards, as required, at weekly intervals over a 4-week period to a maximum dosage of 4.5 mg/day (three times daily). Clinical evaluation was performed at baseline, at the end of the titration phase and at the end of maintenance therapy. Patients were assessed via the German questionnaire versions of the physician-assessed SPES, the self-evaluated TIS and the SHAPS-D. Changes in scale scores were evaluated nonparametrically, using the Wilcoxon-matched pairs test. Cronbach's alpha was used as a measure for item consistency.

RESULTS

Pramipexole significantly improved SPES subscores for motor symptoms, complications of therapy, psychological status and activities of daily living. Pramipexole also reduced the detrimental effect of tremor on activities of daily living and social interactions, as assessed by patients via the TIS. As indicated by the results of the SHAPS-D questionnaire, pramipexole significantly reduced anhedonia in patients who had associated depression. Internal consistency of SPES subscales was found to be unaltered between the initial evaluation and follow-up. Likewise, internal consistency for TIS and SHAPS-D was demonstrated. Pramipexole was well tolerated and accepted by the vast majority of physicians and patients.

CONCLUSION

In addition to ameliorating the core symptoms of akinesia and rigidity in Parkinson's disease, pramipexole improves tremor and depressive symptoms in routine clinical practice. The SPES, TIS and SHAPS-D were found to be useful instruments with validity in this study.

2-Arylureidobenzoic Acids: Selective Noncompetitive Antagonists for the Homomeric Kainate Receptor Subtype GluR5

A series of 2-arylureidobenzoic acids (AUBAs) was prepared by a short and effective synthesis, and the pharmacological activity at glutamate receptors was evaluated in vitro and in vivo. The compounds showed noncompetitive antagonistic activity at the kainate receptor subtype GluR5. The most potent compounds showed more than 50-fold selectivity for GluR5 compared to GluR6 and the AMPA receptor subtypes GluR1-4. The structure-activity relationships for the AUBAs showed distinct structural requirements for the substituents on the two aromatic ring systems. Only para-substituents were tolerated on the benzoic acid moiety (ring A), whereas ring B tolerated a variety of substituents, but with a preference for lipophilic substituents. The most potent compounds had a 4-chloro substituent on ring A and 3-chlorobenzene (6b), 2-naphthalene (8h), or 2-indole (8k) as ring B and had IC(50) values of 1.3, 1.2, and 1.2 microM, respectively, in a functional GluR5 assay. Compound 6c (IC(50) = 4.8 microM at GluR5) showed activity in the in vivo ATPA rigidity test, indicating that 6c has better pharmacokinetic properties than 8h, which was inactive in this test. The AUBAs are the first example of a series of noncompetitive GluR5-selective antagonists and may prove to be important pharmacological tools and leads in the search for therapeutic glutamatergic agents.

Influence of CGS 21680, a selective adenosine A(2A) agonist, on the phencyclidine-induced sensorimotor gating deficit and motor behaviour in rats

RATIONALE

Recently it has been suggested that adenosine A(2A) receptor agonists may be potential antipsychotic drugs. It is, however, not clear whether these compounds may exert their antipsychotic effect without producing extrapyramidal side-effects (e.g. catalepsy, muscle rigidity, ataxia). It is known that such side-effects may be due to overactivation of the GABAergic strio-pallidal pathway, which may be estimated as an increased expression of proenkephalin (PENK) mRNA in the striatum.

OBJECTIVE

The aim of this study was to determine whether CGS 21680, a selective adenosine A(2A) receptor agonist, can reverse the disruption of prepulse inhibition (PPI) of the acoustic startle response induced by the non-competitive antagonist of NMDA receptors phencyclidine (PCP) without producing motor side-effects in rats.

RESULTS

Systemic administration of PCP (5 mg/kg) produced profound reduction of the PPI, which was reversed by CGS 21680 (1 mg/kg). CGS 21680 (0.1 and 1 mg/kg) was without effect on catalepsy, muscle rigidity and rotarod performance in rats as well as on the PENK mRNA expression in the striatum estimated by in situ hybridization. Only after the highest dose used (5 mg/kg) were signs of catalepsy (measured using a 9-cm cork test), disturbed balance and a loss of hind limb control (measured in the rotarod test) seen. Moreover, increased muscle resistance during passive extension measured mechanomyographically after this dose of CGS 21680 was observed.

CONCLUSIONS

The present results support the hypothesis that adenosine A(2A) receptor agonists may be potentially useful antipsychotic agents with the low incidence of extrapyramidal side-effects.

Synergistic effect of SCH 58261, an adenosine A2A receptor antagonist, and L-DOPA on the reserpine-induced muscle rigidity in rats

The aim of the present study was to find out whether a blockade of adenosine A2A receptors by the selective antagonist, SCH 58261, potentiates the attenuating effect of L-DOPA, the well-known antiparkinsonian drug, on parkinsonian-like muscle rigidity in rats. Muscle tone was examined using a combined mechano- and electromyographic method, which simultaneously measured muscle resistance of a rat hindfoot to passive extension and flexion in the ankle joint and the electromyographic (EMG) activity of the antagonistic muscles of that joint: gastrocnemius and tibialis anterior. Muscle rigidity was produced by reserpine (5 mg/kg ip) injected in combination with alpha-methyl-p-tyrosine (alpha-MT, 250 mg/kg ip). L-DOPA (25 mg/kg ip) or SCH 58261 (0.1 mg/kg ip) administered separately, slightly influenced the reserpine + alpha-MT-induced muscle rigidity. However, only ankle joint extension was affected significantly while the effect on flexion of the rat hindfoot was not significant. Neither L-DOPA nor SCH 58261 given separately modified the reserpine-enhanced tonic or reflex EMG activities in both muscles examined. However, when L-DOPA (25 mg/kg) was given together with SCH 58261 (0.1 mg/kg), a clear synergistic effect was seen on both examined movements and muscles. The present results show that the blockade of adenosine A2A receptors potentiates the antiparkinsonian effect of L-DOPA. Since such an effect was seen in different animal models of Parkinson's disease (PD), it seems that co-administration of SCH 58261 may allow for the lowering of the doses of L-DOPA in clinical practice, which indicates a potential therapeutic value of this compound in the treatment of PD.

Fentanyl-induced rigidity during emergence from general anesthesia potentiated by venlafexine

PURPOSE

To present and discuss a case of opioid-induced rigidity with low-dose fentanyl during recovery from anesthesia.

CLINICAL FEATURES

A 41-yr-old woman underwent laparotomy for total abdominal hysterectomy and bilateral salpingo- oophorectomy under general anesthesia. She received a total of 500 micro g of fentanyl by iv intermittent boluses during the three-hour anesthetic. During emergence from anesthesia, while intubated, the patient presented with rigidity. No changes in ventilatory parameters were measured during the episode. The only notable predisposing factor was treatment with venlafexine, an antidepressant that modifies serotonin and norepinephrine levels. She was successfully treated with iv naloxone 20 micro g. The rest of the postoperative period was uneventful.

CONCLUSION

We observed an atypical case of opioid-induced rigidity in contrast to the classical syndrome, which presents at induction with high-dose opioids. This syndrome has many clinical presentations with neurologic and ventilatory signs of varying intensity. Early recognition of the syndrome and adequate treatment is crucial. If treated adequately, opioid-induced rigidity is self-limited with few complications.

Nicotine decreases bradykinesia-rigidity in haloperidol-treated patients with schizophrenia

We applied nicotine 21 mg and matching placebo transdermal patches to thirty haloperidol-treated patients with schizophrenia who smoked. Clinical assessments of bradykinesia-rigidity were lower during nicotine patch administration than during placebo patch administration.