Zahraa Hotait

September 26, 2016

Period 6

Annotated Source List

Bateson, M. C., Gibberd, F. B., & Wilson, R. S. E. (1973). Salivary symptoms in

Parkinson disease. Archives of Neurology, 29, 274-275.

This article describes a study that examined the reported symptom of drooling that
can accompany Parkinsons disease. This symptom had been previously thought to occur
because of overproduction of saliva in patients with Parkinsons disease. However, the study
that is described in the article tested the idea that the excessive salivation is due to reduced
swallowing capabilities rather than the overproduction of saliva itself. The study tested two
groups of Parkinsons disease patients, one of which complained of drooling and the other of
which complained of dry mouths. The results indicated that both groups actually produced
roughly the same amount of saliva, which was less than the amount produced by non-
Parkinson control groups. The article focuses on this outcome, and explains that this finding
demonstrates how excess saliva production is not in fact the cause of drooling in Parkinsons
patients. It emphasizes the idea that defective swallowing is a more likely cause of the
drooling symptom; the article asserts that bradykinesia and abnormal unconscious function of
the mouth, pharynx, and esophagus are more likely to cause drooling. The article also states
that because Parkinsons patients actually produce less saliva rather than more, atropine-like
drugs, which are intended to reduce saliva production, instead cause increased incidence of
dry mouth in Parkinsons patients but do not improve the symptom of drooling.
Although this article focuses on a symptom of Parkinsons disease that is not central
to my intended area of research, motor grip control, it is useful because it describes one facet
of the disease. Understanding the effect of Parkinsons disease as a whole on patients is very
important in the field of neurology. The article also includes the method and timing used to
collect and measure the subjects saliva, making the described experiment replicable if
desired. However, the article is from a journal volume published in 1973 and is therefore very
outdated; my mentor did recommend this article, validating that the information is correct,
but the work is from an outdated volume. Additionally, while having a more comprehensive
understanding of Parkinsons disease and its various symptoms and conditions will be useful
at my internship, it will not be particularly helpful in understanding my more specific area of
research concerning motor grip strength in patients with Parkinsons disease. The article also
included the charted results of the described study, which creates a more technical article
supported by statistics; for this background stage of my research, a conceptual article would
be more helpful to gain an understanding of the overall effects of the disease on patients.

Fabbrini, G., Defazio, G., Colosimo, C., Suppa, A., Bloise, M., & Berardelli, A.
(2009). Onset and spread of dyskinesias and motor symptoms in Parkinson's
Disease. Movement Disorders, 24(14), 2091-209

The article first states that dyskinesias are the most common complication of long-
term dopaminergic treatment. It continues by suggesting that dyskinesias are most common
in the area of the body first affected by Parkinsons Disease; studies are being conducted on
the subject, but a definitive answer has not been found yet. Next, the article describes its own
study to examine the prevalence of levodopa-induced Parkinsonism (LIP). In the study, LID
were assessed at rest and during tasks. The patients who were tested in the study were
previously examined to record other factors such as sex, age, disease severity, and treatment
regimen. Of the patients in the study who did have LID, all experienced LID at the time of
peak dosage. However, some patients also experienced LID at the beginning and end of
dosage. Both motor symptoms and LID began in the limbs, but LID also started in the
craniocervical region in some patients. There was no majority of patients in which the onset
of LID occurred in the same region as the onset of the disease. Patients whose LID spread to
a different area from the original area of LID onset had more severe Parkinsons Disease and
longer and higher levodopa dosage. The patients whose LID spread were evenly distributed
in categories including sex and site of LID onset.
This study is not particularly helpful in my research. I chose the article because I
intended to learn more about levodopa induced dyskinesia in Parkinsons Disease patients,
but the study described in the text did not help me extensively in the end. The study was very
specific, whereas I wanted to gain a background understanding of the effect. Although the
article did report the results of the study in great detail, it seemed very inconclusive because
of the multiple theories that it suggested to explain its results. There seemed to be little
practical use for this article because it does not describe the clinical aspect of the symptom, as
I observe at my internship, nor does it exemplify a study related to my primary area of
interest for research, which concerns hand motor function in Parkinsons patients. One use of
this article, however, is to gain experience reading and comprehending formal research
reports. Throughout my research, I have found the results, figures, and conclusions a little
difficult to comprehend, so reading additional resources such as this description and
analyzation of a research project will help to familiarize myself with the format, language,
and various charts and graphs that I may consistently encounter throughout my research.

Fellows, S. J., Noth, J., & Schwarz, M. (1998). Precision grip and Parkinson's
disease. Brain, 121, 1771-1784.

This article discusses quantitative research studying motor deficits in patients with
Parkinsons disease. It focuses first on guidelines for this type of research, and includes that
the movements chosen to study must be standardized to obtain accurate research; the
movements should be very simple, or could alternatively be imposed from an outside source.
The article states that Parkinsons disease affects internally generated movements more than
those caused by external stimuli, and suggests that this is a result of the greater role of the
supplementary motor area, a major functional area of the basal ganglia, in these self-
generated movements. One such movement is the lifting of an object using precision grip; the
article uses the study of this particular movement because it is voluntary and replicable as
well as complex. This movement requires appropriate arm placement, preparation of the
fingers to anticipate gripping the object, and the adjustment of finger grip in conjunction with
activity in the arm to allocate the correct modification of grip strength in response to the
sensory input during the lifting movement. This also involves an element of memory, as the
subject must predict the mass of the object based on previous experience lifting a similar
object. The article then describes an experiment based on Johanssons work with non-
Parkinsonian subjects, which was repeated to test the ability of Parkinsons patients to
perform an object lifting task. Subjects would use their thumb and forefinger to pick up a
two-part aluminum block with a force transducer between the two parts, which recorded the
grip force exerted by the subject on the block. A second force transducer was placed between
the block and a band connecting the block to a torque motor, which controlled the load that
the subject would have to lift; this second transducer recorded the amount of vertical load
force on the block. The experiment was divided into three parts; the first and second tested
the ability to lift unpredictable loads as opposed to constant loads, respectively. The third trial
tested the ability to adjust precision grip in a situation where the block would slip from the
patients initial grip. The results show that although Parkinsons patients retained the ability
to predict the forces needed based on memory and modify their grip based on sensory input,
they used an abnormally high amount of grip forces for each lift. The timing of the grip force
was also notably abnormal in Parkinsons patients, and it took a greater amount of time for
the Parkinsons patients to move the block after the initial contact with the block than did the
control patients. Additionally, changing the load during the lift displaced the block by a far
greater amount in Parkinsons patients. The results were not significantly affected by
allowing the patient visual control of their finger position or notifying the patient as to the
load before they lifted the block. The article suggests that the prolonged time required by
Parkinsons patients to generate grip forces can be attributed to bradykinesia caused by basal
ganglia dysfunction. The excessively high levels of grip strength could be caused by the loss
of kinaesthetic sense caused by the elevated gating of basal ganglion input, and the twofold
increase of tactile threshold at the fingertips. Accordingly, the supplementary motor area
allots the incorrect level of grip strength forces because the information delivered from the
basal ganglia is misleading. The article briefly mentions other basal ganglia related disorders,
such as Huntingtons disease.
This article will be extremely helpful in my research with motor grip control in
patients with Parkinsons disease. The journal from which it is taken was published in 1998,
so it is an outdated experiment, but the information provided is still relevant to my area of
research based on its recommendation from my mentor. The article begins by providing
guidelines for research on this topic and on discerning a standardized action to measure. It
then provides some background information on the supplementary motor area of the brain,
and the basal ganglia; this section is technical and a little difficult to comprehend at first but
is still very useful to develop understanding of the physiological areas affected by
Parkinsons disease. The article also describes the experiment used to test precision grip,
which is my primary area of interest for research. The experiment is explained and detailed
very specifically so that it can be replicated with the correct materials, procedures, and data
collection. The experiment described was designed to test many elements of precision grip,
including the factors of memory, anticipation, initial grip strength, modification of grip
forces, and registration of sensory input to appropriately adjust the movement in predictable
and unpredictable situations. The multifaceted approach and comprehensive experimentation
and description make this source an ideal model in my research of precision grip strength in
patients with Parkinsons disease.

Friedman, J. H., Trieschmann, M. E., & Fernandez, H. H. (2005). Drug induced

parkinsonism. In Drug induced movement disorders (2nd ed.). Blackwell
Futura.

The text begins with a simplified description of how certain drugs are able to block
dopamine receptors and cause a functional dopaminergic deficiency. The article briefly
discusses the history of the distinction between the drug induced and idiopathic conditions of
Parkinsons Disease. Drug induced parkinsonism (DIP) is most commonly found in patients
who are being treated for psychiatric disorders. The article then proceeds to proceed a set of
Parkinsons symptoms. It states that a tremor in DIP can involve the fingers, hands, jaw, feet,
or tongue, but there is often less tremor in DIP patients than in idiopathic patients. In
addition, DIP can also begin asymmetrically (although drugs often affect the brain
symmetrically). The article then provides more specified examples of a type of DIP called
rabbit syndrome, where patients exhibit chewing like movements. It is stated that a drug
history is a necessary part of an exam while testing for Parkinsons Disease. However, the
distinction between DIP and IPD is usually insignificant and nearly nonexistent.
This excerpt provides additional insight into the individuality of each case of
Parkinsons Disease, as well as other movement disorders not discussed in the article. The
disorder has multiple causes, so its classification varies widely between patients. The
extensive list of possible symptoms is represented differently in each patient. The fact that
causes, symptoms, and effects change greatly from patient to patient is a reminder that
movement disorders specialists need to keep an open mind when diagnosing patients, because
the possibilities are so expansive. Articles like this one help me understand more about each
patient that I observe at my internship; some suffer from drug-induced parkinsonism, whereas
some have idiopathic Parkinsons Disease. Because each patient is so unique, it is important
for me to be able to grasp the multitude of different conditions and symptoms that could be
afflicting him or her. This text helps me to move towards that purpose by describing one facet
of Parkinsons Disease in a comprehendible but more in-depth way.

Grill, D. S. E. (2016, October 3). [Personal interview].

Dr. Stephen E. Grill, who is my mentor for this course, has been treating movement
disorders since 1995. His independently established clinic, the Parkinsons & Movement
Disorders Center of Maryland, has been his place of work for eleven years. Dr. Grill earned
his M.D. at Northwestern University, in Chicago, Illinois. He later earned his Ph.D. also from
Northwestern University, on the campus at Evanston, Illinois. Dr. Grill then began his
Neurology Residency program at Washington University in St. Louis, Missouri. After the
conclusion of his residency, Dr. Grill completed his movement disorders specialized
fellowship, working at the Human Motor Control Section of the National Institute of
Neurological Disorders and Stroke of the National Institutes of Health. In 2005, he co-
founded the Parkinsons and Movement Disorders Center of Maryland, where he now
operates his patient examinations and conducts his research. His primary areas of interest
include sensory feedback, motor grip strength and precision grip, and stimulus masking as
differentiating factors in Parkinsons Disease. Dr. Grill now treats patients with a wide variety
of movement disorders including Parkinsonian disorders and dystonia, and is a well-respected
member of the society of neurologists in the Washington D.C. area.
Dr. Grill is one of my most important resources; his guidance is the driving force
behind my project. Not only does he allow me to observe patients in his clinic and to work as
an intern in his center, he provides a myriad of information regarding movement disorders.
Whether this comes in the form of pointers and comments during patient exams, PowerPoint
presentations, or studies and texts that he provides and suggests for my research, Dr. Grill
allows me to gain access to valuable information. His insight is essential for me to gain a
better understanding of movement disorders and their diverse effects on afflicted patients. Dr.
Grills background demonstrates his high level of experience with the disorders he treats,
lending credibility to his advice and establishing the enormous range of knowledge
encompassed by his studies. He is also very helpful in my process of understanding medical
terminology; many articles that I have read in my research are difficult to understand without
a medical degree, and Dr. Grills explanations allow me to more fully appreciate the
information found in my sources by helping me to decipher the technical language. As a
member of many associations and societies, Dr. Grill is able to network throughout the local
community of neurologists. This presents additional opportunities such as conferences and
talks, from which I am able to gain relevant information and expand my comprehension of
movement disorders.
Gurevich, E. V., & Gurevich, V. V. (2010). Dopamine receptors and the treatment
of Parkinson's Disease. In K. A. Neve (Ed.), The Receptors: The dopamine
receptors (2nd ed., pp. 525-527).

The text begins with a fundamental description of Parkinsons Disease as a

degenerative neurological movement disorder, naming common symptoms such as
bradykinesia, akinesia, resting tremor, rigidity, and changes in posture and gait. The article
then identifies the cause of the disorder as the progressive deterioration of dopaminergic
neurons and the loss of dopamine in the striatum, and briefly discusses the use of levodopa as
the most successful treatment despite its gradual loss of effectiveness in each patient. Then,
the article describes how the deficit of dopamine leads to changes of the signaling pathways
in the brain. The increased use of D1 pathways could cause the levodopa-induced dyskinesias
present in many patients on long term levodopa medication. It discusses how the excitatory
thalamo-cortical projections are inhibited by decreased dopamine levels, and shows how this
reduces the motor cortical output and increases the insufficiency of voluntary movement.
My purpose in reading this article was to gain a more technical understanding of the
cause and effects of Parkinsons Disease. However, the article was extremely difficult to
understand at my level of education. It was definitely useful in that it forced me to realize that
I cannot yet understand articles that are written at such a high level. The background
discussion concerning Parkinsons Disease symptoms, levodopa treatment, and effects of
medication such as dyskinesia were an effective confirmation of these concepts, which I had
already understood. Although I found the most basic information about the various
neurological pathways to be interesting and although I thought it necessary to learn the actual
cause of deterioration of certain brain functions, I found this article to be too complicated to
comprehend at this stage in my internship. I hope to be able to return to this article in a later
stage of my internship and research, and to be able to understand it more fully.

Hejdukov, B. (2003). Manual transport in Parkinson's Disease. Movement

Disorders, 18(5), 565-572.

This article describes a study analyzing the effect of Parkinsons Disease on hand
motor function. The deterioration of hand motor function is one of the most prevalent
problems faced by Parkinsons patients. The article suggests that this handicap would affect
the patients ability to form the grip, lift the object, move the object, and place it down.
Parkinsons patients have been noticed to have a slower development of grip force and
increase of lift force. A group of Parkinsons patients were compared (both on and off
medication) to a control group. The subject began with their arm on a pressure sensitive pad
and an object placed about 10 cm in front of them. At a verbal signal, the subject raised their
hand to pick up the object, moved it to a stand, and returned to the original position; then, the
subject would return the object from the stand to the start position. This process was repeated
as fast as possible in 30 seconds. Hand movements were recorded by an optoelectronic
camera. The results of the experiment showed that Parkinsons patients (on and off groups)
were significantly slower than the control patients. The precision grip in Parkinsons patients
was established more slowly and impaired as compared to the control group. The PD patients
were slower in preparing for and executing each movement, and it took them longer to reach
their grip force. Additionally, PD patients could suffer from sensory deficits, so the external
feedback could be lost. In the transport portion, PD patients were slower to complete the
acceleration and transport-1 stages of transport because of their abnormally low velocity. The
consistency throughout the various components of movement measured in this experiment
was that patients with PD completed each phase with a delay and slower overall movement.
The study suggests that the disturbance in patients with PD was due to the larger role of the
basal ganglia in sequences of movements rather than in the individual sub-movements.
In this article is another example of a possible experiment that could be similar to the
research study in which I will participate. The study in this article is written in such a way
that it is possible to understand and replicate, and it specifies the procedure and method of
data collection. The article provides an explanation for its chosen methods, which will be
incredibly helpful in considering the design of a new experiment. For example, it describes
the phases of movements and their relevance to Parkinsons Disease when discussing the
repeatable movement chosen for subjects to perform in the study. The article includes
conclusions regarding precision grip and motor grip strength in PD patients, which are
relevant to my current research in which precision group is a primary area of interest. It
supports the relevance of the study of precision grip in Parkinsons Disease. The experiment
described was well planned to test many stages of movement in a sequence of movement to
demonstrate the delay of response. The detailed approach provides a sound basis in my
research of the effect of Parkinsons Disease on hand motor function.

Johnson, K. E. (2015). Approach to the patient with Parkinson disease.

Primary Care: Clinics in Office Practice, 42(2), 205-215.

This article gives an extensive overview of the symptoms and key elements of
Parkinsons disease (PD). It describes PD as a gradually progressive neurodegenerative
disease and continues to explain motor, nonmotor, and behavioral implications of the disease.
Imaging techniques have been developed to identify the disease up to 20 years before motor
symptoms are apparent, but have not been applied to any effective treatment. There is some
risk increase from family history of PD, but it is not a concrete factor and many cases are
sporadic and disconnected. PD is easily misdiagnosed because of the complex interaction of
symptoms, and unclearly diagnosable patients should be referred to a movement disorders
specialist soon after the development of symptoms. The article classifies the types of
medications generally used to treat PD into their primary uses of antipsychotics,
antidepressants, and antiemetics. The recommended initial treatment is simply educating the
patient about their disease, and increasing and maintaining aerobic exercise. The deterioration
of motor skills from the dopamine deficiency of Parkinsons disease can be improved by
administering the drug levodopa, which is given with carbidopa to reduce negative effects.
However, the article adds that this medication can cause dyskinesias, which often correspond
with the peak dosage. Levodopa must sometimes eventually be reduced or stopped because of
the occasional resulting hallucinations and psychosis. These negative effects are less
prevalent in other medications such as nonergot dopamine agonists, but are often replaced by
peripheral effects of dopamine (like nausea, hypotension, and edema) and neuropsychiatric
effects including impulse control disorders. The article discusses several other less common
medication options and describes how they work in the brain. Surgical treatment is also
discussed; the article describes the benefits of the implantation of surgical deep brain
stimulation. Next, the article advises doctors to observe mood changes in PD patients because
of the increase of neuropsychiatric symptoms as the disease progresses. Parkinsons Disease
Dementia is common and heightens impulsive behavior while disrupting other areas of the
patients behavior. Psychosis, depression, and sleep disorders (including rapid eye movement
sleep behavior disorder) are also very common occurrences with PD patients, and can worsen
the risk factors, symptoms, and quality of life. The article also mentions the importance of
attentive caregivers to reduce risk. Included in the article is a comprehensive list of symptoms
including motor, craniofacial, sensation, neuropsychiatric, and autonomic dysfunction
symptoms (the latter including symptoms such as nocturia and erectile dysfunction).
 I found this article to be incredibly helpful in describing many of the distinct
symptoms I have observed at my internship. Parkinsons disease has a huge variety of
symptoms, and every case is slightly different. Although the article does include some very
technical components while discussing the various medication options, it also provides sound
clinical and conceptual information. The article explains the occurrence, effects, and
connections of a multitude of symptoms and classifies them into categories, which are
essential to my understanding when I am observing patients undergo the various functional
tests at my internship. This source also provides insight into some social effects of various
Parkinsonian symptoms. For example, it discusses the importance of a caregiver and of
imposing a support system to improve care of patients with Parkinsons disease. It also
describes some of the social manifestations of Parkinsons symptoms, especially
neuropsychiatric symptoms; the article mentions specifically the possibility of an increased
tendency to gamble that can be associated with a neuropsychiatric symptom of Parkinsons
disease. These insights are very relative in order to gain an understanding of how Parkinsons
disease affects patients holistically, with effects ranging from motor symptoms to mental
diseases like depression. The article provides essential information in my study of
Parkinsons disease.

Levine, D. Z. T. (2016, October 8). [Personal interview].

Dr. Zachary Levine is a neurosurgeon who operates at Holy Cross Hospital in Silver
Spring, Maryland. Dr. Levine is a colleague of Dr. Grill, and specializes in Deep Brain
Stimulation (used to reduce dyskinesia in Parkinsons Disease patients), as well as cranial
base surgery and other surgical treatments for movement disorders and epilepsy. Dr. Levine
completed his undergraduate studies at Dartmouth College, after which he attended medical
school at the New York University School of Medicine. He was a member of the schools
honors program. He was then accepted into the neurosurgical residency program at the
George Washington University Medical Center. Dr. Levine is now licensed in Maryland,
Virginia, and Washington D.C. He is also a member of many professional associations,
including the American Association of Neurological Surgeons. Dr. Levines other
achievements include his Singer and Resident research awards for his published
neurosurgical research and his 2010 Humanitarian Award from the Dystonia Association. Dr.
Levine and Dr. Grill share many patients; Dr. Grill provides the medication factor in a
patients treatment while Dr. Levine is responsible for surgical implantation of DBS devices.
Dr. Levine will begin to work at Dr. Grills office this year for a couple days each
week. During this time, he will be available for consultation regarding the Deep Brain
Stimulation implants, which are used to reduce the negative result of high levodopa dosage
(often necessary to treat Parkinsons tremor). Because of his surgical approach to movement
disorders, Dr. Levine provides an alternative perspective to patients conditions. This will be
a helpful point of view to gain information about DBS, which is a common procedure in
patients with Parkinsons Disease. Many of Dr. Grills patients enter the clinic with DBS
electrode implants, making DBS central to my understanding of patients treatment plans.
Part of these patients exams includes checking the electric signals and battery usage of the
DBS device using another output device; the DBS system is an integral part of many patients
conditions, treatments, and exams. Because the manifestations of movement disorders are so
diverse and the range of symptoms and conditions is so wide between patients, the ability to
have the view of two doctors can be very useful. Combining the different perspectives of Dr.
Grill and Dr. Levine can help me form my own opinions and insights into a patients
condition, leading to a more comprehensive view of Parkinsons Disease.
National Institute of Neurological Disorders and Stroke. (2016). Retrieved
October 24, 2016, from http://www.ninds.nih.gov

The National Institute of Neurological Disorders and Stroke is a division of the

National Institutes of Health (NIH). The website has an About page stating the mission of
the NINDS, which is to gain knowledge about the brain and nervous system, and use this
knowledge to aid people suffering from neurological diseases. Along the top of the website is
a bar titled Disorders A-Z where users can browse an index of disorders by their
alphabetical arrangement. Each disorder is linked to a page describing the disorders
respective symptoms, treatments, and research projects. Another page of the website includes
a directory of professional societies relating to different fields of neurology, including the
Movement Disorder Society. Each society is listed with its address and contact information.
In addition, a separate staff directory lists the NINDS staff along with each members title
and contact information. A section of the home page is devoted to current news, showing
recent developments in neurologic research. Users can view and learn about upcoming and
past events such as workshops and councils. Other features of the website include research
resources (such as current topics, research webs, and research programs) and funding
information.
This website is very helpful because of the large concentration of knowledge in one
compact location. For example, on the single disorder page devoted to Parkinsons Disease, I
can easily access basic information of the symptoms and treatment of Parkinsons Disease as
well as notices about clinical trials, organizations related to the disease such as the American
Parkinson Disease Association, and relevant publications about Parkinsons Disease research.
The website provides specific, easily accessible information about a huge variety of
disorders. If I am interested in pursuing more detail about a subject, the site provides contact
information for societies and staff members specialized in very diverse aspects of neurology.
The section of the website displaying current news is also helpful to stay updated about
recent developments within my topic of interest; I can use these news excepts to easily notice
new findings on movement disorders.

National Parkinson Foundation. (2016). Retrieved October 24, 2016, from

http://www.parkinson.org

This website is the home page of official organization for the awareness and treatment
of Parkinsons Disease, the National Parkinson Foundation. There are many included
resources for Parkinsons patients and their families, such as links to videos explaining
symptoms and a discussion forum where users can ask questions about the many facets of
Parkinsons Disease, including speech, nutrition, and surgical treatment. The website also
allows users to donate or to sign up for fundraisers and events to support the Parkinsons
community. The National Parkinson Foundation states that their goal is to improve each
patients quality of life. The foundation is also committed to helping fund research
surrounding the disorder. Users can also interact with each other through the forum, so the
website helps to create a more expansive support group to help each member through their
disease. The website includes a Helpline and contact information to add to the support
system.
This resource is an easily accessible knowledge base. It provides a window into the
large amount of support necessary to help patients to cope with Parkinsons Disease; the
support systems that have been implemented within the Parkinsons community are an
integral part of many patients lives. This is needed because of the demonstrated profound
social effect of movement disorders on patients. The Frequently Asked Questions, news
update articles, and YouTube give a range of information, and these different ways to access
information that are presented by the website ensure that every user is able to find and
understand resources about the disorder. This site is also useful because the forum and contact
information are an easy way to pose a specific answer and receive answers from various
perspectives.

Nutt, J. G. (2001). Motor fluctuations and dyskinesia in Parkinson's disease.

Parkinsonism & Related Disorders, 8, 101-108.

This article discusses the prevalence of dyskinesias in patients with Parkinsons

Disease, and discusses their inherent connection to the long term use levodopa medication
used to treat the tremors associated with Parkinsons Disease. Although the onset is
influenced by a multitude of other factors, the article states that motor complications
commonly develop after five years of treatment with levodopa. It then names the three central
responses to levodopa medications: first, the short-duration response is the immediate
improvement of motor function with dosage. Secondly, the long-duration response is the
build and/or decline of improvement over days. Lastly, the negative/inhibitory response is the
deterioration of motor function after the short-duration response. The article also mentions
that the effects of endogenous dopaminergic contributions may last for weeks after a patient
is taken off of levodopa. A patient with a stable response to levodopa lacks strong fluctuations
in function, and improves over the period of treatment (long term). However, motor
fluctuations begin to appear in the form of bradykinesia when the medication seems to wear
off, suggesting that the short-duration response is shortened. It is suggested that a loss of
endogenous dopaminergic function contributes to the increasing motor disability and the
shortening of the effectiveness of the dosage. During the time when the peak dosage of
levodopa has occurred in a patient, dyskinesias commonly develop. The article presents the
theory that prolonged levodopa usage gradually lowers the threshold to reach the point where
a patient experiences dyskinesia. However, questions are raised about other factors affecting
the occurrence of dyskinesia. The suggested but unproven theory is that the severity or
duration of dyskinesia is dose-related. The article then instructs the physician to educate each
patient about the presence of motor fluctuations. These fluctuations can be observed in a
pattern, which is often influenced by mood, sensation, and anxiety. The short half-life of
levodopa makes it difficult to control and make constant, but a dietician may help in this
regard. Increasing dosage of levodopa can help with motor function fluctuations and prolong
the effects of the medication, but could increase tolerance. To minimize this effect, the article
suggests that patients take 1200 mg or less of levodopa each day, and refrain from taking
levodopa at night. The use of levodopa should also be delayed until it is necessary. Because
dyskinesia is closely related only to levodopa, combining the drug with other
antiparkinsonian agents could reduce the negative effects. The fluctuations and dyskinesia
worsen as the disease progresses, so increasing long-duration response would alleviate the
severity of these effects by reducing the off-dose disability.
This article uses many technical terms that are difficult for me to understand. The
overall idea of the article is useful because it specifies the causes and effects of one condition
resulting from Parkinsons Disease. However, the article proposes a number of unproven
theories, which are not as useful to my preliminary research because they suggest possible
ideas instead of providing a sound foundation. The article was also published in 2001, so the
information it contains could be outdated. The content of the article that I was able to
understand did help my comprehension of the appearance of dyskinesia in many patients. The
clear connection of levodopa/carbidopa medication to motor fluctuations and dyskinesia was
explained in more depth. I also appreciated that the article offered advice to physicians by
providing guidelines about how to inform patients about these conditions. It was helpful to
read the various tips that the article offered about possible methods to delay the adverse
effects of levodopa medication. This provided another explanation for the differences in
individuals treatment plans. A patient with a less severe Parkinsons tremor may avoid the
use of levodopa until the original Parkinsons symptoms become unbearable in order to delay
the development of motor fluctuations and dyskinesia. These conditions add another layer of
depth to the treatment of movement disorders.

Parkinson's & Movement Disorders Center of Maryland.

Retrieved October 8, 2016, from http://www.pdmdcenter.com.

The Parkinsons & Movement Disorders Center of Maryland website is an important

resource to movement disorders patients and their caregivers and families. It provides a basic
overview of the center, including information about the primary specialist (Dr. Stephen E.
Grill, MD, Ph.D.) and the facility. On the website, patients may browse the available services,
make an appointment, and download patient forms, registration materials, and questionnaires.
There are also news updates concerning upcoming support group meetings and other relevant
events. Also available are resources concerning the movement disorders themselves. For
example, under the Clinical Conditions page, one can find a synopsized description of the
symptoms (such as involuntary twisting movements) and treatment options (such as
botulinum toxin injections) of cervical dystonia, a movement disorder affecting the neck. A
subsection of the website provides information and links to support groups and organizations
specializing in a multitude of various movement disorders, such as ataxia and progressive
supranuclear palsy. Patient services are also provided, including information about insurance
policies and materials concerning the outsourced billing department. The website also offers
contact information for the direct clinic and for the facilitys faculty.
This source provides a myriad of necessary resources to me because it is the website
of the center at which I intern. Firstly, it supplies basic background information about the
center itself and the staff members; for example, it describes my mentors education and
research specialization. I can also obtain contact information more easily through this source.
Secondly, it provides basic details about the primary disorders that are treated at the center.
This is an easily accessible resource that I can refer to for reliable information regarding the
movement disorders central to my internship. In addition to the short summaries of the most
prevalent disorders, the website contains links to the websites of national societies focusing
on specific movement disorders. By using that feature, this website provides an excellent way
to find further research resources providing more detail and specification for various topics in
the field. The website is intended to be easily accessible and comprehendible for patients and
their families, so the information is easy to understand and digest; it lacks complicated
technical information and focuses strongly on practical information that is applicable to
patients lifestyles.

Your doctor has ordered a DaTscan test [Pamphlet]. (2011). General Electric
Company.

This pamphlet is an informative resource given to patients who are have been
recommended for or who are considering a DaTscan test. It provides information to allow
patients to understand and prepare for the test. The DaTscan is an imaging test that works by
injecting an imaging drug, Ioflupane I123, into the bloodstream. A gamma camera is then
used to take pictures that will help assess dopamine levels in the brain. Parkinsons disease is
caused by a deficiency of dopamine in the brain, affecting the ability to control various
muscle functions. The pamphlet also briefly describes other Parkinsonian syndromes such as
multiple system atrophy and progressive supranuclear palsy; the DaTscan can show the
presence of a Parkinsonian syndrome but cannot distinguish between them. The source also
states that the DaTscan is the only FDA approved imaging test to affirm diagnosis of
Parkinsonian syndromes; it can also disprove the diagnosis of Parkinsons disease, leading to
a more accurate diagnosis of a different disorder such as essential tremor. The test is only
available upon prescription and can be taken at a nuclear medicine department in a hospital or
in an outpatient clinic. The pamphlet provides patient guidelines and suggestions as to who is
not a suitable candidate for the test (pregnant women, children, patients with an allergy to
iodine, etc.) and explains negative side effects such as dizziness. It also instructs patients to
disclose specific drug usage to their doctor. The source then explains the step-by-step process
of administering the test; iodine is injected first to protect the thyroid, and then DaTscan is
injected through and intravenous line. This drug takes about three to six hours to fully absorb,
after which the imaging test will be performed using the gamma camera.
This source is not directly relevant to my area of research but still serves as a useful
resource to gain a broader understanding of movement disorders. It combines technical
information such as the inherent dopamine deficiency of Parkinsons disease and the
imagining drug (Ioflupane I123) used to test it with clinical application such as symptoms,
side effects, and conditions related to the test. Although movement disorder specialists have a
very high accuracy rate in diagnosing movement disorders such as Parkinsons disease, there
are still some cases that are difficult to diagnose and must be confirmed with a DaTscan to
minimize uncertainty. The scan can also distinguish between drug-induced Parkinsons
disease and other causes. Because of these factors, the DaTscan is helpful to reduce
inconclusiveness in the diagnosis of movement disorders. Understanding the various tests and
medications used concerning Parkinsons disease can assist me in gaining a more complete
knowledge of the disease and its various causes, components, and symptoms. The pamphlet
also provides insight into the importance of educating patients about their condition. It is
essential in movement disorders that the patient and their caregivers understand the
circumstances of their disorder and how to minimize the worsening of their symptoms. The
clear, concise, and simple yet sufficient explanations of Parkinsonian symptoms and of the
DaTscan test exemplify the necessity of patient education.