Levodopa Worsens Gait in Some Patients
In this weeks Neurology Dr. Espay and Bloem examine a rare PD manifestation when levodopa can actually worsen freezing and gait in a few patients. Over the years one trick I have learned is to ask patients if they are better with walking before their first dose of levodopa in the morning. If they are better before levodopa, this may be the clue that they are an "on" medication freezer, and they may need to ask their doc for a medication reduction. See below for the nice abstract of their paper.
Neurology. 2012 Jan 18. [Epub ahead of print]
"On" state freezing of gait in Parkinson disease: A paradoxical levodopa-induced complication.
Espay AJ, Fasano A, van Nuenen BF, Payne MM, Snijders AH, Bloem BR.
From the UC Neuroscience Institute (A.J.E., M.M.P.), Department of Neurology, Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH; I.R.C.C.S. Neuromed (A.F.), Pozzilli (IS), Italy; and Department of Neurology (B.F.L.v.N., A.H.S., B.R.B.), Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical Center, the Netherlands.
To describe the phenotype of levodopa-induced "on" freezing of gait (FOG) in Parkinson disease (PD).
We present a diagnostic approach to separate "on" FOG (deterioration during the "on state") from other FOG forms. Four patients with PD with suspected "on" FOG were examined in the "off state" (>12 hours after last medication intake), "on state" (peak effect of usual medication), and "supra-on" state (after intake of at least twice the usual dose).
Patients showed clear "on" FOG, which worsened in a dose-dependent fashion from the "on" to the "supra-on" state. Two patients also demonstrated FOG during the "off state," of lesser magnitude than during "on." In addition, levodopa produced motor blocks in hand and feet movements, while other parkinsonian features improved. None of the patients had cognitive impairment or a predating "off" FOG.
True "on" FOG exists as a rare phenotype in PD, unassociated with cognitive impairment or a predating "off" FOG. Distinguishing the different FOG subtypes requires a comprehensive motor assessment in at least 3 medication states.
Michael S. Okun, M.D.
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration