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Early Morning Off-Medication Dyskinesias, Dystonia, and Choreic Subtypes
Esther Cubo, MD;
Jean-Michel Gracies, MD, PhD;
Reina Benabou, MD, PhD;
Charles Warren Olanow, MD;
Rema Raman;
Sue Leurgans, PhD;
Christopher G. Goetz, MD
Arch Neurol. 2001;58:1379-1382.
Background Abnormal involuntary movements (dyskinesias) are common in patients
with Parkinson disease (PD) as a consequence of the disease and dopaminergic
replacement therapy. Early morning off-medication choreic dyskinesias have
been recently reported after fetal dopaminergic cell transplantations in patients
with advanced PD.
Objective To determine the frequency and severity of the early morning off-medication
dyskinesias in consecutive patients with advanced PD and an insufficient response
to medical management before they undergo neurosurgery.
Methods Consecutive patients with advanced idiopathic PD were examined and videotaped
before undergoing neurosurgery that included pallidotomy, fetal transplantation,
or deep brain stimulation. The examination took place in the morning in the
practically defined off state, at least 12 hours after the last dose of dopaminergic
drugs. Parkinson disease was characterized using the Unified Parkinson's Disease
Rating Scale and the Hoehn and Yahr stage. Dyskinesias were rated with the
Abnormal Involuntary Movements Scale and the Rush Dyskinesia Rating Scale.
Patients' characteristics and medications were compared using the Wilcoxon
rank sum and the Fisher exact tests.
Results Of 68 consecutive patients (44 [65%] men and 24 [35%] women), 11 (16%)
had early morning off-medication dyskinesia, with a 95% upper confidence limit
of 24%. Focal dystonia was the most common off-medication dyskinesia, and
occurred in 10 patients (15%), with a 95% upper confidence limit of 22%; and
off-choreic dyskinesia occurred in 1 patient (1.5%), with a 95% upper confidence
limit of 4%. There was no difference in PD medications between the patients
with and those without dyskinesias.
Conclusions The most common form of off-medication dyskinesia seen in patients with
advanced PD is dystonia. Early morning off-medication choreic dyskinesias
are rare but do occur in patients with advanced PD before surgical intervention.
The presence and type of off-medication dyskinesias should be monitored in
clinical and surgical studies in patients with PD as part of the safety and
evaluation of clinical benefits.
From the Departments of Neurological Sciences (Drs Cubo and Goetz)
and Preventive Medicine (Ms Raman and Dr Leurgans), Rush-Presbyterian-St Luke's
Medical Center, Chicago, Ill; and the Department of Neurology, Mt Sinai Medical
Center, New York, NY (Drs Gracies, Benabou, and Olanow). Dr Cubo is now with
Hospital Mutua de Terrassa, Terrassa, Spain.
Corresponding author and reprints: Esther Cubo, MD, Calle Maria Odlaga
64, B-D, 28025, Madrid, Spain (e-mail: 35350ecd{at}comb.es).
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