Purposeless Groaning in Parkinson’s Disease
Jia Lun Lim2018, Journal of Movement Disorders
visibility
…
description
2 pages
link
1 file
Purposeless groaning has been reported in advanced progressive supranuclear palsy. We present a case of purposeless groaning occurring as a primary complaint in a patient with advanced Parkinson's disease. Purposeless groaning is thought to be a manifestation of disinhibition and perseveration due to frontal-subcortical dysfunction. Proper recognition of this phenomenon will help clinicians to avoid unnecessary investigations and treatment (e.g., prescription of opioid medications).
Related papers
The Non-Motor Symptom Profile of Progressive Supranuclear Palsy
Journal of Movement Disorders
ObjectiveaaNon-motor symptoms (NMSs) significantly contribute to increased morbidity and poor quality of life in patients with parkinsonian disorders. This study aims to explore the profile of NMSs in patients with progressive supranuclear palsy (PSP) using the validated Non-Motor Symptom Scale (NMSS). MethodsaaSeventy-six patients with PSP were evaluated in this study. Motor symptoms and NMSs were evaluated using the PSP Rating Scale (PSPRS), Unified Parkinson's Disease Rating Scale-III, Montreal Cognitive Assessment, Hamilton Depression (HAM-D) and Anxiety Rating Scales, Parkinson's Disease Sleep Scale (PDSS) and NMSS. NMS severity and prevalence were also compared between patients with PSP-Richardson syndrome (PSP-RS) and those with PSP-parkinsonism. ResultsaaAll subjects in this cohort reported at least 2 NMSs. The most prevalent NMSs in patients with PSP were in the domains of sleep/fatigue, mood/cognition, and sexual function. The least prevalent NMSs were in the domains of cardiovascular including falls, and perceptual problems/hallucinations. Significant correlations were observed between the NMSS scores and HAM-D, PDSS, PSPRS scores and PSPRS sub-scores. The severity of NMSs was unrelated to the duration of illness. Patients with PSP-RS reported a higher severity of drooling, altered smell/taste, depression and altered interest in sex and a higher prevalence of sexual dysfunction. ConclusionaaNMSs are commonly observed in patients with PSP, and the domains of sleep, mood and sexual function are most commonly affected. These symptoms contribute significantly to disease morbidity, and clinicians should pay adequate attention to identifying and addressing these symptoms.
Distinguishing progressive supranuclear palsy from other forms of Parkinson's disease: evaluation of new signs
Annals of the New York Academy of Sciences
Non motor symptoms in progressive supranuclear palsy: prevalence and severity
NPJ Parkinson's disease, 2017
NMSs have been extensively studied in PD patients but not in other forms of parkinsonism such as Progressive Supranuclear Palsy (PSP). The primary objective of this study was to analyze the frequency, severity and the type of non-motor symptoms (NMS) in PSP patients using the non-motor symptoms scale (NMSS). The secondary objective was to differentiate NMS between PSP and Parkinson's disease (PD). We enrolled in this cross-sectional study 50 consecutive PSP and 100 matched Parkinson's disease (PD) patients, in the proportion PSP/PD = 1/2, matched in age, sex, and disease duration. Motor and Non Motor symptoms (different scales for each disease) were evaluated at baseline using PSP scale, SCOPA Motor, Montreal Cognitive Assessment (MOCA), HADS, Hamilton, and Non Motor Symptom scale (NMSS). Comparative analysis was done using chi-squared test, Mann-Whitney test and Fisher's exact test. Fifty PSP (56% female) and 100 PD (59% female) patients completed the study protocol and...
Postural reactions to neck vibration in Parkinson's disease
Movement Disorders, 2006
To test the hypothesis that reduced reactions to proprioceptive input signals contribute to postural instability in Parkinson's disease (PD), pulses of mechanical vibration were applied to the neck muscles of PD patients and healthy controls. This stimulus elicits postural reactions in standing subjects. Participating were 13 moderately affected PD patients, 13 severely affected PD patients, and 13 age-matched healthy subjects. Patients were tested on and off medication. Three-second-long pulses of vibration were regularly (10 times) applied to the posterior neck muscles while subjects kept their eyes open or closed. Postural responses to the stimuli were measured by static posturography. No intergroup difference in the pattern and latencies of responses was found. However, the amplitudes of the postural reactions (shift of center of foot pressure) were significantly larger in advanced PD patients; those of moderately affected PD patients did not differ from those of control subjects. Moreover, the size of postural responses in both latter groups decreased across the trial contrary to that of advanced PD patients. Comparison of the measures during on and off testing revealed no significant differences. These results indicate that neither afferent proprioceptive deficits nor central integrative functions but rather scaling and habituation of erroneous proprioceptive information are disturbed in the postural control of advanced PD. Nondopaminergic structures seem to be responsible for this impairment.
Nonmotor Aspects of Parkinson's Disease
Blue Books of Neurology, 2010
Parkinson's disease is primarily considered to be a movement disorder and is defined by its motor signs. Yet, the behavioral manifestations of the disease are often more debilitating than its motor complications. This review will focus on the non-motor aspects of Parkinson's disease, including mood, psychosis, cognitive, sleep, fatigue, apathy, delirium, and repetitive disorders, that may occur. The phenomenology, pathology, and treatment of the behavioral symptoms of Parkinson's disease will be discussed.
Orthostatic tremor in progressive supranuclear palsy
Movement Disorders, 2007
Patients with orthostatic tremor (OT) can be classified as having "primary OT," with or without postural arm tremor but no other abnormal neurological features, or "OT plus." We describe a patient with OT, with postural tremor of the arms and restless legs syndrome (RLS), who developed features typical of progressive supranuclear palsy (PSP). PSP can be accompanied by OT.
Differentiating non-motor symptoms in Parkinson's disease from controls and hemifacial spasm
PloS one, 2013
Non-motor symptoms (NMS) are important manifestations of Parkinson's disease (PD) that reduce patients' health-related quality of life. Some NMS may also be caused by age-related changes, or manifested as a psychological reaction to a chronic neurological condition. This case-control study compared the NMS burden among PD patients, healthy controls and hemifacial spasm (HFS) patients. In addition, we determined the NMS that discriminated between PD and non-PD subjects. 425 subjects were recruited from a tertiary hospital in Singapore (200 PD patients, 150 healthy controls and 75 HFS patients). NMS burden in subjects was measured using the Non-Motor Symptoms Scale (NMSS). NMSS total score was significantly higher in PD patients (37.9±2.6) compared to healthy controls (11.2±0.9) (p<0.0001) and HFS patients (18.0±2.1)…
Correlations of apathy and depression with postural instability in Parkinson disease
Journal of the Neurological Sciences, 2014
Background: Postural instability (PI) in Parkinson's disease (PD) is associated with depression and apathy based on UPDRS scores. We sought to examine the link using more objective PI measures. Methods: Demographic, clinical, depression and apathy data were recorded for PD patients prospectively recruited from an outpatient university movement disorders clinic. PI was objectively evaluated using the standing center of pressure sway area. Results: Thirty-seven PD patients participated in the study. Bivariate analysis revealed that PI was significantly correlated to both apathy (p = 0.018) and depression (p = 0.014). Hierarchical regression revealed that apathy significantly predicted PI but depression did not significantly add to the prediction. Also, depression did not significantly predict PI and the addition of apathy did not increase this prediction. Conclusion: Apathy and depression are both associated with objective measures of PI, and apathy appears a stronger predictor of PI than depression. Concomitant improvement in PI may be important to consider when measuring apathy or depression interventions in PD.
Pallidal stimulation in Parkinson's disease does not induce apathy
The Journal of neuropsychiatry and clinical neurosciences, 2014
Whereas apathy is known as a common consequence of subthalamic nucleus deep brain stimulation in Parkinson's disease, few studies have investigated the psychiatric consequences of internal globus pallidus deep brain stimulation. Twenty consecutive parkinsonian patients who underwent bilateral pallidal stimulation were assessed 3 months prior to surgery (M‒3) and at both 3 (M3) and 6 months (M6) after surgery, using psychiatric, neuropsychological, and motor scales. Apathy, mood state, and anxiety state were scored using the Apathy Evaluation Scale, the Montgomery-Åsberg Depression Rating Scale, and the anxiety scale from the Association for Methodology and Documentation in Psychiatry, respectively. The mean apathy score remained stable between the preoperative M‒3 assessment (37.2±6.2) and both the postoperative M3 (36.9±7.5) and M6 (37.2±5.0) assessments. The mean depression score did not differ between the M‒3 assessment and M3 and M6 assessments. There was no difference betwe...
Long-term motor effect of unilateral pallidal stimulation in 26 patients with advanced Parkinson disease
Journal of Neurosurgery, 2003
Object. The aim of this study was to evaluate the long-term effects of unilateral pallidal stimulation on motor function in selected patients with advanced Parkinson disease (PD). Methods. The authors enrolled 26 patients with idiopathic PD in whom there was an asymmetric distribution of symptoms and, despite optimal pharmocological treatment, severe response fluctuations and/or dyskinesias. After the patient had received a local anesthetic agent, a quadripolar electrode (Medtronic model 3387) was implanted at the side opposite the side affected or, if both sides were affected, the side contralateral to the more affected side. No serious complications occurred. After 3 months, the total Unified PD Rating Scale (UPDRS) Part III score decreased by 50.7% while patients were in the off-medication state (from 26.5 ± 9.2 to 13.1 ± 6.1) and by 55.4% while they were in the on-medication state (from 10.6 ± 6.3 to 4.7 ± 4.4). Only during the on state was the contralateral effect clearly more ...
JMD
https://doi.org/10.14802/jmd.18004 / J Mov Disord 2018;11(2):87-88
pISSN 2005-940X / eISSN 2093-4939
CASE REPORT
Purposeless Groaning in Parkinson’s Disease
Shen-Yang Lim,1,2 Ai Huey Tan,1,2 Jia Lun Lim,2,3 Azlina Ahmad-Annuar3
1
Division of Neurology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
Mah Pooi Soo & Tan Chin Nam Centre for Parkinson’s & Related Disorders, University of Malaya, Kuala Lumpur, Malaysia
3
Department of Biomedical Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
2
ABSTRACT
Purposeless groaning has been reported in advanced progressive supranuclear palsy. We present a case of purposeless groaning
occurring as a primary complaint in a patient with advanced Parkinson’s disease. Purposeless groaning is thought to be a manifestation of disinhibition and perseveration due to frontal-subcortical dysfunction. Proper recognition of this phenomenon will help
clinicians to avoid unnecessary investigations and treatment (e.g., prescription of opioid medications).
Key WordsaaParkinson’s disease; groaning; moaning.
Purposeless groaning has been reported in advanced progressive supranuclear palsy (PSP), when patients have lost ambulation.1 Recently, we reported a case of purposeless groaning
in a patient with PSP when the patient was still ambulant and
conversing appropriately; the groaning worsened over time with
disease progression.2
Herein, we report a patient with very long-standing Parkinson’s disease (PD) with purposeless groaning as a primary
complaint. We were unable to find any case reports of this phenomenon in the literature, although in a case discussion (where
the final diagnosis was considered to be most likely a drug-induced movement disorder), advanced PSP and PD were mentioned in the differential diagnosis of purposeless groaning.3
CASE REPORT
A 74-year-old woman with a 37-year history of PD (diagnosed at age 37) was examined in the outpatient clinic in July
2017. Her caregiver of 22 years complained that the patient’s
purposeless groaning had become increasingly intrusive, occurring throughout the day, with the patient becoming quiet only
upon falling asleep. This was first noticed in 2013 and then resolved, recurred in 2015, and became worse in 2017.
The patient has been regularly followed up in the clinic by a
neurologist with specialization in movement disorders (SYL)
since 2009. At that time, her Unified PD Rating Scale (UPDRS)
motor score was 48 (indicating severe parkinsonism). Her speech
was hypophonic, slurred, and stuttering. She exhibited a moderate head tilt to the right. She needed assistance to get up from
her chair and was able to walk only a few steps with close supervision. She scored 24/30 on the Montreal Cognitive Assessment (MoCA) in 2010. In 2000, the patient had undergone
staged bilateral pallidotomy in China to treat dyskinesias. The
procedure was complicated by speech deterioration. Her family history is remarkable as her sister (the patient’s only sibling),
also has PD, with a fairly “typical” course (diagnosed at age 58,
and successfully treated with bilateral deep brain stimulation
of the subthalamic nucleus for disabling OFF; at the time of
writing, this sister is still doing fairly well, albeit with hypophonic and slurred speech, 13 years after her PD diagnosis).
Over time, there has been a gradual deterioration in the patient’s condition. When seen in July 2017, there had been no
recent change in her medications, which consisted of 2 tablets
(100/25 mg) of levodopa-carbidopa 3 times daily, 2 capsules
(100/25 mg) of controlled release levodopa-benserazide at
night, 10 mg of baclofen 3 times daily, 2 mg of clonazepam at
night, and 10 mg of bisacodyl at night. She had never been treated with neuroleptic medication (which can potentially cause
Received: January 27, 2018 Revised: February 23, 2018 Accepted: March 20, 2018
Corresponding author: Shen-Yang Lim, MBBS, MD, FRACP, FASc, https://orcid.org/0000-0002-6942-2522
Neurology Laboratory, Level 6 (South Block), University of Malaya Medical Centre, Kuala Lumpur 50603, Malaysia / Tel: +60-3-7949-2891 / Fax: +603-7949-4613 / E-mail: [email protected]
cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2018 The Korean Movement Disorder Society
87
JMD
J Mov Disord 2018;11(2):87-88
tardive akathisia).3
Please see the Supplementary Video 1 (in the online-only Data Supplement) and video legend for a
detailed description of the patient’s purposeless
groaning and examination findings. The subject has
given written informed consent for the publication
of this case report and the video data.
DISCUSSION
Purposeless groaning has been anecdotally mentioned to occur in advanced PD,3 although to our
knowledge, there has been no detailed report of this
phenomenon in the literature. We believe that the
present case study will be helpful to readers encountering this phenomenon in their clinical practice and
that proper recognition will help clinicians to avoid
unnecessary investigations and treatment (e.g., prescription of opioid medications), as highlighted previously by Stamelou and others.1,2
Purposeless groaning is thought to be a manifestation of disinhibition and perseveration due to frontal-subcortical dysfunction.1,2 Our patient also demonstrated the “applause sign” and a grasp response,
which are additional features pointing to frontal lobe
dysfunction.4 Studies of frontal-subcortical dementias (of which PD is a “classic” cause) suggest that
the frontal signs observed in these patients result
from a disruption of the extensive connections of the
frontal cortex with the basal ganglia, as well as other
subcortical brain structures.5 However, we acknowledge that although the patient demonstrated some
symptoms suggesting disinhibition, the correlation
between frontal cortical dysfunction and groaning
remains speculative, and further study of this issue
is warranted.
We speculate that disease progression likely primarily accounts for the patient’s condition, with PD
neuropathology involving progressively more widespread subcortical and cortical brain regions. However, it remains unclear why the phenomenon of
88
purposeless groaning is not more common in clinical practice, despite dementia being highly prevalent in advanced PD. We cannot exclude a contributing role of the previous pallidotomy, but we consider
it unlikely that this procedure was a major contributor to the groaning since this procedure was performed 13 years prior to the onset of the groaning
and since the patient’s MoCA score was still in the
normal range when tested ten years postoperatively.
Supplementary Video Legends
Video 1. The patient is wheelchair bound. She exhibits severe
laterocollis to the right. She is able to say her name and obey
simple commands (e.g., lift her arms or close her eyes). The patient is unable to complete more challenging tests of frontal
lobe function (e.g., go-no go test and Luria sequence; not
shown). The patient makes constant groaning sounds throughout the consultation, even when distracted, such as when undergoing the test for the “applause sign” or the test for voluntary
eye movements. She seems unable to suppress the groaning
when requested to do so. When asked if she feels pain, she
shakes her head to indicate “no.” The applause sign is positive.
The grasp response is present bilaterally, but other primitive
(pollicomental, palmomental, snout and rooting) reflexes are absent. She exhibits some apraxia of eye opening. Vertical eye
movements are intact (not shown).
Supplementary Materials
The online-only Data Supplement is available with this article at https://doi.org/10.14802/jmd.18004.
Conflicts of Interest
The authors have no financial conflicts of interest.
REFERENCES
1. Stamelou M, Rubio-Agusti I, Quinn N, Bhatia K. Characteristic constant groaning in late stage progressive supranuclear palsy: a case report. Parkinsonism Relat Disord
2011;17:575-576.
2. Low SC, Tan AH, Lim SY. Teaching video neuroimages:
purposeless groaning in progressive supranuclear palsy.
Neurology 2017;88:e9.
3. Micheli F, Fernandez Pardal M, Giannaula R, Fahn S. What
is it? Case 3, 1991: moaning in a man with parkinsonian
signs. Mov Disord 1991;6:376-378.
4. Schott JM, Rossor MN. The grasp and other primitive reflexes. J Neurol Neurosurg Psychiatry 2003;74:558-560.
5. Bonelli RM, Cummings JL. Frontal-subcortical dementias.
Neurologist 2008;14:100-107.
Related papers
Cerámica romana del Mercado Grande de Ávila II: cerámica de mesa de los niveles romanizados (2005)
BSAA Arqueología: Boletín del Seminario de Estudios de Arqueología, ISSN-e 1888-976X, Nº. 71, 1, 2005, págs. 209-274
Smart Entry System
International Journal for Research in Applied Science & Engineering Technology (IJRASET), 2023
[Memories of an antituberculous sanatorium]
Biomédica : revista del Instituto Nacional de Salud, 2004
Genetic structure of wildcat (<i>Felis silvestris</i>) populations in Italy
Ecology and Evolution, 2013
The Exception and the Rule
Measures Taken and Other Lehrstucke, 1977
Mikroenkapsulasi Minyak Sawit Mentah Dengan Penyalut Maltodekstrin Dan Isolat Protein Kedelai
Jurnal Teknologi dan Industri Pangan, 2017
Big M's Forgotten Legacy of Freedom
Social Science Research Network, 2020
Bleeding Remission with Microwave Ablation in a Transfusion-Dependent Patient with Hemorrhaging Angiosarcoma of the Pleura
Journal of Vascular and Interventional Radiology, 2018
A lead/proportional-tube electromagnetic calorimeter for direct photon detection
Nuclear Instruments and Methods in Physics Research Section A: Accelerators, Spectrometers, Detectors and Associated Equipment, 1990
Growth promotion and protective potentials of leaf infusions of Parkia biglobosa, Moringa oleifera and Vernonia amygdalina on Abelmoschus esculentus seeds
Scientific Reports
Socio-Demographic Determinants of Road Traffic Fatalities in Women of Reproductive Age in the Republic of Georgia: Evidence from the National Reproductive Age Mortality Study (2014)
International Journal of Women's Health, 2020