Rigidity, Slowness and Gait
Difficulties
CHIEF COMPLAINT
A 73 year old right handed woman was
referred to a tertiary care center due to
worsening right-greater-than-left
bradykinesia, tremor, rigidity, and
unsteady gait. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties HISTORY
Sixteen years previously, the patient first noticed mild
difficulty using her right hand, and decreased right
arm swing when walking. She later developed
shaking of her right arm and then right leg. The
patient was evaluated by a neurologist who diagnosed
her with Parkinson’s disease. Over the years, her
shaking and slowed movements became gradually
worse, to the point where recently she has had
difficulty writing, dressing with buttons, cooking,
and cutting food. She also has become more
unsteady, with two falls in the past year, fracturing
her right arm on one occasion. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties HISTORY (cont’d)
Tremor and stiffness have become so severe that it
is difficult for her to sleep at night. Initially treatment
with levodopa plus carbidopa (Sinemet) provided
excellent benefit, but this has become less effective
over time despite increasing doses (see also below).
She did not tolerate treatment with anticholinergic
agents or dopaminergic agonists due to side effects.
She has a family history of Parkinson's disease in her
mother. The patient has no history of use of
dopaminergic antagonist medications, toxin exposure,
strokes, or encephalitis. CT and MRI scans were
normal. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties PHYSICAL EXAMINATION
Vital signs: T = 98.1˚F, P = 88, BP = 130/82, R = 18
Neck: Supple.
Lungs: Clear.
Heart: Regular rate, no murmurs.
Abdomen: Normal bowel sounds, soft, non-tender.
Extremities: No edema. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties PHYSICAL EXAMINATION (cont’d)
Neurologic exam (2 hours after her last Sinemet dose,
and just before her next dose):
MENTAL STATUS: Alert and oriented x 3. Normal
language. Recalled 3/3 words after 5 min. Copied
shapes correctly, but slowly. Wrote a sentence with
tremulous, micrographic handwriting.
CRANIAL NERVES: Normal, except for mild
“hypomimia” (decreased facial expressiveness). CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties PHYSICAL EXAMINATION (cont’d)
MOTOR: Moderate general bradykinesia (slowing of
movements), for example with finger tapping, worse
on the right side. Constant 3–4 Hz tremor of the
right upper and lower extremities, worse at rest.
Mild cogwheel rigidity, especially of the right arm.
No pronator drift. Power 5/5 throughout.
REFLEXES: 1+ symmetrical throughout, with bilateral
downgoing plantar responses.
COORDINATION: Finger–nose and heel–shin slow,
but no dysmetria. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties PHYSICAL EXAMINATION (cont’d)
GAIT: Stooped, slow gait, lurching forward with few
steps, and decreased right arm swing. Turned
slowly without twisting body (“en bloc” turning). Took
several rapid steps to correct herself and prevent a fall
when gently pulled (“anteropulsion, retropulsion”).
SENSORY: Intact light touch, pin prick, and
graphesthesia. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties LOCALIZATION AND DIFFERENTIAL DIAGNOSIS
DISCUSSION QUESTIONS
1. Based on the symptoms and signs shown in bold
on the previous slides, is this patient more likely to
have typical idiopathic Parkinson's disease, or atypical
parkinsonism?
2. Degeneration of neurons in which structure is
primarily responsible for idiopathic Parkinson's
disease? What is the main neurotransmitter of these
neurons (Review Figure 16.7, p. 750 in Neuroanatomy
through Clinical Cases, 2nd Ed.)? How does loss of
these neurons result in a hypokinetic movement
disorder? CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties HISTORY (cont’d)
Problems with On-Off Fluctuations:
In taking the history from this patient, another problem
in addition to the hypokinesia became apparent.
Escalating doses of Sinemet, had helped her
symptoms. However, she was having more and more
problems with fluctuations from being "on" after taking
a dose of Sinemet to "off" just before a dose. She had
improvement for a short time after taking her
medications, but then developed severe excessive
jerky involuntary movements (dyskinesias). As these
would wear off, she then became “frozen” requiring
another dose of medication. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties HISTORY (cont’d)
Problems with On-Off Fluctuations (cont’d):
She tried sustained release formulations and frequent
dosing intervals of every two hours. Nevertheless, the
therapeutic window had gradually narrowed, and her
on–off symptoms were becoming more severe.
When examined 30 minutes after taking her Sinemet
dose (unlike the exam above), she had severe
bilateral hyperkinetic dyskinesias, normal tone, and
no tremor. Bradykinesia was improved but still present,
worse on the right than the left. CASE III-3 Right-Sided Tremor, Rigidity, Slowness and Gait Difficulties LOCALIZATION AND DIFFERENTIAL DIAGNOSIS
DISCUSSION QUESTIONS (cont’d)
3. How might excess dopamine cause the hyperkinetic
dyskinesias seen in this patient (Review Figure 16.7, p.
750 in Neuroanatomy through Clinical Cases, 2nd
Ed.)?
4. Given the unacceptable response to medications in
this patient, what neurosurgical procedures might be
tried to improve her hypokinetic parkinsonian
movements? Why are these procedures expected to
benefit hypokinesia (Review Figure 16.7, p. 750 in
Neuroanatomy through Clinical Cases, 2nd Ed.). Pathological changes in Parkinson’s disease
(not from the patient in this case) CASE III-3 T2-weighted MRI, Coronal View ? Caudate, head ?
? ? ?
R L CASE III-3 Proton density-weighted MRI, Axial View ? Putamen
Left ventral
pallidotomy ? Internal
capsule,
posterior limb ? ? Thalamus
R L CASE III-3 T1-weighted MRI, Sagittal views of left hemisphere Electrode tract for
pallidotomy ? Left ventral
pallidotomy ? ? Caudate, body A P ? ? Temporal horn, Atrium, lateral
lateral ventricle ventricle ? Thalamus CASE III-3 Asymmetrical Resting Tremor, Rigidity, and Bradykinesia 5. What is the patient’s final diagnosis?

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