KOÇ UNIVERSITY HOSPITAL OUR CENTERS MOVEMENT DISORDERS Movement Disorders Unit – a division of neurological sciences – deals with diagnosis and treatment of Parkinson’s Disease, Essential Tremor and other less common movement disorders. The neurologic diseases manifested by excessive movement (hyperkinetic) or slowed down movement (hypokinetic), which are not related to strength loss in muscles, are also defined as movement disorder. These disorders develop especially when the deep brain structures, called basal ganglia, are affected. Hypokinetic diseases include Parkinson’s disease and Parkinson plus that develop due to involvement of those structures. Hyperkinetic diseases are: Tremor, dystonia, myoclonus, chorea, tic disorders, Wilson disease, akathisia, stereotypic movement disorder and restless leg syndrome. Cerebral ataxia, which is associated with balance and coordination disorder and primarily affects the cerebellum, is also managed by neurologists who are specialized in movement disorders. The Movement Disorders Unit, where neurologists specialized in this group of diseases, cooperates with other relevant clinics, if necessary, to plan and perform diagnosis, treatment and follow-up of movement disorders under a single roof in the light of evidence-based medicine. In Movement Disorders Unit, the diseases are diagnosed and treated by neurologists who have long-standing experience in this field. Our team cooperates with neurosurgery and psychiatry units and determines the most suitable treatments and practices for our patients. The team is also supported by physiatrists, psychologists, physiotherapists and dieticians, when necessary. In Multidisciplinary Surgery Council, physicians of relevant departments meet and discuss whether patients with Parkinson’s disease, Tremor and other movement disorders, who have insufficient response to medical treatment according to the view of a neurologist who is experienced in movement disorders, are appropriate candidates of surgery and they plan the surgical technique for patients who are deemed appropriate along with other treatment options for ineligible patients. In Parkinson’s disease, surgery is mostly preferred for the patients who have tremor that is irresponsive to medication or who have involuntary movements secondary to intense use of medications. Here, the most important treatment method is deep brain stimulation, colloquially known as brain pacemaker. It is crucial that the surgical treatment is decided cooperatively by neurologists and neurosurgeons. Brain pacemaker is not a definite solution in treatment. The aim is to alleviate symptoms of the disease and boost quality of patients’ lives. Following diseases are principally diagnosed and treated at our unit: Parkinson’s Disease Patients most commonly present to Movement Disorders Unit for Parkinson’s disease. Parkinson’s disease develops when the brain cells that produce dopamine are lost. Dopamine is a chemical substance that places a role in movement control and coordination. The disease is generally seen after 60 while there are also young-onset cases. Prevalence of the disease is around 1 percent among the individuals older than 65. The exact cause of Parkinson’s disease is not known. Many studies show that genetic and environmental factors play a role. The risk of Parkinson’s disease is higher in individuals with positive family history of Parkinson’s disease comparing to other individuals in the society. It is known that genetic factors play a bigger role for individuals who develop the disease at younger ages. It is suggested that environmental factors such as living in rural areas, drinking well water and exposure to pesticides can also cause the disease. Parkinson’s disease generally starts with tremor in hands which is followed by slowed down movements and muscle stiffness. Next, tremor can develop in ipsilateral leg followed by contralateral hand and leg. Tremor can also occur in jaw and lips. Facial mimic muscles may slow down, mask-like expression may occur in face and blinking and swinging in arms may reduce. The patient may complaint of tripping and dragging the feet when walking. Speech may slow down, tone of speech may decrease and monotonous speech may be noted. Some patients may complain of gradually reduced size of handwriting. Saliva discharge can be observed in some patients. Muscle stiffness is detected during physical examination. Some patients may suddenly stop and stand still especially while starting walking, crossing, turning or passing through narrow places. Some patients may suddenly stop talking during a conservation. Others may suddenly accelerate especially when walking. In addition to those findings, other potential symptoms and signs are decrease in sense of smell, constipation, sleep problems, lucid dreams and nightmares during sleep, screaming or moving hands and arms while sleeping, pain, urinary problems, sexual problems, hallucination, emotional changes, blood pressure changes and cognitive involvement. Cognitive problems are milder in Parkinson’s disease and they can generally occur after many years. There are various types of Parkinson’s disease, each having a different course. For some patients, the disease progresses very slowly. Symptoms may vary within only one day at advanced stages of the disease. “On” and “off” periods are likely in patients. Some patients complain of involuntary contractions and movements. Diagnosis of Parkinson’s disease is based on clinical symptoms. MRI of Brain and blood tests are performed to rule out other causes of Parkinsonism or when they are deemed necessary. The most important criterion regarding the diagnosis is the examination by a neurologist who is experienced in this condition. Exposure to stress and head trauma may make symptoms of the disease more evident. Certain medications used for treatment of psychiatric diseases and others used for treatment of heart diseases and nausea-vomiting may cause a clinical picture similar to Parkinson’s disease. Symptoms disappear when these medications are stopped. It is critical in Parkinson’s disease that the medications, especially those contain Levodopa, are taken exactly at the same time of the day and patients eat 1 to 1.5 hour before or after the medications. Moreover, protein intake should be low at the daytime and foods that are rich in protein should be consumed in the evening. Recently, importance of regular exercise is emphasized for Parkinson’s disease. It is suggested that exercise help recovery of certain symptoms. Moreover, it is also reported that it slows down progression of the disease. For diseases identified as Parkinson plus, potential symptoms include impaired balance, eye movement disorders, pyramidal findings and autonomic findings in addition to signs and symptoms of the Parkinson’s disease. Tremor It is colloquially known as trembling disease. It is the most common movement disorder. It may be caused by various factors such as excessive exercise, stress, tiredness, insomnia, and excessive caffeine consumption. It generally affects the hands, although it may be seen in head, voice, body and legs. Tremor can develop at rest or during action. Action tremor develops while hands are at horizontal position or during movement. Resting tremor is a symptom of Parkinson’s disease or diseases known as Parkinson plus while action tremor is seen in essential tremor disease and other types of tremor diseases. Essential Tremor: Essential tremor is the most prevalent type of movement disorder. It may be hereditary while sporadic cases are also likely. Prevalence of the condition is 5 percent in individuals older than 65. It may develop at younger ages for individuals with family history positive for tremor. The condition most commonly involves hands. It may be seen in a certain posture or during a certain movement. Unlike Parkinson’s disease, tremor does not occur at rest. It is bilateral (at both sides of the body), but severity may be higher at one side. It can cause severe loss of function; patients can complain that they cannot eat due to tremor. Tremor can also occur in head; it may be in the form of shaking towards both sides or frontward or backward in head. In some cases, tremor occurs both in hands and the head, but tremor may be more rarely observed in jaw, voice and legs. Unlike Parkinson’s disease, slowing down and stiffness are not observed. Dystonia It implies involuntary contractions and twisting movements at certain parts of the body (eye, face and neck). It is the third most common movement disorder following essential tremor and Parkinson’s disease. Dystonia is called primary or secondary depending on the underlying mechanism or other titles depending on part of the body involved. Dystonia that is restricted in one part of the body is called focal (in face, neck, arm) and the disseminated form is called generalized dystonia. This condition negatively affects the quality of patients’ lives. Primary Dystonia: Studies demonstrate that primary dystonia are commonly caused by mutations of certain genes; it is more prevalent at younger ages. Secondary Dystonia: Secondary dystonia may occur after and secondary to cerebrovascular occlusions, traumas during birth, accidents, traffic accident and similar traumas and effects of antipsychotic and antidepressant medications. Medications are used for treatment of patients with dystonia. Botulinum toxin is prioritized for cases of focal dystonia. The toxin blocks effects of substances released from nerve ends on muscles. EMG-guided Botulinum toxin is administered to patients with complaint of contractions in face, neck and extremities in our unit. In Movement Disorders Unit, the diseases are diagnosed and treated by neurologists who have long-standing experience in this field. In the Multidisciplinary Surgery Council, physicians discuss whether patients with Parkinson’s disease, who are deemed to have insufficient response to medical treatment in the light of the assessment made by a neurologist experienced in movement disorders, and also other patients with tremor and other movement diseases are eligible for surgery and which surgery is appropriate for them. For patients who do not meet criteria of surgical management, other treatment options are discussed and planned. In Parkinson’s disease, surgery is mostly preferred for the patients who have tremor that is irresponsive to medication or who have involuntary movements secondary to intense use of medications. Surgical treatment should be decided cooperatively by neurologist and neurosurgeon. For neurostimulator (brain pacemaker) therapy, the aim is to alleviate symptoms of the disease and boost quality of patients’ lives.