Limb Contractures in Parkinsonian Patients
Limb Contractures in Parkinsonian Patients
What modalities can be used to overcome the development of limb contracture in advanced Parkinson's disease (PD)? Which do you particularly recommend?
Maneesh Bhojak, MBBS, MRCP
Limb contractures in parkinsonian patients are extremely rare but lead to severe deformities of hands and feet . Etiology and pathogenic mechanism(s) remain unclear and are a matter of speculation, although some researchers have proposed that recurrent dystonic posture over a long period of time could lead to a fixed deformity. Ergot derivates like bromocriptine could play a role, as these drugs may be associated with a variety of connective tissue fibrotic reactions, such as pleuropulmonary fibrosis and retroperitoneal fibrosis. However, the occurrence of deformities in parkinsonian patients was recognized not only before the introduction of bromocriptine, but also before the levodopa era.
Hand deformities may present with a fixed flexion of the wrist and metacarpophalangeal joints, ulnar deviation, and sometimes a "thumb in hand" deformity. In patients with PD who have motor complications, contractures should be differentiated from dystonia, which is usually a reversible, abnormal posture of a limb that appears during the "off periods" of PD and resolves with levodopa treatment. In contrast to dystonia, contractures are fixed and do not respond to levodopa treatment. Furthermore, passive manipulation is not possible, and contractures persist during sleep.
It is also important to rule out other conditions, such as chronic rheumatoid arthritis, Dupuytren's contracture, putaminal infarction, compressive cervical myelopathy, or a peripheral ulnar nerve lesion.
Parkinsonism-associated contractures are reported more frequently in women and in persons with postencephalitis parkinsonism, parkinsonism dementia syndrome in Guam, and multiple-system atrophy. However, a few cases of contracture among patients with fairly typical PD have also been described.
Unfortunately, the treatment of parkinsonian contractures is usually unsuccessful. Botulinum toxin injections to finger flexors, in combination with physiotherapy, should be tried in all cases. Stereotactic thalamotomy has been reported to improve hand deformities in sporadic cases. However, a PD patient who underwent a ventromedial pallidotomy presented improvement of his parkinsonian symptoms, but contractures remained unchanged.
What modalities can be used to overcome the development of limb contracture in advanced Parkinson's disease (PD)? Which do you particularly recommend?
Maneesh Bhojak, MBBS, MRCP
Limb contractures in parkinsonian patients are extremely rare but lead to severe deformities of hands and feet . Etiology and pathogenic mechanism(s) remain unclear and are a matter of speculation, although some researchers have proposed that recurrent dystonic posture over a long period of time could lead to a fixed deformity. Ergot derivates like bromocriptine could play a role, as these drugs may be associated with a variety of connective tissue fibrotic reactions, such as pleuropulmonary fibrosis and retroperitoneal fibrosis. However, the occurrence of deformities in parkinsonian patients was recognized not only before the introduction of bromocriptine, but also before the levodopa era.
Hand deformities may present with a fixed flexion of the wrist and metacarpophalangeal joints, ulnar deviation, and sometimes a "thumb in hand" deformity. In patients with PD who have motor complications, contractures should be differentiated from dystonia, which is usually a reversible, abnormal posture of a limb that appears during the "off periods" of PD and resolves with levodopa treatment. In contrast to dystonia, contractures are fixed and do not respond to levodopa treatment. Furthermore, passive manipulation is not possible, and contractures persist during sleep.
It is also important to rule out other conditions, such as chronic rheumatoid arthritis, Dupuytren's contracture, putaminal infarction, compressive cervical myelopathy, or a peripheral ulnar nerve lesion.
Parkinsonism-associated contractures are reported more frequently in women and in persons with postencephalitis parkinsonism, parkinsonism dementia syndrome in Guam, and multiple-system atrophy. However, a few cases of contracture among patients with fairly typical PD have also been described.
Unfortunately, the treatment of parkinsonian contractures is usually unsuccessful. Botulinum toxin injections to finger flexors, in combination with physiotherapy, should be tried in all cases. Stereotactic thalamotomy has been reported to improve hand deformities in sporadic cases. However, a PD patient who underwent a ventromedial pallidotomy presented improvement of his parkinsonian symptoms, but contractures remained unchanged.
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