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Abstract
Background: Little is known about how frequently patients with a Unified Parkinson Disease Rating Scale part III (UPDRS-III) score of 3 or 4, including postural and action tremor, could be classified into early Parkinson's disease (PD).Objective: To examine the prevalence of early PD in patients with subtle parkinsonian signs (rest tremor, postural tremor, and rigidity) without bradykinesia, having a UPDRS-III score of 3 or 4.Methods: Parkinsonism was assessed using UPDRS-III based on both the United Kingdom PD Society Brain Bank criteria and the Movement Disorder Society PD criteria. Ninety patients with a UPDRS-III score of 3 or 4, including postural tremor, were evaluated by 123I-FP-CIT SPECT (DaTscan), brain MRI, the Mini-Mental State Examination, and smell test. Some patients were additionally examined by 123I-metaiodobenzylguanidine myocardial scintigraphy or 123I-N-isopropyl-p-iodoamphetamine SPECT.Results: Seventy-five [mean age (standard deviation): 76.9 (8.1)] out of 90 patients (83.3%) showed abnormal findings on DaTscan imaging: 57 out of 75 (76.0%) showed a reduced specific binding ratio (SBR) accompanied by an egg shape pattern (n = 37, 49.3%) or a mixed type pattern (n = 14, 18.7%), both reduced SBR and increased asymmetry index (AI) with a normal shape (n = 4, 5.3%), and reduced SBR only (n = 2, 2.7%); 18 (24.0%) showed an egg shape pattern or a mixed type pattern without reduced SBR. In other words, 69 out of 75 patients (92.0%) showed either an egg shape or a mixed type pattern with or without reduced SBR. All patients were free of dementia, and their olfactory function was significantly impaired compared with controls (n = 141) on the odor-stick identification test for Japanese (p < 0.0001).Conclusions: The prevalence of patients with subtle parkinsonian signs having a UPDRS-III score of 3 or 4, including postural tremor, is unexpectedly high in daily clinical practice, and most of these patients could be categorized into mild early-stage PD.
Highlights
According to both the United Kingdom Parkinson disease (UKPD) Society Brain Bank criteria [1] and the Movement Disorder Society (MDS) clinical diagnostic criteria for Parkinson’s disease (PD) (MDS-PD criteria) [2], the presence of parkinsonism is defined as bradykinesia, in combination with either rest tremor, rigidity, or both, and to make a diagnosis of a manifest parkinsonism, the Unified Parkinson Disease Rating Scale part III (UPDRS-III) score [3] should be at least 5 after removing tremor [1, 2]
The author noticed that subtle parkinsonian signs such as rest tremor, postural tremor, and rigidity without bradykinesia were unexpectedly prevalent in outpatients in daily clinical practice
MIBG myocardial scintigraphy for the diagnosis of PD is highly valuable in advanced patients with a PD of Hoehn-Yahr stage III or more, but in the early stages of PD (Hoehn-Yahr stage 1 and 2), it is less valuable in diagnosis due to its comparatively reduced sensitivity [15], there are some reports that MIBG myocardial scintigraphy is highly effective for detecting early PD and for distinguishing PD from other parkinsonism, multiple system atrophy with predominant parkinsonism (MSA-P), progressive supranuclear palsy (PSP), and corticobasal syndrome (CBS) [16]
Summary
According to both the United Kingdom Parkinson disease (UKPD) Society Brain Bank criteria [1] and the Movement Disorder Society (MDS) clinical diagnostic criteria for Parkinson’s disease (PD) (MDS-PD criteria) [2], the presence of parkinsonism is defined as bradykinesia, in combination with either rest tremor, rigidity, or both, and to make a diagnosis of a manifest parkinsonism, the Unified Parkinson Disease Rating Scale part III (UPDRS-III) score [3] should be at least 5 after removing tremor [1, 2]. The author performed a cross-sectional study of how frequently patients with subtle parkinsonian signs having a UPDRS-III score of 3 or 4, including postural tremor, could be classified into early-stage PD, using 123iodine-labeled N-(3-fluoropropyl)2β-carbomethoxy-3β-(4-iodophenyl) nortropane (123I-FP-CIT) single photon emission computed tomography (SPECT) (DaTscan), brain MRI, the Mini-Mental State Examination (MMSE), and smell test. Little is known about how frequently patients with a Unified Parkinson Disease Rating Scale part III (UPDRS-III) score of 3 or 4, including postural and action tremor, could be classified into early Parkinson’s disease (PD)
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