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A video-atlas of levodopa-induced dyskinesia in Parkinson’s disease: terminology matters

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Abstract

Dyskinesia is a common complication of long-term levodopa therapy in patients with Parkinson’s disease (PD), which often worsens the quality of life. It is usually dose-dependent and emerges possibly due to pulsatile stimulation of dopamine receptors. Delineating the pattern of dyskinesia is crucial for determining the most effective therapeutic approach, a task that often presents challenges for numerous neurologists. This article comprehensively describes various patterns of dyskinesia in PD patients and features video demonstration of some of the common forms of dyskinesia. We have used a real case scenario as an example to lead the discussion on the phenomenology, distinguishing features, and management of various types of dyskinesia. A comprehensive literature search was conducted in PubMed using “dyskinesia” as a keyword. The prototype case with videos highlights the differentiating features of dyskinesia along with the treatment strategies. A wide range of descriptive rubrics have been used for certain dyskinesia which are described in detail in this article. The newer types of dyskinesia associated with continuous dopaminergic stimulation in patients with advanced PD and their implications have been described. As there are distinct ways of managing various types of dyskinesia, understanding the phenomenology and chronology of dyskinesia is vital for the optimal management of dyskinetic PD patients. We suggest that dyskinesia should be classified broadly into peak-dose dyskinesia (PDD), biphasic dyskinesia (BD), and OFF-period dystonia. The occurrence of low-dose dyskinesia and complex dyskinesia of continuous dopaminergic treatments should be known to specialists and will require additional studies.

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Funding

University Health Network and University of Toronto Chair in Neuromodulation and Multidisciplinary Care to AF.

Author information

Authors and Affiliations

  1. Department of Neurology, Memorial Healthcare System, Hollywood, FL, USA

    Harsh V. Gupta

  2. Department of Neurology, Baylor College of Medicine, Houston, TX, USA

    Abhishek Lenka

  3. Department of Neurology, Institute of Human Behaviour and Allied Sciences, New Delhi, India

    Rajinder K. Dhamija

  4. Edmond J. Safra Program in Parkinson’s Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, ON, Canada

    Alfonso Fasano

  5. Division of Neurology, University of Toronto, Toronto, ON, Canada

    Alfonso Fasano

  6. Krembil Brain Institute, Toronto, ON, Canada

    Alfonso Fasano

  7. Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Canada

    Alfonso Fasano

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  1. Harsh V. Gupta
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  2. Abhishek Lenka
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  3. Rajinder K. Dhamija
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  4. Alfonso Fasano
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1) Research project: A. Conception, B. Organization, C. Execution.

2) Manuscript: A. Writing of the first draft, B. Review and Critique.

HVG: 1A, 1B, 1C, 2A, 2B

AL: 2A, 2B

RKD: 1B, 2B

AF: 1A, 3B

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Correspondence to Harsh V. Gupta.

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AF received honoraria and/or research support from Abbvie, Abbott, Boston Scientific, Ceregate Medtronic, Paladin Labs, and Sunovion.

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Supplementary Information

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Supplementary file1 The video demonstrates bilateral upper extremity rest tremor and dyskinesia in left lower extremity. (MP4 22542 KB)

Supplementary file2 This video shows resolution of tremor in upper extremities with an increase in the dose of levodopa but the presence of dyskinesia in left lower extremity. (MP4 7330 KB)

Supplementary file3 There is generalized dyskinesia which lasts all day (square-wave pattern) due to a further increase in the dose of levodopa. (MP4 9699 KB)

Supplementary file4 There is no dyskinesia and an improvement in bradykinesia as well as tremor following bilateral Gpi DBS surgery. (MP4 8227 KB)

Supplementary file5 This video demonstrates dyskinesia in the right lower extremity (the side with prominent parkinsonism). (MP4 20453 KB)

Supplementary file6 There is a rest tremor in left upper extremity and concomitant dyskinesia in the left lower extremity leading to “dyskinesia-parkinsonism.” (MP4 6910 KB)

Supplementary file7 The video shows dyskinesia in upper extremities and freezing of gait also described as pseudo-ON freezing of gait. (MOV 64321 KB)

Supplementary file8 This video shows choreiform movements involving the neck, trunk, and upper extremities in a patient with peak-dose dyskinesia. There is an intermittent dystonic posturing in the left upper extremity while walking. (MP4 20914 KB)

Supplementary file9 This video shows a rest tremor in left hand and oro-lingual dyskinesia. On occasion, oro-lingual dyskinesia alternates with jaw tremor. (MP4 27722 KB)

Supplementary file10 This patient has a prominent tremor in his left-hand which alternates with dyskinesia. (MP4 25800 KB)

Supplementary file11 This video shows extension at the shoulder joint (dystonia) [right>left] while walking and dyskinetic gait as a peak-dose phenomenon. (MP4 11876 KB)

Supplementary file12 The video demonstrates jaw dystonia in a patient with MSA (multi system atrophy). (MP4 34061 KB)

Supplementary file13 The video shows dystonic posturing in the lower limbs (inversion of the ankles) and bradykinesia in the upper limbs (right more than the left). (MP4 18750 KB)

Supplementary file14 This patient has dyskinesia in the left lower limb as an overflow phenomenon which is present while rapid alternating movement of the hands. (MP4 10372 KB)

Supplementary file15 The video shows high knee elevation while walking in a patient with PD during biphasic dyskinesia, often referred to as “silly walks.” (MP4 13092 KB)

Supplementary file16 This patient with more than 20 years disease duration developed severe evening dyskinesia which lasted for 2 hours every evening. (MP4 19421 KB)

Supplementary file17 The video demonstrates dyskinesia in both lower limbs (left more than the right) and left upper limb following embryonic dopamine cell implantation without taking LC. (MP4 33460 KB)

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Gupta, H.V., Lenka, A., Dhamija, R.K. et al. A video-atlas of levodopa-induced dyskinesia in Parkinson’s disease: terminology matters. Neurol Sci 45, 1389–1397 (2024). https://doi.org/10.1007/s10072-023-07209-6

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