EXTERNAL MOVEMENT PROBLEMS (cont.)                        6

STRESS:        I haven't heard of professional agreement, but I
believe that the need for dopamine replenishment increases with
any kind of stress or strenuous activity, either physical or
mental. Certainly, PWP find that motor symptoms become more
pronounced during periods of stress, such as an argument or in
preparation for any kind of trial. I think PWP are subject to a
special sort of fatigue, that responds to dopamine.

Chronic Fatigue:           PWP often complain of constant
tiredness or lack of energy, even in the morning after a restful night.
"Chronic Fatigue Syndrome" is a recognized clinical
condition, but I think it is unrelated to PD because it affects
others as well. Ordinary fatigue or exhaustion follows prolonged
strenuous exertion, such as an athletic contest or a difficult mountain
climb, as muscles are depleted of chemicals that enable them to
function, for example blood sugars and oxygen. Ordinary fatigue abates
upon prolonged rest, which permits weary muscles
to recover their normal chemical state.

Quick Exhaustion:          What some PWP call "Chronic Fatigue",
I prefer to call "Quick Exhaustion". It is not due to running
out of blood sugar or oxygen, but mimics the real thing with labored
breath and rapid pulse, even in moderate exertion such
as climbing a flight of stairs, or doing a tedious manual task. Ignoring
this kind of fatigue may trigger pain in an unrelated area, such as the
upper back. Its sudden onset and equally quick recovery, after a brief
rest or an extra dose of levodopa, shows
the connection with PD. In a treadmill test, the technician may notice
the unusually quick "cooling off" of pulse and breathing rates.

BALANCE:         Balance in a normal individual is maintained by
many sources: There is the system of the inner ear to detect
acceleration and angular position, complex visual cues to sense rotary
or linear speed, direction, and position, and there is
the internal sense of how weight is distributed between
different parts of the feet. Ordinary acts of standing erect or walking
involve autonomous coordination of many different
muscles, which is lost in PD. The brain's marvelous ability to
compensate preserves some aspects of balance, and the PWP's unconscious
development of new habits also helps.

Posture:           The PWP's typical standing posture is easily
recognizable. Without doubt it arises from the unaccustomed
weakness or tension of certain muscles, and impairment of the
many continual reflexes needed to keep standing. In a simple
test, the neurologist gives the PWP a gentle push backward,
which produces a distinctive reaction.

Falling:                   Falls are frequent in PD, sometimes
anticipated and sometimes not. The PWP feels and is much more
vulnerable when the footing is unfamiliar or uncertain, for
example an icy pavement. As the disease progresses, the
patient usually begins to depend on a cane or staff to help
keep his balance; later on turns to use of a walker, and
still later a wheelchair.

EXTERNAL MOVEMENT PROBLEMS (cont.)                         7

GAIT:        The various forms of the PD gait are also easy to
recognize. Failure to swing arms has already been mentioned,
but action of the legs and feet also is quite different from
normal. Poor balance is partly to blame, and PWP have trouble
with the common sobriety test of heel-to-toe walking along a
line, and compensate by exaggerating the lateral component of
each step. Another compensation is that PWP replace lost
autonomous reflexes by habitual attention to each step.

Toe Dragging:             This annoying gait impairment results
in continual stumbling over small obstacles such as doorsills
or doormats. The ankle flexor muscle (front of the calf) gets
weaker than the extensor (back of the calf). To compensate,
one may put more weight on the ball (toe) of each foot.

Shuffling:             Instead of stepping normally from toe of
one foot to the heel of the other, PWP neglect to transfer
weight from heel to toe, walking mainly on their heels.

Shortened Stride:              Seems to be caused mainly by too
much weight on heels. Conscious kicking each foot forward
in a reduced version of the "goose step" helps to increase
stride length, but still not to the normal distance.

Festination:            The peculiar phenomenon of very short
rapid steps while leaning forward, due to combined impairment
of lower leg action and balance. Walking faster and faster,
the PWP will fall unless he reaches support.

Freezing:               The PWP cannot start, or suddenly stops,
often at a partial obstruction such as a narrow doorway, as
though one or both feet were glued to the floor. Hard for others
to understand, but the subject is unable to move, and the
incidence is very common among PWP. A visual cue such as a
pattern on the floor, or an object to step over, "unfreezes" the
walking, for reasons that are equally hard to understand. One PWP has
invented a visual aid that seems miraculous; a small brightly colored
wand extending at a right angle from the lower end of a cane provides
something to step over, and eliminates the
freezing. The most common form of subliminal compensation for loss of
internal guidance is a growing habitual dependence on external stimuli.

EXTERNAL MOVEMENT PROBLEMS (cont.)                         8

COORDINATION:               The PWP tends to lose coordination of
voluntary movement such as speech, swallowing, or tasks done
with the hands. The loss affects accuracy, speed, and doing
more than one thing at a time.

Mis-position:             Another routine neurologist's test is
to have the PWP, with eyes closed and arms extended, touch
the tips of forefingers together. The miss distance depends
on status of medication dosage as well as progress of the
disease.

Mis-direction:             The PWP, with eyes open, is asked to
touch alternately the tip of his nose and the neurologist's
index fingertip, as fast as he can. Accuracy is usually  poor,
and worse with one eye closed. In everyday living activity, the common
kitchen task of breaking an egg with a fork (hit the
center, not too weak or too strong) becomes a challenge.

Slowness:           In laboratory tests, researchers have found
that the slowness of coordinated movement, such as tapping, is
not due entirely to hesitation or caution to improve aim, but largely to
a genuine deficit in the speed that is commanded by
the brain. In a recent trial curiously, the speed to reach and grasp a
stationary object was impaired, but when the object was moving, PWP
responded much faster than they thought possible.

Bilateral Ability:                  Psychology researchers have
used many ingenious mechanical tests to explore the effect of PD
on coordination. For example, in turning a crank with each hand
at a preset speed, PWP were about normal. But when the required motions
were out of phase, or otherwise different, PWP did much worse than
normal control subjects.

Fine Guidance:                  PWP are familiar with decreased
dexterity in fine tasks, such as threading a needle or
adjusting a watch. The loss is probably due as much to
visual defects as to mechanical control. More trouble comes
from apparent loss of touch sensitivity in the fingertips,
like that experienced when working in cold weather.

EXTERNAL MOVEMENT PROBLEMS (cont.)                         9

EYE CONTROL:         PWP often of difficulty or loss of interest
in reading, which they blame on inability to concentrate. The
true cause may be in muscles that control eye direction, so
that the PWP literally "can't see straight".

Jitter:            The PD tremor that appears near the time for
the next medication dose, or when you are tired, extends also
to muscles that direct the eyes. PWP may notice that visual objects,
such as printed words, are doing a little dance, that makes reading
difficult, especially if the type is small or the lighting dim.

Convergence:        For both eyes to be aimed at the same point
in an object, their position must vary slightly as the object distance
changes. This feature is what permits autonomous
judgement of distance by humans and other animals (mostly predators)
with eyes at the front, rather than sides, of the
head. But it also helps greatly in interpretation of detail, to have two
similar images that can be merged in the brain. In PD,
the control that keeps both eyes focused on a close object such
as a printed page is impaired, and the eyes tend to drift into
the "distance" position, resulting in a double image. The PWP notices,
sometimes every few seconds, that he is using only one eye, and needs to
make a conscious effort to pull the images together.

SPEECH PROBLEMS:            Listeners have trouble understanding
PWP because they may speak in a low, slurred monotone, made worse by
occasional stuttering.

Voice:                 PWP often need a microphone to be heard,
even in a small group, and especially in a noisy place.
Training and exercise, such as singing, can help. I have heard
of a specialized course called Lee Silverman Voice Training,
which is highly recommended. One cause of voice weakness may be failure
of the vocal cords in the pharynx to close completely during
vocalization. This condition has been treated by
injection of collagen into the vocal cords to strengthen them.

Slurring:                         The slurring comes from poor
coordination of lips, cheeks and tongue when enunciating
certain consonant combinations, as in "rural railroads", etc.
For uncertain reasons, some PWP tend to speak very rapidly,
adding to the difficulty.

Stuttering:              Researchers differentiate between loss
of verbal fluency, which probably originates in the mental
process of speech, and of phonemic fluency, more likely due to
poor control of speech muscles. Researchers find that the
latter type predominates in PWP.

EXTERNAL MOVEMENT PROBLEMS (cont.)                        10

FRIGHT REFLEXES:                 PWP seem generally to be more
"jumpy" than others, whether from a constant personality
trait, stress associated with the disease, medicines, or from
a basic change in neural circuitry.

Blink Reflex:                   In this interesting phenomenon,
first described by the philosopher Descartes, everyone blinks
involuntarily when an object, apparent or real, seems to be
rapidly approaching the face. Researchers find that in PD, the blink
reflex is hyperactive.

Startle Reflex:            Just as normal people jump visibly
on hearing a loud unexpected noise, PWP seem to be more
sensitive, and may jump even when the noise is a familiar one,
such as a telephone ring. The jump is similar to one of internal origin,
called myoclonus.

Cheers,
Joe
--
J. R. Bruman   (818) 789-3694
3527 Cody Road
Sherman Oaks, CA 91403-5013