Edited by: Oscar Arias-Carrión, Hospital General Dr. Manuel Gea Gonzalez, Mexico
Reviewed by: Gennaro Pagano, King’s College London, United Kingdom; José M. Salas-Pacheco, Universidad Juárez del Estado de Durango, Mexico
Specialty section: This article was submitted to Movement Disorders, a section of the journal Frontiers in Neurology
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Dropped head can occur in patients with Parkinson’s disease and make their quality of life unpleasant because they cannot obtain a frontal view. The pathophysiologic involvement of dopamine agonist or central or peripheral mechanisms has been proposed. Levodopa therapy with the withdrawal of dopamine agonists was sometimes effective, but the effect in most patients did not persist for the entire day. We describe a patient with Parkinson’s disease whose dropped head responded throughout the day to the continuous intrajejunal infusion of levodopa-carbidopa intestinal gel (LCIG). During off-periods before treatment with LCIG, severe akinesia and freezing of gait were evident, and she could not continuously obtain a frontal view because of the dropped head. About 20 min after the intrajejunal infusion of LCIG, these features remarkably improved, and she could obtain a frontal view. The angle of dropped head was improved from 39.39 to 14.04°. This case suggests that infusion of LCIG can reduce the severity of dropped head for a longer period than oral levodopa.
Dropped head can occur in patients with Parkinson’s disease and make their quality of life unpleasant because they cannot obtain a frontal view. The pathophysiologic involvement of dopamine agonist or central or peripheral mechanisms has been proposed (
Eleven years ago, a 72-year-old right-handed woman noticed left-hand tremor. In 2006, she consulted a hospital physician, and cogwheel rigidity, resting tremor in the right hand, and akinesia were present. These features responded to treatment with oral levodopa (200 mg/day). In February 2008, she received levodopa (200 mg/day) and pramipexole (0.5 mg/day). She showed signs of moderate parkinsonism, including resting tremor in the right hand, right-dominant rigidity in all four limbs, and akinesia. In August 2009, the dose of pramipexole was increased to 1 mg/day because of the resting tremor. She complained that her trunk became bent, and lumbar pain was evident. She showed mild-to-moderate trunk flexion. Pramipexole was discontinued, and the symptoms resolved. Since 2010, the severity of akinesia increased, and gait difficulty gradually developed. In June 2014, she received levodopa (300 mg/day), selegiline (10 mg/day), and zonisamide (50 mg/day). In May 2015, wearing-off was evident, and the dose of levodopa was increased to 400 mg/day. In October, peak-dose dyskinesia was evident, and zonisamide was withdrawn. In April 2016, wearing off and troublesome dyskinesia developed. She also noticed painful lower abdominal contractions several times during off-periods in the night. Treatment with zonisamide (25 mg/day) was therefore resumed, but the lower abdominal contractions did not resolve. In October, she noticed dropped head while receiving a stable dosage of levodopa (400 mg/day), selegiline (10 mg/day), and zonisamide (25 mg/day). Since two phenotypes of levodopa-responsiveness exist in patients with abnormal posture including dropped head (
A patient with dropped head before
During off-periods before treatment with LCIG, severe akinesia and freezing of gait were evident, and she could not continuously obtain a frontal view because of the dropped head (Videos S1 and S2 in Supplementary Material). The severity of dropped head increased during off-periods and mildly decreased during on-periods. About 20 min after the intrajejunal infusion of LCIG, these features remarkably improved, and she could obtain a frontal view (Videos S3 and S4 in Supplementary Material). The Hoehn-Yahr stage decreased from 4 to 2, and balance also improved. The axial sum scores (items 8, 12, and 13) on the new revised Unified Parkinson’s Disease Rating Scale (UPDRS)-III (
The angle of dropped head was 39.39° before the infusion of LCIG (Figure
Treatment with oral levodopa improves head position, but this finding was inconsistent previously (
After infusion of LCIG, dropped head in our patient deteriorated after the evening, and the ability to maintain a good status of dropped head appeared to be limited. However, this case suggests that infusion of LCIG can reduce the severity of dropped head for a longer period than oral levodopa.
No investigations or interventions were performed outside of routine clinical care for this patient. As this is a case report, without experimental intervention into routine care, no formal research ethics approval was required. Written, fully informed consent was received from the patient. This case study reports routine clinical care provided for a patient only.
HK was responsible for the overall study design and contributed to analysis and interpretation of the data and wrote the manuscript. HK, YS, TN, and NS contributed to running the study and the acquisition of data. HK, HY, and SU contributed to drafting and critical revision of part of the submitted materials.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The Supplementary Material for this article can be found online at
The severity of Parkinson’s disease before the continuous intrajejunal infusion of levodopa-carbidopa intestinal gel.
The severity of Parkinson’s disease after the continuous intrajejunal infusion of levodopa-carbidopa intestinal gel.