Drugs that affect the seizure threshold

Antiasthmatics-- aminophylline, theophylline

antibiotics-- inh, metronidazole, penicillin, lindane

antidepressants: buproprion, SSRI, TCA

general anesthesia-- enflurane, ketamine

hormones-- estrogen, esp without progesterone

immunosuppressants-- chlorambucil, cyclosporine

local anesthetics- lidocaine, bupivicaine, procaine

narcotics-- fentanyl, meperidine, pentazocine, propoxyphene

psychostimulants- amphetamines, cocaine, methylphenidate

neuroleptics-- clozapine, phenothiazines, butyrophenones

others-- anticholinergic, anticholinesterase, antihistamine, baclofen, heavy metals, lithium, mefenamic acid, oral hypoglycemics, oxytocin

Seizure risk associated with neuroactive drugs: Data from the WHO adverse drug reactions database; Kumlien E, Lundberg PO; Seizure (Dec 2009)


PURPOSE: To explore the association between the use of neuroactive drugs and reports of epileptic seizures. MATERIAL: Using the WHO adverse drug reactions (ADR) database, VigiBase, we surveyed reports of suspected seizures from 1968 until February 2006. Case reports of ADRs, that were classified as convulsions were collected and compared to the total number of ADRs reported. RESULTS: The total number of ADRs was 7,375,325. The number of convulsive events was 71,471. The ratio of convulsive ADRs to the total number of ADRs reported for each drug was evaluated and expressed as a percentage. The 10 drugs most frequently associated with convulsive ADRs were maprotilene (14.42%), escitaloprame (9.78%), buproprione (9.49%), clozapine (9.0%), chlorprothiexene (8.89%), amoxapine (8.74%), donepezil (8.40%), rivastigmine (6.41%), quetiapine (5.90%) and trimipramine (5.69%). CONCLUSIONS: Based on the reports in VigiBase, ADR reports relating to antidepressants, antipsychotic and cholinomimetic drugs included seizures more often than other neuroactive drugs.

Epilepsy random pearls

1. Valproate works for tilt positive treatment (Eugene Ramsey)

2. Potential analogy of SUDEP and SIDS (failure of brainstem to respond to hypopnea (Mary Donner)

3. In VA study 80 % of patients had undiagnosed serious dyslipidemia, 70 % htn (Ramsey)

4. Asking patients if they turn hues esp. to shade of gray, almost certainly diagnoses NCS

5. Lamotrigine works extremely well for classic migraine (comorbid with epilepsy), less well for common migraine

6. Epilepsy patients describe panic attacks eloquently, but they may be unrecognized seizures (feeling in stomach, etc.)

7. Drug AE's are age related .

8. Carbamazepine causes weight gain, usually not recognized and may worsen tremor(Ramsey)

9. Topirimate helps BP, tremor, glucose control, weight

10. Ethosuximide worsens headache

11. PPI's raise gastric pH, making phenytoin absorption not happening

12. Stopping inducer, PHT or CBZ dramatically decreases clearance of LTG and TPM resulting in blood levels shooting up

13. Simvastatin levels go down 80 % with CBZ. Only statin not affected is ____/ Also beware of Calcium channel blockers (including nimodipine for SAH), HAART, drugs for ED

SMA atrophy

most common fatal genetic disease in newborns

Aut recessive carrier frequency 1:35 occurrence 1:6000

Caused by deletion mutation in SMN 1

Human diseases with no mouse models

Down's syndrome-- mice lack chromosome 21

Parkinson's disease-- mice endogenous A53T

SMA no SMN2 gene

Treatment of Parkinson's disease: gyrokinetics

gyrokinetics.com

lee silverman voice technique

advanced pt techniques

vital stim

tongue biting and seizures pearls

Lateral tongue biting is poorly sensitive but highly specific (99%) for a generalized seizure.
Lateral tongue biting usually indicates true epileptic seizures as opposed to bites to the tip of the tongue which are typically nonepileptiform events.
Lateral tongue biting has a predictive value of 71% for ipsilateral seizure focus.

from AAN website

Differential diagnosis of thunderclap headache

Subarachnoid hemorrhage
unruptured aneurysm
cerebral sinus thrombosis
cervical artery dissection
hypertensive crisis
spontaneous intracranial hypotension
acute ischemic stroke
acute cerebral hematoma
pituitary apoplexy
intracranial infection
"benign" thunderclap (explode category)

Treatable autoimmune encephalitis

Bataller L et al. Autoimmune limbic encephalitis in 39 patients: immunophenotypes and outcomes. JNNP 2007: 78: 381-385.

17 patients were studied at University of Pennsylvania, as well as 22 "outside cases" with sera sent in. . The most important points were that

1. Most of the patients were accurately diagnosed clinically before antibodies were returned.

2. 9/17 had antibodies to known neuronal antigens (paraneoplastic or VGKC's) and 5/17 to novel cell membrane antigens (hippocampus/cerebellum). For the whole group, including the sent in cases, the numbers were 19/39 had antibodies to known antigens, 17/39 to nCMA's.

3. A significant treatment response effect was seen in those with VGKCA's and nCMA's.

4. Those with known intraneuronal antigens (anti Hu, anti Ma) are associated with cancer and may be associated with a worse prognosis than the antibodies to VGKCA's and nCMA's

5. Ovarian teratoma and thymoma are paraneoplastic treatable and benign conditions once the tumor is excised

6. No MRI or CSF characteristics help in diagnostic process.

In another article, some cases of ovarian teratoma associated paraneoplastic encephalitis are related to NMDA receptor antibodies (NMDAR) (Dalmau J, et al. Ann Neurol 2007; 61: 25-36. ) Posner's group described 12/12 with teratomas of ovary who had NMDAR with antibodies to the NR2 subunit, which binds glutamate in the forebrain and hippocampus, AND, a VIRUS LIKE PRODROME.

In yet another article, Mathew et al. (Neurology 2007; 68: 900-905) described orchiectomy for Ma2 related encephalitis as successful in showing otherwise undocumented tumors in 6/25 patients who underwent the procedure (the other 19 had known germ cell tumors). The criteria for orchiectomy were 1) present Ma2 antibodies with clinical/MRI evidence of encephalitis 2) life threatening or progressive neurologic deficits 3) age< 50 4) absent evidence for other tumors 5) new testicular enlargement, microcalcifications on testicular ultrasound, cryptorchidism or other evidence of testicular disease. All testicular specimens showed germ cell tumors. Tumor markers, body CT, PET, and other tests were negative in those undergoing the procedure.

Other antibodies reported include Hu, Ri, Ma1, Ma2, CAR, CRMP 3, amphiphysin, and others.

Thunderclap headache and benign CNS angiopathy

Chen SP et al. Reccurrent primary thunderclap headache and benign CNS angiopathy: spectra of the same disorder? Neurology 2006; 67:2164-2169.

56 patients with recurrent thunderclap headache were recruited. Segmental vasoconstriction was found in 22 (39 %). HA recurred .7 times per day for fourteen days. Each attack lasted 3 hours, and 84 % of patients reported at least one trigger. Nimodipine aborted attacks in 83 % and stopped headaches within 3 months. 4 patients (7%) developed stroke. Authors note that this entity is identical to benign CNS angiopathy. Exertion and defecation are greater triggers in vasoconstriction group.  Other triggers are emotional situations,laughing, bathing, bending down.

Blogger note: this is identical to Call Fleming syndrome frequently discussed in USA. See http://strokenotes.blogspot.com/search?q=call for more minutiae about it.

Review article
Ducros A. Reversible cerebral vasoconstriction syndrome.  Lancet Neurology 2012;11:906-917

additional pearls

1.  Pain peaks in 1-2 weaks, angiogram findings in about 3 weeks.

2.  Many synonyms exist (see below)

3.  Thunderclap headache usually peaks within 1 minute, unilateral or bilateral and mimics aneurysm rupture; each episode may last 3 hours but can vary with up to 3 day duration, and 4 attacks over the 3 month period with moderate headache in between

4.  Ten percent have focal findings; ten percent may have seizures including inaugural, and they rarely recur.  Marching numbness can mimic migraine, focality, a stroke.

5. Beware of neck pain (dissection).  Other differentials are CVT (check d Dimer and MRV), transfusion or products (red cell transfusion, alpha interferon, IVIG), phenytoin intoxication, CEA, low pressure headache.

6.  May screen for pheochromocytoma or glomus tumor or carcinoid. Do a drug screen in some patients.  Not only is cocaine in differential, cannabis is a trigger as well as LSD.  Other triggers include SSRI's, triptans, ergot derivatives, nicotine patches, ginseng and binge drinking.  Inquire about scorpion poison and star fruit.

7.  Convexity SAH may be subtle, and missed on CT, strokes occur in watershed areas (including cerebellar watershed areas); brain edema can mimic PRES.

8.  Catheter angiography can trigger TIA. 

9. Postpartum cases occurs in first week after delivery.  Inquire about exposure to vasoconstrictors during anesthesia, depression. 

10.  Synonyms and old names:  isolated benign CNS vasculitis, acute benign cerebral angiopathy, reversible cerebral segmental vasoconstriction, Call Fleming syndrome, CNS pseudovasculitis, benign angiopathy of CNS, postpartum angiopathy, migraine angiopathy, migraine angiitis, migraine vasospasm, primary thunderclap headache, cerebral vasculopathy, vasospasm infatal migrainous infarction

11.  Factors that independently make RCVS worse:  those who receive glucocorticoids, serotonergic antidepressants, patients with ischemic stroke (Singhal AB, Topcuoglu MA. Glucocorticoid associated worsening in reversible cerebral vasoconstriction syndrome.  Neurology 2017; 88:228-236.

Transient epileptic amnesia syndrome

Butler CR, Ann Neurol 2007; 61:587-598

Another hard to diagnose syndrome. 50 patients were recruited with recurrent amnesia, other cognitive functions intact, and compelling evidence of epilepsy. 24 controls also were studied. Clinical pearls to diagnosing this include: average age 62, frequent spells (eg one a month for a year), duration 30-60 minutes, occurrence upon awakening, prompt cessation with antiepileptic drug treatment. Neurocognitively patients complained of forgetting, but did well on standard (? what) neuropsych, but with accelerated forgetting of verbal and visual material over 3 weeks and some loss of autobiographical memory. Its diagnosis is usually missed.

Ictal asystole: clinical characteristics & SUDEP

Neurology 2007; 69: 434-441.


Occurred in .27 % of patients undergoing VEEG. There was a sudden loss of atonia 42 seconds into the seizure with characteristic EEG findings of hypoperfusion. It occurred in TLE and extratemporal epilepsy. Clinical predisposing characteristics were not identified. Patients should be sent for pacemakers to avoid SUDEP.

Other predisposing factors for SUDEP are long QT syndrome, Brugada syndrome, and catecholaminergic ventricular arrythmia. Absence of treatment or insufficient treatment are neurologic risk factors. 

Carbamazepine, which can decrease heart rate variability, has been proposed as a risk factor for SUDEP.  SUDEP in most cases is triggered by a GTCS.  Four cases that were monitored during SUDEP showed EEG flattening before cardiorespiratory changes.  Another showed seizure triggered ventricular fibrillation.  Sleeping prone may be a risk factor,

Nice review article:
Tomson T, Nashef L, Ryvlin P.  Sudden unexpected death in epilepsy:  current knowledge and future directions.  Lancet Neurology 2008; 7:1021-1031.

More pearls  Kloster R. et al. JNNP 1999; 67:439-444

risk factors
male  predominance
Laying prone (17/24) usually during sleep.
At least one AED is subtherapeutic
Pulmonary edema is present in 26/42
Seizure just before death in 28/39

Alcohol levels were usually zero.

NeuroBehcet's pearls

multiple sources but NEJM CPC from May 28, 2009 was one.

1. Known as Silk Route disease due to occurrence along trading paths in Asia
2. Criteria include (major) oral ulcers occurring at least three times per year, genital ulcers or scars, ocular involvement (uveitis), skin (erythema nodosa, folliculitis, acne), positive skin pathergy test. Minor criteria are arthritis, DVT, superficial thrombophlebitis, epididymitis, positive family history, GI, CNS, or vascular involvement.
3. Neurologic involvement occurs in 5-10 %, with vascular involvement (venous sinus thrombosis or arterial thrombosis), or parenchymal infiltration. Brain stem and basal ganglia are common areas of predilection. The disease can be relapsing-remitting, chronic progressive, or secondary progressive.
4. Abnormal labs include high sed rate, CRP, complement, IL6,8 , TNF, and distinctive CSF neutrophilic pleocytosis.
5. Best treatment is not know, but in CPC authors suggested high dose pulsed steroid and cyclophosphamide, and maintenance immunoosuppression with azathioprine.

GAD 65 autoimmunity in PSP mimics

Article with reply by Mayo group in Neurology 1009 June. Original case was a 54 year old woman with supranuclear gaze plasy and parkinsonism mimicking PSP. There were stiff man like symptoms and strong GAD65 positivity. PSP was excluded in part by prominent early upgaze palsy, and startle induced spasms typical of SMS, and video ENG findings of a fatiguing pattern of saccade initiation with repetive saccades. The Mayo report (Pittock SJ, Mayo Clin Proc 2006) presented with brainstem, eps and spinal cord syndromes and were initially misdiagnosed as PSP or MSA. Pittock's group also reported OCB in CSF and improvement with prompt initiation of immunotherapy.

Superior division oculomotor paresis

Clin note in Neurology June 2009.

KEY POINTS
Clinical Patient has diplopia in vertical gaze, right ptosis, and right retroorbital pain. Exam showed ptosis, hypotropia, and elevation paresis in the right eye (looking in and up). Angio showed cavernous right ICA aneurysm that was coiled. The IIIn divides into superior and inferior divisions near SOF or anterior cavernous sinus. Clinical presentation is ptosis and superior rectus palsy.

BNP levels in neurologic disease

2 uses
1. Document cadiac valvulopathy among patients exposed to pergolide
2. Document CHF in stroke patients ie possible need for anticoagulation and cardiac evaluation

SWEDDs non Parkinson's disease

4-15 % of patients entered into trials for PD had normal presynaptic nigrostriatal dopaminergic imaging and were termed "subjects with scans without evidence of dopaminergic deficits." (SWEDD's). Withdrawal of dopamine was nondeleterious and rescanning 4 years later continued to show no deficit. Case was presented of a subject with jerky assymmetric rest and action tremor, arm dystonia, hypomimia, increased limb tone, and slow repetitive finger movements. 3/10 had abnormal thumb extension (Froment's sign in this case), none had micrographia, and none had loss of sense of smell. True bradykinesia, as defined by progressive decrement of speed and amplitude of repetitive movement (decremental bradykinesia) was not present and should be contrasted to just slowing or hesitation of voluntary movement. The action tremor occurred as the arms were held up (postural tremor).

Blogger note: differential diagnosis could include corticobasal ganglionic degeneration, difference being more rapid progression in that condition, particularly if functional imaging is not done or not available.

Small, spastic furrowed tongue of Allgrove's syndrome

Houlden H. Neurology (Neuroimages) 2009; 72:1366.

35 yo with slowly progressive achalasia, alacrima, motor neuropathy, bulbar palsy, and a small furrowed tongue. Sister had same plus adrenal deficiency (triple A syndrome). DNA analysis of ALADIN gene confirmed.

Chronic progressive myeloneuropathies

Acquired
Nutritional deficiency-- B12, folate, vitamin E, copper, nitrous oxide deficiency with impaired
B12 metabolism, AIDS myelopathy with impaired B12 metabolism
Infectious-- HTLV I, AIDS, syphilis
Inflammatory- Sjogren's, sarcoid
Geographic - toxic-- cassova toxicity, lathyrism, fluorosis, subacute optico myeloneuropathy,
tropical myeloneuropathies
Toxic-- chemo ( cisplatin, cytarabine, intrathecal therapy, organophosphate
Genetic
With metabolic abnormality: adrenomyeloneuropathy, Krabbe disease, MLD, CTX, familial
vitamin E deficiency, abetalipoproteinemia, cobalamin and foalte metabolism defects,
respiratory chain defects, APBD
Without metabolic abnormalities: HSP, SCA


Evaluation:
vitamin B12, folate, vitamin E, calcium, glucose, TSH, alkphos, lactate, pyruvate, paraneoplastic screen, arylsulfatase A, beta galactosidase, peroxisomal screen ( VLCFA, pristanic acid, phytanic acid), ACE level, ceruloplasmin, copper, ANA, cyclic citrullinated peptide antibodies, SPEP, SIEP, lyme screen, VDRL, HIV, HTLV I/II, NMO IgG, SSA, antibodies to Gad 65, AST, ALT
CSF--cells, diff, MS panel, lyme titers, JC virus pcr, and paraneoplastic screen.

APBD Adult polyglucosan body disease

Neurology 2009; 72: 1609-1613 (CPC)
Jewish diseases with leukoencephalopathy:
APBD--Ashkenazi
megelencephalic encephalopathy with subcortical cysts-- Libyan
mitochondrial neurogastrointestinal encephalomyelopathy-- Ashkenazi and Libyan
cerebrotendinous xanthomatosis-- Moroccan
metachromatic leukodystrophy-- Yemenite
Canavan disease
mucolipidosis type IV

APBD-- uniquely occurs in 50 yo with CNS and PNS involvement
AR
diagnosis with skin.fibroblasts measurement of glycogen branching enzyme activity
Genetic spectrum well beyond Ashkenazi Jews. Allelic to type 4 glycogen storage disease. Unlike glycogen storage, liver is affected in kids.

Clinical
progressive late onset spastic paraparesis, progressive, neurogenic bladder, sensorimotor neuropathy with painful feet. Cognitive involvement even dementia is common.
CSF normal
MRI progressive involvement of hemisphere and PVWM, post limb of ic, brainstem tracts, sparing of corpus callosum and u fibers. Lesions are hyperintense on T2 and not enhancing. Atrophy of spinal cord is early and invariable. Sural nerve biopsy or axillary apocrine biopsy are diagnostic of polyglucosan bodies.

UPDRS

Hoehn and Yahr Staging of Parkinson's Disease

1. Stage One
1. Signs and symptoms on one side only
2. Symptoms mild
3. Symptoms inconvenient but not disabling
4. Usually presents with tremor of one limb
5. Friends have noticed changes in posture, locomotion and facial expression

2. Stage Two
1. Symptoms are bilateral
2. Minimal disability
3. Posture and gait affected

3. Stage Three
1. Significant slowing of body movements
2. Early impairment of equilibrium on walking or standing
3. Generalized dysfunction that is moderately severe

4. Stage Four
1. Severe symptoms
2. Can still walk to a limited extent
3. Rigidity and bradykinesia
4. No longer able to live alone
5. Tremor may be less than earlier stages

5. Stage Five
1. Cachectic stage
2. Invalidism complete
3. Cannot stand or walk
4. Requires constant nursing care

This rating system has been largely supplanted by the Unified Parkinson's Disease Rating Scale, which is much more complicated.

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Unified Parkinson's Disease Rating Scale (UPDRS)

The UPDRS is a rating tool to follow the longitudinal course of Parkinson's Disease. It is made up of the 1) Mentation, Behavior, and Mood, 2) ADL and 3) Motor sections. These are evaluated by interview. Some sections require multiple grades assigned to each extremity. A total of 199 points are possible. 199 represents the worst (total) disability), 0--no disability.

I. Mentation, Behavior, Mood

Intellectual Impairment
0-none
1-mild (consistent forgetfulness with partial recollection of events with no other difficulties)
2-moderate memory loss with disorientation and moderate difficulty handling complex problems
3-severe memory loss with disorientation to time and often place, severe impairment with problems
4-severe memory loss with orientation only to person, unable to make judgments or solve problems

Thought Disorder
0-none
1-vivid dreaming
2-"benign" hallucination with insight retained
3-occasional to frequent hallucination or delusions without insight, could interfere with daily activities
4-persistent hallucination, delusions, or florid psychosis.

Depression
0-not present
1-periods of sadness or guilt greater than normal, never sustained for more than a few days or a week
2-sustained depression for >1 week
3-vegetative symptoms (insomnia, anorexia, abulia, weight loss)
4-vegetative symptoms with suicidality

Motivation/Initiative
0-normal
1-less of assertive, more passive
2-loss of initiative or disinterest in elective activities
3-loss of initiative or disinterest in day to say (routine) activities
4-withdrawn, complete loss of motivation


II. Activities of Daily Living

Speech
0-normal
1-mildly affected, no difficulty being understood
2-moderately affected, may be asked to repeat
3-severely affected, frequently asked to repeat
4-unintelligible most of time

Salivation
0-normal
1-slight but noticeable increase, may have nighttime drooling
2-moderately excessive saliva, hay minimal drooling
3-marked drooling

Swallowing
0-normal
1-rare choking
2-occasional choking
3-requires soft food
4-requires NG tube or G-tube

Handwriting
0-normal
1-slightly small or slow
2-all words small but legible
3-severely affected, not all words legible
4-majority illegible

Cutting Food/Handing Utensils
0-normal
1-somewhat slow and clumsy but no help needed
2-can cut most foods, some help needed
3-food must be cut, but can feed self
4-needs to be fed

Dressing
0-normal
1-somewhat slow, no help needed
2-occasional help with buttons or arms in sleeves
3-considerable help required but can do something alone
4-helpless

Hygiene
0-normal
1-somewhat slow but no help needed
2-needs help with shower or bath or very slow in hygienic care
3-requires assistance for washing, brushing teeth, going to bathroom
4-helpless

Turning in Bed/ Adjusting Bed Clothes
0-normal
1-somewhat slow no help needed
2-can turn alone or adjust sheets but with great difficulty
3-san initiate but not turn or adjust alone
4-helpless

Falling-Unrelated to Freezing
0-none
1-rare falls
2-occasional, less than one per day
3-average of once per day
4->1 per day

Freezing When Walking
0-normal
1-rare, may have start hesitation
2-occasional falls from freezing
3-frequent freezing, occasional falls
4-frequent falls from freezing

Walking
0-normal
1-mild difficulty, day drag legs or decrease arm swing
2-moderate difficultly requires no assist
3-severe disturbance requires assistance
4-cannot walk at all even with assist

Tremor
0-absent
1-slight and infrequent, not bothersome to patient
2-moderate, bothersome to patient
3-severe, interfere with many activities
4-marked, interferes with many activities

Sensory Complaints Related to Parkinsonism
0-none
1-occasionally has numbness, tingling, and mild aching
2-frequent, but not distressing
3-frequent painful sensation
4-excruciating pain

III. Motor Exam

Speech
0-normal
1-slight loss of expression, diction,volume
2-monotone, slurred but understandable, mod. impaired
3-marked impairment, difficult to understand
4-unintelligible

Facial Expression
0-Normal
1-slight hypomymia, could be poker face
2-slight but definite abnormal diminution in expression
3-mod. hypomimia, lips parted some of time
4-masked or fixed face, lips parted 1/4 of inch or more with complete loss of expression

*Tremor at Rest
Face
0-absent
1-slight and infrequent
2-mild and present most of time
3-moderate and present most of time
4-marked and present most of time

Right Upper Extremity (RUE)
0-absent
1-slight and infrequent
2-mild and present most of time
3-moderate and present most of time
4-marked and present most of time

LUE
0-absent
1-slight and infrequent
2-mild and present most of time
3-moderate and present most of time
4-marked and present most of time

RLE
0-absent
1-slight and infrequent
2-mild and present most of time
3-moderate and present most of time
4-marked and present most of time

LLE
0-absent
1-slight and infrequent
2-mild and present most of time
3-moderate and present most of time
4-marked and present most of time

*Action or Postural Tremor

RUE
0-absent
1-slight, present with action
2-moderate, present with action
3-moderate present with action and posture holding
4-marked, interferes with feeding

LUE
0-absent
1-slight, present with action
2-moderate, present with action
3-moderate present with action and posture holding
4-marked, interferes with feeding

*Rigidity

Neck
0-absent
1-slight or only with activation
2-mild/moderate
3-marked, full range of motion
4-severe

RUE
0-absent
1-slight or only with activation
2-mild/moderate
3-marked, full range of motion
4-severe

LUE
0-absent
1-slight or only with activation
2-mild/moderate
3-marked, full range of motion
4-severe

RLE
0-absent
1-slight or only with activation
2-mild/moderate
3-marked, full range of motion
4-severe

LLE
0-absent
1-slight or only with activation
2-mild/moderate
3-marked, full range of motion
4-severe

*Finger taps

Right
0-normal
1-mild slowing, and/or reduction in amp.
2-moderate impaired. Definite and early fatiguing, may have occasional arrests
3-severely impaired. Frequent hesitations and arrests.
4-can barely perform

Left
0-normal
1-mild slowing, and/or reduction in amp.
2-moderate impaired. Definite and early fatiguing, may have occasional arrests
3-severely impaired. Frequent hesitations and arrests.
4-can barely perform

*Hand Movements (open and close hands in rapid succession)

Right
0-normal
1-mild slowing, and/or reduction in amp.
2-moderate impaired. Definite and early fatiguing, may have occasional arrests
3-severely impaired. Frequent hesitations and arrests.
4-can barely perform

Left
0-normal
1-mild slowing, and/or reduction in amp.
2-moderate impaired. Definite and early fatiguing, may have occasional arrests
3-severely impaired. Frequent hesitations and arrests.
4-can barely perform

*Rapid Alternating Movements (pronate and supinate hands)

Right
0-normal
1-mild slowing, and/or reduction in amp.
2-moderate impaired. Definite and early fatiguing, may have occasional arrests
3-severely impaired. Frequent hesitations and arrests.
4-can barely perform

Left
0-normal
1-mild slowing, and/or reduction in amp.
2-moderate impaired. Definite and early fatiguing, may have occasional arrests
3-severely impaired. Frequent hesitations and arrests.
4-can barely perform

*Leg Agility (tap heel on ground, amp should be 3 inches)

Right
0-normal
1-mild slowing, and/or reduction in amp.
2-moderate impaired. Definite and early fatiguing, may have occasional arrests
3-severely impaired. Frequent hesitations and arrests.
4-can barely perform

Left
0-normal
1-mild slowing, and/or reduction in amp.
2-moderate impaired. Definite and early fatiguing, may have occasional arrests
3-severely impaired. Frequent hesitations and arrests.
4-can barely perform

*Arising From Chair (pt. arises with arms folded across chest)
0-normal
1-slow, may need more than one attempt
2-pushes self up from arms or seat
3-tends to fall back, may need multiple tries but can arise without assistance
4-unable to arise without help

*Posture
0-normal erect
1-slightly stooped, could be normal for older person
2-definitely abnormal, mod. stooped, may lean to one side
3-severely stooped with kyphosis
4-marked flexion with extreme abnormality of posture

*Gait
0-normal
1-walks slowly, may shuffle with short steps, no festination or propulsion
2-walks with difficulty, little or no assistance, some festination, short steps or propulsion
3-severe disturbance, frequent assistance
4-cannot walk

*Postural Stability (retropulsion test)
0-normal
1-recovers unaided
2-would fall if not caught
3-falls spontaneously
4-unable to stand

*Body Bradykinesia/ Hypokinesia
0-none
1-minimal slowness, could be normal, deliberate character
2-mild slowness and poverty of movement, definitely abnormal, or dec. amp. of movement
3-moderate slowness, poverty, or small amplitude
4-marked slowness, poverty, or amplitude

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Schwab and England Activities of Daily Living

Gillingham FJ, Donaldson MC, eds., Third Symp. of Parkinson's Disease, Edinburgh, Scotland, E&S Livingstone, 1969, pp.152-7.

Rating can be assigned by rater or by patient.

* 100%-Completely independent. Able to do all chores w/o slowness, difficulty, or impairment.

* 90%-Completely independent. Able to do all chores with some slowness, difficulty, or impairment. May take twice as long.

* 80%-Independent in most chores. Takes twice as long. Conscious of difficulty and slowing

* 70%-Not completely independent. More difficulty with chores. 3 to 4X along on chores for some. May take large part of day for chores.

* 60%-Some dependency. Can do most chores, but very slowly and with much effort. Errors, some impossible

* 50%-More dependant. Help with 1/2 of chores. Difficulty with everything

* 40%-Very dependant. Can assist with all chores but few alone

* 30%-With effort, now and then does a few chores alone of begins alone. Much help needed

* 20%-Nothing alone. Can do some slight help with some chores. Severe invalid

* 10%-Totally dependant, helpless

* 0%-Vegetative functions such as swallowing, bladder and bowel function are not functioning. Bedridden.

Disclaimer: The information and reference materials contained herein is intended solely for the information of the reader. It should not be used for treatment purposes, but rather for discussion with the patient's own physician.

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