Please note that no treatment should be altered without prior consultation with your specialist or GP.

I am a 39 year old female and have noticed turning to the left of second and third toes on both legs. There were lot of tremors in my legs before this happened. Also the fourth toe in both legs has gone under the third toes.

I saw two neurologists who did not think I had PD. But I read that PD causes turning of toes as an early symptom in young cases.

My mother was diagnosed with Parkinson's at age 40. Could you please let me know if it is PD or what may be the cause of it. I take Celexa for depression. Could it be side effect of this?

Waiting for your reply. Thanks

I do not know what Celexa is - do you know the pharmacological name? Toe crunching or turning can occur in young onset PD and also as a side-effect of L-dopa for PD (wearing off or early morning dystonia). Usually young onset PD is an autosomal recessive disorder, i.e. affects siblings but not parents (they are carriers but are not affected by the disease).

T Lynch

Dear Dr Lynch , thanks for answering my previous questions (133) .

I recently had my dose of Sinemet Plus increased to 2x 125mg 3x a day which helped me a great deal . When I went back to my GP I was then prescribed Sinemet 275mg , 1 tablet 3x a day .After 3 hours of taking this I can feel my symptoms coming back which makes it impossible to get a good night's sleep .

1. My question is: is the 275mg dose classed as a low dose or could I take maybe 4 tabs a day, and would it help if I was to take Sinemet CR at night ?

2. Although I still have no diagnosis, the shaking I get while at rest is not helped by the Sinemet. Is this common with PD and what other drugs could be prescribed to help this.

3. I still think I am too young to be suffering with this disease as I don't know of anybody else my age (34) who also suffers . Do you think that it is PD with all the infomation I have given you ?

Sorry for the delayed replies. I will answer both questions 139 and 148.

1. Sinemet 275mg 3/day is a moderate to high dose of levodopa. You could increase to 4/day but I think extending the benefit of the Sinemet by the addition of Selegeline and/or Entacapone would be preferable. In addition taking a siesta early afternoon to recharge the batteries may help to boost the Sinemet effect.

2. Sleep is commonly interrupted in PD. Using a low dose tricyclic antidepressant (e.g. Amitriptyline 10mg or 25mg) is preferable to adding more Sinemet overnight. Being off levodopa overnight in some may allow theh dopamine system to reset itself.

3. Rest tremor is the hardest symptom to treat - it usually reappears with excitement or stress. I often get people to use low dose Diazepam (Valium) e.g. 2mg one to one and a half hours before a stressful/exciting event (e.g. public speaking). Diazepam is a good muscle relaxant and amyiolytic that can suppress tremor. The dose can be adjusted to your needs and usually people with PD do not get addicted as they do not have the addictive neurochemical, dopamine, in the brain.

4. You have rest tremor, stiffness and slowness - 3 of the 6 cardinal features of PD. Also, your symptoms responded to levodopa. Therefore I share your strong suspicion that you may have early PD (young onset PD). There are many people of your age with PD unfortunately. I am sure the PALS group could put you in touch with someone of your age with PD - if not I would be happy to ask someone with YOPD. It is important to be aware that our treatments at present will be surpassed over the next few years, hopefully with agents that can reverse or stop the disease.

Dr Lynch

I would like to know what information you can give me on the connection to dysconjugate gaze and PD, & if Botox injections would correct the eye disorder? My sister 's doctor told her about the Botox injections for her eye condition and we can't find anything on it ... please help.

PD is not usually associated with problems with eye movement. Atypical parkinsonism (e.g. progressive supranuclear palsy) is commonly associated with poor eye movements - initially down gaze followed by horizontal gaze. Sometimes a latent strabismus (squint, lazy eye) can appear in late life as our eye muscle fatigue slightly - this can result in dysconjugate gaze. Botulinium toxin (Botox) injection was first used to correct malaligned eyes in the 1980's - it is quite a successful procedure in good hands but has to be repeated every 3-4 months as the Botox wears off.

Dr. Lynch

Do you have to pay for Sinemet and Requip tablets in this country (Ireland)?

Parkinson's disease qualifies for a long term disability card that entitles people to free medication once the prescription is written on the long term disability card. You can apply for the card at your local health board.

Dr. T. Lynch

I am a 26 year old female. About 1 month ago I woke up and was not able to put pressure on my right leg. It was extremely weak. When I tried to walk on it holding on to something my right foot foot turned. I had excruciating pain from my side under my rib cage down my right cheak into my right leg. I was hospitalized and had a lumbar MRI. Everything came back normal and they discharged me with a walker.

Recently the right foot turns in more and I have tingling in my right and left leg. Also I have slight cramping in my right leg and ankle area. I have had both an MRI of my brain and my spine and all came back pretty normal. I went to the ER over the weekend because the tingling sensations and slight numbness had gotten worse. The neurologist on call told me he wanted me to get a second opinion it could possibly be foot inversion dystonia.

In December of 1999 I was in a car accident and had traumatic brain injury which caused me neurological disorders, such as:

1. vestibular balance problems wich caused me to use a cane when walking,
2. cognitive problems which causes me to no longer be able to work,
3. my periphial vision is off,
4. I get extremely motion sickness, migraines, etc.

Also, my mother has multiple sclerosis.

My questions to you are:

1. Do my symptoms sound like dystonia?
2. If so, could it be caused by my previous head injury? and
3. Do my mother's Multiple Sclerosis genes have something to do with me possibly having dystonia.

I thank you for taking the time to read this, and information that you can provide me with would be greatly appreciated.

Thank You,

Dystonia is a twisting movement or posture so your symptoms could be dystonia-related. It is unlikely to be related to your mother's MS as dystonia is only rarely associated with MS and your MRI brain practically excludes MS as it was normal. Sometimes trauma can bring on dystonia - this is usually trauma to a limb rather than the brain. However occasionally brain trauma can result in a shake or dystonia - it is hard to comment further without seeing the right foot twisting. You should ask these same questions of your doctor to see if he/she can answer them for you.

Dr. T. Lynch

My sister is currently taking Sinemet CR and Requip for her Parkinson's. She is constantly adjusting the dosage trying to decrease off times and on two occasions has required hospitalization due to taking too much Sinemet.( 50/200 x 6 plus 6-7 1/2 mg Requip) Her Parkinson's overall is mild but she attributes all her discomforts to Parkinson's thus looks primarily to these medications for relief.

During this last 6 week period of increased medication, she experienced a great deal of stomach difficulties, constipation, some confusion and hopelessness. Now that her dosage is down to 4 x 50/200 CR these symptoms are slowing and decreasing, but she complains of acute pains which can best be described as a burning sensation especially in the groin area and stomach bloating which generally begin two hours after taking her Sinemet. She attributes this burning to her Sinemet not "kicking in", thus she looks for relief from the next dose...cheating if necessary. Her skin is also hypersensitive to touch. No one seems to be able to make much sense of all of it.

She has had a complete diagnostic work up over the past year. Currently they are giving her liquid antacid with her Sinemet to see if this might help. She does not complain so much about the off time stiffness, but this burning sensation bothers her more when she sits or lays down. She describes it as being an overwhelming pain. Zanex has been used to deal with these episodes.

Last year, stomach inflamation/irration was seen on the scope and seemed to be effectively treated with Aciflex and decreasing her Sinemet.

1. Could this burning sensation be associated again with stomach/intestional lining inflamation?
2. Is there any harm in trying Aciflex without another diagnostic scope?
3. Do any of these problems sound like they are Sinemet related?
4. Are they more prevalent if the dosage has gotten too high, then decreased and are we seeing withdrawal type symptoms?
5. Could most of this be anxiety related?
6. I think she is still on too much medication, but how can that safely be determined?

It seems like the medication's side effects are worse than the disease. So many questions...such a complex frustrating disease.

Complex is an understatement.

After 5 years of the disease the dose of Sinemet is high. Sometimes people keep increasing the dose to stay "on" but then run into trouble later because of an array of side-effects including confusion, hallucinations, weaning off, dyskinesias, dystonia, etc. The burning sensation may be a side-effect but stress and anxiety probably are aggravating the symptoms. The series of problems are not easy to resolve.

What I do in this setting is admit the patient to hospital - treat any medical problem (eg. constipation, urine infection) adjust medication (e.g. add Entacapone and Selegeline to boost Sinemet while lowering the Sinemet dose, change CR to regular Sinemet, take Sinemet on an empty stomach if tolerated, etc. etc.), improve sleep with low dose tricyclic antidepressant (e.g. Amitriptyline), treat anxiety and depression and provide an exercise regime, i.e. a lot of hard work by the patient and staff.

Dr. T. Lynch

Follow-up to Question #132

Thank you for your response. I live in Atlanta. After another MRI of my brain and neck, my doctor is having me see a IQ specialist. My MRIs came back fine. If I don't have Parkinson's I'll take everyone out for a night on the town! I have almost every symptom in the book "When Parkinson's Strikes Early" (I believe you have a foreword in it).

Anyways, after much arguing! My doctor - Dr. Alan Harris- said he'll refer me to a Dr. Watts of Emory in Atlanta. Any other suggestions?

Dr Ray Watts in Atlanta is an excellent neurologist with a particular expertise in movement disorders. You are in good hands.

T Lynch

In October 2001, I started having problems with my neck (i.e. stiffness) and my doctor had an idea I had a trapped nerve as physiotherapy had a very limited effect. Since then my symptoms now include a kind of shake whilst resting which goes away with movement, my left side is stiff all the time, I have a certain degree of dificulty walking because of the stiffness and I am very slow moving on my left hand side.

My neurologist suspected I might have a dopamine dystonia, for which I was prescribed Sinemet Plus which has not had any effect.

After reading all the infomation I possibly could find to do with Parkinson's I find myself confused. Yes, its true that my symptoms are what you could class as classic Parkinson's but at the age of 34 I am way to young to have this disease. If the dose of Sinemet was increased and my symptoms eased, would you say that a diagnosis of Parkinson's could be made, bearing in mind my age?

Unfortunately PD can affect young people even before 40, 30 and rarely 20.

PD can cause stiffness, slowness, tremor, stooped posture, poor balance and freezing of gait. Your symptoms match some of these "classic" signs and symptoms. It is possible to diagnose PD in someone of your age by the clinical history and examination. Occasionally if there is some confusion regarding the diagnosis a PET (flurodopa) scan can confirm the diagnosis. A flurodopa PET shows decreased uptake of flurodopa (dopamine) in the basal ganglia (automatic centre for movement in the brain) of patients with PD.

Hopefully you will turn out not to have PD but your complaints certainly warrant careful investigation.

T Lynch

I am 33 and suspect Parkinson's - I guess I am looking for any comment you might have or suggestion. I have ached for at least 2-3 years. But over the last 2-4 months I have had these things happen:

• loss of balance;
• vision trouble/loss of focus;
• slurring and forgetting words-In Mid Sentence!!;
• incredibly fatigued and so very achy - I struggle to get up every morning;
• rolling fingers with a slight twitch in my right hand;
• cramped toe on right foot;
• very distrubing sleep patterns where I wake up 2-5 times a night - don't know why.

Anyways - I am being tested with an MRI for Dysphasia and Mynoclos (Restless Legs).

Here's the concern: it seems like things are happening faster - or maybe I'm just noticing them. I feel stupid - I've always felt old! I thought all 33 year olds ached!

How do I find a good neurologist and what if they don't or won't diagnose me. I have had 4 MRIs and 2 CAT scans just over the past 2 years because of aches and pains and stiffness in my joints. They can't find anything.

I think my family thinks I'm crazy! What would you tell a young lady like me??

It is hard to comment on all your symptoms with a neurological examination. There are 100s of excellent neurologists in the states with expertise in PD. I could give you a list of neurologists trained in movement disorders in your state if you wish. Without seeing a neurologist the problem may remain clouded as many things can cause your array of symptoms.

T Lynch

My Dad is starting to get mixed up and confused could this be the start of Alzheimer's disease? Is it connected to Parkinson's after a length of time?

Confusion and memory impairment occurs in aproximately 1/3 of PD patients. It can often happen due to infections (urine, chest), constipation, other medical illness or as a consequence of the medication (e.g. Artane, Cogentin, etc). Sometimes it can occur because of progression of the disease to diffuse Lewy body disease or associated Alzheimer's disease. Your doctor will be able to tease out the likeliest cause in your father's case.

T Lynch