Two men with Parkinson disease for approximately a decade complained of involuntary arm elevation developing during the “off” periods between levodopa dose cycles (videos 1 and 2 on the Neurology® Web site at Neurology.org; figure). Treatment with tolcapone and subthalamic deep brain stimulation implantation, respectively, reduced “off” time and eliminated this previously unreported motor complication.1 Atypical levodopa-related dystonic complications may develop late in those with relatively younger-onset Parkinson disease.2 The “flamenco dancer” posture, with shoulder abduction and elbow flexion, developed in the initially affected hemibody. The importance of recognizing this unusual “off” dystonia rests on the corrective benefits attained by enhancing dopaminergic or electric stimulation.
Figure. Abnormal posture in the off-medication state.
Shoulder abduction and elbow flexion demonstrated by case 1 (A, video 1) and case 2 (B, video 2) during the off-medication state. (C) Classic flamenco dancer's posture (2015 ClipArt Best, open access clip art collection).
Supplementary Material
Footnotes
Supplemental data at Neurology.org
Author contributions: Dr. Lovera: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, accepts responsibility for conduct of research and gave final approval, acquisition of data. Dr. Rodriguez-Porcel: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, accepts responsibility for conduct of research and gave final approval, acquisition of data. Dr. Urrea-Mendoza: analysis or interpretation of data, accepts responsibility for conduct of research and gave final approval, acquisition of data. Dr. Fasano: drafting/revising the manuscript, analysis or interpretation of data, accepts responsibility for conduct of research and gave final approval. Dr. Espay: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, accepts responsibility for conduct of research and gave final approval, acquisition of data.
Study funding: No targeted funding reported.
Disclosure: L. Lovera has received personal honoraria as a consultant/scientific advisory board member from Merz. F. Rodriguez-Porcel and E. Urrea-Mendoza report no disclosures relevant to the manuscript. A. Fasano has received grant support from the University of Toronto, the McLaughlin Centre, and the Michael J. Fox Foundation; he received speaking honoraria from UCB Pharma, Medtronic, Boston Scientific, AbbVie, Novartis, Chiesi Pharmaceuticals, and TEVA; he is on an advisory board for AbbVie and provided consultancies for UCB Pharma, Medtronic, Boston Scientific, and AbbVie. A. Espay is supported by the NIH (K23MH092735); has received grant support from CleveMed/Great Lakes NeuroTechnologies, and the Michael J Fox Foundation; personal compensation as a consultant/scientific advisory board member for AbbVie, Chelsea Therapeutics, TEVA, Impax, Merz, Pfizer, Acadia, Cynapsus, Solstice Neurosciences, Eli Lilly, Lundbeck, and US WorldMeds; royalties from Lippincott Williams & Wilkins and Cambridge University Press; and honoraria from UCB, TEVA, the American Academy of Neurology, and the Movement Disorders Society. Go to Neurology.org for full disclosures.
References
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