Online Health Chat with Dr. Hubert Fernandez
October 29, 2010
Cleveland_Clinic_Host: Millions of people in the United States have movement disorders, including Parkinson’s disease. Each body movement requires a series of interactions between the brain, spinal cord, nerves and muscles. Movement disorders are a result of abnormal brain function and come in a variety of involuntary movements that may be slow, awkward or deliberate. Therefore, purposeful movement can become difficult and at times embarrassing.
Many movement disorders are inherited, while the causes of others may be attributed to injuries, autoimmune diseases, infections and certain medications, or simply unknown. The most common types of movement disorders include: restless legs syndrome, Tourette’s syndrome, Parkinson’s disease, dystonia, essential tremor, tics and dyskinesias. Incidence rates and demographics vary for different types of movement disorders.
Dr. Fernandez and the Center for Neurological Restoration at Cleveland Clinic physicians offer expertise and the total “team approach” in delivering the latest treatments for movement disorders to help people improve function and quality of life. Common treatment options include medications, therapy and surgical management.
Dr. Hubert Fernandez, MD, is a neurologist at the Cleveland Clinic, and Section Head of Movement Disorders for the Center for Neurological Restoration. His specialties include pharmacological, nonpharmacological and surgical treatment of movement disorders; clinical trials, “nonmotor” aspects of Parkinson’s disease and movement disorders, such as dementia, depression, anxiety; hallucinations; Parkinson’s disease; Huntington’s disease; Tourette’s syndrome; tremors; dystonia; chorea; tics and gait disorders. He completed his medical degree in the Philippines, his internship in Internal Medicine at the University of Pennsylvania/ Pennsylvania Hospital, and residency in Neurology at Boston University/Boston Medical Center.
Dr. Fernandez completed his fellowship in Movement Disorders at Brown University/Memorial Hospital of Rhode Island. He has authored/co-authored over 150 publications in Parkinson disease and Movement Disorders and is currently the Medical Editor of the Movement Disorders Society website. Join us in a free online chat with Dr. Fernandez, a Cleveland Clinic neurologist, who will answer your questions regarding movement disorders.
To make an appointment with Hubert Fernandez, MD or any of the other specialists in our Center for Neurological Restoration at Cleveland Clinic, please call 216.636.5860 or call toll-free at 866.588.2264. You can also visit us online at clevelandclinic.org/neurorestoration.
Movement Disorders Overview
carefree: How are movement disorders diagnosed? I have issues when trying to use certain muscles (like standing up and starting to walk). The doctors don’t think this is related to a movement disorder as my reflexes are normal. Are reflexes always affected?
Speaker_-_Dr__Hubert_Fernandez: When a patient moves more than usual, or moves much less than normal, he or she is said to have a movement disorder. Some movements are more concerning than others. The diagnosis is mainly clinical. Tests that are occasionally done are there to rule out other causes but not to rule in a diagnosis.
Reflexes are not really that affected, in general, in movement disorders.
jellybean: How is the differentiation between tics, akathesias, dyskinesia other movement disorders made?
Speaker_-_Dr__Hubert_Fernandez: You are correct, they are overlapping and the diagnosis can be tricky. But the distinction is made on clinical grounds. Perhaps, in this case, it is best to see a Movement Disorders Specialist to give the most accurate diagnosis. There are no diagnostic tests that can distinguish these movement disorders, so the more experienced your clinician is, the better it will be (I would think?)
caregiver: For those with intellectual disabilities, many have involuntary and abnormal muscle movements (tics, etc.) Are these considered a movement disorder?
Speaker_-_Dr__Hubert_Fernandez: Yes! Movement disorders can occur in any type of patients--young or old, male or female, mentally below average, average or superior!
jackop: Do movement disorders involve both voluntary and involuntary muscle movements?
Speaker_-_Dr__Hubert_Fernandez: Por supesto que si! (yes, of course)..:-)
Parkinson’s disease (PD)
chuckie: What is the difference between PD and Parkinsonism?
Speaker_-_Dr__Hubert_Fernandez: Parkinsonism is the general condition where someone has tremor at rest, stiffness, slowness, and balance problems. If one has 2 or 3 of these, then s/he has parkinsonism. One does not have to have all 4! Parkinson disease is the most common specific cause of parkinsonism. But there are other sources of parkinsonism—such as strokes, drug side effects, and also other neurodegenerative disorders (termed “Parkinson-plus syndromes”) that are “brothers” of PD but not exactly PD.
stacy: If Parkinson’s disease is diagnosed early and is mild and treatment begun quickly, is it possible to slow or stop the progression of the disease? I understand that there is no cure.
Speaker_-_Dr__Hubert_Fernandez: Well, we are working really hard at answering that question. The only way to answer that question is through a "clinical trial". We need to test one potential drug/agent/intervention at a time and see if PD patients who get exposed to this agent sooner will have a slower disease progression.
At the Cleveland Clinic (and also in other PD Centers) we are testing several agents to see if it can slow or stop disease progression in PD. So, before starting on a new PD medication, if you are newly diagnosed, PLEASE consider participating in a clinical trial. It might benefit you, and it will certainly benefit the entire community. WE NEED YOU!
hartline: I have no positive results from all PD medications. Does this mean I do not have PD, but do have Parkinsonism? Are there different medications for Parkinsonism as opposed to PD?
Speaker_-_Dr__Hubert_Fernandez: Very good question. The more you respond to the anti-PD meds, the more likely you have PD. However, up to 15% of PD patients will not respond well to medications. Also, we have to be careful about defining a “poor responder”. Sometimes, patients classify themselves as a poor responder because they have really bad side effects, or they did not feel a significant change but the dose was too low, or they were only observing what the medications did for their tremor (which is always unpredictable) and not their response to stiffness and slowness (which more reliably respond to medication. To me, poor response means that they tried a good dose of the medication and he did not feel a significant response to the stiffness in the slowness.
As for your other question, the medications used for Parkinson's disease and other forms of parkinsonism are generally the same. However the response of the medications on Parkinson’s disease is much stronger compared to the other forms of parkinsonism. Nonetheless is still worse trying these medications.
nilly: Does Parkinson’s Disease have any effect on the eyes or vision?
Speaker_-_Dr__Hubert_Fernandez: Dopamine (the substance that is not being produced in enough quantities in the brain of patients with PD) is also present in the retinal layer of the eye. Thus, PD patients can have eye changes. However, the good news is that it is mostly "subclinical"...meaning it is appreciated mostly with sophisticated eye exams but not something patients typically complain about.
Having said that, some of our PD patients complain of impaired depth perception, impaired contrast sensitivity, double vision, blurred vision, droopy eyelids, or eyes always closed. Some of these may be directly due to PD and others are a side effect of the medication(s).
petey: Can you discuss the complications of having Parkinson’s Disease and Lewy Body Disease or other forms of dementia?
Speaker_-_Dr__Hubert_Fernandez: That requires a long answer (and my fingers are starting to hurt...just kidding). But the main challenge in someone with Parkinson's and dementia is that it limits our ability to be creative with regards to PD medications. We have to simplify our medications significantly as increasing or adding medications can worsen their cognition. As a result, they tend to be not as well motorically controlled compared to a Parkinson patient who is not demented. Thus, they fall more easily, and they develop complications more easily (such as infections, fractures, sores, etc).
clearly: Are there cognitive issues related to Parkinson’s?
Speaker_-_Dr__Hubert_Fernandez: Yes, some are subtle and what we call "subclinical" and some can be affected more.
Typically, our PD patients have what we call the "tip of the tongue syndrome". They know what they want to say, but they are just blanking on the right word. Then others are forgetful. Some have difficulty concentrating or "multi-tasking" and others have a slower "processing time" so they have to analyze things more carefully and slowly.
pattylamielle: My 83 year old mother was diagnosed with Parkinson's about 2 years ago. She has now developed LIP SMACKING. It is uncontrollable and the only time it goes away is during sleep. Do you have any recommendations?
Speaker_-_Dr__Hubert_Fernandez: She is either experiencing dyskinesias (involuntary movements from the PD medications), or has dry mouth (if she is on an anticholinergic drug such as artane) and is trying to wet her lips in the process. Typically, lip smacking is seen as a side effect of antipsychotic medications such as risperidone or olanzapine, etc (so make sure she is not on any of these!).
If it is dyskinesias from the PD meds, one way of treating this is to lower her medications or to add amantadine. Or, if it is not so bothersome, to simply ignore it. You should talk to her neurologist about these choices. Thanks!
prjones: I have been considered a candidate for Deep Brain Stimulation surgery to treat my PD, but I am concerned about the risks. What are the most common risks and will the improvement outweigh the risk?
Speaker_-_Dr__Hubert_Fernandez: Deep brain stimulation surgery is actually not as scary as it sounds. Patients are awake during the surgery because it is painless and we need their feedback to make sure that we are in the right location. Most patients can leave the hospital in 2 to 3 days. However, it is still brain surgery, so it has the typical side effects of bleeding and infection and wire breakage and malfunction. These are exceedingly rare in our Center and in other Centers who do a lot of these procedures. Clearly, one has to weigh the benefit of better motor control versus the risk of surgery. You can discuss this further with your neurologist and/or neurosurgeon.
happy2: Does a patient have to continue taking PD meds after DBS surgery?
Speaker_-_Dr__Hubert_Fernandez: It depends. In general, we are able to decrease the medications by 25-50%. In some rare patients, we are able to discontinue the medications entirely. In others there may be no change at all. The bottom line is that medication adjustment and decrease in dose is more of a reaction (in trying to balance the stimulation and the medication) and not a goal. In finding that balance, sometimes we need to decrease the meds more in some, less in others.
munchkin: My father has made the decision to have deep brain stimulation. After surgery, what precautions will he need to take (lifestyle mostly)?
Speaker_-_Dr__Hubert_Fernandez: Not much, actually, if the DBS is working. He should always carry "the magnet" so if the DBS is inadvertently shut off at security doors in malls or airports, he can turn it back on again. He should be careful about MRI and other procedures that can shut of the device or alter settings. He should be wearing a bracelet or some identification in his wallet that he has a DBS. But mostly that's it.
bluebyu: Can you talk about the DNA test for Parkinson’s Disease? Is this something that you do often? Is there any advantage to having it done and finding out whether you have the mutation?
Speaker_-_Dr__Hubert_Fernandez: Genetic testing for PD is just in its infancy stage. We have not discovered all the genes that can cause or predispose someone to having PD. We are only beginning to scratch the surface. Therefore, I tend not to order them. It can give a false sense of security for those who test negative and unnecessary worry for those who test positive.
playerb: Can children get Parkinson’s disease? What would some ‘warning signs’ be?
Speaker_-_Dr__Hubert_Fernandez: Yes, it is called "juvenile parkinsonism". The typical symptoms of tremor, stiffness, and slowness may also be seen in children with parkinsonism. However, there are a few unique characteristics if one gets this in childhood:
- There is a higher likelihood of developing dyskinesias and dystonias. In fact dystonia can occur even before starting on any PD medication
- There is a high likelihood of it being hereditary
- They typically need only a smaller dose of PD medications
- It can improve (to some degree) with sleep
johnloper: Are there any certain food or mineral supplements that are helpful to patients with Parkinson’s disease?
Speaker_-_Dr__Hubert_Fernandez: Very good and important question! Actually, we have been looking at these for quite some time now. To date, none has been definitively proven to delay or help with PD. We looked at Vitamin E because of its neuroprotective properties, but this did not pan out as significant in the DATATOP trial. We have some reason to think that CoQ10 and creatine may slow disease progression in PD, but the jury is still out on this one. We are testing very high doses of CoQ10 (1200 mg and 2400 mg per day). So it is important also that if anyone of you are newly diagnosed with PD, and still are unmedicated, that you go to a Center where compounds such as these are being tested!
Cheri: My elderly friend has Parkinson's with tremors. Her identical twin developed the same symptoms but mirrored on the opposite side of the body. Is this typical for twins and if one twin develops symptoms is it likely that the other will too?
Speaker_-_Dr__Hubert_Fernandez: Actually, the answer is not so clear cut. We have one large NIH sponsored study that tried to answer your question. This was based on the World War II Veteran Twin Registry. In that study, if the Parkinson’s occurred before the age of 50, the identical twin has a higher chance of also getting Parkinson at some point. But if the PD occurred after the age of 50, then the chances of the other twin getting it was not different, say, from a fraternal twin getting it.
I hope I answered your question. Bottom line, the percentages differ, with the age being the biggest factor.
Cheri: Back to the twins question they were definitely both symptomatic after age 50. What I find interesting is that the symptoms are on opposite sides of their bodies. Is that usual?
Speaker_-_Dr__Hubert_Fernandez: The side for symptoms is really the toss of a coin. It is not unusual to me. There is a 50-50 chance of it being on the same side or opposite side.
johnloper: Are there any certain food or mineral supplements that are helpful to patients with Parkinson’s disease?
Speaker_-_Dr__Hubert_Fernandez: Very good and important question! Actually, we have been looking at these for quite sometime now. To date, none has been definitively proven to delay or help with PD. We looked at Vitamin E because of its neuroprotective properties, but this did not pan out as significant in the DATATOP trial. We have some reason to think that CoQ10 and creatine may slow disease progression in PD, but the jury is still out on this one. We are testing very high doses of CoQ10 (1200 mg and 2400 mg per day). So it is important also that if anyone of you are newly diagnosed with PD, and still are unmedicated, that you go to a Center where compounds such as these are being tested!
matlida: My 24 y.o. daughter has Klippel Feil Syndrome, and has always had cervical dystonia on the right side and writer's cramp or toes cramps. She began having right sided fasciculations associated with her pain exacerbations about 5 months ago. For the past 2 months though, she has had severe, uncontrollable generalized spasms throughout her entire body which cause painful abnormal body positioning, and even obstruct her airway now-they have no pattern. She was hospitalized twice, but we are learning it is basically untreatable since there is no organic cause -according to the scans. The doctors recommend minimizing stress and relaxing. That is too simplistic I think, considering the complexity of her conditions. My questions: is it common for cervical dystonia to generalize in such a severe and sudden way? If so, how much improvement can we expect? .Lastly, her Chicago neurologist told her to take 2.5 mg immediately when an episode begins. (She is a long time Valium user) that doesn't seem to do anything to relieve the crises. Any other suggestions? thank you.
Speaker_-_Dr__Hubert_Fernandez: No, it is uncommon for cervical dystonia to generalize in the way that you describe. Perhaps it is time to get a second opinion from another neurologist or movement disorders specialist? Pain is not so common with dystonia, but it is certainly possible. I also hope that your daughter has been ruled out for seizures...just to be sure. Best of luck to you!
carlmoner: Both my mother and father had dystonia. Is it hereditary?
Speaker_-_Dr__Hubert_Fernandez: Just like Parkinson's disease, dystonia can be hereditary or it can be non-hereditary. If one of your parents had dystonia and you are suffering from dystonia as well, then there is a possibility that you have a hereditary form of dystonia.
However, having one or both parents with dystonia does not necessarily mean that you will also acquire this illness. There are no gene tests to determine if you have the genetic dictation for some but not for all types of hereditary dystonia.
ChyvonneB: Is it safe to become pregnant while receiving Botox injections for Cervical Dystonia?
Speaker_-_Dr__Hubert_Fernandez: Great question! The use of botulinum toxin during pregnancy is designated as a CLASS C by the FDA, meaning that its safety in pregnancy and the fetus has not been adequately studied. Therefore, whenever botulinum toxins are to be used during pregnancy, the benefits must be carefully weighed with the risks. But it is not an absolute contraindication, per se.
ChyvonneB: I read your response to question one. Is it the general thought of doctors that Cervical Dystonia is not painful? (I beg to differ). My experience with Cervical Dystonia has been very painful due to spasms and muscle imbalance.
Speaker_-_Dr__Hubert_Fernandez: Not quite. In general, dystonias do not hurt, EXCEPT cervical dystonia. They hurt quite a bit. I thought the case was describing body and extremity spasms so I said this was rather unusual (but not impossible) for dystonia. But for cervical dystonia, absolutely, they hurt!
ChyvonneB: I have Cervical Dystonia. I see a neurologist for Botox shots. But, most other medical professionals I've seen (i.e. physical therapists, pain management specialists, etc.) have never dealt with anyone who has had CD, so they don't really know what to do with me. This has been quite frustrating, because there is a lack of knowledge about CD. Do you think the Cleveland Clinic's dept. of neurology would ever consider offering comprehensive services from support staff who would become highly trained to deal specifically with Cervical Dystonia patients and/ or people who have related movement disorders. (Also, a good medical massage therapist would be a blessing under this type of program as well).
Speaker_-_Dr__Hubert_Fernandez: I hope so, too! That is one of my priorities when I moved to the Cleveland Clinic a few months ago--to set up truly comprehensive centers in Parkinson's disease, Huntington's disease and dystonia.
Thank you for your comment!
Restless Leg Syndrome/ Periodic Limb Movement Syndrome
kc234: When should I consider seeing a doctor for Restless Legs Syndrome?
Speaker_-_Dr__Hubert_Fernandez: Restless leg syndrome is perhaps the most common movement disorder in the world. It is experienced by roughly 10% of the general population. However, only about 3-4% of these patients are significantly disabled from this condition such that they seek medical attention.
The typical symptoms of restless leg syndrome are that of cramping, tingling, burning, on oral restless sensation in the leg that occurred mostly in the relaxed state and also at night. To relieve this sensation the patient then tries to walk about. The patient then feels significant relief and returns to bed only for the symptoms to return. This is the typical cycle experienced by a patient with restless leg syndrome every night. If you are really bothered by this and have difficulty sitting through a movie, sleeping in bed at night, or relaxing on the plane because of restless leg syndrome, then yes it is time to see a doctor.
martin90: How can I get a good night’s sleep, despite Restless Legs Syndrome?
Speaker_-_Dr__Hubert_Fernandez: Fortunately, restless leg syndrome is rather easy to treat. There are medications that relieve the symptoms of RLS and therefore will make you sleep more soundly. Examples of these are dopamine agonists, Neurontin® (gabapentin), benzodiazepines, and some opiates. You will need to see your doctor to see which one of these medications would be the best for you.
sevyressag: I have periodic limb movement/RLS and am now taking Mirapex® for it. Sometimes it works and sometimes it doesn't. Seems if my hemoglobin is low the movement is worse. Mirapex® makes my drowsy so I can only take it at night just before bedtime. Is there any medication for RLS that doesn't make you drowsy?
Speaker_-_Dr__Hubert_Fernandez: There are lots of other medications you can try. A lot of them make people drowsy, so it is taken at night, for the most part (which is when the RLS and PLMS is worse anyway). You can try the long acting Mirapex® or Requip® if you want. To me, they are the most effective. But gabapentin, clonazepam (also makes people sleepy) are good choices also.
Your low hemoglobin needs to be investigated. Iron deficiency anemia is a common cause of RLS. If you have that, then iron pills will help significantly. Good luck!
blanketyblank: What is Giles de la Tourette Syndrome (GTS)?
Speaker_-_Dr__Hubert_Fernandez: Tourette syndrome is a disorder characterized by tics and by behavioral abnormalities occurring usually before the age of 18. Tics are repetitive movements. They are rather stereotypic. They can only be suppressed momentarily, and they can be disabling. Frequent grunting, sniffing, and twitching are common examples of tics. Typically in Tourette's syndrome, there is associated obsessive-compulsive behavior. Therefore both the tic and the OCD symptoms will both need to be treated.
coldseas: How can I have GTS if I don’t have coprolalia?
Speaker_-_Dr__Hubert_Fernandez: The tics in Tourette's syndrome can be motor tics or vocal tics. Examples of motor tics are sniffing, twitching, shrugging. Examples of vocal tics are grunting and coprolalia. Therefore there are many manifestations of tics.
baffled: Why do people with Tourette’s blurt out inappropriate comments/words? Why those words? My niece says that she is not even thinking those things. They just come out. I can say that I “understand’” involuntary muscle movements (tics), but why the words – and in particular – those sorts of words?
Speaker_-_Dr__Hubert_Fernandez: Well, they say lots of other words...they grunt, sniff, scratch, scream vowels, etc. I have one patient who screams different colors...red, yellow, blue, green! But what is catching our attention certainly are the vulgar words.
I can't explain why. Each brain is wired differently. And it is not that tic patients who cuss were not taught properly. The tic brain is struggling with what it wants to blurt out and what it wants to suppress. Sometimes, one wins out more than the other?
hopefloats: Is there medication that can help my TS (Tourette Syndrome)?
Speaker_-_Dr__Hubert_Fernandez: Definitely. There are now several medications to help with Tourette's. I think that the trick here is that you treat the patient has a whole, not only for the tics but for also the behavioral problems associated with it.
Huntington’s Disease (HD)
cryme: In regards to Huntington’s Disease what determines the time of onset (meaning age)?
Speaker_-_Dr__Hubert_Fernandez: It is very variable. The average age of onset of Huntington's disease is between 30-54 years old, but it can occur as early as 4 years old, and the oldest HD patient I diagnosed was about 75 years old.
The higher the tri-nucleotide repeats in the HD gene test, there is some (but not absolute) correlation that the disease will manifest early. This is not an exact science though, so I do not generally disclose the number of repeats to the patient, unless they really want to know. For the most part, the most important information they need to know is whether the gene test is positive, negative or indeterminate.
lancers: What are some early indicators of Huntington’s Disease (HD)?
Speaker_-_Dr__Hubert_Fernandez: The first manifestation of Huntington's disease is different for each person. Sometimes the initial manifestation is simply difficulty concentrating or multitasking.
Sometimes, the first manifestation is that of depression, anxiety, or irritability. The more specific initial manifestation of Huntington's disease is that of loss of coordination or jitteriness or clumsiness.
johnstone: What types of tests and examinations are performed to determine if someone has HD?
Speaker_-_Dr__Hubert_Fernandez: Fortunately, we now have a gene test to look for the genetic dictation seen in Huntington's disease. This is over 99% specific and sensitive. Therefore, if a gene test is taken, we need to perform some genetic counseling if the patient is still asymptomatic.
greatdanes: What can help improve memory in a patient with Huntington’s Disease?
Speaker_-_Dr__Hubert_Fernandez: That is a tough question. We tried to use the same medications used in Alzheimer's disease and in Parkinson's disease with memory problems. At least our own experience is that a lot of our HD patients did not tolerate it.
A promising agent is Namenda® (memantine). It enhances cognition, but is a close brother of amantadine which can help with the extra movements in Huntington's disease. But we need to perform clinical trials to make sure this is true throughout.
martin: How are Parkinson’s disease and essential tremors differentiated?
Speaker_-_Dr__Hubert_Fernandez: Sometimes, it can be tricky and sometimes it can be pretty straightforward. In general, PD tremors occur at rest (when the hand is not being used), and also they have stiffness and slowness. Essential tremors have shaking more with action (when they are using their hand such as handwriting, brushing teeth, drinking coffee, etc) and they don't have much stiffness and slowness. But this is not an absolute distinction. There can be quite a bit of overlap between the two. An experienced Movement Disorders specialist or general neurologist will be able to help out, hopefully!
glasshouses: Does the consumption of alcohol affect ET?
Speaker_-_Dr__Hubert_Fernandez: Yes it does. Small to moderate intake of alcohol, be it beer or wine or other alcoholic drinks, often transiently relieves the symptoms of essential tremor. However, obviously, we did not recommend this as a permanent treatment.
jethro: Will ET cause death or shorten life span?
Speaker_-_Dr__Hubert_Fernandez: The good news is that essential tremor is typically not a progressive disorder and therefore it is not known to shorten life span or to lead to death. In half the cases, the medications we gave or prescribe relieve the tremor. However, in some cases the tremor is refractory to medications and we may consider deep brain stimulation surgery.
Exercise and Movement Disorders
caregiver: What are the exercise guidelines for a person with movement disorders? Does it differ depending on the disorder?
Speaker_-_Dr__Hubert_Fernandez: The most important thing is that the exercise is performed safely! It does not matter what form of exercise it is if the patient falls, or gets hurt.
The second most important thing is that it is done regularly (preferably every other day, if not every day, for at least 30-45 minutes). We prefer aerobic exercises rather than weight lifting, etc.
Our group at the Clinic has done quite a bit of research on this and we feel that forced exercise (such as having the patient keep up with a non-PD person in a tandem bike) is better than voluntary exercise.
But the bottom line is that try to stay as active as possible but do it in a safe manner. Walking, swimming, biking, spinning, water aerobics are all good!
rottenweiler: Over the past six years I have experienced progressive weakness/numbness in my legs. My doctors attribute this to six weeks of radiation treatments of a spinal tumor/vascular malformation back in 1966 at University Hospital, Cleve. OH. I am normally very active, but this is dramatically impacting my life. I am a 68 yr. old school administrator. Rads received is unknown; med. records no longer available. Is this a common occurrence for post radiation treatment, 40 years after the treatments? My options are?
Speaker_-_Dr__Hubert_Fernandez: Very important question. Unfortunately, I may not be the best expert to help you with this as your condition does not sound like a "movement disorder". We need to make sure, first, that there is no tumor recurrence. Then, we need to find out if indeed there are post-radiation changes (there are immediate and long-term radiation changes to consider. Then finally, we need to consider whether you are suffering from an unrelated neuromuscular condition. You will probably need to see a neuro-oncologist first followed by a neuromuscular expert...?
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Hubert Fernandez is now over. Thank you again Dr. Fernandez for taking the time to answer our questions about Parkinson’s disease and Other Movement Disorders.
Speaker_-_Dr__Hubert_Fernandez: Thanks everyone for participating! I hope you learned as much as I did? It was a pleasure "chatting" with all of you. I promise, I typed as fast as I could. Sorry, if I was not able to answer the questions of others. Perhaps, we can just meet in person? Have a great day everyone!