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“Off” state in Parkinson disease

This man experiences a latency of about an hour after taking levodopa before it kicks in. During this "off" state, he exhibits the classic signs of Parkinson disease. He has the characteristic coarse, "pill-rolling" resting tremor, which is limited to the right upper extremity. He has bradykinesia, or slowness of movement, accompanied, as typical, by a stooped posture, hypophonia (diminished voice volume), and a poverty of associated movements, including hypomimia or masked face (absence of facial expression), reduced eye-blinking, reduced or absent arm swings, and a lack of shifting positions while seated. He also has cogwheel rigidity, best evident while rotating his right wrist, and lead pipe (steady) rigidity on the left (not shown). He has difficulty rising from the seated position and can only take a few shuffling steps unassisted. He is rescued from his "off" state with a subcutaneous injection of apomorphine, a soluble dopamine agonist. (Contributed by Dr. Joseph Jankovic.)