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) As noted above, these various motor impediments and tremors characteristically begin in one limb (more often the left) and spread to one side and later to both sides, until the patient is quite helpless Yet in the excitement of some unusual circumstance (as escaping from a re, for example), the patient with all but the most advanced disease is capable of brief but remarkably effective movement (kinesis paradoxica) Regarding other elicitable neurologic signs, there is an inability to inhibit blinking in response to a tap over the bridge of the nose or glabella (Myerson sign), but grasp and suck re exes are not present and buccal and jaw jerks are rarely enhanced Commonly there is an impairment of upward gaze and convergence; if prominent or noted early in the disease, this sign suggests more the possibility of progressive supranuclear palsy.

The original Fraxel laser and subsequent models use an optical tracking system of mirrors that creates the fractionated beams and focuses them on the skin. This mechanism is able to provide constant output and adjustment corrections for changes in velocity. This means that the user delivers the pulses while constantly moving the handpiece across the skin surface. Other manufacturers use special lenses that fractionate the beam. Cynosure s Af rm and Af rm Multiplex lasers use such lenses to fractionate the beam into 1000 pixels in a 10-mm spot size. These are then delivered as single pulses. The addition of forced air cooling adds improved patient comfort and safety to these systems. Palomar has a 1540-nm laser (Lux1540 ) that uses a fractionating lens to evenly disperse the 10-mm laser beam and deliver energy penetrating to depths of over 1000 microns. Newer technologies include the aforementioned Af rm Multiplex and fractional CO2 and erbium lasers. The Af rm Multiplex represents a unique type of treatment in that it offers the combination of two wavelengths in one treatment session. Each treatment delivers sequential pulses of both 1440-nm and 1320-nm lasers. The 1440-nm wavelength is predominantly absorbed in the epidermis and upper dermis penetrating to depths of 400 to 500 microns, and the 1320-nm laser penetrates more deeply to provide bulk heating of deeper dermal elements (2 mm) for additional skin tightening (Figure 4.6). Fractionated CO2 (Active FX , Lumenis) and erbium lasers (Harmony Pixel ., Alma Lasers ; PROFractional, Sciton Inc.) offer a different type of fractional resurfacing

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The bradykinesia may extend to eye movements, in that there is a delay in the initiation of gaze to one side, slowing of conjugate movements (decreased maximal saccadic velocity), hypometric saccades, and breakdown of pursuit movements into small saccades There are no sensory changes, but a variety of paresthetic complaints are common Drooling is troublesome; an excess ow of saliva has been assumed, but actually the problem is one of failure to swallow with normal frequency Seborrhea and excessive sweating are probably secondary as well, the former due to failure to cleanse the face suf ciently, the latter to the effects of the constant motor activity Postural instability can be elicited by tugging at the patient s shoulders from behind and noting the lack of a small step backward to maintain balance The tendon re exes vary, as they do in normal individuals, from being barely elicitable to brisk.

Activity Frequency:

Even when parkinsonian symptoms are con ned to one side of the body, the re exes are usually equal on the two sides, and the plantar responses are exor Exceptionally, the re exes on the affected side are slightly brisker, which raises the question of corticospinal involvement; but the plantar re ex remains exor In these respects, the clinical picture differs from that of corticobasal ganglionic degeneration, in which rigidity, hyperactive tendon re exes, and Babinski signs are combined with apraxia (see further on) There is a tendency to orthostatic hypotension and sometimes syncope; this has been attributed by Rajput and Rozdilsky to cell loss in the sympathetic ganglia However, syncope is never as prominent as in the Shy-Drager type of striatonigral degeneration (page 925).

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