Treating the Motor Symptoms of Parkinson Disease John C. Morgan, MD, PhD; Susan H. Fox, MBChB, MRCP(UK), PhD ABSTRACT Purpose of Review: After a patient is diagnosed with Parkinson disease (PD), there are many therapeutic options available. This article provides examples of prototypical patients encountered in clinical practice and illustrates the various pharmacologic and nonpharmacologic treatment options for the motor symptoms of PD. Recent Findings: Levodopa became available in the late 1960s and remains the gold standard for the treatment of PD even today. Since that time, amantadine, monoamine oxidase type B inhibitors, dopamine agonists, and catechol-O-methyltransferase inhib- itors have emerged as monotherapy, add-on therapies, or both, in the armamentarium against PD. The most appropriate time to start such drugs remains a clinical decision according to patient symptoms. However, earlier use of levodopa is the more common practice due to its superior benefit and the side effects of dopamine agonists. Deep brain stimulation continues to be the most effective treatment for motor symptoms in appropriate patients, and advances in technology may improve efficacy. New ways to deliver levodopa have emerged (effective extended-release oral preparations and levodopa/carbidopa intestinal gel), and these medications provide additional options for certain patients. Exercise and neurorehabilitation are increasingly recognized as important tools to combat the motor symptoms of PD. Nondopaminergic drugs may help nonYlevodopa-responsive motor symptoms. Summary: Treatment of PD is multifaceted and requires a tailored pharma- cotherapeutic and nonpharmacologic approach for a given patient. Patients should be at the center of care, and clinicians should try to provide optimum benefit through the many treatment options available. Continuum (Minneap Minn) 2016;22(4):1064–1085. INTRODUCTION This article reviews treatment options of the motor symptoms of early through advanced Parkinson disease (PD). The management of early PD affords the widest array of pharmacotherapies and other modalities for the clinician to choose from, depending on the pre- senting patient. Early PD has an evolv- ing definition, but the diagnosis still depends on the core motor features of asymmetry, bradykinesia, resting tremor, and cogwheel rigidity. 1 Anticholinergics were the main treatment for PD for perhaps a century, until the late 1960s, when Cotzias and others defini- tively proved that levodopa was effec- tive for the motor symptoms of the disease. 2 Thus, for the past 50 years, treatment has largely focused on ame- liorating the dopaminergic deficit in PD. While levodopa remains the most effec- tive pharmacotherapy for PD motor symptoms, there are many other op- tions that are quite useful in the ap- propriate patient. Address correspondence to Dr John C. Morgan, Movement Disorders Program, Department of Neurology, Medical College of Georgia, Augusta University, 1429 Harper Street, HF-1154, Augusta, GA 30912, jmorgan@augusta.edu. Relationship Disclosure: Dr Morgan has received personal compensation as a speaker and consultant for Impax Laboratories Inc and Teva Pharmaceutical Industries Ltd, as a speaker for the National Parkinson Foundation, and as a consultant for AbbVie, Acadia Pharmaceuticals, Acorda Therapeutics, Cynapsus Pharmaceuticals Inc, Lundbeck, UCB Inc, and Veloxis Pharmaceuticals. Dr Morgan has received research/grant support as principal investigator or subinvestigator from AbbVie, ACADIA Pharmaceuticals Inc, Biotie Therapies, Civitas Therapeutics, Kyowa Hakko USA Inc, Lundbeck, the National Institutes of Health, National Parkinson Foundation, and the Parkinson Study Group, and has served as an expert witness in various court cases. Dr Fox has received salary support for serving as the co-editor of the International Parkinson and Movement Disorder Society website, as a speaker for Ipsen Pharmaceuticals, Inc; Teva Pharmaceutical Industries Ltd; and Zambon Company SpA; and for serving on the advisory boards of Lundbeck, Orion Pharma Ltd, and Novartis International AG. Dr Fox has received research/grant support from Avanir Pharmaceuticals, the Michael J. Fox Foundation, the National Institutes of Health, and Parkinson Society of Canada and has received research/grant support as site principal investigator for clinical studies from Adamas Pharmaceuticals Inc, Cynapsus Pharmaceuticals Inc, and Kyowa Hakko USA Inc. Dr Fox receives royalties from Oxford University Press. Unlabeled Use of Products/Investigational Use Disclosure: Drs Morgan and Fox discuss the unlabeled/investigational use of amantadine and methylphenidate for freezing Continued on page 1065 1064 www.ContinuumJournal.com August 2016 Review Article Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.