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Associated Neurotransmitters
Dopamine

The main neurotransmitter thought to be involved in hypokinesia is dopamine. Essential to the basal ganglionic-thalamo-cortical loop, which processes motor function, dopamine depletion is common in these areas of hypokinesic patients. Bradykinesia is correlated with lateralized dopaminergic depletion in the substantia nigra. The dopamine pathway in the substantia nigra is essential to motor function, and commonly a lesion in this area correlates with displayed hypokinesia. Tremor and rigidity, however, seem to be only partially due to dopamine deficits in the substantia nigra, suggesting that there are other processes involved in motor control. Treatments for hypokinesia often either attempt to inhibit the uptake of dopamine or increase the amount of neurotransmitter present in the system.

GABA and Glutamate

The inhibitory neurotransmitter GABA and the excitatory glutamate are found in many parts of the central nervous system, including in the motor pathways that involve hypokinesia. In one pathway, glutamate in the substantia nigra excites the release of GABA into the thalamus, which then inhibits the release of glutamate in the cortex and thereby reduces motor activity. If there is too much glutamate initially in the substantia nigra, then through interaction with GABA in the thalamus and glutamate in the cortex, movements will be reduced or will not occur at all.

Another direct pathway from the basal ganglia sends GABA inhibitory messages to the globus pallidus and substantia nigra, which then send GABA to the thalamus. In the indirect pathway the basal ganglia sends GABA to the globus pallidus which then sends it to the subthalamic nucleus, which then disinhibited sends glutamate to the output structures of the basal ganglia. Inhibition of GABA release could disrupt the feedback loop to the basal ganglia and produce hypokinesic movements.

GABA and glutamate often interact with each other and with dopamine directly. In the basal ganglia, there is a nigrostriatal pathway where GABA and dopamine are housed in the same neurons and released together.

Motor Motivation
Often debated is whether the efficiency, vigor, and speed of movements in patients with hypokinesia are tied to motivation for rewarding and against punishing stimuli. The basal ganglia has been tied to the incentives behind movement, therefore suggesting that a cost/benefit analysis of planned movement could be affected in hypokinesia. Interestingly, rewards have not been shown to change the aspects of a hypokinesic individual’s movement. In fact, the motor planning and control of a patient with hypokinesia is already as efficient as possible (as shown by slightly faster but generally the same movement after DBS of the subthalamic nucleus). This suggests that hypokinetic individuals simply have a narrower range of movement that does not increase relative to motivation.

Other studies have come to the same conclusion about rewards and hypokinesia but have shown that aversive stimuli can, in fact, reduce hypokinesic movement. Shiner et al., in their assessment of this finding, suggest that dopamine is either less involved or has a more complex role in the response to punishment than it does to rewards, as the hypodopaminergic striatum allows more movement in response to aversive stimuli.

Cognitive Impairment
Bradykinesia has been shown to precede impairment of executive functions, working memory, and attention. These cognitive deficiencies can be tied to non-function of the basal ganglia and pre-frontal cortex, which is also linked to the motor-dysfunction of hypokinesia. Tremor and rigidity have not had observable connections to cognitive impairments, supporting the idea that they are not as involved in the dopamine pathway in the basal ganglionic-thalamo-cortical loop. Dopaminergic treatments have shown improvement in cognitive functions associated with hypokinesia, suggesting they are also dependent on dopamine levels in the system.

Connections to Other Medical Conditions

 * Stroke- Frontal and subcortical lesions due to stroke more likely to cause hypokinesia than posterior lesions.
 * Schizophrenia- Lack of connections between right supplementary motor area to the pallidum and the left primary motor cortex to the thalamus shown in patients with schizophrenia which is thought to lead to hypokinesia.
 * Hyperammonia- Chronic hyperammonia and liver disease can alter neurotransmission of GABA and glutamate by increasing the amount of glutamate in the substantia nigra and inhibiting movement.
 * Progressive supranuclear palsy- Very similar to Parkinson’s disease, supranuclear palsy does not actually display hypokinetic characteristics of movement (no progressive decrement despite small amplitude). Hypokinesia can help to distinguish this disorder from Parkinson’s.

Treatments
Dopaminergic drugs are commonly used in the early stages of the hypokinesia to treat patients. However, with increased intake they can become ineffective because of the development of noradrenergic lesions. While initially the dopaminergic drugs may be effective, these noradrenergic lesions are associated with hypokinesic gait disorder development later on.

Once the reaction to dopaminergic drugs begins to fluctuate in Parkinson’s patients, Deep Brain Stimulation (DBS) of the subthalamic nucleus and medial globus pallidus is often used to treat hypokinesia. DBS, like dopaminergic drugs, initially provides relief but chronic use causes worse hypokinesia and freezing of gait. Lower frequency DBS in non-regular patterns has been shown to be more effective and less detrimental in treatment.

Methylphenidate, commonly used to treat ADHD, has been used in conjunction with levodopa to treat hypokinesia in the short-term. The two work together to increase dopamine levels in the striatum and prefrontal cortex. Methylphenidate mainly inhibits dopamine and noradrenaline reuptake by blocking presynaptic transporters and levodopa increases the amount of dopamine, generally improving hypokinesic gait. Some patients, however, have adverse reactions of nausea and headache to the treatment and the long-term effects of the drug treatment still need to be assessed.

Another treatment that is still in an experimental stage is the administration of nociception FQ peptide (NOP) receptor antagonists. This treatment has been shown to reduce hypokinesia in animal studies when increasing nociception FQ in the substantia nigra and subthalamic nucleus. Low doses can be taken with dopaminergic treatment to decrease the amount of L-dopa needed, which can reduce its long-term side effects and improve motor performance.

Dance therapy has also been shown to reduce hypokinesic movements and rigidity, though targeted more at the muscular aspects of the disorder than the neural activity.

Demographic Differentiation
Gender

More men than women typically develop hypokinesia, which is reflected in young and middle aged populations where females have displayed higher levels of nigrostriatal dopamine than males. In the elderly, however, this differentiation is not present. Typically, women exhibit more tremor in the beginning development of hypokinesia. In the disorder, men tend to display more rigidity and women more bradykinesic motor behavior, though this is not true in all cases.

Age of Onset

Hypokinesia is displayed in the brain and outwardly slightly different depending on when an individual is first affected. In young-onset hypokinesia (younger than 45 years of age), there is typically slightly more cell loss in the substantia nigra and more displayed dystonia and muscle stiffness. In old-onset hypokinesia (older than 70 years of age), there is typically more of a hypokinesic gait and difficulty walking and no dystonia. Both onsets can display resting tremor, although more generally found in old-onset cases.