Corticobasal Degeneration (CBD)
Corticobasal degeneration is a form of atypical parkinsonism (a parkinsonism-plus syndrome), which means that it shares some features with Parkinson's disease such as stiffness (rigidity), tremor, slowness of movement (bradykinesia) and instability. CBD, however, is distinct from Parkinson's disease in regards to other clinical features, including its response to treatment. CBD was first described by Rebeiz and colleagues in 1968. As the name implies, it results in gradual loss of nerve cells (neurodegeneration) in the surface of the brain (the cerebral cortical areas) as well as deep structures (the basal ganglia). These brain regions are heavily involved in the control of movement, so CBD causes problems with mobility. In contrast to other types of atypical parkinsonism, the neurodegeneration in CBD is markedly asymmetrical, thus the symptoms usually start on one side of body and remain worse on that half throughout the course of the disease.
Symptoms and Signs
The most characteristic presenting feature of CBD is the gradual loss of use of one hand or leg (called "apraxia"). Patients may also experience abnormal postures of their limbs or neck (dystonia), painful rigidity, muscle spasms, and eventually irreversible muscle contractures, all involving the same side of the body. They may have jerking movements (myoclonus) of one hand while at rest or with activity. Some patients also have language dysfunction (e.g. primary progressive aphasia) or slurred speech (dysarthria), difficulty opening or moving their eyes, as well as difficulties with their concentration, and behavior. Although disorders of thinking and memory (cognitive changes) may be noted early in the course of the disease, dementia usually occurs only in more advanced stages. On examination, there is often loss of sensation in one or both sides of the body, even though patients typically do not complain of numbness. On occasion, an affected limb can seem to have a "mind of its own," and make seemingly purposeful movements that the patient cannot control. This problem, known as "alien" hand or limb, is sometimes accompanied by the feeling that one's limb is somehow foreign. The symptoms of CBD usually worsen over 3-8 years and often result in great disability, including the inability to communicate or ambulate. Gait and balance difficulties, however, occur later in patients with CBD compared with other forms of atypical parkinsonism.
There is no diagnostic test for CBD, but a neurologist usually suspects the diagnosis based on a patient's history, physical examination and clinical course. Early in the disease, it can be challenging to differentiate CBD from other forms of parkinsonism, such as Parkinson's disease or progressive supranuclear palsy (PSP) and in some cases there is an overlap in clinical features between the different parkinsonian disorders. Imaging with CT or MRI may show asymmetrical shrinkage (atrophy) of the cerebral cortex (brain surface) on the side opposite to the more affected limbs. Brain scans, however, cannot yet reliably distinguish CBD from other similar neurodegenerative diseases. In some cases, the diagnosis of CBD cannot be confirmed until an autopsy examination of the brain is performed, which usually shows "ballooned" neurons, protein aggregations (neuronal inclusions) and other characteristic abnormalities resulting from abnormal accumulation of the tau protein.
The cause of CBD is not yet known. Like other neurodegenerative diseases, patients with CBD accumulate misfolded proteins within specific brain cells. Mishandling of tau, a protein that normally acts to stabilize the cellular skeleton of neurons (nerve cells), appears to play a major role but the details remain elusive. CBD is usually not an inherited condition.
As with the other atypical parkinsonian syndromes, treatment with levodopa and related medications sometimes lessens muscle rigidity and improves mobility, but results are often disappointing. Muscle spasms and jerking can be reduced with muscle relaxants, such as clonazepam, and with botulinum toxin injections into affected parts of the body. Medications for memory loss, depression and anxiety may be useful in patients with these problems.
Other treatments for CBD include physical therapy and stretching exercises designed to relieve rigidity and to prevent contractures and deformities as well as to maintain good strength and condition of muscles. Devices which make walking safer, such as a walker, can be helpful. Speech, physical, and occupational therapy may be beneficial. Because of swallowing problems, some patients require placement of a feeding tube (PEG) directly into the stomach in order to maintain adequate nutrition and prevent aspiration pneumonia. If general health and nutrition can be maintained, some CBD patients live for several years after the onset of symptoms, although their quality of life in the advanced stages of the disease is usually significantly impaired.
At present, there are no therapies that can reverse or even slow the progression of CBD. Furthermore, since CBD is quite rare, clinical drug trials are sometimes not available for affected patients. Nonetheless, there is reason for hope. Because the biology of CBD may be related to other neurodegenerative diseases, it is possible that therapies designed for other conditions will also prove helpful for patients with CBD.
CurePSP: Foundation for PSP, CBD and Related Brain Diseases
30 E. Padonia Road, Suite 201
Timonium, MD 21093
Phone: (410) 785-7004
Toll free: (800) 457-4777
Fax: (410) 785-7009
©2011 Joseph Jankovic, M.D.
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