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About Us

Location

Toronto Western Hospital
McLaughlin Pavilion – 7th Floor, The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic

Contact

Phone: 416 603 6422

Referral Fax: 416 603 5004

Movement Disorders Clinic Nurse
Phone: 416 603 5875

Hours

Monday – Friday
9:00am – 4:00pm


Location

Contact

Hours

Location

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Hours

Location

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Hours


Referrals

Now accepting Ocean eReferrals

This clinic is now accepting referrals through Ocean eReferral to help everyone save time and increase efficiency.


To minimize our wait times, we currently are unable to accept referrals directly from Family Physicians. We recommend that you refer your patient to a local General Neurologist for initial consultation and early follow-up. The General Neurologist can refer to us when subspecialty clinic evaluation is warranted. If an assessment by a local neurologist is not possible or the patient needs to be seen on an urgent basis, consultations can be provided if the physician discusses the patient directly with Dr. Lang or another of the movement disorders faculty members.

We appreciate that some patients request second or third opinions from a Movement Disorder neurologist. We can provide further opinion on diagnosis and care for such patients but the wait time for these referrals may be over 12 months long. These patients should remain under the care of their current Neurologist until an appointment can be made here and preferably afterwards for ongoing follow-up. Under appropriate circumstances, we are pleased to provide ongoing advice and care for patients as needed. If you are referring such a patient, please provide us with the reason for the referral as well as the consultation notes from the Neurologists who have previously seen the patient.

For urgent referrals, please fax the referral to 416 603 5004 marked with Urgent. Call 416 603 5800 ext. 5307 and indicate that you have an urgent referral and wish to discuss with Dr. Lang or another of our faculty movement disorder neurologists.

Please Note: Our faculty waiting lists for patients range from 9 months to 24 months. We will not accept urgent referrals unless one of our faculty movement disorder neurologists agrees that the patient needs to be seen immediately. Referrals marked as urgent without agreement from Dr. Lang will be put on our patient referral waiting list.

Please note that only physicians may send a referral. Please send an Ocean eReferral or fax the completed referral letter and include the following:

  • Clinical notes
  • Relevant imaging

Our office will call the referring physician within 2 to 3 months with information about the patient's first appointment. The referring physician's office is responsible for providing the patient with the appointment information, including time and location, and important documents, test results and imaging that they must bring.

Please note that clinic appointments may be virtual visits. The clinic team will let you know what type of appointment is appropriate for your care. Learn more about virtual visits at UHN »

What We Do

Movement Disorders involve problems with too much or too little movement because of neurological conditions. Some of these disorders are familiar, such as Parkinson's disease, but there are many others: Dystonia, tremor, Myoclonus, tics, ataxia and other inherited conditions.

Our clinic provides care for more than 9,000 visits a year. Our work includes botulinum toxin treatment, clinical trials and research that uses imaging of the brain, surgery, surveys, as well as the study of genetics and brain function.

Learn more about the Edmond J. Safra Program in Parkinson's disease and how we're improving the lives of those living with Parkinson's disease today and for the future.

Conditions Treated

All neurological disorders associated with hyperkinetic or akinetic-rigid (ie. parkinsonism) movement disorders. For example:

  • Ataxias
  • Corticobasal syndrome
  • Dystonia (including Cervical, orofacial, segmental and generalized types)
  • Functional movement disorders
  • Multiple system atrophy
  • Myoclonus
  • Parkinson's Disease
  • Progressive supranuclear palsy
  • Spastic paraplegia
  • Spinocerebellar atrophy
  • Tardive dyskinesia
  • Tics
  • Tremors
  • Wilson's disease and other neurometabolic disorders causing movement disorders

Tests & Services

Resources

How to Prepare

Your first appointment can take 2 hours or more. After your visit to the clinic, you will likely go to the Blood Collection Lab for blood tests. Follow-up appointments usually take 30 minutes to 1 hour.

Learn more about what you can expect when you have a clinic appointment.​​

Health Information

Note: This content is only available on desktop. For mobile access, please visit our mobile-friendly page.​

Materials and Resources to Help You

Disorder-Specific Information

The following information will help you learn about your movement disorder. It is not intended to replace the information and advice from your doctor.

Only the most common movement disorders are listed here. Talk to your doctor if you don't see your disorder; they can help.


Parkinson's Disease

Parkinson's disease is a neurodegenerative disorders, meaning a progressive loss of nerve cells in the brain and other parts of the nervous system.​ Symptoms affect multiple body systems including movement, cognition, emotion, sleep, and the autonomic system (blood pressure, bladder, and bowel).

Neurological disorders are the leading cause of disability in the world. Parkinson's is the fastest growing neurological disorder affecting 2-3% of the population over 65.

Newly Diagnosed

Getting a diagnosis of Parkinson's can be devastating. Give yourself time to adjust and learn about the disease to familiarize yourself. Ask questions. We are here for you with information and resources to help. Over time, you will become a Parkinson's expert, take charge and manage your health.

The resources here are a starting point. Not every resource will be applicable to you. Some resources will be relevant now, later on, or not at all. Your doctor can help identify topic areas that will help you as you navigate your Parkinson's journey.

All resources are in PDF  format unless otherwise indicated.

Motor Symptoms

Motor symptoms can happen anytime in the course of the disease and usually respond well to medication. Motor symptoms differ from person to person. Not everyone with Parkinson's will experience all these motor symptoms, but everyone with Parkinson's will experience slowness (bradykinesia).

Motor or "movement" symptoms can include:

  • Stiffness (rigidity): muscle stiffness
  • Slowness (bradykinesia): slowing down of spontaneous movement. For example, slower walking or less arm swing while walking.
  • Tremor: a rhythmic, involuntary shaking that occurs in a finger, arm, or leg. For some people tremor occurs when they're relaxed and at rest, for others it gets worse when they're doing something like drinking from a cup or eating with a spoon. Tremor is a common symptom, but not everyone with Parkinson's has tremor.

Other motor symptoms include:

  • Postural instability: balance and coordination problems that can lead to problems with walking.
  • Freezing of gait: difficulty initiating walking or turning, especially in crowded spaces. Feeling like your feet are glued to the floor.
  • Dyskinesia: involuntary movements of the face, trunk, or limbs.
  • Masked-face: less facial expression.
  • Micrographia: smaller and often illegible handwriting.
  • Speech problems: softer or monotone speech, sometimes mumbling or slurring words which can make it difficult for those around you to clearly understand.
  • Swallowing problems: coughing, choking, or clearing the throat while eating or drinking.

Non-motor Symptoms

Non-motor (non-movement) symptoms are sometimes called the "invisible" symptoms of Parkinson's. They are common and different for each person. You may experience some and not others. Non-motor symptoms can occur at any time in the course of the disease, even before motor symptoms or before a diagnosis.

Non-motor symptoms can impact the quality of life for Parkinson's and for their families and loved ones. Talk to your doctor; they are here to help.

Parkinson's disease can impact how you think and feel:

  • Apathy is a lack of motivation and interest in activities that you would normally find joy in.
  • Depression is feeling extreme sadness or a sense of emotional emptiness for a long time. It's more than temporary feelings of sadness, unhappiness, or frustration. These feelings may affect your ability to carry out day-to-day activities.
    Depression is one of the most common, and most disabling, non-motor symptoms of Parkinson's disease. As many as 50% of people with Parkinson's experience the symptoms of clinical depression at some stage of the disease. Some people experience depression up to a decade or more before experiencing any motor symptoms of Parkinson's.
  • Anxiety is often described as a sense of dread, constant worry, or difficulty concentrating. Physical symptoms can include sweating, pounding or racing heart, feeling breathless, dizzy, restless, or nauseous. There are many types of anxiety. Anxiety can be managed. Getting enough rest, eating well, exercising, massage therapy, meditation, and mindfulness can help.
  • Memory or thinking (cognitive) problems: difficulty multitasking and concentrating.
  • Psychosis: hallucinations (seeing things that aren't there) and delusions (paranoid beliefs).

Parkinson's can also cause other difficulties:

  • Gastrointestinal: digestive issues and constipation is common.
  • Excessive daytime sleepiness or fatigue: feeling sluggish or exhausted.
  • Light-headedness or dizziness: feeling faint when sitting up or standing due to the body not being able to regulate blood pressure quickly.
  • Pain: sometimes there can be unexplained discomfort or pain in one part or the whole body.
  • Skin changes: oily or dry skin. Parkinson's patients have an increased risk of melanoma and should have annual skin examinations with a dermatologist. Report any unusual skin conditions to your doctor.
  • Sleep issues: insomnia (difficulty falling or staying asleep), restless legs syndrome (an uncomfortable sensation in the legs) or REM sleep behaviour disorder (physically acting out dreams).
  • Smell loss: often an early sign of Parkinson's.
  • Vision changes: some patients experience double vision or dry eyes because of slower blinking.
  • Drooling: decreased swallowing can cause a buildup of saliva.
  • Sweating: excessive sweating can occur.
  • Sexual changes: reduced libido and dysfunction (not age-related) can occur, while some medications can increase sexual behaviours to bothersome levels. Talk to your doctor about any concerns you may have.

Medication

Medication is used to improve your quality of life living with Parkinson's. It's important to take your medications at the prescribed dose and time. Your doctor will work closely with you to develop the best regimen for you.

  • Parkinson's Medications: What you need to know – this information sheet by Parkinson Canada will help you understand the types of Parkinson's medications and side effects.
  • Medications to Treat Parkinson's – this is a more in-depth look at Parkinson's medications by Parkinson Canada, geared mostly toward health care professionals. On page 32 there is a useful tool to track your response to medications.
  • Botulinum Toxin injections  are sometimes used to help with abnormal movements and other symptoms of Parkinson's disease such as dystonia or drooling.

Advanced Therapies

Deep Brain Stimulation (DBS)

Duodopa®

Focused Ultrasound

Vyalev

Vyalev is a 24-hour infusion treatment for advanced Parkinson's. It helps to control symptoms by increasing the "ON" time and decreasing the "OFF" time. It combines two medications, foslevodopa and foscarbidopa.

Physiotherapy

Physiotherapy is part of the multi-disciplinary approach to Parkinson's care. In early Parkinson's, physiotherapy provides education in physical activity and self-management strategies. In the mid and later stages, it can help minimize deterioration, improve gait, balance, daily activities, and reduce the risk of falls.

Occupational Therapy

An Occupational Therapist can help you identify challenges, set realistic goals, and strategize solutions to help you continue doing the things you enjoy that are important to you. Strategies may be adapting to your environment, adjusting the activity, and perhaps changing your mindset from "I think I can" to "I will".

Nutrition

A balanced and healthy diet is the foundation of good health. There are some dietary adjustments that can help your medications work more effectively or help with side effects.

  • Nutrition and PD – fact sheet by the Parkinson's Foundation with information about healthy foods and Parkinson's.

Speech, language and swallowing

Changes or difficulty chewing and eating, speaking or swallowing are common in Parkinson's. These changes can happen at any time but usually increase as PD progresses. Sometimes these problems are not obvious and difficult to describe.

Mental Health

When it comes to mental health there is a large amount of variation between people with Parkinson's. Some people experience minimal mental health issues, and for some, their main difficulties are mental health related i.e., depression, anxiety, cognitive issues, or psychosis.

Sleep issues, fatigue and apathy can contribute to mental health difficulties, and sometimes Parkinson's mediations can contribute to impulsivity and psychosis.

Talk to your doctor if you have any concerns or questions about mental health.

Other Considerations

Driving

Falls Prevention

Communicating

Dental Care

Skin Care


Ataxia

Ataxia is a symptom of incoordination usually due to diseases affecting the part of the brain known as the cerebellum.

Symptoms of Ataxia can include:

  • Decreased coordination
  • Difficulties walking, poor balance and falls
  • Decreased fine motor skills
  • Gradual loss of muscle strength
  • Muscle stiffness
  • Muscle tremors
  • Difficulty with speech

  • Treatment for Ataxia is multi-disciplinary and may include a Neurologist, Physiotherapist, Speech-Language Pathologist and Mental Health specialist, among others.
  • Living with a long-term condition such as Ataxia can be stressful and can cause intense feelings of anxiety. In some cases, this can trigger the onset of depression.
    • Talk to you doctor if you are feeling down or hopeless or are no longer taking pleasure in the things you enjoy.
    • Depression can be treated with cognitive behavioural therapy or antidepressants.
  • Medications can help manage the symptoms that occur with Ataxia.
    • Medications for nerve pain, muscle relaxants for stiffness, or cramps may be prescribed.

Physical therapy

  • Physical therapy can help you maintain muscle strength and flexibility. It can also help with balance and mobility. A Physiotherapist will teach you a number of physical exercises you can do every day to help strengthen and stretch your muscles.
  • A Physiotherapist may be able to help you increase your stamina levels to help you cope with fatigue.

Speech therapy

  • Speech therapy can help with vocal projection and clarity.
  • A Speech Therapist or Speech-Language Pathologist may suggest:
    • changing your posture to improve the quality of your voice
    • exercises to strengthen the muscles used when speaking
    • speaking slower to emphasize each word
    • breathing techniques to improve your speech
    • exercises to stimulate your swallowing reflex and strengthen the muscles used when swallowing
  • You may also be referred to a Dietitian for dietary advice.
    • For example, your diet may need to include food that's easier to swallow.

Occupational therapy

  • Occupational therapy teaches you strategies and modifications that can make the day-to-day activities easier and help you continue to do the activities you like to do.
  • An Occupational Therapist can also advise you about modifications you can make to your home to make your life easier, such as installing guide rails, grab bars, or a stair lift.
  • Find a Occupational Therapist

Assistive devices

  • Walking poles and walkers can help with balance and mobility.
  • Wheelchairs are sometimes necessary and can be helpful for long distances such as in airports or going to appointments.
  • Communication aids can help with speech difficulties.


Atypical Parkinsonism

Lewy Body Dementia

Lewy Body Dementia (LBD) is a common Atypical Parkinsonism. LBD is associated with abnormal deposits of the alpha-synuclein protein (Lewy bodies) in the brain resulting in one of the most common forms of dementia and problems with thinking, hallucinations (typically visual), movement, behaviour and mood. Sometimes it is called "Dementia with Lewy bodies." Lewy bodies are also seen in patients with Parkinson's disease, that is why some features are shared between the two diseases.

In LBD the Lewy bodies spread throughout the brain, and the symptoms can be broad, affecting many functions of the person affected.

The main symptoms are decision-making and problem-solving difficulties associated with memory decline.

Some of the common features include experiencing a shorter attention span, and issues with the sense of direction, which can result in getting lost easily.

Patients with LBD may have issues with movements similar to Parkinson's disease, like hand tremor, slowness of movement, and stiffness. LBD can affect the functions of the upper limbs and may cause trouble walking.

One of the frequent features associated with LBD are hallucinations, typically visual hallucinations. The affected individual usually reports seeing things that are not there, like seeing colours, shapes, people or animals, or seeing things in different forms.

Acting out dreams during sleep, which is called REM Sleep Behaviour Disorder (RBD), is a prevalent feature of LBD.

Usually, to make the diagnosis of LBD you may need more than one visit to the specialist's office, going through a detailed medical history, physical examination, and may require a brain MRI and a sleep study.

There is currently no cure for Lewy body dementia (LBD), but treatments can help manage symptoms and improve quality of life. These treatments often include medications, therapies, and lifestyle adjustments.

LBD is best managed with a multidisciplinary team, where the family doctor, Neurologist, Psychiatrist/Psychologist, Physiotherapist, and Social Worker all work together for the best patient care.

For some patients, the doctor may start Parkinson's disease medications, which can help with movement difficulty.

For the cognitive and behavioural symptoms, a detailed neuropsychiatric evaluation should be done, as some of the behavioural issues can be solved without the need for medication. Medication to improve cognition (memory and thinking) may be useful for some patients.

Physical therapy can help you maintain muscle strength and flexibility. It can also help with balance and mobility. A Physiotherapist may be able to help you increase your stamina levels to help you cope with fatigue.

Occupational therapy teaches you strategies and modifications that can make day-to-day activities easier and help you continue to do the activities you like to do.

Speech therapy can help with vocal projection and clarity. A Speech-Language Pathologist may suggest changing your posture to improve the quality of your voice, exercises to strengthen the muscles used when speaking, speaking slower to emphasize each word, breathing techniques to improve your speech, and exercises to stimulate your swallowing reflex and strengthen the muscles used when swallowing.


Corticobasal Syndrome

Corticobasal Syndrome (CBS) is a progressive neurodegenerative disorder included under the broad "umbrella" term of Atypical Parkinsonism. It usually starts in mid adulthood (40s – early 60s) with stiffness, difficulty performing dexterity tasks with one extremity, involuntary movements, or even affect mobility with poor balance and falls. Initially, a combination of these symptoms affects mostly one side of the body with relentless progression to the other side. The symptoms of CBS can be similar to those of Parkinson's including slowness of movements, stiffness and tremor, however, additional symptoms not usually seen in Parkinson's appear in patients with CBS within 5 years of onset.

CBS is a rare disease, meaning that each year 5 people per 100,000 are living with the disease, and an average of 1 person per 100,000 are newly diagnosed with CBS. Since CBS can start in varied forms and show a diverse combination of symptoms, it is a challenge to diagnose it during the first 2-3 years.

Movement

  • Slowness, stiffness
    The difficulty in controlling hand movements can be a first manifestation of CBS. These can be due to increased muscle stiffness in the form of rigidity. These can cause problems performing simple tasks like buttoning a shirt, using cutlery or manipulating any kind of tools. The difficulty starts mostly on one side and the patient may adopt strategies to compensate, such as using the non-dominant hand to complete these activities. In CBS, these symptoms progress and may affect the opposite hand, or less commonly, a leg. They can be worsened if any of the problems discussed below are present.
  • Tremor and Myoclonus
    Shakiness of a limb typically occurs when trying to complete any action. Brief, shock-like jerks may occur possible and frequent in CBS and is called myoclonus. These involuntary movements can cause difficulty doing activities that require use of the affected limb.
  • Dystonia
    An increase in muscle contraction that causes awkward or abnormal postures or movements of the affected limb can also be present in CBS. Constant muscle contraction can cause muscle soreness and its combination with rigidity can lead to permanent changes in the tissues and painful contractures.
  • Alien limb
    The inability to control movement of an arm or leg occasionally causes involuntary slow movements which can get as complex as if the limb has a "mind of its own". An arm may interfere with the activities that the other hand is doing.

Apraxia

The inability to perform complex tasks or gestures with the hands is a common problem. The actions affected are typically those that were learned by practice throughout life, such as the ability to use eating utensils, do up buttons, or tie shoelaces. When apraxia is present in a leg, walking can become "frozen" for several seconds at a time and lead to balance problems and instability.

Sensory abnormalities

Contributing to the movement problems of CBS are sensory problems. It's not a simple loss of sense of touch, but can take the form of an inability to recognize common objects by feeling alone, or the inability to know the position of a finger or a limb in space.

Balance

Several of the above-mentioned symptoms can contribute to an unsteady walk. The presence of uncoordinated leg movements can be aggravated by a decrease in the postural reflexes that help us maintain an up right posture and ultimately increase the risk of falls. The progression of these issues may lead to an inability to walk unassisted, requiring a walking aid.

Speech

In CBS, speech can be affected. Slurring (dysarthria) or stuttering is common. Additional difficulties can occur such as understanding or expressing language (aphasia), and difficulty saying what you want to say despite knowing the right words (apraxia of speech).

  • Tremors in CBS can be treated with medications such as Propranolol, which is typically used to treat other more common types of tremors. If the tremor is significantly interfering with your activities, you can ask your doctor about medications and whether they might help you.
  • Myoclonus can be treated with medication when it interferes with activities or becomes troublesome. The range of drugs used is wide, and most of them are considered anti-epileptics. You can ask your doctor about these treatments and whether they might help you.
  • For dystonia either of the neck, limbs, or the face, treatment with botulinum toxin injections can be used. This medication acts as a temporary relaxant of the muscle, producing a decrease in the symptoms of dystonia. The effects last about 8-12 weeks and can be repeated every few months to maintain the benefit.
  • For significant drooling, several measures can be taken. Chewing gum can stimulate swallowing and reduce the amount of drooling. Medications applied to the inside of the mouth can decrease the activation of your salivary glands.
  • Unfortunately, there are no drugs that efficiently reduce or prevent the symptoms of alien limb, apraxia, and sensory abnormalities of CBS.

Physical therapy

  • Physical therapy can help you maintain muscle strength and flexibility. It can also help with balance and mobility. A Physiotherapist will teach you a number of physical exercises you can do every day to help strengthen and stretch your muscles.
  • A Physiotherapist may be able to help you increase your stamina levels to help you cope with fatigue.
  • Regular passive stretching can help decrease the occurrence of muscle spasms and cramps, and joint deformities.

Speech therapy

  • Speech therapy can help with vocal projection and clarity.
  • A Speech therapist or Speech-Language Pathologist may suggest:
    • changing your posture to improve the quality of your voice
    • exercises to strengthen the muscles used when speaking
    • speaking slower to emphasize each word
    • breathing techniques to improve your speech
    • exercises to stimulate your swallowing reflex and strengthen the muscles used when swallowing
  • You may also be referred to a Dietitian for dietary advice.
  • For example, your diet may need to include food that's easier to swallow.

Occupational therapy

  • Occupational therapy teaches you strategies and modifications that can make day-to-day activities easier and help you continue to do the activities you like to do.
  • Walking aids are of remarkable importance in patients with CBS. Given the tendency to fall backwards, a walker should be weighted in front (i.e., with sandbags over the lower rung) to prevent falls.
  • Installation of handrails at home, especially in the bathroom, helps as well as removing throw rugs or low coffee tables from the patient's living space.
  • Sometimes a heavy walker resembling a small shopping cart with three or four fat, soft rubber wheels and a hand brake can help prevent falling backwards. Shoes with smooth soles can make it easier to slide the first foot forward if freezing of gait is a present symptom.
  • An Occupational Therapist can also advise you about modifications you can make to your home to make your life easier, such as installing guide rails, grab bars, or a stair lift.
  • Access an Occupational Therapist


Progressive Supranuclear Palsy

PSP is a progressive neurodegenerative disorder that has no known cause or cure. It affects brain cells that control balance, walking, coordination, eye movements, speech, swallowing, and thinking. These symptoms begin, on average, when an individual is in their early 60's but may start as early as in their 40's and is slightly more common in men than women.

Initially, someone with PSP can have similar symptoms than someone with Parkinson's such as slowed movements, stiff posture, and in some cases, even tremor. However, additional symptoms which are not usually seen in Parkinson's appear less than 5 years later and include repeated falls, trouble with eye movement, swallowing and speech difficulties, and changes in behaviour and thinking.

The fact that PSP can start in varied forms and show a diverse combination of symptoms makes it very hard to diagnose during the first 2-3 years. PSP is a rare disease, meaning that each year five or six people per 100,000 are living with the disease and an average of 1.1 people per 100,000 are newly diagnosed with PSP.

Do you want additional information? Keep reading or follow these links:

Balance and walking

Loss of balance is usually the first symptom. It can be experienced as dizziness and during doctor visits be mistaken for inner ear problems. However, the balance difficulties of PSP worsen, affecting the ability to maintain an up-right position during a turn or standing up/sitting down from a chair. It often causes backward or unexplained falls and eventually requires the use of a walking aid at some point in the disease. Prevention of falls is a critical measure in the management and a goal to maintain the quality of life of patients with PSP.

Eye movements

A region in the base of the brain, called the midbrain, contains cells that control eye movements. PSP affects the midbrain cells, causing (difficulty with eye movements, particularly difficulty in the ability to move the eyes up or down. This can interfere with eating or with descending a flight of stairs. However, even months to years before a specialist is seen, family members and friends may notice subtle changes like the inability to maintain eye contact during conversation or a complaint of tunnel vision while driving a car.

Speech

The complex and coordinated movements that allow speech production are under the control of brain cells located in the vicinity of those that control eye movements. As these brain cells suffer from PSP, the movements of the mouth, tongue and throat also weaken resulting in different speech sounds. In most PSP patients after an average of three or four years, speech becomes slurred and slow. Additional features are an irregular, explosive (called spastic speech), a drunken quality (ataxic speech) or a soft speech similar as that of Parkinson's disease patients. A combination of at least two of these three features is often seen in the speech of patients with PSP.

Cognition and behaviour

PSP can have diverse cognitive symptoms. These are called executive dysfunction. Symptoms include difficulty planning, making decisions and slowing thoughts. Some patients with PSP may complain of forgetfulness, or difficulty finding words. Additionally, personality changes like the loss of interest in ordinary pleasurable activities or increased irritability, difficulty resisting impulses or even inappropriate social behaviour can be seen at some point in the disease. Important to note, these behavioural changes may cause a patient with PSP to have a decreased ability to make decisions about safe movements and predispose them to repeated falls.

Swallowing

Similar to how the muscles used in speech are affected, the first stage of the swallowing process (oral-pharyngeal phase) can be affected in PSP. Typically, patients will have to clear their throat after dinking liquids, cough or even choke. When this symptom progresses, choking with saliva can be a problem, and measures to prevent aspiration (inhaling liquid or food) will be needed. Repeated, or minor episodes of small amounts of food and drink dripping into the lungs can cause aspiration pneumonia, which is the most common cause of death in PSP.
The risk of aspiration is aggravated by overloading the mouth or taking big gulps of beverages that PSP patients might do due to recklessness or impulsiveness (part of the cognitive symptoms). Speech-Language Pathologists are the most qualified health care professionals to assess this and give recommendations to help.

There is a lack of highly effective drugs for the treatment of PSP, and a cure has not yet been discovered. Drugs used in Parkinson's can occasionally help decrease the slowness and stiffness, and very rarely balance symptoms.

For significant drooling, several measures can be taken. Chewing gum can stimulate swallowing and reduce the amount of drooling. Medications applied to the inside of the mouth can decrease the activation of your salivary glands.

An increase in muscle contraction that causes awkward or abnormal postures or movements of the affected limb can also be present in PSP. This is called dystonia. For dystonia either of the neck, limbs, or the face, treatment with botulinum toxin injections can be used. This medication acts as a temporary relaxant of the muscle, producing a decrease in the symptoms of dystonia. The effects last about 8-12 weeks and can be repeated every few months to maintain the benefit.

Physical therapy

  • An evaluation and treatment plan from a Physiotherapist or Physiatrist (a physician specializing in rehabilitation of chronic conditions) can help.
  • Physical therapy can help you maintain muscle strength and flexibility. It can also help with balance and mobility. It may help you increase your stamina levels and help you cope with fatigue.
  • Repeating certain exercises at home by oneself can keep the joints limber and improve well-being. Useful exercises can be found in Parkinson's disease organizations.
  • Given balance problems in PSP, exercises while standing should be done cautiously and useful exercises can be performed seated in a chair or lying on a mat. Using a stationary bicycle is feasible if mounting and dismounting are safely monitored.
  • Another important goal of physical therapy is teaching the patient to use gait-assistive devices such as a walker.

Speech therapy

  • Speech therapy can help with vocal projection and clarity.
  • A Speech therapist or Speech-Language Pathologist may suggest:
    • changing your posture to improve the quality of your voice
    • exercises to strengthen the muscles used when speaking
    • speaking slower to emphasize each word
    • breathing techniques to improve your speech
    • exercises to stimulate your swallowing reflex and strengthen the muscles used when swallowing
  • You may also be referred to a Dietitian for dietary advice.
  • For example, your diet may need to include food that's easier to swallow.

Occupational therapy

  • Occupational therapy teaches you strategies and modifications that can make day-to-day activities easier and help you continue to do the activities you like to do.
  • Walking aids are of remarkable importance in patients with PSP. Given the tendency to fall backwards, a walker should be weighted in front (i.e., with sandbags over the lower rung) to prevent falls.
  • Installation of handrails at home, especially in the bathroom, help as well as removing throw rugs or low coffee tables from the patient's living space.
  • Sometimes a heavy walker resembling a small shopping cart with three or four fat, soft rubber wheels and a hand brake can help prevent backwards fall. Shoes with smooth soles can make it easier to slide the first foot forward if freezing of gait is a present symptom.
  • An Occupational Therapist can also advise you about modifications you can make to your home to make your life easier, such as installing guide rails, grab bars, or a stair lift.
  • Access an Occupational Therapist

Managing of visual symptoms

  • Difficulty looking down can be helped by special prism glasses, but this can be a limited benefit if additional problems directing the person's attention to objects are present.


Multiple System Atrophy

Multiple system atrophy (MSA) is a rare progressive neurodegenerative disorder that affects the brain and other areas of the nervous system. Some of these are involved in the control of movement, balance, coordination, while others are responsible for blood pressure, bladder, bowel, and sexual function.

There are various types of MSA, although they all share the abnormal accumulation of a protein that leads to progressive loss of function and death of different types of cells in the nervous system. This protein is called alpha-synuclein and it also accumulates abnormally in individuals with Parkinson's disease. However, MSA can be further distinguished from Parkinson's disease by the involvement of several other areas of the nervous system, including the cerebellum (responsible for coordination and balance), as well as the autonomic nervous system (involved in the control of involuntary actions such as blood pressure, heart rate and bladder control).

Symptoms of MSA usually start between the ages of 50 and 60 and may include slowness of movements, muscle stiffness, and/or shaking or tremor. Other symptoms include difficulties with balance and coordination.

Another symptom is the failure of the autonomic nervous system that controls involuntary actions such as blood pressure. Some patients may experience blood pressure drops when rising from a seated or lying down position with associated light-headedness or fainting spells. Additional signs of autonomic involvement also include problems with heart rate, erectile dysfunction, problems with urination, and/or constipation.

To date, there is no cure or available treatment to delay the progression of MSA. However, there are several medications and nonpharmacologic (non-drug) treatments that may alleviate some of the underlying symptoms.

Specific drugs might be used in selected individuals to control urinary symptoms, constipation, light-headedness and fainting spells. Occasionally, some patients with MSA can also be prescribed medications to enhance motor (movement) function.

Additional treatments include strategies not related to medications or drugs. For instance, dietary changes might improve some of the constipation experienced by individuals with MSA. Gait training and mobility aids are also an essential part of the MSA management to avoid falls and injuries.

Other health care providers, such as physical, occupational and speech therapists, assist doctors in the management of MSA and provide supportive care to patients.

Physical therapy

  • Physical therapy can help you maintain muscle strength and flexibility. It can also help with balance and mobility.
  • A Physiotherapist might also help with deconditioning and avoiding falls that can result in additional injuries.
  • A Physiotherapist will teach you a number of physical exercises you can do every day to help strengthen and stretch your muscles.
  • A Physiotherapist may be able to help you increase your stamina levels to help you cope with fatigue.

Speech therapy

  • Speech therapy can help with vocal projection and clarity.
  • A Speech therapist or Speech-Language Pathologist may suggest:
    • changing your posture to improve the quality of your voice
    • exercises to strengthen the muscles used when speaking
    • speaking slower to emphasize each word
    • breathing techniques to improve your speech
    • exercises to stimulate your swallowing reflex and strengthen the muscles used when swallowing
  • Find a Speech-Language Pathologist
  • You may also be referred to a Dietitian for dietary advice.
    • For example, your diet may need to include food that's easier to swallow.

Occupational therapy

  • Occupational therapy teaches you strategies and modifications that can make day-to-day activities easier and help you continue to do the activities you like to do.
  • An Occupational Therapist can also advise you about modifications you can make to your home to make your life easier, such as installing guide rails, grab bars, or a stair lift.
  • Access an Occupational Therapist

Additional Resources


Dystonia

Dystonia is a movement disorder that involves involuntary muscle contractions that can result in continuous or repetitive movements (including tremor), twisting, or abnormal postures. It can affect your whole body (generalized), or just one part (focal). It can start at any age.

Clenched or curled toes or a cramped foot are signs of dystonia. These contractions are often painful and can make daily activities difficult.

Dystonia can be classified into three groups: idiopathic (cause unclear), genetic (usually confirmed on genetic testing) and acquired (such as damage to the brain, environmental factors or due to medication). Dystonia therefore can be a symptom of another movement disorder, such as Parkinson's disease, or it can be a movement disorder on its own.

Symptoms of dystonia can be variable and may be continuous or intermittent. They can initially be mild and may not result in abnormal posturing until a later stage. Sometimes stress or significant life events can worsen dystonia.

Symptoms may include:

  • uncontrolled muscle spasms or cramps, such as writer's cramp
  • parts of your body twisting into unusual positions
    • your neck may twist to one side, or your feet may turn inwards
  • tremor
  • uncontrolled blinking
  • voice or speech difficulties

At present, there are no disease modifying treatments available for dystonia. Treatment is therefore based on symptom control and can include the following:

  • medications to help relax muscles
  • botulinum toxin injections administered into affected muscles can be very effective for dystonia of muscles in a single area
  • in severe cases, surgical treatment such as deep brain stimulation can be considered
  • Physiotherapy: the aim is to treat the secondary issues that come with dystonia. It can help by improving awareness of body posture and body movement through various techniques such as facilitation, taping, and biofeedback. A Physiotherapist can also help you establish appropriate exercise programs.
  • Occupational therapy: can recommend assistive devices if needed, such as ankle-foot orthotics, dental devices, and writing devices for writer's cramp.
  • Speech and language therapy: may be able to address any speech or swallowing difficulties resulting from dystonia.
  • Regular relaxation practices may help with pain and benefit your sense of overall well-being.


Functional Movement Disorders

Functional Movement Disorders (FMD) are a group of disorders that fall under the umbrella term of Functional Neurological Disorders (FND). They may cause bothersome neurological symptoms that result in an inability to walk, speak, or control limb or facial movements the way you normally would. Although not widely talked about, FND is very common, accounting for the second most frequent reason why someone may be referred to a neurologist.

While symptoms of FMD can vary from person to person, they are united by common characteristics that can be detected by a neurologist trained in diagnosing FMD. These "positive signs" show that altered activity in certain brain circuits are disrupting a person's ability to move normally. This is why doctors sometimes say that FMD is a "software" problem of the brain, rather than a "hardware" one (as in a stroke or MS). People with FMD usually don't have brain damage that can be detected on MRI or other advanced tests. Instead, the brain circuits are structurally intact but aren't working correctly.

FMD can have multiple risk factors. It is often triggered by injuries, illness, or emotional stress. It can also arise in the context of other neurological disorders, like Parkinson's Disease, which is sometimes called "functional overlay."

Studies have shown that FMD can be as disabling as other neurological disorders like Epilepsy and Multiple Sclerosis. While FMD is not fatal, it may result in severe disability and difficulties in many areas of life. Fortunately, FMD is often treatable.

Newly Diagnosed

Getting a diagnosis of FMD can be confusing. It can be hard to understand what it means, why you are experiencing the symptoms, and what you should do. Here are a few important things to know about FMD:

  1. FMD is a disorder of the brain. It is a real condition that causes real disability. It is not "made up," "imagined," "all in your head," or something a person does to themselves. FMD is not your fault.
  2. FMD is diagnosed based on "positive signs" seen on physical examination. These are specific indicators, that a trained neurologist looks for during your examination to verify that you have an FMD, and may be able to show you during your assessment. It is not diagnosed by exclusion, meaning you should not be diagnosed with an FMD as a "last resort" after many tests, or simply because a doctor hasn't reached a different diagnosis.
  3. FMD is often treatable, and with proper support some patients recover completely. Treatment methods for this disorder are advancing all the time. The first step to recovery is for the patient experiencing symptoms to understand that FMD is the cause of these symptoms, and that it's possible to get better. Recognizing that FMD is a disruption in how the brain communicates with the body, leading treatment centres like Toronto Western now take a multi-disciplinary approach to FMD treatment. This means that the patient becomes a member of a team, which includes a Neurologist, Psychiatrist, Physiotherapist, and Nurse Practitioner. People with FMD often also benefit from support from a Psychologist or Social Worker.
  4. It is helpful to learn more about FMD, the sorts of symptoms it can cause, and appropriate treatment strategies. A great resource is neurosymptoms.org for more information.

FMDs come in many forms. Some of the most common are uncontrollable, unwanted movements (tremor, dystonia, jerks), inability to move normally (weakness, paralysis), and disruptions of a person's ability to walk (gait). These symptoms may be episodic (come and go over time). They may be worse or better at different times (fluctuate).

FMDs are a type of Functional Neurological Disorder (FND). Because FND affects core, multi-purpose brain systems (including the Salience Network), you may have other symptoms as well. It is common for people with FMD to have other FND symptoms, such as seizure-like events, problems with swallowing or speech, visual symptoms, dizziness, and others. Pain, fatigue, cognitive fog, and headaches are also common among people with FMD.

FMD is a "whole brain" disorder. It affects a person's physical ability, capacity to work, relationships, and emotional health. Recognizing this, most experts today believe the best care for FMDs is multi-disciplinary. Medications are typically not used for the treatment of FMD.

At the Integrated Movement Disorders Program, patients receive cutting-edge treatment for FMD. Our multi-disciplinary team works collaboratively with patients to stabilize symptoms and facilitate recovery. Sessions include aspects of physical therapy, cognitive behavioral techniques, pain management, and activity planning to help patients manage improvement across physical, social, and emotional domains of life. Recovery from FMD is a process, often with ups and downs, with the goal of our program to give you the tools to keep getting better.

There are several strategies that you can implement and may help the condition:

  • Mindfulness such as box breathing, meditation, and sensory grounding (Resources are in PDF format)
  • Learn triggers that tend to worsen your symptoms, such as lack of sleep or emotional stress
  • Pacing yourself, by gradually increasing activity over time, rather than doing as much as possible on "good days"
    • This may help prevent a "boom and bust" cycle of good and bad days
  • Ensuring you are having adequate sleep
  • Practicing FND-informed physiotherapy techniques
  • Living with a condition like FMD can be stressful and can cause intense feelings of anxiety or depression
    • Talk to you doctor if you are feeling down or hopeless or are no longer taking pleasure in the things you enjoy
    • Depression can be treated with cognitive behavioural therapy or antidepressants


Tremor

Tremor is an involuntary rhythmic movement involving one or more parts of the body. It is one of the common movement disorders encountered in clinical practice. Tremor can involve any part of the body, and most commonly the hands are affected. When severe, tremor can be disabling and interfere with daily activities. It can also result in social embarrassment.

Tremor can develop spontaneously or it can result from another disorder, such as Parkinson's disease or dystonia. Tremors can sometimes run in families or can result from certain medications, such as steroids, stimulants or inhalers. In many cases, however, the cause is unknown.

Tremor can be present at rest (resting tremor) or more commonly when carrying out activities (action tremor). The most common cause of a resting tremor is Parkinson's disease. There are many causes for an action tremor.

Tremor conditions

The following are examples of the more common conditions movement disorder specialists see in their clinical practice:

Essential tremor

Essential tremor (ET) is one of the most common movement disorders. The condition can affect the hands, head, legs, trunk, and/or voice. The tremor tends to affect both sides of the body and is predominantly present when carrying out activities, such as writing or eating and drinking (action tremor), and less so when resting. Essential tremor can start at any age, even at a young age, and often runs in families.

Dystonic tremor

Dystonic tremors occur in individuals who have dystonia. The tremor can affect both sides of the body; however, most commonly one side is affected more than the other. Although the tremor can sometimes mimic a Parkinsonian tremor, there are usually no additional features, such as slowness of movements.

Cerebellar (intention) tremor

Cerebellar tremor can result from damage to the coordination center of the brain (cerebellum). This type of tremor is characterized by slow irregular clumsy movements in the hands, which tend to worsen as you get closer to the target, such as picking up a small coin or pressing a button.

Parkinsonian tremor

Parkinsonian tremor is one of the hallmark features of Parkinson's disease. Unlike essential tremors, a Parkinsonian tremor tends to occur at rest and affects one side of the body initially. When severe, the tremor can also become present with action. This is also known as a re-emergent tremor.

Tremor often affects the hands, and therefore can result in difficulty doing activities such as eating or dressing , keyboarding or writing. When the muscles of the throat are involved it can result in a wavering voice. Tremor can also occur in the neck, causing the head to shake. Less commonly, tremor can involve the legs or trunk.

Treatment options can include the following:

  • Medications, such as propranolol or primidone, can be used to help reduce tremors.
  • Botulinum toxin injections can be very effective, especially with head tremors.
  • In severe cases, surgical treatment such as Deep Brain Stimulation (DBS) or focused ultrasound (MRgFUS), may be considered.
  • Occupational therapy: can recommend alternative utensils, such as weighted cutlery.
  • Lifestyle changes, such as avoiding caffeine, reducing stress and incorporating relaxation exercises (including meditation and mindfulness), can be very useful in reducing the severity of tremor.


Wilson's Disease

Wilson's disease is a rare hereditary disease in which excessive amounts of copper accumulate in the body, mainly in the liver. When its storage capacity is full, copper is released into the bloodstream and can damage the liver, brain, and other vital organs. Wilson's disease is present at birth, but symptoms do not show up until copper builds in the liver, brain and other organs.

You are at increased risk of Wilson's disease if your parents or siblings have the condition. Diagnosing the condition as early as possible dramatically increases the chances of successful treatment.

For more information on Wilson's Disease, the Canadian Liver Foundation has information.

Symptoms of Wilson's disease can include:

  • Fatigue, lack of appetite or abdominal pain
  • A yellowing of the skin and the whites of the eye (jaundice)
  • Golden-brown eye discoloration (Kayser-Fleischer rings)*
  • Fluid buildup (swelling) in the legs or abdomen
  • Cardiac symptoms including irregular heartbeat and congestion
  • Problems with speech, swallowing, salivation, or physical coordination
  • Sleep problems including insomnia, excessive sleepiness, sleep-related movement disorders
  • Uncontrolled movements (e.g., tremors), muscle stiffness, or slowing of movements
  • Behavioural and psychiatric problems (e.g., depression, hallucinations, emotional lability, etc.)
  • Seizures and epilepsy

* You may need to consult your ophthalmologist to evaluate this.

Wilson's disease can have serious complications or even be fatal if left untreated. Wilson's disease is typically treated with dietary changes, medications, and in some cases, liver transplantation.

  • Medication can help treat Wilson's disease: there are several medications that facilitate the removal of excess copper from the body, while some prevent its absorption from the gut.
  • A diet low in copper is recommended. Avoid mushrooms, chocolate, dried fruit, nuts, sesame seeds, sesame oil and shellfish. A Dietitian can help – talk to your doctor.
  • Liver transplantation may be warranted, especially in cases of severe liver damage.
  • Physiotherapy and Occupational therapy can be beneficial as well – talk to your doctor.

Your Mental Health

Mental health is just as important as physical health. Learn about supports available to you, and how to get help when you need it. Find mental health support:

Physical Health Resources

Physical Activity

Physical Activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure1. There is no doubt that exercise is an essential treatment for any movement disorder.

 Tips

  • Schedule movement into your daily routine
  • The best time to exercise is typically when you're feeling "on"
  • Sedentary, light, moderate, high-intensity activities – knowing the difference
  • Balance fatigue (boom/bust cycles)
  • Challenge barriers and find solutions to physical activity. A Physiotherapist can help with relapse prevention training, feedback, education and more.

Exercise

Planned, structured and repetitive movement with the purpose of improving or maintaining physical fitness.1 Exercise is prescribed like medication and is essential in the treatment of movement disorders.

Websites

  • Brian Grant Foundation
    Provides an 8-page booklet with recommendations for Parkinson's exercises.
  • Parkinson's Foundation
    Recommends establishing early exercise habits to benefit from a slowed decline in quality of life.
  • Keep On Moving
    Empowering People with Parkinson's disease - Parkinson's UK

Videos

Physical Rehabilitation Movement Retraining

Finding Support


1Caspersen, C. J., Powell, K. E., and Christenson, G. M. (1985). Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 100, 126–131

Online Resources

Many organizations provide trustworthy information on movement disorders. You will find links to reliable online information for the following diseases:

The Dystonia Medical Research Foundation Canada (DMRFC) website promotes awareness, educational and research information; they also facilitate support groups.

Your health care provider may refer you to services or specific health care providers. You may also find public resources and private services below that you may be eligible for.

Community Resources

Contact the Ontario Health atHome (free) to inquire about an assessment and services that you may be eligible for under government-covered care.

  • Ontario Health atHome can help you find occupational therapy, and they can help with nursing care, physiotherapy, home healthcare supplies, speech-language therapy, social work, and healthy eating.
  • Phone: 310 2222 (no area code needed) Toll-Free: 1 888 470 2222

To find a Dietitian:

  • Dietitian services are generally not covered by OHIP. Talk to your doctor and check with your insurance provider.
  • You can access a Dietitian through the Telehealth Ontario phone line at 1 866 797 0000 for free.
  • CommunitiCare Health offers nutrition counselling and management.
  • You can find a Dietitian through the Dietitians of Canada directory.

To find an Occupational Therapist:

  • The Ontario Society of Occupational Therapists (OSOT) online search tool is a directory to aid Ontarians looking to access private OT services.
  • Contact the Ontario Health atHome Phone: 310 2222 (no area code needed) Toll-Free: 1 888 470 2222.

To find a Physiotherapist:

To find a Speech-Language Pathologist:

To find Mental Health support:


Legal Information

Parkinson's disease

‭(Hidden)‬ Patient Education Resources

Resources from the Patient & Family Education Program PDF Icon

Our Team

Meet Our Team

Our Team Approach

The Movement Disorders Clinic was established in the 1980s and has grown from a single neurologist to the largest clinic of its kind in Canada, with eleven faculty neurologists working with a number of Fellows and nurses. Thanks to generous philanthropic support, we are now entitled as the Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic. We have also been awarded a Parkinson's Foundation Center of Excellence designation due to our international reputation for excellence in research, teaching and patient care.

Parkinson's Foundation Logo  

There's much more to movement disorders than tremors and unsteadiness. People with movement disorders can suffer personality changes, trouble sleeping and memory loss. Some disorders are very complex and can have a great impact on a person's life.

At Krembil Brain Institute, we want to change that. We want to restore a patient's health when it comes to their brain and slow the progression of their disease.

Director of the Movement Disorders Clinic: Dr. Anthony Lang. Visit Dr. Lang's research profile

Neurologists

Nursing

Mrs. Athea Tuitt
Phone: 416 603 5875

Ms. Yu Yan Poon
Phone: 416 603 5875

Mr. A. Valencia, Nurse Practitioner
Phone: 416 603 5800 ext. 2664​

Our Research

Clinical Research at the Movement Disorders Clinic

We are involved in a large number of clinical research trials including pharmacologic studies evaluating a number of drugs at various stages of Parkinson's disease and other Movement Disorders.

The Toronto Western Hospital Movement Disorders Program remains a world leader in the surgical management of Parkinson's disease including the evaluation of deep brain stimulation (DBS) in novel sites or for new indications and the use of MRI-guided Focused Ultrasound.

Collaborators in the surgical arm of the program include Dr. Alfonso Fasano and Dr. Renato Munhoz in neurology and Dr. Andres Lozano, Dr. Mojgan Hodaie and Dr. Suneil Kalia in neurosurgery.

Neuropsychological and imaging evaluations of patients participating in these studies represent an important component of our collaborative research. Additional neurophysiologic studies in surgical patients as well as in other movement disorders are carried out by Dr. Robert Chen.

Clinical trials are very active in the program. Dr. Susan Fox directs a program in clinical neuropharmacology and early proof of principle studies. Dr. Connie Marras conducts clinical epidemiological studies including evaluating families with genetic forms of various movement disorders and assessing risk factors that could contribute to diseases such as Parkinson's disease.

We have recently developed a specialty clinic in the ataxias directed by Dr. Elizabeth Slow and Dr. Renato Munhoz.

Neuroimaging is an important component of our program and Dr. Antonio Strafella directs a very active functional imaging research program using positron emission tomography and functional MRI.

Molecular and cell biology and clinical genetics of movement disorders including Parkinson's disease are areas of expanding interest with Dr. Lorraine Kalia in the Tanz Centre for Research in Neurodegenerative Diseases, Krembil Brain Institute.

Neuropathologist Dr. Gabor Kovacs and Dr. Naomi Visanji also work out of the Tanz Centre for Research in Neurodegenerative Disease, Krembil Brain Institute. Their work is supported by the Rossy Program for progressive supranuclear palsy research (PSP) led by Dr. Anthony Lang. Some of their work looks at identifying where the disease and the pathological accumulation of the tau protein starts in the brain, to better monitor patients and predict prognoses.

This broad-based research program is directed at attempting to solve the 'Parkinson puzzle' and other Movement Disorders at many levels including attempts at understanding the cause(s), improving the accuracy of diagnosis preventing/slowing the progression and treating the later stages more effectively.

We are committed to discovering causes of, and better treatments for, Parkinson's disease and other movement disorders through our extensive research program. Patients at our centre have the opportunity to participate in research and feel part of the process of finding answers. The participation of our patients and their families helps us to make progress in our understanding of the disease so that we can improve treatments or find cures. We have many studies going on at any one time.

Learn about Clinical Research and how taking part can help:

Consent to allow us to review your medical records and contact you about the possibility of participating in various research projects that we and our collaborators are conducting. This form does not commit you to participate in any research


Learn about: Research Studies that are currently recruiting »

Learn about Brain Donation Research:

UHN Research Initiatives

The Krembil Research Institute is the research arm of the Toronto Western Hospital The overall goal of Krembil's research program is to develop innovative treatments for chronic debilitating conditions that include chronic neurological disorders (e.g., Parkinson's disease, stroke, epilepsy, spinal cord injuries, dementia, concussion, pain and depression), ophthalmologic disorders (e.g., glaucoma, macular degeneration and retinopathy) and musculoskeletal system disorders (e.g., osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus and ankylosing spondylitis. Learn more about Krembil Research Institute | UHN Research.

UHN's Research Institutes span the full spectrum of diseases and disciplines, including cancer, cardiovascular sciences, transplantation, neural and sensory sciences, musculoskeletal health, rehabilitation sciences, and community and population health. Learn more about Research at UHN | UHN Research.

Canadian Research Initiatives

International Research Initiatives

Research Studies that are currently recruiting

If you are interested in hearing more about any of our research studies please email mdcclinicaltrials@uhn.ca

Empowering Patients: Perspectives on Clinical Research

Our 3-part video series demystifies assumptions about clinical research and shows that the motivation for participating can be altruistic and empowering.

 

Empowering Patients: Perspectives on Clinical Research Playlist

Research Studies

Study Name:
Biomarkers
Study Focus:

Biomarkers in PD


Study Procedures:
  • Lumbar puncture
  • Skin biopsy
  • Blood and saliva
  • Questionnaires

Study Frequency:
    ​​
  • 1-2 visits​​

Special Requirements:
  • Patients taking blood thinners or with conditions predisposing to neuropathy will be excluded.
  • Looking for:
    • early untreated PD less than 2 years since diagnosis
    • advanced PD
    • MSA or PSP
    • RBD
    • Healthy participants
    ​​
Study Name:
Educational Study
Study Focus:

To provide additional education to DBS candidates and evaluate if the success of Deep Brain Stimulation (DBS) is related to the fulfillment of patients' expectations, than merely improvement of motor status

Study Procedures:
  • Two virtual educational sessions
  • Short questionnaire
​​
Study Frequency:
Not available
Special Requirements:
  • Diagnosis of Parkinson's disease
  • DBS candidates

Study Name:
FOG on Split-belt Treadmill
Study Focus:

To gain new insight into the mechanisms causing freezing of gait (FOG).​

Study Procedures:
  • Gait analysis​ on a treadmill
  • Questionnaires

Study Frequency:

One visit

Special Requirements:
  • PD diagnosis
  • Able to walk without pain or discomfort

Study Name:
Free-Viewing Eye Tracking
Study Focus:

Exploring eye movements as a novel biomarker for neurological disorders

Study Procedures:
  • Questionnaires
  • Eye tracking
  • Clinical assessments
​​

Study Frequency:
  • Single visit

Special Requirements:
  • Current diagnosis of PSP, MSA, CBS, parkinsonism, dystonia, ataxia, tic disorder, functional movement disorder or other movement disorder
Study Name:
Gait Adaptation
Study Focus:

By using a treadmill, researchers hope to learn more about the role of the cerebellum (a part of the brain) in different Neurological indications. The results could help develop new ways to assess brain function, find useful markers for diagnosis, and create better treatments to improve walking for people with these conditions.

​​​
Study Procedures:
  • Walking analysis on a treadmill
  • Neurological assessments

Study Frequency:
  • 1 visit or 2 visits depending on the condition

Special Requirements:
  • PD with or without DBS
  • ET with or without DBS
  • NPH before shunt

Study Name:
LRRK2 Biomarker Study
Study Focus:

Find markers of risk for Parkinson’s disease in people with variants in the LRRK2 gene

Study Procedures:
  • Questionnaires
  • Eye movement testing
  • Neurological examination and electrocardiogram
​​​
Study Frequency:
  • 1 visit

Special Requirements:
  • LRRK2 genetic mutation
​​
Study Name:
LUMA Study
Study Focus:

To assess the efficacy and safety of study drug to see if it may delay the progression of Parkinson's disease in people in the early stages of their condition

Study Procedures:
  • DaTscan (a brain scan to detect changes associated with Parkinson's disease)
  • Spinal Fluid collection
  • Urine and blood sample collection
  • Brief daily Assessments using an electronic device
  • ECG (to check heart rhythm)
  • Pulmonary function test (breathing tests)
  • Daily intake of study drug (tablets taken by mouth)

Study Frequency:
  • Multiple visits (study participation is a minimum of 48 weeks and may go up to 144 weeks with visits to the clinic occurring every 4-6 weeks)

Special Requirements:
  • 30 to 80 y/o diagnosed with PD within the last 2 years and currently NOT taking any PD medications

Study Name:
Pathophysiology of PD
Study Focus:

Changes in brain functions


Study Procedures:
  • TMS Brain Stimulation EEG
  • Clinical assessments

Study Frequency:
  • 1 to 4 visits
  • 4 hours
  • 3 months


Special Requirements:
  • Mild to moderate PD with STN DBS
  • DBS turned off for a portion of the visit


Study Name:
PD QoL Scales
Study Focus:

Study aimed at improving the tools used to measure quality of life in PD

Study Procedures:
  • Two virtual interviews
  • One Survey


Study Frequency:
  • 45 minutes to 1.5 hours
  • 3 virtual visits
  • 7-10 months


Special Requirements:
  • Individuals with Parkinson's disease
  • Able to recall and report on their PD symptoms
  • 18 years or older
  • Fluent in English


Study Name:
PDGENE
Study Focus:

Provide genetic testing for people with Parkinson's disease and contribute to a database and biobank for ongoing genetic research.

Study Procedures:
  • Cheek swab or blood draw
  • Survey
​​
Study Frequency:
  • Single visit
​​
Special Requirements:
  • Parkinson's disease diagnosis
​​
Study Name:
Percept
Study Focus:

Examining the Effects of Unblocking the Full Potential of Medtronic PerceptTM PC IPG on Symptoms of Individuals with Parkinson's Disease.

Study Procedures:
  • Programming
  • Questionnaires
​​
Study Frequency:


Special Requirements:
  • Diagnosis of PD with DBS
  • Had IPG replacement from Activa PC to Medtronic PerceptPC

Study Name:
PPMI
Study Focus:

Biomarker discovery in Parkinson's disease and people at risk for Parkinson's disease

Study Procedures:
  • Lumbar puncture (spinal tap)
  • Skin biopsy
  • Blood and urine
  • Questionnaires
  • DaTscan (A brain scan identifying the neurodegeneration seen in Parkinson's disease)
  • MRI

Study Frequency:


Special Requirements:


Study Name:
Sleep Study
Study Focus:
This study aims to improve our understanding of sleep stages and disorders. The goal is to provide better support for individuals with Parkinson's disease in the future.​
Study Procedures:
  • Questionnaire
  • Sleep test at Sunnybrook

Study Frequency:
  • 1 visit

Special Requirements:
  • PD with DBS
  • Percept IPG (Battery)

Study Name:
Brain plasticity and neuromodulation in Parkinson's Disease
Study Focus:

Changed brain activity in Parkinson's Disease


Study Procedures:
  • TMS Brain Stimulation
  • MRI

Study Frequency:
  • 2-4 visits
  • 4 hours
  • 3 months

Special Requirements:
  • PD patients with STN-DBS are eligible
  • No severe tremor or dyskinesia
  • No history of seizure


Study Name:
C-OPN
Study Focus:

Canadian Open Parkinson Network (C-OPN) is a national registry designed to unite and mainstream research efforts to more efficiently find ways to treat Parkinson's disease

Study Procedures:

Information about the study is here: https://copn-rpco.ca/

Interested participants can simply sign-up online here: https://copn-rpco.ca/participants/

Study Frequency:
Not available
Special Requirements:

People of any age living in Canada and diagnosed with Parkinson's disease or any Parkinson Plus Syndrome

Study Name:
LRRK2 Genetic Registry
Study Focus:

Gene mutations


Study Procedures:
  • Creating a directory of PD patients with gene mutations

Study Frequency:
  • Future research

Special Requirements:
  • Gene mutations causing PD

Study Name:
PD Diaries
Study Focus:

To monitor how well Parkinson's disease medications are working and if they are taken as prescribed

Study Procedures:
  • Questionnaires

Study Frequency:
  • 24 months, 7 visits

Special Requirements:
  • Diagnosed with Parkinson's disease
  • Have not gone under surgeries for PD (such as DBS)

Study Name:
Biomarkers
Study Focus:

Biomarkers - To develop a test to diagnose different neurodegenerative diseases

Study Procedures:
  • Lumbar puncture
  • Skin biopsy
  • Blood and saliva
  • Questionnaires

Study Frequency:
  • 1-2 visits

Special Requirements:
  • Looking for:
    • Early untreated PD less than 2 years since diagnosis
    • Advanced PD​​
    • MSA or PSP
    • RBD
    • Healthy participants
​​
Study Name:
C-OPN
Study Focus:

Canadian Open Parkinson Network (C-OPN) is a national registry designed to unite and mainstream research efforts to more efficiently find ways to treat Parkinson's disease

Study Procedures:

Information about the study is here: https://copn-rpco.ca/

Interested participants can simply sign-up online here: https://copn-rpco.ca/participants/

Study Frequency:
Not available
Special Requirements:

People of any age living in Canada and diagnosed with Parkinson's disease or any Parkinson Plus Syndrome

Study Name:
Free-Viewing Eye Tracking longitudinal arm
Study Focus:

Study Procedures:
  • Questionnaires
  • Eye tracking
  • Clinical assessments

Study Frequency:
  • Annual visit up to 10 years

Special Requirements:
  • Current diagnosis of undifferentiated parkinsonism

Study Name:
Imaging synaptic pruning in Parkinsonisms
Study Focus:

Using PET imaging scans to differentiate between neurodegenerative diseases

Study Procedures:
  • PET
  • MRI
  • Clinical Assessments

Study Frequency:
  • 1 visit
  • 6 hours

Special Requirements:
  • PSP/MSA/CBD movement disorders
  • No pacemaker
  • No claustrophobia
Study Name:
Prospective multidisciplinary analysis of imaging and outcome data from patients with movement disorders and/or cognitive impairment
Study Focus:
Additional MRI sequence​
Study Procedures:
  • MRI
  • Clinical assessments

Study Frequency:
  • Visit and follow-up are related to standard of care

Special Requirements:
  • 18 y/o and older patient with neurodegenerative disorder from MDC and Memory clinic that requires an MRI in relation to standard of care

Study Name:
Dystonia Coalition
Study Focus:

To better understand symptoms of dystonia

Study Procedures:
  • Blood Samples
  • Questionnaires
  • Videotaping
Study Frequency:

1 Visit – usually at same time as BTX visit (prior to injection):

  • 1.5 hour

Special Requirements:
  • Dystonia diagnosis
  • 18+ years old with last botox 2+ months prior

Study Name:
Free-Viewing Eye Tracking
Study Focus:
Exploring eye movements as a novel biomarker for neurological disorders​
Study Procedures:
  • Questionnaires
  • Eye tracking
  • Clinical assessments

Study Frequency:
  • Single visit​


Special Requirements:
  • Current diagnosis of PSP, MSA, CBS, parkinsonism, dystonia, ataxia, tic disorder, functional movement disorder or other movement disorder

Study Name:
Musician’s Dystonia
Study Focus:

Studying connections between the cerebellum and parts of the brain for musicians


Study Procedures:
  • TMS(cTBS) Brain Stimulation
  • MRI

Study Frequency:
  • 2 visits
  • 2 hours
  • 3 months

Special Requirements:
  • Musician's Dystonia diagnosis
  • No pacemaker
  • No claustrophobia
Study Name:
Writer’s cramp
Study Focus:

Cortical plasticity in Focal hand dystonia before and after botox injection


Study Procedures:
  • TMS Brain Stimulation
  • Writing assessment

Study Frequency:
  • 4 visits
  • 4 hours
  • 3 months

Special Requirements:
  • Right hand writer's cramp diagnosis
  • Receiving benefit from botox injection

Study Name:
Biomarkers
Study Focus:

Biomarkers - To develop a test to diagnose different neurodegenerative diseases

Study Procedures:
  • Lumbar puncture
  • Skin biopsy
  • Blood and saliva
  • Questionnaires
Study Frequency:
  • 1-2 visits

Special Requirements:


Study Name:
Brain connectivity in Musician's Dystonia
Study Focus:

Studying connections between the cerebellum and parts of the brain for musicians (with or without dystonia)


Study Procedures:
  • TMS brain stimul​​ation
  • MRI
Study Frequency:
  • 2 visits
  • 3 hours
  • 3 months

Special Requirements:
  • Play a musical instrument that uses the hand our mouth
  • No cardiac pacemaker or metal implanted in body
  • No claustrophobia
Study Name:
Brain Plasticity in Parkinson's Disease
Study Focus:

Comparing brain activity of healthy individuals age matched to patients with PD with two non-invasive brain stimulation techniques


Study Procedures:
  • TMS brain stimulation
  • LIFUS ultrasound
  • MRI

Study Frequency:
  • 4 visits
  • 5 hours
  • 3 months

Special Requirements:
  • 45-80 years of age
  • No neurological disease or disorder
  • No psychiatric disease or disorder
  • Not taking medication that has a neurological effect
  • No cardiac pacemaker or metal implanted in body
Study Name:
Effect of Low-intensity Focused Ultrasound (LIFUS) and neurological drugs on Brain plasticity in Healthy Individuals
Study Focus:

To look at how LIFUS applied to the brain changes how the brain works, in relation to the known effects of four well-studied drugs with neurological effects


Study Procedures:
  • TMS brain stimulation
  • LIFUS ultrasound
Study Frequency:
  • 5 visits
  • 5 hours
  • 3 months

Special Requirements:
  • 18-65 years of age
  • No major neurological disease or disorder
  • No major psychiatric disease or disorder
  • Not taking medication that has a neurological effect
  • No cardiac pacemaker or metal implanted in body

Study Name:
Gait Adaptation
Study Focus:
By using a treadmill, researchers hope to learn more about the role of the cerebellum (a part of the brain) in different Neurological indications. The results could help develop new ways to assess brain function, find useful markers for diagnosis, and create better treatments to improve walking for people with these conditions.​
Study Procedures:
  • Walking analysis on a treadmill

Study Frequency:
  • 1 visit

Special Requirements:
  • Healthy individuals

Study Name:
Walking analysis on Split-belt Treadmill and gait mat
Study Focus:

To understand typical walking characteristics in the general population

Study Procedures:
  • Walking analysis on a treadmill
  • Walking analysis on gait mat

Study Frequency:
  • 1 visit

Special Requirements:
  • Healthy individuals

Study Name:
Chronos
Study Focus:

Use of Chronos programming software in ET patients who just received DBS.

Study Procedures:
  • Speech Analysis
  • Tremor Scale
  • Walking Analysis
Study Frequency:
  • Six visits

Special Requirements:
  • ET DBS candidates
​​
Study Name:
Free-Viewing Eye Tracking
Study Focus:
Exploring eye movements as a novel biomarker for neurological disorders
Study Procedures:
  • Questionnaires
  • Eye tracking
  • Clinical assessments

Study Frequency:
  • Single visit

Special Requirements:
  • Current diagnosis of PSP, MSA, CBS, parkinsonism, dystonia, ataxia, tic disorder, functional movement disorder or other movement disorder

Study Name:
Tremor Habituation
Study Focus:

To understand DBS loss of benefits in ET patients

Study Procedures:
  • In clinic assessments

Study Frequency:

One visit, 4-hours

Special Requirements:
  • Undergone DBS surgery for Essential Tremor
  • Experiencing DBS loss of benefits

Research Studies Glossary

Biomarkers – an indicator of the presence or severity of a disease.

DBS – Deep Brain Stimulation

ECG or EKG – Electrocardiogram checks how your heart is functioning by measuring the electrical activity of the heart.

EEG – Electroencephalography measures electrical activity of the brain with the electrodes placed along the scalp.

ET – Essential Tremor is a neurological condition that causes involuntary and rhythmic shaking.

LIFUS – Low intensity focused ultrasound.

MCI – Mild cognitive impairment, in which people have more memory problems than normal for people their age.

MRI – Magnetic Resonance Imaging uses magnetic fields and radio waves to create pictures of the anatomy and the processes of the body.

MSA – Multiple System Atrophy, a neurodegenerative disorder that can mimic Parkinson's.

PD – Parkinson's Disease, a neurodegenerative brain disorder that can lead to shaking, stiffness, and difficulty with walking, balance, and coordination.

PET – Positron Emission Tomography is a nuclear imaging technique to create 3D colour images to see how your body's cell are working.

Phase 2 clinical trial – Studies a drug's effectiveness and determines risks and side effects in people with a disease or condition.

Phase 3 clinical trial – Compares a drug to standard therapies for a disease or condition.

Placebo – Substances that are made to resemble drugs but do not contain an active drug, they are usually a starch or sugar.

PSP – Progressive Supranuclear Palsy is an uncommon brain disorder that affects movement, walking and balance, speech, swallowing, vision, mood, behaviour and thinking.

RBD – REM Behaviour Disorder occurs when you act out vivid dreams when you are asleep.

snOH – Symptomatic Neurogenic Orthostatic Hypotension is a drop in blood pressure when standing up, changing positions, or standing for a long period of time.

TMS – Transcranial magnetic stimulation is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain.​

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