Hyperkinesias (dystonia, dyskinesia) are, with fluctuating akinesias, the most debilitating disturbances appearing during the advanced course of Parkinson’s disease.1 The origin of these disturbances is controversial; as hyperkinesias are seen after long term treatment with levodopa or dopaminoagonist drugs many researchers think that these motor fluctuations could be prevented by dopaminomimetic drug restriction,1 others think that hyperkinesias will appear anyway after enough years, independently of dopaminomimetic drug restriction—that is, the supersensitivity of striatal structures to external administration of dopaminomimetic drugs is an epiphenomenon of natural degeneration in Parkinson’s disease.2

Ten years apart from one another we had the chance to observe two patients with Parkinson’s disease with prevalent akinetic symptoms who came to us already in an advanced stage of Parkinson’s disease, classified as stage IV according to the Hoehn and Yahr scale.3 These patients had never been treated with dopaminomimetic agents (levodopa, dopaminoagonists), or amantadine or anticholinergic drugs, and both developed dyskinesias and motor fluctuations when levodopa was increased to the amounts commonly used in patients with stage III-IV Parkinson’s disease treated for 6–10 years.

Patient 1 was a 76 year old man living in the inner mountainous part of central Italy. When he came to us he was incapable of rising from his bed; hypomimia, akinesia, flexed dystonic posture, and rigidity were rated 20 at …