Parkinson's disease

treatment

There is no cure for Parkinson's disease (PD). Treatment for PD is built around medications to relieve the symptoms. The U.S. Food and Drug Administration (FDA) also has approved a surgically implanted device that lessens tremors. In some severe cases, brain surgery may offer the greatest benefit.
Medications :
Medication selection and dosage is tailored to the individual. The doctor considers factors such as severity of symptoms, age, and presence of other medical conditions. No two individuals will respond identically to a particular drug or dosage level, so this process involves experimentation, persistence, and patience. As the disease progresses, drug dosages may have to be modified and medication regimens changed.
Levodopa/Carbidopa: Sometimes a combination of drugs is given. Levodopa and carbidopa combined (Sinemet® and Sinemet CR®) are the main drug treatment for PD. Levodopa is rapidly converted into dopamine by enzymes in the body. Because PD is caused by too little dopamine, this increase helps balance the levels of dopamine, decrease symptoms such as bradykinesia (slow trembling) and rigidity, and, less effectively, reduce tremor. Levodopa is often ineffective in relieving problems with balance. Carbidopa helps decrease the metabolism of levodopa, thereby increasing the amount available for the brain. Side effects include nausea and vomiting (especially early in treatment), hypotension (low blood pressure), and dyskinesias (abnormal movements). Slow dosage adjustment and taking medication with food can reduce these effects. Using the lowest effective dose may prevent or delay the appearance of motor dysfunction. Levodopa may become ineffective over time. Depression, confusion, and visual hallucinations also may occur when using levodopa, especially in the elderly.
Dopamine agonists: Dopamine agonists mimic dopamine's function in the brain. They are used primarily as adjuncts to levodopa/carbidopa therapy. They can be used as monotherapy but are generally less effective in controlling symptoms. Side effects are similar to those produced by levodopa and include nausea, sleepiness, dizziness, and headache. Dopamine agonists include bromocriptine (Parlodel®), pramipexole (Mirapex®), ropinirole (Requip®), and rotigotine (Neupro®). The FDA approved rotigotine transdermal system (Neupro®) for the treatment of early PD in May 2007. Neupro®, which is a medicated patch that is applied to the skin once a day, provides the dopamine agonist rotigotine continuously over a 24-hour period. Redness and tenderness are common at the site of application on the body.
Amantadine: Amantadine (Symmetrel®) is an antiviral drug with dopamine agonist properties. It increases the release of dopamine. It is often used to treat early-stage Parkinson's disease, either alone, with an anticholinergic drug, or with levodopa. Generally, it loses its effectiveness within three to four months. Doctors may cycle individuals on and off amantadine. Side effects include spotting of the skin, edema, confusion, blurred vision, insomnia, and anxiety.
MAO-B inhibitors: Dopamine is oxidized by monoamine oxidase B (MAO-B). Selegiline (Carbex®) inhibits MAO-B, increasing the amount of available dopamine in the brain. MAO-B inhibitors boost the effects of levodopa. Side effects may include nausea, dizziness, abdominal pain, confusion, hallucinations, and dry mouth.
Anticholinergics: Anticholinergics reduce the overactivity of the neurotransmitter acetylcholine to balance the reduced dopamine levels. This class of drugs is most effective in the control of tremors and they are used in combination with levodopa. Anticholinergic drugs include benztropine mesylate (Cogentin®), diphenhydramine (Benadryl®), and trihyxyphenidyl (Artane®). Side effects associated with anticholinergic drugs include dry mouth, blurred vision, constipation, and urinary retention.
COMT (catechol-O-methyl transferase) inhibitors: COMT inhibitors help increase levodopa therapy by inhibiting the COMT enzyme, which metabolizes levodopa before it reaches the brain. Inhibiting COMT increases the amount of levodopa that enters the brain. These drugs are only effective when used with levodopa. COMT inhibitors include entacapone (Comtan®) and tolcapone (Tasmar®). But because tolcapone has been linked to liver damage and liver failure, the drug is normally used only in people who are not responding to other therapies. Entacapone is a COMT inhibitor that shares some of the properties of tolcapone, but does not seem to cause liver problems. Entacopone is now combined with carbidopa and levodopa in a medication called Stalevo®. Side effects include vivid dreams, visual hallucinations, nausea, sleep disturbances, daytime drowsiness, headache, and dyskinesias (difficulty in performing movements).
Surgery :
Surgery is another method of controlling symptoms and improving quality of life when medication ceases to be effective or when medication side effects, such as jerking and dyskinesias (difficulty in performing movements), become intolerable.
Not every individual suffering from Parkinson's disease (PD) is a good candidate for surgery. Surgery has not been found to be effective in those who respond poorly to levodopa/carbidoopa. Only about 10% of Parkinson's patients are estimated to be suitable candidates. There are three surgical procedures for treating Parkinson's disease: ablative surgery, stimulation surgery or deep brain stimulation (DBS), and transplantation or restorative surgery.
Doctors will help individual's with PD to determine if surgery is appropriate for them. Seeking more than one opinion may be helpful.
Deep brain stimulation: Deep brain stimulation (DBS) involves a surgically implanted, battery-operated medical device (called a neurostimulator) used to deliver electrical stimulation to areas of the brain that control movement. The electrical charge blocks nerve signals that trigger abnormal movement. In DBS, an electrode (lead) is inserted through a small incision in the skull and is implanted in the targeted area of the brain. An insulated wire (extension) is then passed under the skin in the head, neck, and shoulder, connecting the lead to the neurostimulator, which is surgically implanted in the chest or upper abdomen. Side effects of deep brain stimulation include bleeding at the implantation site, depression, impaired muscle tone, infection, loss of balance, paresis (slight paralysis), dysarthia (slurred speech), and parethesia (tingling) in the head or the hands.
Ablative surgery: Ablative surgery locates, targets, and then ablates (destroys) the clearly defined area of the brain that produces chemical or electrical impulses that cause abnormal movements. In this surgery, a heated probe or electrode is inserted into the targeted area. The individual remains awake during the procedure to determine if the problem has been eliminated. A local anesthetic is used to dull the outer part of the brain and skull. The brain is insensitive to pain, so the individual does not feel the actual procedure. In some cases, it may be difficult to estimate how much tissue to destroy and the amount of heat to use.
This type of surgery involves either ablation in the part of the brain called the globus pallidus (called pallidotomy) or ablation of brain tissue in the thalamus (called thalamotomy). A related procedure, cryothalamotomy, uses a supercooled probe that is inserted into the thalamus to freeze and destroy areas that produce tremors.
Pallidotomy may be used to eliminate uncontrolled dyskinesia (difficulty in movement) and thalamotomy may be performed to eliminate tremor. These procedures are successful in approximately 75% of cases.
Cryothalamotomy uses a super-cooled probe that is inserted into the thalamus to freeze and destroy areas that produce tremors. Ablative surgery is safe and rarely causes complications such as affecting other areas of the brain.
Transplantation or restorative surgery: In transplantation (or restorative) surgery, dopamine-producing cells are implanted into the striatum. The cells used for transplantation may come from one of several sources, including the individual's own body, human embryos, and pig embryos.
Using cells from the individual's body has been unsuccessful so far because of an insufficient supply of dopamine cells and the inability of the implanted cells to survive.
To use fetal cells, between three and eight embryos are needed per procedure, and even under the most favorable conditions, 90% of transplanted cells do not survive. This procedure is only moderately effective in some patients and usually in those younger than age 60. Preliminary studies have shown that pig embryo cells do survive transplantation and have an effect on symptoms. Stem cells, primitive cells that can grow into nerve cells, are able to survive and reproduce. Once they grow as nerve cells, they can be transformed into dopamine-producing cells. Stem cells are obtained from discarded blood in a newborn's umbilical cord, the bone marrow of an adult, unused embryos from fertility clinics, or an aborted embryo. There is much controversy surrounding the use of stem cells.
Nutrition and lifestyle changes: Proper diet and exercise is very important for individuals with movement disorders, including PD. In helping individuals to eat, caregivers should allow plenty of time for meals. Food can be cut into small pieces, softened, or pureed to ease swallowing and prevent choking. While some foods may require the addition of thickeners, other foods may need to be thinned. Dairy products, in particular, tend to increase the secretion of mucus, which in turn increases the risk of choking.
Some individuals may benefit from swallowing therapy, which is especially helpful if started before serious problems arise. Suction cups for plates, special tableware designed for people with disabilities, and plastic cups with tops can help prevent spilling. The individual's doctor can offer additional advice about diet and about how to handle swallowing difficulties or gastrointestinal problems that might arise, such as incontinence or constipation.
Maximizing physical activity is a goal in all movement disorders. Patients should perform daily activities to the extent possible. If they cannot, a regular exercise program or physical therapy may help condition them physically and teach them adaptive strategies. Because the disease, medications, and inactivity can lead to constipation, patients should consume a high-fiber diet, such as bran cereals, whole wheat bread, fresh vegetables, and brown rice. Dietary supplements, including psyllium and stimulant laxatives (such as bisacodyl or Dulcolax®), may be needed for constipation.
Although their coordination may be poor, individuals should continue walking, with assistance if necessary. Those who want to walk independently should be allowed to do so as long as possible. Careful attention should be given to keeping their environment free of hard, sharp objects to help ensure maximal independence while minimizing the risk of injury from a fall. Individuals can also wear special padding during walks to help protect against injury from falls. Some individuals have found that small weights around the ankles can help stability. Wearing sturdy shoes that fit well can help as well, especially shoes without laces that can be slipped on or off easily. Velcro shoes may help provide extra stability.
Speech therapy: Some movement disorders, such as PD, can impair speech, affecting the ability of the individual to express complex thoughts. Speech therapy may improve the individual's ability to communicate and swallow. It is important for caregivers to understand that individuals with these movement disorders may not be communicating due to the disease and not due to a lack of sociability.
Social Activity: Unless and until the disease's progression prohibits it, people with movement disorders should participate in outside activities, socialize, and pursue hobbies and interests. These activities also give family members and caregivers valuable time for themselves.
Caregiver support: Movement disorders confront individuals and their caregivers with many complex problems that must be dealt with for the life of the patient. While it may be emotionally difficult, it is important for patients and caregivers to make informed, carefully considered decisions regarding the future while the patient is capable of making his or her contribution to a planned course of action.
Physical therapy: According to the American Physical Therapy Association, the goal of physical therapy or physiotherapy is to improve mobility, restore function, reduce pain, and prevent further injury by using a variety of methods, including exercises, stretches, traction, electrical stimulation, and massage. Physical therapy has been reported useful in neurological disorders.

integrative therapies

Although there are a few clinical studies using integrative therapies for the treatment of Parkinson's disease (PD), there have been studies in other neurological disorders that may present with similar symptoms as PD. Listed below are integrative therapies that have been studies clinically in various movement disorders, including PD.
Good scientific evidence :
5-HTP: Cerebral ataxia results from the failure of part of the brain to regulate body posture and limb movements. 5-HTP has been observed to have benefits in some people who have difficulty standing or walking because of cerebral ataxia. Some research shows that 5-HTP may allow individuals with unsteady movements to stand alone without assistance, walk without aid, or improve coordination. Other research shows no benefit. Further research is needed before a conclusion can be drawn. 5-HTP may interact with other mood altering medications such as antidepressants and anti-anxiety drugs.
Music therapy: Music therapy has been reported to improve symptoms in people with Parkinson's disease. Modest improvement in symptoms including motor coordination, speech intelligibility and vocal intensity, bradykinesia (slow movement), emotional functions, activities of daily living, and quality of life were seen.
Unclear or conflicting scientific evidence :
Acupressure, Shiatsu: The practice of applying finger pressure to specific acupoints (energy points) throughout the body has been used in China since 2000 B.C. Shiatsu technique involves finger pressure at acupoints and along body meridians (energy lines). It can incorporate palm pressure, stretching, massaging, and other manual techniques. Shiatsu practitioners commonly treat musculoskeletal and psychological conditions, including neck/shoulder and lower back problems, arthritis, depression, and anxiety. Preliminary clinical evidence from one small study with individuals with facial spasm report improvement when using Shiatsu acupressure. Further research is needed.
Acupuncture: Acupuncture has been reported to help relieve symptoms of some neurological disorders including cerebral palsy, hemiplegia (full or partial paralysis of one side of the body due to disease, trauma or stroke), Parkinson's disease (characterized by fine muscle coordination and tremors), spinal cord injury, Tourette's syndrome (characterized by "tics"), and trigeminal neuralgia. One study found that parents were impressed with acupuncture therapy on functional well-being in Huntington's disease in children. There is insufficient evidence available from well-designed studies for using acupuncture in neurological disorders such as Tourette's syndrome. More trials need to be performed.
Alexander technique: The Alexander technique is an educational program that teaches movement patterns and postures with an aim to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve various medical conditions, and promote well-being. Preliminary research suggests that Alexander technique instruction may improve fine and gross movements and reduce depression in patients with Parkinson's disease. Well-designed human trials are necessary.
Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system) and how this relationship affects the preservation and restoration of health. Although there is not enough reliable scientific evidence to conclude the effects of chiropractic techniques in the management of Parkinson's disease, anecdotal reports suggest a positive impact on fine muscle coordination in some individuals. More clinical research is necessary.
Coenzyme Q10: Coenzyme Q10, or CoQ10, is produced by the human body and is necessary for the basic functioning of cells. There is promising evidence from one case control study and two case series to support the use of CoQ10 in the treatment of symptoms associated with Parkinson's disease (PD). These studies are lacking in sample sizes. A future randomized controlled trial with a substantial number of participants is necessary for proper evaluation of efficacy of CoQ10 in PD. Further research using CoQ10 for neurological conditions is necessary.
Cowhage: Traditional Ayurvedic medicine and preliminary evidence suggests that cowhage (Mucuna pruriens) contains 3.6-4.2% levodopa, the same chemical used in several Parkinson's disease drugs. Cowhage treatments have yielded positive results in early studies. However, additional high quality clinical research is needed to confirm these results.
Avoid if allergic or hypersensitive to cowhage, its constituents, or members of the Fabaceae family. Use cautiously with Parkinson's disease and/or when taking levodopa, dopamine, dopamine agonists, dopamine antagonists, or dopamine reuptake inhibitors as cowhage seeds contain the dopamine precursor levodopa. Use cautiously if taking monoamine oxidase inhibitors (MAOIs) or other antidepressants. Use cautiously if taking anticoagulants (blood thinners) or with diabetes. Avoid with psychosis or schizophrenia. Avoid if pregnant or breastfeeding as cowhage may inhibit prolactin secretion.
Ginseng: A clinical study found that patients with neurological disorders may improve when taking Asian ginseng (Panax ginseng). This supports research findings that report Panax ginseng improving cognitive function. More research is needed in this area.
Melatonin: Melatonin is a naturally occurring hormone that helps regulate sleep/wake cycles (circadian rhythm). Melatonin has been reported useful in neurological conditions including Parkinson's disease, periodic limb movement disorder, and tardive dyskinesia. The use of melatonin in these conditions, however, is not supported by rigorous scientific testing. Better-designed research is needed to determine if melatonin is beneficial in individuals with neurological disorders.
Reiki: Reiki is a system of lying on of the hands that originated as a Buddhist practice approximately 2,500 years ago. One randomized trial suggests that Reiki may have an effect on autonomic nervous system functions such as heart rate, blood pressure, or breathing activity, important in neurological disorders that may damage autonomic function, including neurological conditions. Large, well-designed studies are needed before conclusions can be drawn.
Taurine: Taurine may affect cellular hyper excitability by increasing membrane conductance to potassium and chloride ions, possibly by altering intracellular (within the cell) availability of calcium. Results from a single non-randomized trial suggest that taurine supplementation may result in improvements in myotonic (slow relaxation after contraction of muscles) complaints. Well designed clinical trials are needed.
Vitamin B6: Vitamin B6 (pyridoxine) is required for the synthesis of the neurotransmitters serotonin and norepinephrine and for myelin formation. Pyridoxine deficiency in adults principally affects the peripheral nerves, skin, mucous membranes, and the blood cell system. In children, the central nervous system (CNS) is also affected. Major sources of vitamin B6 include: cereal grains, legumes, vegetables (carrots, spinach, peas), potatoes, milk, cheese, eggs, fish, liver, meat, and flour. Some prescription drugs called neuroleptics, which are used in psychiatric conditions, may cause movement disorders as an unwanted side effect. Vitamin B6 has been studied for treatment of acute neuroleptic-induced akathisia (NIA, a neuromuscular disorder characterized by a feeling of "inner restlessness" or a constant urge to be moving) in schizophrenic and schizoaffective disorder patients. Preliminary results indicate that high doses of vitamin B6 may be useful additions to the available treatments for NIA, perhaps due to its combined effects on various neurotransmitter systems. Further research is needed to confirm these results.
Vitamin E: Vitamin E has been studied in the management of tardive dyskinesia and has been reported to significantly improve abnormal involuntary movements, although the results of exiting studies are not conclusive enough to form a clear recommendation. Vitamin E may be more effective in higher doses and in people who have had tardive dyskinesia for less than five years.
Other supplements that have unclear or conflicting scientific evidence include ashwagandha root (Withania somniferum), dehydroepiandosterone (DHEA), dong quai root (Angelica sinensis), homeopathic dilutions of belladonna (Belladonna atropa), choline, psychotherapy, selenium, and yohimbe bark (Pausinystalia yohimbe).
Historical or theoretical uses lacking sufficient evidence :
Integrative therapies used in neurological disorders, such as PD, that have historical or theoretical uses but lack sufficient clinical evidence include: aloe (Aloe vera), arabinoxylan, aromatherapy, art therapy, asparagus (Asparagus officinalis), arnica (Arnica montana), bacopa (Bacopa monnieri), bitter orange (Citrus aurantium), black cohosh (Actaea racemosa), cat's claw (Uncaria tomentosa), chelation therapy (EDTA), chondroitin sulfate, cordyceps (Cordyceps sinensis), devil's claw (Harpagophytum procumbens), horse chestnut (Aesculus hippocastanatum), kava kava (Piper methysticum), kudzu (Pueraria lobota), hypnosis, magnet therapy, lycopene, massage, muira puama (Ptychopetalum olacoides), omega-3 fatty acids, prayer, qi gong, relaxation, St. John's wort (Hypericum perforatum), and valerian (Valeriana sp.).

prevention

Proper diet: It is best to avoid stimulants, alcohol, and smoking.
It may be best to eliminate potential food allergens, including dairy (e.g. milk, cheese, and sour cream), eggs, nuts, shellfish, wheat (gluten), corn, preservatives, and food additives (such as dyes and fillers). A clinical study found a higher risk of Parkinson's disease (PD) among dairy product consumers in both men and women, suggesting that dairy consumption may increase the risk of PD, particularly in men. Dairy may increase mucous production. More studies are needed.
Studies suggest that moderate consumption of coffee may actually help reduce the chances of developing PD. Research suggests it is the caffeine content that offers protection, so decaffeinated coffee may offer no benefits in PD prevention.
Preventing complications of PD, such as inability to swallow foods, is important. Food can be cut into small pieces, softened, or pureed to ease swallowing and prevent choking. While some foods may require the addition of thickeners, other foods may need to be thinned. Dairy products, in particular, tend to increase the secretion of mucus, which in turn increases the risk of choking.
Weight control: Body mass index is associated with a risk of Parkinson disease. Losing weight may reduce the chances of developing PD.
Exercise: Maintaining physical fitness is important to those suffering from movement disorders such as PD. Those with movement disorders who exercise and keep active tend to do better, with less symptoms and a slower disease progression, than those who do not. A daily regimen of exercise can help the person feel better physically and mentally. Individuals should walk as much as possible, even if assistance is necessary. Talking with a healthcare provider about an exercise program is important.
Mobility: PD can cause the sense of balance to be off, making it difficult to walk with a normal gait or stride. If shuffling of the feet is noticed, slow down and check the posture. It is best to stand up straight with the head over the hips and the feet eight to ten inches apart. It can also help to purchase a good pair of walking shoes. If the individual becomes frozen in place, rocking gently from side to side may help decrease the time of inability to move.
In the later stages of the disease, the individual may fall more easily. PD may affect the balance and coordination centers in the brain. In fact, a person may be thrown off balance by just a small push or bump. The following suggestions may help:
Wearing rubber-soled shoes is recommended by healthcare professionals. This type of shoe is less likely to slip than are shoes with leather soles. Rugs should be removed from the home to avoid tripping and falling. Carpeting should be secured firmly to the floor. It is recommended that handrails be installed, especially along stairways and in the bathroom, and that electrical and telephone cords be kept out of the way.
Daily activities: Dressing can be the most frustrating of all activities for someone with PD. The loss of fine motor control makes it hard to button and zip clothes, and even to step into a pair of pants. A physical therapist can point out techniques that make daily activities easier. It is best to allow plenty of time so as not to feel rushed when dressing. Clothing may be laid nearby for ease of putting them on. Clothes that can be slipped on easily, such as sweat pants and t-shirts, simple dresses, or pants with elastic waistbands are recommended.
Even in the early stages of PD, the voice may become very soft or hoarse. To communicate more easily, healthcare professionals recommend facing the individual and deliberately speak louder than necessary. Practicing reading or reciting out loud, focusing on breathing, and a strong voice may be beneficial. A speech pathologist may be consulted to improve verbal communication skills in individuals with PD.