More about Parkinson's disease

SITARA CHOUDHURY MD

 

 

Parkinson's disease, which mostly afflicts older people, results from gradual degeneration of nerve cells in the portion of the midbrain that controls body movements. The first signs are likely to be barely noticeable - a feeling of weakness or stiffness in one limb, perhaps, or a fine trembling of one hand when it is at rest (activity causes the tremor to disappear). Eventually, the shaking will worsen and spread, muscles will tend to stiffen, and balance and coordination will deteriorate. Depression and other mental or emotional problems are common.

Usually the disorder begins between the ages of 50 and 65, striking about 1 percent of the population in that age group; it is slightly more common in men than in women. Medication can treat its symptoms, and the disorder is not directly life-threatening. About half of all patients treated with drugs have no major disabilities 10 years after the onset of the disease.

Causes
Bodily movements are regulated by a portion of the brain called the basal ganglia, whose cells re-quire a proper balance of two substances called dopamine and acetylcholine, both involved in the transmission of nerve impulses. In Parkinson's, cells that produce dopamine begin to degenerate, throwing off the balance of these two neurotransmitters. Researchers believe that genetics sometimes plays a role in the cellular breakdown, and in rare instances, Parkinson's may be caused by a viral infection or by exposure to environ-mental toxins such as pesticides, carbon monoxide, or the metal manganese. But in the great majority of Parkinson's cases, the cause is unknown.

Symptoms
The disease takes hold slowly, beginning with a sense of weakness and a slight tremor of the head or hands, then gradually progressing to more generalized symptoms. These can include:
slow, jerky movements; a shuffling gait; and stooped posture,
unsteady balance; difficulty rising from a sitting position.
continuous "pill-rolling" motion of - the thumb and forefinger.
indistinct speech; voice weakened to a monotone.
swallowing problems in later stages.
in severe cases, rigid trunk and limbs; fixed facial expression and unblinking, staring eyes.

Call your doctor if:
you suspect Parkinson’s disease might be at the root of any of the abve symptoms. In the disease’s early stages, drugs can be very beneficial.

Diagnostic and test procedures
Usually, the outward symptoms of Parkinson's are distinctive enough for a diagnosis to be made.
The metabolic changes in the brain can be traced with imaging tests such as PET-positron emission tomography.
Treatment
Most treatments aim at restoring the proper balance of the neurotransmitters acetylcholine and dopamine by increasing dopamine levels. Drugs are the standard way of doing this, but neurosurgeons have had some success with experiments involving operative procedures.

Conventional medicine
Symptoms can be effectively controlled for years with medication. The drug most often prescribed is levodopa - also called L-dopa - which the body metabolizes to produce dopamine. (Direct ad-ministration of dopamine is ineffective; the brain's natural protections block its uptake.) To suppress nausea and other possible side effects, levodopa is often used in conjunction with a related drug called carbidopa.
But some patients cannot tolerate carbidopa and so take levodopa alone. If you take only levodopa, it's important not to take it at the same time as food or vitamins containing vitamin B6, which interferes with its effectiveness.

Most doctors try to postpone starting patients on levodopa as long as possible, because the medication tends to lose effectiveness over time. However, there is some controversy about waiting to begin treatment with levodopa because it can be so beneficial. Researchers have thus investigated ways to offset the loss of effective-ness. Some studies have found that, when used in conjunction with levodopa and carbidopa, the antioxidant selegiline hydrochloride reduces many of the adverse effects associated with long-term drug use.
A new class of dopamine-like drugs imitates dopamine's activity rather than adding to the amount of it in the brain. Two of them, bromocriptine and pergolide, appear promising. Other medications prescribed for Parkinson's disease include apomorphine, benztropine, amantadine, and anticholinergic drugs; all can help control various symptoms - in some cases by releasing dopamine from nerve cells, in others by reducing the effects of acetylcholine rather than increasing the amount of dopamine.

Neurosurgeons have explored various ways of grafting dopamine-producing cells in the brain rather than trying to correct the neurotransmitter imbalance with drugs. One promising approach uses fetal-tissue implants. Some improvements have been observed, but because of the source of the cells, the technique is highly controversial.
Another experimental technique, stereotactic surgery, creates lesions in the thalamus, the brain's inner chamber. In some studies, this procedure appears to eliminate tremor in 80 per cent of patients and to relieve rigidity in almost all. A similar form of surgery - using electrical stimulation instead of lesions-also shows promise.
Scientists are also investigating the use of glial cell-derived nerve growth factor to treat Parkinson's and other neurodegenerative diseases. This substance is produced naturally by tissues throughout the body; some experiments indicate that injections of this nerve growth factor may help preserve and even restore nerve cells in the brain and spinal cord-specifically those that produce dopamine and that help initiate muscle movement.
Some treatments focus on the effects of the disorder rather than the causes. Your doctor might refer you to a physical therapist to restore normal body alignment, enhance your balance and motor responses, and improve your ability to initiate motion. A physical therapist may also give you muscle-strengthening exercises to help with speaking or swallowing.
In many Parkinson's patients, a weakening of social ties because of physical difficulties can lead to depression. Antidepressants can help. In addition, the American Parkinson Disease Association (see the Appendix) can provide information about support groups and exercise classes in your area-valuable sources of companionship.

Alternative choices
Conventional medicines such as levodopa are widely acknowledged as the best treatments for Parkinson's disease. However, many of the alternative therapies mentioned below can be very helpful for relieving symptoms or easing tight muscles. Some of the herbal and dietary therapies can be applied in conjunction with conventional medicines, but be sure to consult your doctor about possible adverse interactions.

Acupuncture
According to some studies by acupuncturists, Parkinson's disease may be accompanied by an imbalance of energy along one or more meridians . The muscle stiffness, soreness, and imbalance of Parkinson's may be alleviated by a series of treatments.

Body work
Deep-muscle massage stretches the connective tissue around tight muscles, ridding them of cramping and allowing greater freedom of movement. Massage can also improve motion in your joints, soften hardened muscle tissue, and stimulate your lymphatic system.
Reflexology practitioners say that the brain, head, and spine all respond to indirect massage. See the illustration below for reflexology techniques that may help relieve some Parkinson's symptoms.
Chi yi, a Chinese deep-breathing exercise, in-creases the oxygen supply in the blood and may thereby help alleviate depression. Sit with your back against the back of a chair and your feet flat on the floor. Reach toward the ceiling with both arms, inhaling deeply through your nose as you do so.

Hold your breath as you ball your hands into fists, squeezing your arm muscles. Exhale slowly through your nose to a count of six as you bring your tensed arms down, crossing them on your chest over your heart.
Lower your chin to your chest. Take four short breaths, completely filling your lungs, and feel your chest expand. Hold for a few seconds, then exhale slowly.

Repeat this exercise several times each day, concentrating on the rhythm and depth of each breath. If tremor prohibits arm or head movements, concentrate on the breathing, working toward a rate of only four or five breaths per minute. Limit practice to five minutes per day.
Yoga is an ideal form of exercise for Parkinson's patients because of its slow movements. Regular exercise is important to avoid the atrophying of muscles and shrinking of tissues from disuse. See the illustration opposite for one useful type of yoga exercise.

Chinese herbs
Taken several times a day, combinations that include rhubarb (Rheum palmatum), peony (Paeonia officinalis), licorice (Glycyrrhiza uralensis), and magnolia bark (Magnolia officinalis) are said to stop tremors and relax stiff muscles. Because using Chinese herbs is complicated, consult an expert in the field for correct dosages.

Herbal therapies
Passionflower (Passiflora incarnata) acts as an anti-spasmodic when ½ tsp of tincture is taken three times a day. Or take it twice daily as a tea: Pour one cup boiling water over 2 tsp dried leaves; steep for 15 minutes. Passionflower has been shown to reduce passive tremor when taken in combination with levodopa better than when either remedy is taken alone. But be sure to check with your doctor first if you are already taking levodopa. Daily doses of 500 mg of evening primrose oil (Oenothera biennis) may reduce tremors.

Homeopathy
A trained homeopath might prescribe a single remedy, a series, or a combination of remedies for the many different symptoms of Parkinson's.

Mind/Body medicine
The Feldenkrais method, which consists of a large number of exercises performed either in group classes or solo with a practitioner, aims at improving autonomic motor responses. While lying down, you are guided through a series of light, slow movements designed to support your neuromuscular system and alter habitual pat-terns of movement.

Nutrition and diet
Parkinson's patients should pay close attention to diet; weight loss-possibly caused by persistent involuntary movements - is a common problem.
A diet called the 7:1 plan-for the ratio of carbohydrates to proteins - is designed for patients taking levodopa (proteins reduce the drug's effectiveness). Researchers disagree as to whether the proteins should be eaten throughout the day or restricted to the evening meal, when interference with levodopa might be less of a problem. Consult your doctor to determine which method works best for you. Either way, a low-protein diet can lead to deficiencies in calcium, iron, and B vitamins; supplements are therefore advised. (If you are taking levodopa without carbidopa, how-ever, avoid vitamin B6; the vitamin will interfere with the levodopa.)

Fava beans, also called broad beans, are a natural source of
levodopa. One-half cup contains 250 mg, or the same amount as one pill. But don't substitute beans for pills without first consulting your doctor.
Patients attempt to relieve the constipation that often accompanies Parkinson's by eating bran. But recent research shows that bran is high in vitamin B6, which interferes with the effectiveness of levodopa when the drug is taken alone. Prune juice, grains, and fiber laxatives should be substituted instead.
Foods seasoned with hot spices have been known to cause uncontrollable physical movement in some people with Parkinson's. Avoid such foods.

At-home care
Adding banisters in hallways and along walls can make it easier for a Parkinson's patient to get around.
Chairs and sofas that are equipped with high-er arms make sitting down and rising more manageable.
Thick carpeting offers protection in falls, common with Parkinson's patients.
(Reprint)

 

More about Parkinsons disease

SITARA CHOUDHURY MD Parkinsons disease, which mostly afflicts older people, results from gradual degeneration of nerve cells in the portion of the midbrain that controls body movements. The first signs are likely to be barely noticeable - a feeling of weakness or stiffness in one limb, perhaps, or a fine trembling of one hand when it is at rest (activity causes the tremor to disappear). Eventually, the shaking will worsen and spread, muscles will tend to stiffen, and balance and coordination will deteriorate. Depression and other mental or emotional problems are common. Usually the disorder begins between the ages of 50 and 65, striking about 1 percent of the population in that age group; it is slightly more common in men than in women. Medication can treat its symptoms, and the disorder is not directly life-threatening. About half of all patients treated with drugs have no major disabilities 10 years after the onset of the disease. Causes Bodily movements are regulated by a portion of the brain called the basal ganglia, whose cells re-quire a proper balance of two substances called dopamine and acetylcholine, both involved in the transmission of nerve impulses. In Parkinsons, cells that produce dopamine begin to degenerate, throwing off the balance of these two neurotransmitters. Researchers believe that genetics sometimes plays a role in the cellular breakdown, and in rare instances, Parkinsons may be caused by a viral infection or by exposure to environ-mental toxins such as pesticides, carbon monoxide, or the metal manganese. But in the great majority of Parkinsons cases, the cause is unknown. Symptoms The disease takes hold slowly, beginning with a sense of weakness and a slight tremor of the head or hands, then gradually progressing to more generalized symptoms. These can include: slow, jerky movements; a shuffling gait; and stooped posture, unsteady balance; difficulty rising from a sitting position. continuous pill-rolling motion of - the thumb and forefinger. indistinct speech; voice weakened to a monotone. swallowing problems in later stages. in severe cases, rigid trunk and limbs; fixed facial expression and unblinking, staring eyes. Call your doctor if: you suspect Parkinsons disease might be at the root of any of the abve symptoms. In the diseases early stages, drugs can be very beneficial. Diagnostic and test procedures Usually, the outward symptoms of Parkinsons are distinctive enough for a diagnosis to be made. The metabolic changes in the brain can be traced with imaging tests such as PET-positron emission tomography. Treatment Most treatments aim at restoring the proper balance of the neurotransmitters acetylcholine and dopamine by increasing dopamine levels. Drugs are the standard way of doing this, but neurosurgeons have had some success with experiments involving operative procedures. Conventional medicine Symptoms can be effectively controlled for years with medication. The drug most often prescribed is levodopa - also called L-dopa - which the body metabolizes to produce dopamine. (Direct ad-ministration of dopamine is ineffective; the brains natural protections block its uptake.) To suppress nausea and other possible side effects, levodopa is often used in conjunction with a related drug called carbidopa. But some patients cannot tolerate carbidopa and so take levodopa alone. If you take only levodopa, its important not to take it at the same time as food or vitamins containing vitamin B6, which interferes with its effectiveness. Most doctors try to postpone starting patients on levodopa as long as possible, because the medication tends to lose effectiveness over time. However, there is some controversy about waiting to begin treatment with levodopa because it can be so beneficial. Researchers have thus investigated ways to offset the loss of effective-ness. Some studies have found that, when used in conjunction with levodopa and carbidopa, the antioxidant selegiline hydrochloride reduces many of the adverse effects associated with long-term drug use. A new class of dopamine-like drugs imitates dopamines activity rather than adding to the amount of it in the brain. Two of them, bromocriptine and pergolide, appear promising. Other medications prescribed for Parkinsons disease include apomorphine, benztropine, amantadine, and anticholinergic drugs; all can help control various symptoms - in some cases by releasing dopamine from nerve cells, in others by reducing the effects of acetylcholine rather than increasing the amount of dopamine. Neurosurgeons have explored various ways of grafting dopamine-producing cells in the brain rather than trying to correct the neurotransmitter imbalance with drugs. One promising approach uses fetal-tissue implants. Some improvements have been observed, but because of the source of the cells, the technique is highly controversial. Another experimental technique, stereotactic surgery, creates lesions in the thalamus, the brains inner chamber. In some studies, this procedure appears to eliminate tremor in 80 per cent of patients and to relieve rigidity in almost all. A similar form of surgery - using electrical stimulation instead of lesions-also shows promise. Scientists are also investigating the use of glial cell-derived nerve growth factor to treat Parkinsons and other neurodegenerative diseases. This substance is produced naturally by tissues throughout the body; some experiments indicate that injections of this nerve growth factor may help preserve and even restore nerve cells in the brain and spinal cord-specifically those that produce dopamine and that help initiate muscle movement. Some treatments focus on the effects of the disorder rather than the causes. Your doctor might refer you to a physical therapist to restore normal body alignment, enhance your balance and motor responses, and improve your ability to initiate motion. A physical therapist may also give you muscle-strengthening exercises to help with speaking or swallowing. In many Parkinsons patients, a weakening of social ties because of physical difficulties can lead to depression. Antidepressants can help. In addition, the American Parkinson Disease Association (see the Appendix) can provide information about support groups and exercise classes in your area-valuable sources of companionship. Alternative choices Conventional medicines such as levodopa are widely acknowledged as the best treatments for Parkinsons disease. However, many of the alternative therapies mentioned below can be very helpful for relieving symptoms or easing tight muscles. Some of the herbal and dietary therapies can be applied in conjunction with conventional medicines, but be sure to consult your doctor about possible adverse interactions. Acupuncture According to some studies by acupuncturists, Parkinsons disease may be accompanied by an imbalance of energy along one or more meridians . The muscle stiffness, soreness, and imbalance of Parkinsons may be alleviated by a series of treatments. Body work Deep-muscle massage stretches the connective tissue around tight muscles, ridding them of cramping and allowing greater freedom of movement. Massage can also improve motion in your joints, soften hardened muscle tissue, and stimulate your lymphatic system. Reflexology practitioners say that the brain, head, and spine all respond to indirect massage. See the illustration below for reflexology techniques that may help relieve some Parkinsons symptoms. Chi yi, a Chinese deep-breathing exercise, in-creases the oxygen supply in the blood and may thereby help alleviate depression. Sit with your back against the back of a chair and your feet flat on the floor. Reach toward the ceiling with both arms, inhaling deeply through your nose as you do so. Hold your breath as you ball your hands into fists, squeezing your arm muscles. Exhale slowly through your nose to a count of six as you bring your tensed arms down, crossing them on your chest over your heart. Lower your chin to your chest. Take four short breaths, completely filling your lungs, and feel your chest expand. Hold for a few seconds, then exhale slowly. Repeat this exercise several times each day, concentrating on the rhythm and depth of each breath. If tremor prohibits arm or head movements, concentrate on the breathing, working toward a rate of only four or five breaths per minute. Limit practice to five minutes per day. Yoga is an ideal form of exercise for Parkinsons patients because of its slow movements. Regular exercise is important to avoid the atrophying of muscles and shrinking of tissues from disuse. See the illustration opposite for one useful type of yoga exercise. Chinese herbs Taken several times a day, combinations that include rhubarb (Rheum palmatum), peony (Paeonia officinalis), licorice (Glycyrrhiza uralensis), and magnolia bark (Magnolia officinalis) are said to stop tremors and relax stiff muscles. Because using Chinese herbs is complicated, consult an expert in the field for correct dosages. Herbal therapies Passionflower (Passiflora incarnata) acts as an anti-spasmodic when tsp of tincture is taken three times a day. Or take it twice daily as a tea: Pour one cup boiling water over 2 tsp dried leaves; steep for 15 minutes. Passionflower has been shown to reduce passive tremor when taken in combination with levodopa better than when either remedy is taken alone. But be sure to check with your doctor first if you are already taking levodopa. Daily doses of 500 mg of evening primrose oil (Oenothera biennis) may reduce tremors. Homeopathy A trained homeopath might prescribe a single remedy, a series, or a combination of remedies for the many different symptoms of Parkinsons. Mind/Body medicine The Feldenkrais method, which consists of a large number of exercises performed either in group classes or solo with a practitioner, aims at improving autonomic motor responses. While lying down, you are guided through a series of light, slow movements designed to support your neuromuscular system and alter habitual pat-terns of movement. Nutrition and diet Parkinsons patients should pay close attention to diet; weight loss-possibly caused by persistent involuntary movements - is a common problem. A diet called the 7:1 plan-for the ratio of carbohydrates to proteins - is designed for patients taking levodopa (proteins reduce the drugs effectiveness). Researchers disagree as to whether the proteins should be eaten throughout the day or restricted to the evening meal, when interference with levodopa might be less of a problem. Consult your doctor to determine which method works best for you. Either way, a low-protein diet can lead to deficiencies in calcium, iron, and B vitamins; supplements are therefore advised. (If you are taking levodopa without carbidopa, how-ever, avoid vitamin B6; the vitamin will interfere with the levodopa.) Fava beans, also called broad beans, are a natural source of levodopa. One-half cup contains 250 mg, or the same amount as one pill. But dont substitute beans for pills without first consulting your doctor. Patients attempt to relieve the constipation that often accompanies Parkinsons by eating bran. But recent research shows that bran is high in vitamin B6, which interferes with the effectiveness of levodopa when the drug is taken alone. Prune juice, grains, and fiber laxatives should be substituted instead. Foods seasoned with hot spices have been known to cause uncontrollable physical movement in some people with Parkinsons. Avoid such foods. At-home care Adding banisters in hallways and along walls can make it easier for a Parkinsons patient to get around. Chairs and sofas that are equipped with high-er arms make sitting down and rising more manageable. Thick carpeting offers protection in falls, common with Parkinsons patients. (Reprint)