Parkinson’s Disease: Solving The Mystery

Although an understanding of Parkinson’s disease dates back to at least the early 19th century, there is still much research to be done. Here is what you need to know about diagnosis and treatment options.

By Elena Acoba

Parkinson’s disease is confounding. The medical community doesn’t know what causes it. No two patients have the same symptoms or progress through the degenerative movement disorder in the same way. It’s hard to diagnose. There is no cure or way to slow its progression. And medical treatments lose their effectiveness over time.

But that doesn’t mean that someone with Parkinson’s can’t live a fulfilling life. “There are currently no treatments that delay the progression of Parkinson’s disease,” says Sarah Sullivan, D.O., a neuro-hospitalist with Northwest Medical Center and Oro Valley Hospital. “There are treatments, however, that improve a patient’s symptoms and quality of life, as well as decrease risks such as falls.”

About 60,000 Amer-icans are diagnosed with Parkinson’s disease every year. Around 10 to 20 percent of them have young onset, meaning they were diagnosed at age 50 or younger, says Rebecca Gilbert, M.D., Ph.D., vice president and chief scientific officer of the American Parkinson Disease Association. Some one million Americans live with the disease, including about 14,200 Arizonans.

It’s a difficult diagnosis for someone to receive.

“Patients often feel overwhelmed and anxious upon first hearing the words,” says Dr. Sullivan. “I review the medication and treatment options that we will consider in an effort to reassure patients that although we cannot cure the disease, there are many things we can do to manage it.”

Sarah Sullivan, D.O., a neuro-hospitalist with Northwest Medical Center and Oro Valley Hospital.

The first line of treatment for symptoms is the medication levodopa in various formulations and dosages. This drug allows the brain’s nerve cells to create dopamine, the neurotransmitter whose absence triggers Parkinson’s symptoms. The exact formula and dosage need continual adjustment taking into account the patient’s specific symptoms and disease progression.

The medication eventually no longer works, or its side effects become hard to tolerate. At that point, patients can consider deep brain stimulation (DBS). This could extend the relief of movement symptoms for 10 years or more, says Joseph Christiano, M.D., a neurosurgeon with Western Neuro.

In the procedure, two electrodes are placed in areas of the brain where Parkinson’s is disrupting movement control. These leads are connected to a battery pack that’s inserted under the skin of the chest. Electrical pulses adjusted to the patient’s specific needs are transmitted into the brain to help it control tremors and other movement symptoms.

“Ninety-plus percent of people see results,” says Dr. Christiano. “They can get significant improvement for various symptoms such as tremor, slowness and stiffness, gait issues and imbalance.”

With results like that, one might seek out the brain surgery as soon as possible. But, like a lot about Parkinson’s, it’s not that simple.

“Every patient’s Parkinson’s is slightly different,” Dr. Christiano says. “Medication often is very effective in the early stages and allows time for both the diagnosis and the trajectory of the disease to become clear. There are other disorders that appear similar to Parkinson’s disease, and it is important to clearly establish the right diagnosis.”

A typical Parkinson’s patient can consider DBS as early as three years after diagnosis, but this may depend on how fast the symptoms worsen.

“DBS is a well-studied, safe and effective treatment for Parkinson’s disease, and will be the next logical choice for many patients at some point in their disease,” says Dr. Christiano.

“There are other disorders that appear similar to Parkinson’s disease, and it is important to clearly establish the right diagnosis” – Joseph Christiano, M.D.

The Federal Drug Administration recently has approved the use of focused ultrasound to manage tremors. The nonsurgical procedure creates a lesion in the area of the brain where Parkinson’s has caused abnormal circuitry for movement.

Although medical options appear limited, many people can keep Parkinson’s symptoms at bay with lifestyle changes. This may be one benefit of having an early diagnosis even though there is no cure.

Rebecca Gilbert, M.D., Ph.D., vice president, chief scientific officer of the American Parkinson Disease Association. Photo by Abdulai Sesay.

“Some would argue that knowing that you have the disease is vital so that you can understand the changes that are happening in your body, increase exercise and plan for the future,” says Dr. Gilbert. “This should occur as early as possible.”

There are many ways to keep movement stable as long as possible.

Some physical therapy programs specific to Parkinson’s focus on exaggerating movements like arm swing and stride. Exercises that encourage loud speech help with maintaining vocal control.

Movement-dependent activities like video games, boxing, yoga, dance, swimming and tai chi help elevate mobility and mood. Any exercise is good, but doing them as intensely as possible shows more benefit.

Appropriate diets can address constipation, a common issue with Parkinson’s patients. Dr. Sullivan also suggests working with a doctor or dietician on the timing of eating certain foods, such as those high in protein, which can affect levodopa absorption.

An entire health team can respond to issues as they come up. Dr. Gilbert suggests a movement disorder specialist, primary care provider, rehabilitation specialists, nurse, nutritionist, neuropsychologist and social worker.

Research continues on many fronts: discovering genetic and environmental factors that cause the disease; detecting it before symptoms occur and brain damage becomes irreversible; and formulating treatments that can slow or stop its progression and for non-motor symptoms.

Joseph Christiano, M.D., a neurosurgeon with Western Neuro.

For Dr. Christiano, the way DBS is done — the procedure doesn’t change the brain structure — shows that the medical community has not given up.

“The key point,” he says, “is we are hopeful that somebody will come up with a cure for Parkinson’s, and since we didn’t change the brain cells, it might still be effective for DBS patients.”

PARKINSONISM

Some people who present with typical Parkinson’s symptoms also may show unrelated symptoms. This condition is known as Parkinsonism or Parkinson’s plus. Parkinsonism can appear in people with a history of stroke, head injuries or exposure to certain medications. It’s also evident in other diseases, such as Lewy body dementia and progressive supranuclear palsy.

“Because there is no single definitive test of Parkinson’s disease, these conditions sometimes are misdiagnosed as Parkinson’s early on,” says Dr. Sullivan.

Medications and therapies for classic Parkinson’s don’t work as well in these patients, and the disease may progress faster.

CHARACTERISTIC SYMPTOMS OF PARKINSON’S DISEASE

  • Tremors at rest
  • Decreased blinking
  • Handwriting that gets smaller
  • Small movements of the hands and feet
  • Arm, leg stiffness
  • Stooped posture
  • Decreased arm swing
  • Shuffling walk
  • Turning by taking several steps instead of pivoting
  • Changes in vocal quality There also are symptoms not related to movement, including
  • Loss of smell or reduced sensitivity to odors
  • Sleep problems
  • Depression, anxiety, psychosis
  • Gastrointestinal, urinary issues
  • Excessive sweating
  • Cognitive, personality changes

RESOURCES

April is Parkinson’s Disease Awareness Month, and Tucson has several resources to offer. Dr. Sullivan sees much interest among patients on how to live well with Parkinson’s.

“It’s something I see in Tucson a lot,” she says. “They are hungry for more information, more education. Many Tucson patients and winter visitors are intensely motivated to participate in their care. They want to stay young, vital, vibrant and active.”

Here are some locally based resources.

American Parkinson Disease Association Arizona runs three programs: a lecture series on the first Tuesday of the month; a support group for patients and caregivers every third Tuesday of the month; and for newly diagnosed patients, an eight-week class: “Parkinson’s Roadmap for Education and Support Services.” For more information: www.apdaparkinson.org or 326-5400.

The Parkinson and Movement Disorder Alliance lists several support group meetings and exercise classes, as well as online and streaming resources. The organization will hold an educational event July 25. For more information: www.pmdalliance.org or 800-256-0966.

Parkinson Wellness Recovery focuses on exercise and other ways for the brain to adapt to the effects of the disease. For more information: www.pwr4life.org or 591-5346.

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