Some Facts About Parkinson's Disease
http://www.dash.com:80/netro/nwx/tmr/tmr0197/parkinson0197.html


Mark E. Abell, BS, PA-C

If you were tuned to your television set during the opening ceremonies
of the World Olympics in Atlanta, Georgia, you would have seen
Mohammed Ali take the courageous steps to light the Olympic Torch.
What a task. Mohammed Ali, one of the greatest athletes of all time,
has been dealing with Parkinson's disease -- and there is no cure.
Getting up to the platform alone must have been difficult; lighting
the torch while attempting to steady his gait (the stance as well as
the movements during walking) seemed near impossible. Ali is not
alone, however. Janet Reno, the Attorney General of the United States,
also has the disease, but to a much lesser degree.

So, what is this disease? What causes it, and what can we do about it?
Is it progressive? Is it inherited? Have there been any developments
made towards better treatment or a cure?

These are all good questions, although some of them remain without an
answer. Parkinson's disease, also known as paralysis agitans, is a
neurological disorder which is generally seen only in the elderly
population but not altogether unheard of in young people.

The disease was first described in 1817 by James Parkinson
(1755-1854), an English physician; but at that time very little
information was known about its complete characterization. In fact,
most of what is known today about the disease has emerged from
developments made during the neurochemical era, namely during the
latter part of this century. While there is not yet a cure for the
disease, there are a number of medications which help slow the
progression. Yet, most of the medications, including levodopa
(Sinemet) lose their effects later in the disease.

I have seen a good number of Parkinsonian patients (those with
Parkinson's disease) during the six years practicing medicine as a
physician assistant. Most of my exposure to the disease was at a
rehabilitation hospital in West Virginia. Essentially, the patient
with Parkinson's disease has bradykinesia (slow movements), rigidity,
a tremor (usually a resting tremor -- the tremor disappears when the
hand or arm is being used, as in grasping a cup of coffee or a pencil,
but it later returns), and a very characteristic posture (mostly
leaning forward) and gait (usually shuffled, as if dragging the feet).
Some of the patients depicted in the world-acclaimed movie, One Flew
Over the Cuckoos Nest, were afflicted with the disease; they moved
about slowly and dragged their feet, amongst other things.

There are many characteristics of the disease and many of the classic
ones are used by clinicians to help diagnose the disease (as there are
no special tests used to diagnose the problem, Parkinson's disease is
diagnosed by symptoms and presentation.) Many people have a lack of
facial expressions as if they are without feelings or emotions. There
may be a monotone voice or even a drooling of the mouth. Other classic
signs of Parkinson's disease include pill rolling
(pronation/supination of the forearm and flexion of the fingers) as
well as cogwheeling, which is most noticed with passive movements of
the limbs. Later in the illness, many patients lose the ability to
perform the simplest of tasks; falls then become the rule rather than
the exception as the patient deteriorates. It is important to
remember, however, that a clinician (your physician or health care
provider) should not use the presentation alone to diagnose the
disease as there are a lot of other causes of the previously mentioned
symptoms. Moreover, some medications (i.e., Reglan, which is sometimes
used to treat diabetics with abdominal problems) can cause
pseudo-Parkinson's disease or iatrogenic Parkinsonian tremors. The
problem disappears by stopping the medication.

You might be asking yourself, "Who can get this tragic disease?"
Anyone can, of course, but men are usually more prone to be afflicted
with Parkinson's disease than women. So, move over women -- you are
potentially safe! The ratio between men and women, actually, is almost
2:1. The mean age for the disease is said to be in the 6th decade of
life, although there have been reported cases of the disease in the
young, up to five percent, between the ages of twenty-one and
thirty-nine. If you are looking for a link between Parkinson's disease
and your genes, forget it. Only about five percent or so of patients
have a family history; in fact, it is believed that all of what causes
the disease arises after birth and has nothing to do with your genes.
So, you cannot blame your parents or grandparents.

So, what causes this tragic and degenerating disorder? Well, we aren't
very sure. We do know that the problem is caused by a decrease in the
available dopamine in a part of the brain referred to as the
substantia nigra, which is part of the brainstem. Dopamine is a
neurotransmitter, which means that the chemical is needed by the brain
in order to carry out functions affecting the transmission of nerve
impulses; in this case, we are referring to impulses which result in
body movements. The treatment, then, would be to find a way to replace
the dopamine in the brain, which is accomplished (theoretically, and
with some success in most patients) with a medication called levodopa,
which is marketed as a combination drug, carbidopa-levodopa. In a time
when Sinemet (or levodopa) was not yet available, many synthetic
anticholinergic medicines were used, such as benzotropine, for
example.

These medications do not come without side effects, such as a dry
mouth, urinary problems, constipation, etc. Sinemet was first
indicated for the treatment of Parkinson's disease caused by an injury
to the brain, such as with carbon dioxide poisoning or brain trauma.
The fact that it works makes it available for most forms of the
disease, and, in most cases, the drug works well (at least for the
first five years or so). The effects of drugs like Sinemet soon
diminish, leaving the patient with a pronounced form of Parkinson's
disease, but less dramatic than if the patient was never on any
therapy at all. The use of Sinemet in the treatment of Parkinson's
disease should be reserved for reducing the slow movements and
rigidity; the drug does very little in reducing the tremors.

Sinemet is probably the most commonly used medication to treat the
symptoms of Parkinson's Disease; and as noted previously, the
medication is marketed as carbidopa-levodopa. Dopamine, in and of
itself, in entirely ineffective in the treatment of the disease as it
does not cross the blood-brain barrier -- in other words, dopamine, if
administered by mouth, will not enter the brain, where it is needed.
Levodopa, theoretically, is transformed into the active form,
dopamine, within the basal ganglia, that area of the brain that
encloses the substantia nigra. By giving the patient extrinsic
dopamine (in the form of levodopa), one is providing the patient with
an adequate amount of dopamine, hence the required levels of the
neurotransmitter is present and, again theoretically, the symptoms
should get better.

Recall that the use of Sinemet does not do much to help the tremors,
but is used in the treatment of rigidity and bradykinesia; and those
two characteristics of the disease are measured (in terms of
frequency) to determine the affects of the medication in the treatment
of the disease. The carbidopa is used in conjunction with the levodopa
to help offset some of the side effects of levodopa, namely (and
perhaps most widely seen) is nausea.

This is all well and good, but what else is being done about
Parkinson's disease? Well, now that celebrities have come forward with
this disease, one would think that there might be a more pronounced
impetus towards a cure. We can think in a similar fashion when talking
about spinal cord trauma and Christopher Reeves. The fact that
celebrities bring situations into the limelight is not new; the tactic
is used daily to sell us products -- why not an idea? Sure, there's
medication for the symptoms of the disease, but the cure for
Parkinson's disease is a long way off. During the interim, however,
modalities such as physical therapy (as well as emotional support for
the families) has proven extremely beneficial in some cases.

This brings me back to the rehabilitation days in West Virginia
(Southern Hills Regional Rehabilitation Hospital in Princeton, WV)
when I worked alongside Susan Bertrand, M.D., a physiatrist (doctor of
physical medicine). First of all, the patient with Parkinson's disease
should be evaluated to understand how much is lost in terms of the
patient's abilities. Dr. Bertrand, a bright and very apt physiatrist,
was always quick to remind me that the paramount issue with a patient
and his or her problem is safety and not so much the disease. And, she
is right. Let's understand that the disease cannot be cured; so let's
at least develop ways to ensure that the patient can live a life in a
safe environment.

In the physical therapy realm, the most effective treatment of
Parkinson's disease is relaxation maneuvers, i.e., gentle, slow
rocking, rotation of the extremities and trunk and even the use of
yoga. Once relaxation techniques are employed, the therapists can
initiate movement exercises of the extremities starting with the most
distal (furthest from the truck of the body -- as in the hands and
feet), as the disease affects the distal muscles first and then
progresses to the proximal muscles). Entire therapeutic programs have
been developed with physical therapy and have proven to either slow
the progression of the disease or limit the patients need for
assistance when performing ADLs (Activities of Daily Living). The
bottom line is that the person with Parkinson's disease is encouraged
to remain active. When treating our patients at the rehab facility, we
always consulted with a neurologist for changes in medications dosing.


There are various ways to approach the ways in which the medications
are used; and we usually reserved that to the most trained. Not only
is it easier, but it just makes sense. We are there to treat the
patient with the best care available; seeking the help from someone
who has been trained to do so gives the patient the care he or she
expects. While the neurologist adjusted the medications, we initiated
physical therapy. It remained, however, clear to us all that the
disease is tragic and relentless. Within the laymen literature, I have
seen reports (as well as in television news clips) that there is
research being made with the transplantation of fetal brain tissue
into adults with Parkinson's disease, but there is a heated debate
over the morality of such studies. I have yet to run across any recent
literature supporting the research and the jury is obviously not yet
out.

Parkinson's disease is the most common neurological degenerative
disease seen in the elderly population. As the population grows older
and people are living longer, it comes as no surprise that the
diseases (such as Parkinson's disease, amongst others) increases in
frequency. We are able to allow people to live longer, but we cannot
cure many of the degenerative diseases. While treatment is promising,
research continues and there are hopes for better, long lasting
treatment in the coming years. A cure is a long way down the road; the
best we can hope for is bringing these patients (along with their
families) to a realization of the disease and its manifestations, and
then provide them with tools by which they can promote better health,
welfare, and safety. For more information about Parkinson's disease,
the reader is encouraged to visit the following Web Sites; each one,
to its own credit, offers an excellent data base as well as some
support systems. To contact the National Parkinson Foundation, go to
http://www.parkinson.org; the site has a lot of useful information,
particularly for the patient and the family. The Parkinson's Web can
be viewed at
http://neuro-chief-e.mgh.harvard.edu/parkinsonsweb/Main/PDmain.html;
there are a number of links to other Parkinson's disease web sites at
http://neurosurgery.mgh.harvard.edu/fnctnlhp.htm#OtherPDInfo.

Editor's Note: Mark E. Abell, BS, PA-C is a practicing physician
assistant living in Ashburn, Georgia, located in the southwestern part
of the state. He works at Ashburn Family Medical Center with Dr. Penn
White, who also resides in Ashburn.

Mark is also a freelance writer, owner of Freelance Med-Write, a small
firm offering freelance work for agencies, hospital, and clinics.

Mark received his BS degree from Alderson-Broaddus College (Philippi,
West Virginia) in 1991. He also attended Louisiana Tech University in
Ruston, La from 1984-1986, where he studied math, English, and
history. He has been writing freelance since 1986 and has worked with
a number of newspapers, including The Paradigm Times and his local
newspaper in Ashburn, The Wiregrass Farmer. Mark is married to Tammy
Abell, who is a senior nursing student at Darton College in Albany,
Georgia. They have two children, ages 13 and 10.

Mark may be contacted at: e-mail: [log in to unmask] or on the World
Wide Web at: http://www.magicnet.net/~jabbott/mabell/

The reader is also advised to contact the following organizations for
more information about Parkinson's disease:

Parkinson Disease Foundation
710 West 168th Street
New York, NY 10032 USA
(212) 923-4700

United Parkinson Foundation
International Tremor Foundation
833 West Washington Boulevard
Chicago, Illinois 60607 USA
(312) 733-1893
e-mail: [log in to unmask]

American Parkinson Disease Association, Inc.
1250 Hylan Boulevard
Staten Island, NY 10305 USA
Phone: 1-800-223-2732

The Parkinson Foundation of Canada
National Office
710-390 Bay Street
Toronto, Ontario M5H 2Y2
Canada
Phone: (416) 366-0099
1-800-565-3000
Fax: (416) 366-9190
World Wide Web: http://www.interlog.com/~vinovich/pf/pf.html


                   c January 1, 1997, Joel R. Cooper, All rights
                   reserved








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