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. 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