Knowing about Parkinson’s disease

Written by Dr Harold Gunatillake FRCS-Health writer

When you get up one morning, if you become tottery on your feet and tends to fall, and your writing becomes scrawly, the picture is suggestive of Parkinson’s disease.
When you wake up in the morning, if you feel spinning suddenly and cannot control your balance when walking, think of “Positional Vertigo” (Benign Paroxysmal Positional Vertigo), not uncommon as one gets older.

A little more than 1 in 1000 Australian adults has Parkinson’s disease. Most of them are over 70 years old, but could get it even at the age of 30. It is estimated that 4 million people world-wide are suffering from Parkinson's, In Sri Lanka though prevalent exactly how common is difficult to assess as there are no records available.

James Parkinson was the son of John Parkinson, an apothecary and surgeon practicing in Hoxton Square, London. Where James studied is not known, but in 1784 his name appeared on a list of surgeons approved by the Corporation of London. On May 21, 1783, he married Mary Dale of Hoxton Square; they had six children. James eventually succeeded his father in his practice in Hoxton Square.

Although Parkinson’s disease is one of the best known medical eponyms, Parkinson himself received little attention from his English-speaking colleagues, until an article written by the American J. G. Rowntree in 1912 appeared in volume 23 of the Bulletin of the Johns Hopkins Hospital, titled: “English born, English bred, forgotten by the English and the world at large, such was the fate of James Parkinson”.

It is easy to diagnose a person with full blown picture of Parkinson’s disease, even by a lay person. It is difficult in the early stages, in most situations, clinching a diagnosis could be overlooked, as those early symptoms may be common to most other neurological conditions. Parkinson’s disease is a brain stem dis-order that causes to lose muscle control gradually. In the full blown picture you see tremors in fingers, sometimes referred to as ‘pin-rolling’ movement between the thumb and the index finger, with tremors of the other fingers. Tremors may appear later on and may not be the earliest symptom. Stiffness of the lower extremities is another early symptom observed during the early stages, and subsequently a shuffling gait becomes obvious. General body movements too, slow down with poor balance could be detected in the early stages of the disease. It was originally referred to as “shaking palsy”.

It is fortunate that life expectancy is not shortened in this disease though disability is permanent and progressive.  Most cases get the disease at the age of 60 or over, and rarely earlier. Boxer Muhammad Ali got it at the age of 42, and actor Michael Fox at the age of 30.

Early signs could be tremors of the fingers as mentioned earlier, or shaking of the hands or legs or lips. Tremors seem to disappear when in use and re-appears at rest. Sleep, complete relaxation, and voluntary movements usually stop the tremors.

 Stiffness of leg muscles causes difficulty walking. Balance and posture problems may result in frequent falls. Getting out of a chair is difficult. Hand writing becomes crowded and walks with a stooped posture, as one is trying to catch one’s own centre of gravity. A statue like masked face without much expression could be a later sign.

Daily activities like bathing, eating dressing gets harder with progression of the disease.

There could be problems with digestion of food, and urinary incontinence could be a nuisance. Constipation is common.

Most of these patients end up with dementia and confusion, similar to Alzheimer’s disease. Depression is another late symptom.

Diagnosing Parkinson’s
Brain scans do not show any changes in diagnosis, but helpful ruling out other conditions.

Other signs your doctor will do will be:

  • Ask you to tap your finger and thumb together or tap your foot to check for slowed movement
  • Rest your hand to observe absence of tremor
  • Check for rigidity of neck and limbs
  • Check for balance whilst standing by gently pulling from behind.

What causes Parkinson’s disease?
A small area in the brain stem (area of the brain below the main mass) called substantia nigra stops producing dopamine, a chemical that assists nerve cells to communicate with each other. As these cells secreting the chemical dies, the brain does not receive the necessary messages about how and when to move. Without enough dopamine, patients experience symptoms such as tremors, muscle rigidity, balance problems, slow movement and others. Currently, doctors can treat these symptoms with drugs that boost dopamine levels. However, there are no available treatments to reduce the rate of clinical decline. "A medication that could slow the progression of Parkinson disease would be a major breakthrough for patients living with the disease," said Walter Koroshetz, MD, deputy director, NIH National Institute of Neurological Disorders and Stroke.

Stages of PD
Doctors can assess and measure the stages of the symptoms. The Hoehn and Yahr Scale is one common tool that focusses on the severity of symptoms. The Unifies Parkinson Disease Rating Scale evaluates mental clarity and function, behaviour and mood, activities of daily living and motor functions. Treatment can be assessed according to the stage of the disease.

In the brain an amino acid called Levodopa is converted to dopamine. Levodopa is been used for a long time and seems to be the most effective medication even today. It reduces the rigidity of the muscles so that one can move much easily. Eventually levodopa may wear off, especially when taken with a high-protein diet. The side effects taking levodopa are nausea, vomiting, drowsiness, hallucinations, and uncontrollable movements of the extremities.

There are drugs that mimic dopamine, called dopamine agonists, which may be more effective to delay the symptoms. They include Apokyn, Mirapex, Parlodel, and Requip. Apokyn can be injected. These medications also have similar side effects.

Most Parkinson’s medications fit into one of the following broad categories:

  • Levodopa – dopamine replacement therapy.
  • Dopamine agonists – mimic the action of dopamine.
  • Anti-cholinergics – block the effect of another brain chemical (a neurotransmitter called acetylcholine) to re-balance its levels with dopamine.
  • Amantadine – has anticholinergic properties and enhances dopamine transmission.
  • MAO type B inhibitors – prevents the metabolism of dopamine within the brain.
  • COMT inhibitors – used along with levodopa. This medication blocks an enzyme known as COMT, to prevent levodopa breaking down in the intestine and to allow more of it to reach the brain.

It is very important to take your medication at the recommended time and on time every day, whether you are at home, at work, in hospital or in a nursing home. Medications taken late can severely hamper the movements of people living with Parkinson’s.

Surgery is an option
Neurosurgery (brain surgery) is an option to treat Parkinson’s symptoms, but it is not suitable for everyone. There are strict criteria and guidelines as to who can be a candidate for surgery, and this is something that only your doctor and you can decide.

The three commonly used forms of surgery are:

  • Thalamotomy – a lesion (cut) is placed on part of the brain to alleviate some forms of tremor.
  • Pallidotomy – a lesion is placed on a different part of the brain to alleviate dyskinesias (wriggling movements).Both pallidotomy and Thalamotomy use radio-frequency energy to permanently destroy a pear sized area in the globus pallidus or the thalamus. These procedures are irreversible and have become less popular than deep brain stimulation.
  • Deep brain stimulation – an electronic deep brain stimulator is placed in the brain to control tremor. Electrical stimulation helps the brain to reduce rigidity, tremors. It does not stop the progression of the disease or affect other symptoms. It is suitable for selected cases only.

Grafting Nerve (Neural) stem cells
This is still experimental. Grafts of stem cells are placed into the area called striatum of the brain stem, and these cells will provide the proper amount of dopamine.

Spinal cord stimulation
Researchers in the US found that when they electrically stimulated the spinal cord of mice and rats that had depleted levels of dopamine, the chemical that is lacking in the brains of people with Parkinson's, their slow, stiff movements were replaced with the behaviours of healthy animals. They hope one day to offer the same benefits to Parkinson's patients by developing a small spinal cord stimulator that is implanted under the skin.

The low frequency oscillations or seizures in rats and mice with Parkinson's are similar to those seen in humans with the disease, and the researchers suggest that it is these that impair motor function, so reducing them with electrical stimulation is what restores the motor function.

The researchers anticipate that once the device is proven to be safe and effective in further research and human trials, it will be similar to those already used to treat chronic pain, where small leads are implanted over the spinal cord and connected to a portable generator. During the trial period the generator is external, but a permanently fitted one could be implanted under the skin,

Management
Parkinson's disease is best managed by a team approach - the GP, neurologist, physiotherapist, occupational therapist and speech therapist all have a role to play.

Diet
A well-balanced diet with calcium, vitamin D and fruits can help to control the disease. As proteins in the diet can interfere with levodopa, the problem can be avoided by taking the medicine about half an hour before the meal. It has been observed that coffee drinkers and smokes may have a lower risk of developing Parkinson’s disease.
Exercise may have a protective effect by enabling the brain to use dopamine more effectively. It may improve coordination, balance, tremors and gait. Tai chi and yoga may also help with balance and flexibility.
Constipation
Constipation is a common complication of Parkinson’s disease but it can be managed with medical treatment, extra fibre in the diet and lifestyle changes

Famous figure who suffered from Parkinson’s disease in Sri Lanka
Veluppillai Chelvanayakam a Sri Lankan lawyer and Member of Parliament underwent surgery in Edinburgh to relieve the stress from Parkinson disease at the hands of a neurosurgeon, Francis John Gillingham and the operation “proved successful.” Despite the success of this operation, he died on 26 April 1977 at his home in Jaffna. He was known for the Bandaranaike-Chelvanayakam Pact which agreed to provide government services in Tamil and devolve powers to a set of provincial councils.

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