What is Parkinson’s Disease?
Parkinson’s Disease is one of the most common neurodegenerative diseases that are progressive in nature. The disease is a result of degeneration of dopamine-secreting neurons in basal ganglia. The loss or lack of dopamine also causes an imbalance in neurotransmitters in the brain like an increase in acetylcholine neurotransmitter. This increases the influence of acetylcholine neurotransmitter. The disruption of neurotransmitter activity results in neuromotor symptoms which are referred to as parkinsonian symptoms.
How does Parkinson’s present clinically?
The cardinal signs and symptoms of the disease are:
- Resting tremor
- Postural instability
- Bradykinesia – slowness of movement
Due to these cardinal signs, a person demonstrates an inability to perform functional tasks like transfers, ambulation, driving etc.. With a poor standing and or sitting balance, a patient may have more falls and not be able to complete daily tasks like dressing, cooking, or laundry safely and independently. The poor balance and frequent falls also lead to other medical complications which can be fatal and are related to high mortality rate. Being dependent functionally leads to many psychological problems like anxiety, depression, and social isolation.
People with severe rigidity who is unable to perform any range of motion exercises of joints can develop severe contractures. Along with slowness of movements, freezing episodes are common in patients with PD. A person suffering from PD suddenly freezes or stops in the middle of the tasks. Initiation of any tasks is also challenging in these patients. This is because the disease affects the basal ganglia. Basal Ganglia is a part of the brain that is responsible for the initiation of the movement.
How to Diagnose Parkinson’s Disease?
The diagnosis of the PD is difficult as there is no particular test that confirms the disease. Patient’s clinical presentation is the sole key to diagnose the disease. Additionally, a neurologist will run a few other diagnostic tests to rule out the other neurological disease. This is one of the main reasons, why the disease is misdiagnosed with other similarly presented neurological disorders like Lewy body dementia, or parkinsonism.
Additionally, the absence of particular confirmatory tests makes it difficult to diagnose the disease in the earlier stages. This is where a person can have most and the best chances of recovery and preserving the highest functional level.
The current research is making some head start towards identifying the biomarkers that are present in the brain that can help with early diagnosis of PD but it is still a work in progress.
There is no cure of the Parkinson’s disease. As I mentioned above, drug therapy manages the symptoms in the best way. The research shows positive results with surgical interventions that can either delay the progression of the disease or manage the symptoms in a better way than the traditional medicines. Unfortunately, though, surgical interventions come with very specific criteria. Thus, this might not be an option of every PD patient.
Medical Management of Parkinson’s disease:
Drug therapy usually concentrates on storing the neurotransmitter balance in the brain. Medicine is the first treatment of choice to manage the symptoms. As we know, a deficit of dopamine in brain cells is primarily responsible for PD symptoms. So any medicine that increases the level of dopamine level in the brain can manage the symptoms.
Even though, as easy as it sounds, it is difficult to increase the level of dopamine in the brain as the medicine has to be able to cross the blood-brain barrier and still have to have enough concentration for the brain cells to process. The combinations of L- Dopa or Levodopa and carbidopa, is used for the same reason. This combination can cross the blood-brain barrier in full form and can be used by brain cells to treat the symptoms. Sinemet is the most commonly used drug brand name.
A primary care physician or a neurologist generally start the medicine at a lower dose. Depending on the stage of the disease as well as the severity of the symptoms, the dosage needs to be adjusted frequently.
L- Dopa Therapy:
Depression is the most commonly encountered side effects in patients who are on Levodopa therapy. Along with a few other side effects, problems like on-off phenomenon or end of dose akinesia, make the drug less likable for all health care provides. The decrease in the effects of the drug during the middle of the dose intervals (on-off phenomenon) or complete loss of drug effects towards the end of a dose cycle (end of dose akinesia) are poorly understood mechanisms. Research is unclear if these are due to how the medicine is absorbed or metabolized or are solely depends on the person’s genetic makeup. Yet, the drug remains the cornerstone for the PD treatment.
Research does not support the use of Levodopa in the late stages of the disease due to its poor results. In other words, once the disease advances to a certain point, levodopa therapy is unable to restore the function efficiently.
A neurologist may choose to prescribe several other agents to treat the symptoms depending on the patient’s condition. Due to the potentials side effects, physicians are less inclined to use these newer drug agents.
Parkinson’s Therapeutic Approaches:
Time of the rehab session is crucial for the best recovery. Rehab professionals usually coordinate the session time with the time of the medicines. The idea is to retrain the neural connection when the patient has the best ability to perform the tasks and retain the information from the task.
By strengthening and retraining the neural connection, a person is able to perform the daily tasks independently even when the medicines wear out of the body system. Rehabilitation can never make a Parkinson’s patient not to need their medicines. But there is enough evidence out there that supports to slow down the progression of the disease as well as does not need to ramp up the dosage frequently with consistent rehabilitation.
There is some conflicting evidence regarding a patient being able to manage their symptoms and have an active lifestyle with physical therapy alone when treated at a very early stage of the disease. The small sample size and not having true diagnostic tests for the disease makes it difficult to confirm the above sentence.
The rehabilitation approach depends on the severity and stage of the disease.
Research supports the positive effects of rehabilitation in the early to middle stages of the disease. A therapist can teach many compensatory techniques in the late middle stage. Therapeutic approaches for severe cases of the disease include prevention of further decline and maintaining the current level of function.
“LSVT BIG” training is a very famous training for PD treatment. Studies support the use of LSVT training to improve the amplitude of the movement, including big steps, big arm movement, louder speech etc..
Rhythmic counting, playing slow music, marking steps on the floor for a patient to follow are some examples of the training that therapists may do. Counting or instructing a patient with short and simple commands that are easy to follow helps the patient to continue the movement and avoid or lessen the freezing episodes.
PD patients demonstrate really slow gait with small steps. Counting out loud, having patients follow the beats of music are some examples of useful strategies that can help improve the gait pattern.
Aquatic therapy helps to manage PD symptoms. It is important to perform aquatic therapy under proper supervision as PD patients demonstrate poor balance, rigid muscle tone, and postural deficits.
Postural exercises are very important not only to improve body posture but also to regain the muscle balance. Biofeedback, electrical stimulations, active exercises, as well as postural correction braces are used to correct the body posture to anatomically near normal position. This also prevents body aches and helps with pain management.
The range of Motion exercises:
In severe cases of rigidity, contracture management is crucial. A clinician may train family members to perform a range of motion exercise. This aids to preserve the motion as well as prevent contractures.
A slow gentle stretching within the patient’s tolerance limit may be advisable to improve the range. A clinician may choose to use splints or braces to improve the joint mobility to the functional range if desired.
Deep brain stimulator (DBS) is a surgical intervention that is available for appropriate patients. As the name suggests, DBS stimulates a particular area of the brain, that in turns blocks the unwanted neurotransmitter. This allows a person with PD to be able to perform smoother movements. There are specific criteria to be eligible for DBS surgery. A neurologist will consider the patients who may not be able to manage the symptoms with maximum medications. Also, patient’s age, quality of life as well as survival rate post surgery also plays role in consideration of DBS.
The other surgical interventions are to the removal of part of the brain like thalamotomy, pallidotomy, and subthalamotomy. All of these procedures come with few side effects as well as the loss of some other functions.
To summarize, the drug therapy along with physical therapy remains the main choice to treat Parkinson’s symptoms.