Parkinson’s Disease- Causes, Symptoms & Treatments
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Imagine not being able to tie your shoes or to write a check legibly because tremors cause your hands to shake so badly you can’t control them. Or, how about not being able to get out of a chair because your body won’t move? If you can’t lift your foot, it won’t take you from one place to another. These are only a few of the symptoms that more than one million persons in the U.S. alone experience because they are afflicted with Parkinson’s disease. Worldwide, more than 11 million people share the disease, according to the Parkinson’s Disease Foundation.
What is Parkinsons Disease?
Parkinson’s disease is a neurological disorder and starts when the cells which produce dopamine (a chemical which passes information to and from the brain and controls movement) start to die. Our brain also produces several other chemicals which work together to control movement. One of these chemicals is also known as acetylcholine.
A lack of dopamine, as well as acetylcholine, is collectively responsible for causing Parkinson’s. Parkinson’s affects around 2% of people over the age of 65 and is thought to be a form of brain-related aging. It is possible for patients to be affected by this disease as early as 40 and is known as early-onset Parkinson’s.
How Does the Brain Control Movement
The ability to move certain muscles when necessary is taken for granted by most people. The action of motor neurons to tell the skeletal muscle to contract seems to be the simplest of physiologic requests. The control of purposeful movement is vastly more complicated than that. Voluntary movement is regulated, in part, by neural activity in two interconnected regions deep in the brain, the basal ganglia, and the substantia nigra. Literally translated to “black substance”, because of the darkly colored pigmentation of the nerve cells in this region, loss of neurons within the substantia nigra is a hallmark of the pathology of PD.
What causes Parkinson disease
As is the case with many other neurodegenerative disorders, the vast majority of Parkinson disease cases occur spontaneously with no known genetic inheritance from generation to generation. These so-called sporadic cases make up more than 90% of all cases of PD. However, inherited forms of PD have been identified of both the dominant and the recessive type. With both early and late age onset forms, the various gene defects responsible have pointed to selected biochemical pathways that could serve as key targets for future therapeutic intervention. One area of particular interest is the role played by oxidative damage in the substantia nigra as a causal factor in PD.
Inherited Forms of Parkinson Disease
While the majority of cases of PD appear to occur spontaneously, what is referred to as “sporadic” disease, there are instances where PD can be passed on genetically in an affected family. As is the case for many inherited disorders, there are two types of inherited PD, so-called “autosomal dominant” and “autosomal recessive”.
Human cells maintain two copies of each of their chromosomes and thus two copies, or alleles, of each gene. In disorders where the presence of one defective copy of a single gene can cause disease it is said to be dominant, conversely, when a mutation must be present in both alleles of a gene in order to cause disease it is referred to as recessive.
In the genetics of human diseases, some genes are identified as increasing the chances of developing a disorder but are not directly causally related to the appearance of the disease, these genes are described as “risk factors.” In these cases, you might have increased risk of developing the disease but never actually develop it. Where a mutation in a gene directly leads to the development of the disease, the mutation is said to be disease-causing.
Genes That Cause Parkinson Disease
Several genes have now been implicated in hereditary forms of this disorder. Understanding the function of these genes is helping researchers to identify what things go wrong not only in inherited forms of this disease but also in non-inherited (or sporadic) forms. Using genetic mapping studies, a list of genes, not surprisingly originally numbered according to the order in which they were discovered, have been associated with developing PD.
Studies of the proteins produced by these various genes have begun to suggest that alterations in certain cellular functions may be important to the development of Parkinson disease. More importantly, continuing research links some of the different genes to being active in the same pathways within the cell. Thus, evidence mounts as to the importance of these pathways in PD including 1) how cells degrade certain proteins after their useful service life is over, 2) how mitochondria generate enough energy for the cell, and 3) how specific RNA molecules in the cell are managed.
One recent study showed that types of genes called PINK1 (PARK6) and Parkin (PARK2) act together in one pathway affecting mitochondria inside the cell (1). An earlier study had shown that under energetically stressful conditions inside the cell that DJ1 (PARK7) and Parkin (PARK2) can interact with one another (2). These types of associations make it more likely that learning how to intervene in these specifically altered pathways may point the way to new treatments for this disorder.
Signs and Symptoms of Parkinson’s Disease
At first, the symptoms of Parkinson’s disease are mild, though they become worse as the disease progresses. With the motor symptoms of Parkinson’s disease, patients can have problems walking. For example, they may have difficulty starting the movement or slowing it down. When walking, they have a shuffling gait. As the balance is impaired, the sufferers may have a stooped position. Parkinson’s disease patients may have stiff muscles in their legs and some patients suffer from muscle pain.
Parkinson’s disease can also cause a loss of fine hand movements, which can make it difficult to carry out tasks that involve holding an object. Many Parkinson’s disease patients experience tremors, which start when the patients’ limbs are at rest. Once patients start using the affected limbs, the tremors go away. The tremors can become worse when patients are tired, stressed or excited. As the disease progresses, patients can have tremors in their feet, head, lips and even their tongue.
Parkinson’s disease can also cause other symptoms and cognitive problems, such as memory loss, confusion, and dementia. Some may have hallucinations, anxiety or depression. The disease is also known to cause a mask-like appearance in which patients do not display emotions on their face. Other symptoms of Parkinson’s disease include constipation, oily skin, fainting, difficulty swallowing, drooling, slowed speech and a monotone voice.
Parkinson’s is a progressive disorder which usually starts on one side of your body before affecting the other. Signs and symptoms to look out for include:
- muscle stiffness
- general slow movement, especially a slow walk
- tremors in your body, most notably in the hands and legs, or even in the neck and head
- changes in your speech, making it difficult for people to understand you
- general loss of facial expressions
- poor posture and balance, making trips and falls more likely
- depressions, mood swings, and other behavioral changes
- memory loss and inability to reason
- bowel and bladder problems
- difficulty swallowing and weight loss
- fatigue and sleep disorders
- feeling light-headed and having low blood pressure
- increased sweating and saliva
The actual causes of Parkinson’s are not fully understood, although there seems to be a pattern of the disease developing in those who have a family history of this condition. Some theories suggest that harmful toxins in the environment are to blame, although in-depth research is needed to confirm this.
Diagnosis and Treatment of Parkinson’s Disease
There is no definitive test to check for Parkinson’s, and so it is a case of monitoring the symptoms and then making a diagnosis based on these. If your doctor thinks you have the disease, they will refer you to a neurologist who will then assess your symptoms and conduct MRI scans and blood tests to rule out possibilities of other diseases.
Controlling Parkinson’s is the best option when looking for a treatment because as yet, there is no cure. The best form of treatment is using drugs which mimic dopamine in the body to help keep the symptoms of Parkinson’s under control. These drugs are not without their side effects and can cause sickness and a sudden need to sleep.
Other treatments are based on limiting the amount of dopamine which is broken down by the body and some treatments look at replacing the dopamine with a view to working on different areas of the brain in order to minimize side effects.
Surgery is used as a last resort and involves placing electrodes in the brain and stimulating those areas of the brain which are responsible for movement. This treatment is known as deep brain stimulation and tiny pulses are repeatedly sent to the brain to help control symptoms.
Despite the many treatments on offer, they are usually supplemented with physiotherapy and speech therapy to offer the patient the greatest chance of coping with the disease. Some patients are lucky enough to experience nothing more than a few tremors, while others find that the condition debilitates them and that they need help with all areas of their personal and daily lives.
With proper care and management, there is no reason why sufferers of Parkinson’s cannot live to full life expectancy.
As mentioned earlier, there is no cure for Parkinson’s Disease; however, by increasing the level of dopamine in the brain, certain medications help to alleviate the symptoms associated with the disease. Those symptoms include tremor, bradykinesia (slowed movement), rigid muscles, impaired posture and balance, loss of automatic movements such as blinking and smiling, speech changes such as slurring and hesitating, and dementia.
Levodopa is the most effective Parkinson’s medication to date. It passes into the brain and is converted to dopamine. Carbidopa ensures the levodopa doesn’t prematurely convert to dopamine outside the brain and is also thought to prevent nausea in some patients. The benefit of levodopa wears off as the disease progresses, thus requiring medication adjustments. Sinemet tablets are manufactured in three strengths:
- Sinemet 25-100, yellow oval tablets containing 25 mg of carbidopa and 100 mg of levodopa. They are scored and coded 650 on one side and “Sinemet” on the other.
- Sinemet 10-100, dark dapple-blue oval tablets containing 10 mg of carbidopa and 100 mg of levodopa. They are scored and coded 647 on one side and “Sinemet” on the other.
- Sinemet 25-250, light dapple-blue oval tablets containing 25 mg of carbidopa and 250 mg of levodopa. They are scored and coded 654 on one side and “Sinemet” on the other.
The most common side effects of Sinemet include dyskinesias, other involuntary movements, and nausea. Other side effects include chest pain, asthenia, cardiac irregularities, hypotension, orthostatic hypotension, hypertension, syncope, phlebitis, palpitation, dark saliva, and gastrointestinal bleeding.
Dopamine agonists mimic the effects of dopamine on the brain and cause neurons to act as if dopamine is present. They don’t work as well as levodopa, but their effects sometimes last longer. These medications include:
- Pramipexole (Mirapex) tablets available in 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, and 1.5 mg dosages.
- Ropinirole (Requip) tablets available in 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, and 5 mg dosages.
- Apomorphine (Apokyn) is a subcutaneous injectable dosage.
Side effects include hallucinations, sleepiness, water retention, and low blood pressure when standing. They may also increase risk of compulsive behaviors such as hypersexuality, compulsive gambling, and compulsive overeating.
Monoamine Oxidase B (MAO B) Inhibitors
Monoamine oxidase B (MAO B) is an enzyme in the brain that breaks down dopamine. Monoamine oxidase B (MAO B) inhibitors reduce this enzyme’s activity. These medications include:
- Selegiline (Eldepryl) available in 5 mg capsules.
- Rasagiline (Azilect) available in 0.5 mg and 1 mg tablets.
Side effects include confusion, headache, hallucinations, and dizziness. They can’t be used in combination with antidepressants, Cipro, St. John’s wort, or certain narcotics.
Catechol O-Methyltransferase (COMT) Inhibitors
Catechol O-methyltransferase (COMT) inhibitors block an enzyme that breaks down levodopa and is combined with carbidopa and levodopa therapy. Medications include:
- Tolcapone (Tasmar) is available in 100 mg and 200 mg tablets. It has been linked to acute fulminant liver failure and is only used for patients who haven’t responded to other medications.
- Entacapone (Comtan) is available in 200 mg tablets and doesn’t cause liver damage but may increase side effects including involuntary movements, nausea, hallucinations, and confusion.
Anticholinergics inhibit parasympathetic nerve impulses by blocking the neurotransmitter acetylcholine to its receptor. Medications include:
- Benztropine (Cogentin) is administered either via intramuscular injection or intravenously. Effects can be seen within minutes.
- Trihexyphenidyl (Artane) is available in 2 mg and 5 mg tablets and as a lime-mint flavored elixir.
In many patients, the drug benefits do not outweigh the side effects which include fever, irregular heartbeats, anxiety, hallucinations, confusion, agitation, hyperactivity, and seizures.
Glutamate (NMDA) Blocking Drugs
Glutamate is a neurotransmitter in the brain responsible for sending signals between cells. Abnormally high amounts of glutamate can overexcite nerve cells. Glutamate (NMDA) blocking drugs limit glutamate activity. Medications include:
- Amantadine (Symmetrel) is a light orange 100 mg triangular tablet usually taken twice daily. For unresponsive patients, dosages can be increased up to 400 mg daily.
Side effects include purple mottling of the skin and hallucinations.
Surgical Treatments & Deep Brain Simulation
Surgical interventions of varying types for limiting the symptoms of PD have emerged over the last three decades. While treatment with medications is always the first choice, these surgical treatments have proven useful for many people. The earliest surgical treatments involved intentionally damaging specific structures in the brain that are involved in modulating movement control. The idea behind this is that some of the symptoms of PD, largely the tremors, could be dampened. These included procedures known as pallidotomy (damaging a brain region known as the globus pallidus) and thalamotomy (damaging a specific area of the thalamus).
One option for treating Parkinson’s disease is deep brain stimulation (DBS). This treatment helps particularly with the walking problems, tremors, slowed movements, rigidity, and stiffness. DBS is a surgical procedure in which the surgeon implants an electrode, or lead, into the patient’s brain at specific motor locations. The lead connects to an extension wire, which attaches to the neurostimulator. The National Institute of Neurological Disorders and Stroke (NINDS) explains that the neurostimulator sends the electrical impulses through the extension to the lead, where the electrical impulses block the abnormal nerve signals that cause tremor and Parkinson’s disease symptoms.
A study published in the New England Journal of Medicine with funding from the Department of Veterans Affairs (VA) and the NINDS investigated the use of DBS for Parkinson’s disease at two different sites in the brain. The two sites that surgeons implanted the electrode in were the subthalamic nucleus and the globus pallidus interna, which are both parts of the basal ganglia system.
The study included 300 Parkinson’s disease patients who were followed for two years. Stimulation of both the subthalamic nucleus and globus pallidus interna provided benefits for patients, as both brain regions are linked to motor control pathways. The researchers found that the most effective method was bilateral stimulation, meaning both sites received electrical stimulation from the neurostimulator.
DBS can help greatly with Parkinson’s disease. While medications like L-dopa can improve motor symptoms, they become less effective as the disease progresses. But as the researchers of the DBS study note, DBS does not treat the non-motor symptoms of Parkinson’s disease and may worsen them in some patients. As a result, Parkinson’s disease patients undergoing DBS still need to take medications for the other symptoms of the disease.
Managing the Disease
Benefits of Exercise for Parkinson’s Patients
One way to manage Parkinson’s disease is exercise. Exercise and therapy can have direct effects on the mobility of a person with a neurological condition such as Parkinson’s disease. Studies have shown aerobic exercise augments blood flow in the body, which helps with the removal of waste products. This is especially important because one of the non-motor symptoms of Parkinson’s disease is constipation.
The balance training can increase the number of synapses in the brain. Additionally, exercise can help boost survival factors in brain cells, and thus limit cell death in certain cases. Other research has shown moderate exercise can complement medication and help it work more effectively. Exercise programs should be prescribed specifically for each Parkinson’s patient since every case is different.
Three Types of Therapy for Parkinson’s Disease
Several different types of therapy, such as speech, occupational, and physical therapy, are available for Parkinson’s patients. Speech therapy focuses on people’s ability to swallow and talk, as well anything else related to their vocal musculature. Occupational therapy centers around activities of daily living, such as getting dressed and cooking. Physical therapy concentrates on walking, overall mobility, balance, and whole body strengthening. Some areas evaluated during therapy include walking, posture, balance, strength, flexibility, and functional limitations.
Activities to Promote Balance and Strength
Additionally, those with Parkinson’s disease can participate in other activities to help build strength and improve balance. Kayaking motions can assist with reducing the stiffness in the trunk area of the body and some sports like boxing gives people practice shifting their weight back and forth. Tai Chi focuses on whole body movement while dances such as the tango or the waltz can also be beneficial as these dances use long, drawn-out movements. Also, multi-tasking activities, like walking while counting backwards, use both motor function and cognition.
U-Step Walker and Laser Cane
Several assistive devices are also available for Parkinson’s disease patients. These include the U-Step Walker and Laser Cane. The U-Step Walker contains a breaking mechanism to help control the speed of the walking. The breaking function of the U-Step Walker allows users to stop before they begin moving too fast and fall. The Laser Cane, along with the U-Step Walker, also utilize lasers to provide visual cues in the form of a red line on the floor in front of the user. This can help when Parkinson’s patients have trouble with freezing during walking and give them a target to step through.
Increased Exercise Improves Motor Coordination
The human brain has the ability to create new connections and bypass damaged areas to regain lost motor skills and muscle control, based on studies of stroke victims. Increased exercise is helpful to patients with Parkinson’s disease because the body responds to the increase in oxygen and glucose, both critical to brain function, by forming new capillaries to deliver additional blood to nerve cells.
Results of research on the effects of pedaling a bicycle have encouraged doctors treating patients with Parkinson’s disease. Research showed that a faster pace on a tandem bicycle achieved markedly increased manual dexterity and cycling showed great potential as an effective resource. It is possible that high cadence cycling simulates normal brain activity, opening the door to further research.
Cycling has been shown to improve mobility, balance, and muscle control in patients with Parkinson’s Disease. One explanation of the benefits of cycling might be that bicycling uses a different part of the brain than walking uses, or perhaps the rhythmic pressure of the pedals on a patient’s feet may cue the nervous system to perform the cycling movement.
Parkinson’s-plus syndromes cause the common Parkinson’s symptoms, but these conditions also involve other parts of the nervous system, hence the name Parkinson’s-“plus.” Since other areas are involved, Parkinson’s-plus syndromes may not respond completely to Parkinson’ s disease medications (levodopa/carbidopa.) The plus syndromes also tend to progress more rapidly than regular Parkinson’s disease. The following are four of the best-known Parkinson’s-plus syndromes:
Progressive Supranuclear Palsy
This plus syndrome is drug-resistant. Its most unique characteristic is the inability of a patient to move his or her eyes up or down. Gazes can freeze upward, causing difficulty with walking downstairs, dressing, and many other tasks. PSP may cause a patient to have stiff muscles in the neck, adding to the inability to scan with the eyes.
Other characteristics of progressive supranuclear palsy include early loss of balance, speech and swallowing problems, as well as accompanying depression and cognitive issues.
Cortico-basal Ganglionic Degeneration
This plus syndrome involves the shrinking of the cortex of the brain. It presents with similar symptoms as Parkinson’s disease: stiffness, balance issues, speaking problems, and cognitive degeneration. Tremor can be a symptom, but it is not as big of an issue as it in Parkinson’s disease.
Problems specific to CBGD include symptoms (initially) only affecting one side of the body (asymmetry), body “jerking”, limb apraxia or incoordination, and “alien limb” or movement of a particular limb without direction from the brain. Later issues with CBGD include depression and/or dementia. Again, cortico-basal ganglionic degeneration does not respond well to Parkinson’s medications.
Multiple System Atrophy
This group of syndromes mimics pure Parkinson’s disease, but eventually, other specific symptoms develop that classify them as plus disorders. With multiple system atrophy, more than one group of nerve cells degenerate. In Parkinson’s disease, dopamine-producing cells are affected, but with MSA, other cells are also impaired or destroyed. One of these syndromes presents like Parkinson’s, but patients can exhibit extreme balance issues. Another MSA syndrome can very closely mimic Parkinson’s, but it has almost no response to Parkinson’s medications. A third MSA syndrome has additional autonomic dysfunctions. These functions are part of the autonomic nervous system, and they include blood pressure regulation, bladder control, sexual function, and breathing.
Dementia With Lewy Bodies
The last category of Parkinson’s-plus disorders most gravely affects the mind. Parkinson’s-like symptoms can occur, such as tremor, shuffling gait, and movement problems. Dementia with Lewy bodies causes abnormal protein deposits in the brain (Lewy bodies.) This syndrome resembles Parkinson’s and Alzheimer’s because it causes dementia, depression, and hallucinations.
Unlike the other Parkinson’s-plus syndromes, it seems that DLB progresses at a slow-to-steady rate, and Parkinson’s and Alzheimer’s medications may slow the progress of the disease.
Coping with the Disease
It’s hard enough having a neurological illness under the best environmental circumstances. When a person doesn’t have the right information or support, it can be nearly impossible. Some tips for coping with Parkinson’s disease (or any other chronic, neurological illness) include:
Learning All You Can About Your Illness
Find out about the best doctors in your area. Get second opinions. Have the doctors explain your test results. With Parkinson’s disease, a lot of the diagnosis is through key symptoms. When your doctors are quite sure it is Parkinson’s disease, study up on the illness anywhere you can. Go to the library to seek medical reference books. Send away for information from Parkinson’s disease organizations. Go to reputable websites for more information. Never stop learning about new treatments.
Communicate With Your Spouse Or Caretaker
Keeping communications open with your caretaker and/or spouse is imperative to maintaining good disease control. Let him or her know what you can or cannot do. If you can no longer work full-time, you may need to reassess your finances. Sharing your personal feelings about Parkinson’s disease also allows you to maintain some control over the situation. Holding feelings in can be stressful and also harmful for your condition. Your significant other or personal caretaker should be one of your biggest supporters, both physically and emotionally.
Have a Strong Outside Support Network
Besides your immediate caretaker and family, it is important to be connected to your wider circle of friends and relatives. These bonds help people with Parkinson’s disease cope on a day-to-day basis. Isolation is a terrible situation to be in, especially when facing a debilitating neurological illness. Strengthen bonds with your support network to get help with errands, childcare, driving, etc. For networking on a deeper level, try a support group for Parkinson’s disease. Bonding with people who are going through your situation and truly understand your plight can be soul-soothing.
Aging Parents and Eldercare-The Web site includes articles, comprehensive checklists and links to key resources designed to make it easier for family caregivers to quickly find the information they need to care for a loved one.
American Parkinson Disease Association-The American Parkinson Disease Association (APDA) is the largest grassroots network working tirelessly to provide the support, education, and research that will help everyone impacted by Parkinson’s disease live life to the fullest.
Bachmann-Strauss Dystonia & Parkinson Foundation-In 2014, The Bachmann-Strauss Dystonia & Parkinson Foundation formed a collaborative research alliance with MJFF and established The Bachmann-Strauss Prize for Excellence in Dystonia Research to broaden public awareness and recognize key scientific discoveries in dystonia.
Davis Phinney Foundation-The Davis Phinney Foundation was created in 2004 by Olympic medalist and retired professional cyclist, Davis Phinney, to help people with Parkinson’s live well today.
Northwest Parkinson’s Foundation-Northwest Parkinson’s Foundation’s mission is to improve the quality of life of people affected by Parkinson’s through awareness, education, advocacy, and care.
NeuroTalk Communities-A place for people with neurological and brain disorders to find support.
PD Movement Lab-PD Movement Lab helps people with Parkinson’s foster a renewed sense of self. Through practical movement strategies, they can learn techniques to improve mobility and adapt creatively. And from interviews with outstanding PwPs, they can discover models and ideas for an active and engaged life.
Parkinson’s Foundation-The Parkinson’s Foundation makes life better for people with Parkinson’s disease by improving care and advancing research toward a cure.
Parkinson Association of the Rockies-The Parkinson Association of the Rockies connects and empowers people with Parkinson’s to thrive. Through support groups, exercise classes and in-home consults with a Licensed Clinical Social Worker, the Association connects people to the community and critical resources.
The Parkinson Alliance-The Parkinson Alliance is the umbrella organization for the Parkinson’s Unity Walk, the largest single-day community fundraising event, and Team Parkinson.