What is PD


Parkinson's disease (PD) is a chronic, progressive, neurodegenerative disorder of the central nervous system associated with damage to and loss of dopamine-producing nerve cells (neurons) deep in the brain. Parkinson’s disease is second only to Alzheimer’s affecting between 1 million to 1.5 million people in the United States. Between 7 and 10 million people are estimated to be living with Parkinson’s around the world. Clinically, the disease is characterized as a movement disorder by a decrease in ease of movements, difficulty in walking, postural unsteadiness, rigidity, and tremor, as well as other non-movement related symptoms. Parkinson's disease results from loss of dopamine-producing nerve cells (neurons) deep in the brain. Degeneration of neurons in a region of the brain substantia nigra a basal ganglia structure located in the midbrain , resulting in decreased availability of the neurotransmitter dopamine.

The English doctor James Parkinson first described Parkinson’s disease in 1817.  From Dr. Parkinson’s initial insights, we now know Parkinson's as a disorder of the central nervous system resulting from damage and cell death of the substantia nigra dopaminergic neurons cells.  Substantia nigra cells produce dopamine, a chemical called a neurotransmitter responsible for carrying nerve signals within the brain for coordination of movement. Loss of dopamine causes neurons to function abnormally, impairing body movement.  Parkinson's is classified as a movement disorder; other diseases in this class include essential tremor, dystonia, torticollis, and Tourette’s syndrome.

 Parkinson’s disease affects men and women and according to the National Institutes of Health, Parkinson’s disease affects about 50% more men than women. Although the average age of onset is about 60, the disease can occur in younger people. Typically, first onset of symptoms before age 50 (about 4%) are referred to having early onset or young-onset Parkinson’s disease (YOPD)

There is no definitive test, or biomarker, for Parkinson's disease; it is usually diagnosed by exclusion, or “ruling things out.”   The rate of misdiagnosis can be relatively high, especially for young-onset cases or when a non-specialist makes the diagnosis. Diagnosing is especially challenging for individuals who do not display the characteristic tremor. To determine if you have Parkinson’s your doctor will review your medical history, self-reported symptoms and conduct a clinical examination.

A Parkinson’s diagnosis requires you have two out of these primary motor symptoms:

  • Tremor (usually a resting tremor, often in the hands, arms, legs, torso, or lips and face.  The tremor tends to be relatively slow, about 4-6 cycles per second, and often shows a “pill-rolling” movement in the hands and fingers.)
  • Rigidity (muscular stiffness and tightness, often displaying a “start and stop” jerky motion called “cogwheel rigidity” when a limb is manually moved)
  • Bradykinesia / Akinesia ( lack of movement or extreme slowness in movement)

To support the diagnosis, your doctor will also look for other symptoms:

  • Micrographic (small handwriting)
  • Facial masking (reduced facial expression)
  • Postural instability ( Decreased arm swing or leg drag on one side of the body while walking, shuffling gait, or balance problems, often resulting in falls)

Also important are the non-movement symptoms of Parkinson’s disease, sometimes called "non-motor" or "dopamine non-responsive" symptoms.  These common symptoms can have a major impact on people with Parkinson’s. For example,

  • Cognitive impairment, ranging from mild memory difficulties to dementia
  • Mood disorders, such as depression and anxiety, occur frequently, particularly in people with Parkinson’s (PWPs) with later onset. 
  • Sleep difficulties
  • Loss of sense of smell
  • Constipation
  • Speech and swallowing problems
  • Unexplained pain
  • Drooling
  • Orthostatic hypotension, fall of blood pressure when standing

Just because something is listed as a symptom of Parkinson’s disease it does not mean a person with Parkinson’s will experience that symptom. Each case is different and do not respond in the same way, such as symptoms, the rate of progression, or treatment response.

Non-pharmacological treatments are important for many patients. Such treatments not only help to relieve some of the motor symptoms of Parkinson's disease, but can also aid in management of postural instability and non-motor symptoms. Determining which non-drug treatments may best address and treat your Parkinson's disease should be done in consultation with physicians and other caregivers involved in your overall treatment plan.

Exercise. Given current knowledge about the universal health benefits of exercise, it is not surprising that exercise and physical therapy are the most frequently suggested non-pharmacological treatments for Parkinson's disease. Exercise programs can help people with Parkinson's stay active and relatively limber, and improve balance and motor coordination. Some doctors also prescribe physical therapy or muscle-strengthening exercises.
Exercise may have effects on some of the non-motor symptoms of Parkinson's as well. For example, exercise can reduce sleep dysfunction and can improve overall emotional health.
Other exercise programs that can be beneficial include yoga, tai chi, and chi gong. Rock Steady Boxing http://Haus.RSBaffiliate.com

Speech Therapy. Parkinson's can bring on problems with speech, including reduced or fading volume, vocal clarity issues, and reduced or increased pace of speaking. Speech therapy is increasingly viewed as an intervention that can greatly enhance ability to communicate and overall quality of life. Lee Silverman Voice Treatment (LSVT) is the program most frequently recommended.

Occupational Therapy. Occupational therapists seek to help people with Parkinson's in a variety of tasks that impact daily living and quality of life, including physical movement, handwriting, dressing, eating, to adaptation of utensils and other household items.

Psychological Therapy/Counseling. Depression and anxiety can be core symptoms of Parkinson's disease, biochemically based much like rigidity or tremor are. Left untreated, these symptoms can significantly diminish a person's quality of life and overall health. Pharmacological treatments in conjunction with psychological therapy and counseling can be helpful.

Similar to available pharmacological treatments, no currently available surgical treatment has been proven to either slow the disease or "rejuvenate" the sick and dying nerve cells affected by PD. Today's PD surgeries offer symptomatic benefits.
Because of the level of risk inherent in any brain surgery, it is usually an option only for patients with advanced or quickly debilitating Parkinson's disease or those with severe medication-induced side effects, such as debilitating dyskinesia or other quality-of-life impacts. The decision about undergoing surgery should be made in consultation with physicians and caregivers involved in a patient's treatment regimen. Identifying an experienced surgical team is essential.

Deep Brain Stimulation (DBS)
Today, the most commonly discussed surgical treatment is deep brain stimulation (DBS), a procedure that seeks to reduce "on/off" fluctuations as well as dyskinesia. While we do not understand how DBS works, it seems to counteract the abnormal neuronal functioning that occurs in PD. DBS is increasingly attractive for many Parkinson's patients, particularly as more surgeons become proficient with the technique.
DBS is not well suited for all patients. Generally, patients with typical PD who have had a good response to levodopa, but who are experiencing medication-related motor side effects such as dyskinesia might be good candidates. DBS is usually not recommended for patients with dementia.
In DBS, a very thin electrode (about the diameter of a piece of spaghetti) is implanted into the brain, targeting motor circuits that are not functioning properly. Small electrical pulses from a device similar to a cardiac pacemaker are then used to stimulate a small brain region and block the signals that cause some Parkinson's symptoms. DBS electrodes are usually placed in regions of the brain called the globus pallidus (GPi) or subthalamic nucleus (STN) to improve motor function. The stimulator can be adjusted as necessary to optimize effects.
Generally, DBS does not improve symptoms that do not respond to levodopa. DBS may improve motor function in PD patients, and may also allow reductions in the amount of medication a PD patient requires, although this is not always the case. DBS also reduces motor fluctuations and “off” time. While DBS can produce major improvements in many of the motor symptoms of PD, its effectiveness varies from patient to patient. Realistic expectations and an acceptance of the risks and benefits associated with surgery are essential attributes in the DBS decision process.

Other Surgical Approaches
Because deep brain stimulation has become the surgical method of choice where available, other surgeries such as pallidotomy and thalamotomy are used less often. Both of these approaches permanently damage small regions of the brain to reduce symptoms. These procedures are not reversible.

There are a number of drugs that are used to treat the symptoms of PD, and multiple other drugs used in parallel to treat the inevitable side effects of Parkinson’s drug treatment.
Every person living with Parkinson's disease experiences a different range of symptoms. For this reason, not all treatments are of equal value to all patients. A PWP must work closely with the doctor and all medical caregivers involved with their treatment regimen to develop a workable approach. Decisions about which treatments to use, how long they can be expected to remain beneficial, and when to begin treatment are highly individualized in PD. The section below offers an overview of some of the most commonly prescribed medications currently used to treat Parkinson's.


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The Crooked Path Blog

The Crooked Path is a blog written by Corey King, a CCPSG member and diagnosed with PD at the age of 47.  

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