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Early Diagnosis and Medical Treatment of Parkinson's
How is Parkinson's disease diagnosed?
Symptoms of Parkinson's
The causes of Parkinson's disease
How is Parkinson’s disease diagnosed?
Parkinson’s disease is not always easy to diagnose. As is the case with many other health problems, there are no blood tests or specific radiological examinations to definitively confirm its presence. The diagnosis rests exclusively on the symptoms described by the patient and on a complete neurological examination by the physician.
In some people, diagnosing Parkinson’s disease is made easier by the presentation of the classic signs of tremor at rest, slowed movements and stiffness on only one side of the body.
In a person with Parkinson’s disease, radiological imaging examinations are normal. However, the physician may ask for certain tests, a CT scan for example, to rule out the possible presence of other diseases. Other, more specialized imaging examinations in nuclear medicine, may be useful for detecting Parkinson’s disease, but in the current context, they are mainly used as research tools and not diagnostic tests.
Symptoms of Parkinson’s disease
The clinical appearance of Parkinson’s disease is marked by four key, or cardinal, signs:
1. tremor (or trembling) at rest
2. akinesia and bradykinesia
4. postural instability
1. Tremor (trembling) at rest
Tremor at rest is the most recognized sign of Parkinson’s disease. In 70% of patients, it is the first sign to appear. Tremor generally starts unilaterally (meaning on only one side of the body) in the hand or foot. It appears as alternate flexion and extension of the fingers; adduction and abduction of the thumb as when crumbling something. As the disease progresses, the trembling may eventually affect the opposite arm and leg as well. The main characteristic of this trembling is that it improves during the execution of voluntary movements. This “resting” feature distinguishes it from other forms of tremor.
2. Akinesia and bradykinesia
Akinesia and bradykinesia are signs which, clinically, are defined as scarcity (akinesia) and slowness (bradykinesia) of movements. In the face, these signs appear as a decrease in facial expression and blinking of the eyes. Some people are affected by an excess of saliva in the mouth, a direct result of slowed swallowing.
The voice may become monotonous and low. There are also difficulties in the execution of movements as well as slowness of execution. This results in a decrease in fine motor dexterity, and the person may experience difficulty buttoning clothes or shaving, will walk slower and have a tendency to take small steps.
Rigidity is an increase in muscle tone. Most often, the patient reports stiffness and describes no other clinical symptoms of rigidity. Rigidity is mainly a sign noted by the physician during a physical examination and is especially useful in establishing a diagnosis. Rigidity may appear as a decrease in arm swing on the side of the body affected by Parkinson’s disease.
4. Postural Instability
Postural instability is a late sign of Parkinson’s disease, which appears after many years of progression.
In summary, the main features that enable a diagnosis of the disease are the presence of two of the following three factors: tremor (trembling) at rest, bradykinesia and rigidity. Lastly, it is important to know that a person with Parkinson’s disease may also experience any of the following symptoms:
- Seborrheic dermatitis (greasier skin, especially around the nose and eyebrows, and a greasier scalp)
- Increased sweating
- Decreased sense of smell
- Increase in urinary frequency
- Dizziness when standing (orthostatic hypotension)
- Non-specific sensory symptoms – numbness, pain, burning sensation, restlessness, fatigue
- Sleep difficulties
Medical treatments for Parkinson’s disease
Since you've been diagnosed with Parkinson's, you've most likely discovered your progress and symptoms are different from other people with Parkinson's. You are unique - which means the treatment you receive will be geared to your specific needs.
At some point, you will start taking medication to lessen the symptoms. This will probably happen when you feel your normal daily activities are affected.
Six classes of medication are available to treat the symptoms of Parkinson’s disease, including Levodopa, dopaminergic agonists, anticholinergics, amantadine, monoamine-oxidase B inhibitors (MAO-B), and COMT inhibitors.
This remains the most effective medication to date for treating the symptoms of Parkinson’s disease. Levodopa is absorbed in the intestine and carried into the blood stream to the brain. Once in the brain, it is converted into dopamine and stored in the nerve cells to replace the depleted dopamine. Levodopa is always combined with a peripheral inhibitor (the carbidopa in Sinemet or the benserazide in Prolopa), which slows the peripheral conversion of dopamine and enables more levodopa to reach the brain. This also reduces the side effects, such as nausea and vomiting.
Levodopa improves the symptoms of rigidity and bradykinesia for the majority of patients. However, its effect on tremor is highly variable and it is not very effective in treating postural instability.
Dopaminergic agonists act by stimulating the dopaminergic receptors in the brain and by binding to them in the same way as naturally produced dopamine. This is the most effective class of medications after levodopa.
There are four dopaminergic agonists currently available in Canada: bromocriptine (Parlodel), pergolide (Permax), pramipaxole (Mirapex), and ropinerole (ReQuip).
Although no direct comparative studies have been done, there appears to be no major differences between the various agonists with respect to their efficacy, ease of use or side effects. They must all be prescribed at very low doses and very gradually increased to avoid side effects.
Agonists have been shown to be effective as initial treatment for PD and also in association with levodopa in more advanced stages of the disease.
Monamine-oxidase B inhibitors (MAO-B)
Selegiline is in irreversible monoamine-oxidase B inhibitor. In the brain, MAO-B is partially responsible for breaking down dopamine. Although selegiline potentiates the effect of symptom relief provided by levodopa, it may also exacerbate side effects such as dyskinesia, hallucinations, nausea, etc.. Selegiline can be used in monotherapy in young patients in the early stages of the disease whose motor symptoms are mild, or in association with levodopa in people with motor fluctutations.
Levodopa and dopamine are broken down partly by catechol-O-methyltransferase (COMT). COMT inhibitors block the action of this enzyme both in the intestine and the brain. By slowing the breakdown of levodopa, more of it becomes available in the brain.
Entacapone (Comtan) is a peripheral COMT inhibitor, administered in doses of 200 mg with each dose of levodopa. In people with motor fluctuations, it reduces off time, increases on time and extends the duration of the motor response to levodopa.
Anticholinergics were the first medications used in the treatment of Parkinson’s disease. Although more specific drugs are now available, anticholinergics are still useful, mainly in the treatment of trembling. It should be understood that trembling is often one of the more difficult symptoms to control with medication.
Anticholinergics include the following medications: trihexyphenidyl (Artane), orphenadrine (Dispal), benztropine (Cogentin), procyclidine (Kemadrin), diphenhydramine (Benadryl) and ethopropazine (Parsitan).
Amantadine (Symmetrel) is an antiviral agent that, by chance, was found to have an antiparkinsonian action. Its mechanism of action is not well understood. It appears to stimulate the release of dopamine in the brain. It can be used in monotherapy when the disease is in its very early stages, or in association with other medications if the disease is progressing.
The decision to start treatment depends on many factors. In general, treatment should be started once symptoms prevent a person from leading a normal personal, social or professional life. Other factors, such as the person’s age, the side involved (dominant or non-dominant), and the main symptoms, such as tremor, bradykinesia and difficulty moving around, must also be taken into consideration. The main goal of treatment is to relieve the symptoms of PD so that the person with the disease can continue with his/her activities of daily living.
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Neurosurgical options for treating Parkinson’s disease
Pallidotomies have been used since the 1990’s, not only for problems of rigidity, but in an attempt to counteract the dyskinesias that may appear after prolonged exposure to levodopa and other antiparkinsonian agents. Thalamotomy continues to be used in some cases for control of severe tremor.
Deep brain stimulation surgery, which enables control of tremor, dyskinesia, rigidity, postural disorders and walking problems has become the surgical treatment of choice in the last few years. This surgery involves the implantation of electrodes into the part of the brain known as the subthalamic nucleus. Stimulation using electrodes avoids damaging the cells around the target and enables the regulation of the degree of inhibition of the target cells by modifying the voltage of the electrical current provided by adjustable batteries.
This procedure involves positioning in the nucleus an electrode which is attached to a fine wire running under the skin to the battery, which is usually implanted in the chest wall.
Subthalamic stimulation is the most recommended operation at this time. It significantly decreases the amount of medication required to control the disease. As the stimulator can be regulated, it is possible to change the power of the stimulation according to the progress of the disease. However, it must be noted that not every patient with Parkinson’s disease is a suitable candidate for this procedure.
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Combined therapies for optimal treatment
Although the treatment of Parkinson’s disease is mainly pharmacological, the addition of various complementary treatments has been shown to be very effective at better controlling certain symptoms or even delaying their appearance. Accordingly, posture, walking, balance, rigidity, endurance and pain control are likely to be improved with physiotherapy. The maintenance of autonomy in all aspects of daily and domestic life may be improved by an evaluation and follow-up with an occupational therapist. Communication and speech can be maintained or corrected by the interventions of a speech-language pathologist. A consultation with a dietitian may be useful in restoring the medication’s effectiveness or to counter side effects. A global approach greatly improves the treatment of Parkinson’s disease and may ensure a better quality of life for those suffering from it.
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What consideration should be given to alternative therapies and medicine?
Interest in alternative approaches to health continues to grow. Approaches such as massage, chiropractic treatment, acupuncture, osteopathy, homeopathy, phytotherapy, aromatherapy, pressure therapy and reflexology are gaining increasing consideration as alternatives to so-called traditional medicine. While it is true that there is no harm in trying to feel better, these therapies should be viewed with caution and discernment. For example, choose a type of massage that is best suited to your needs, condition and energy level.
If you have Parkinson’s disease, it is essential you find out as much as you can about the quality and benefits of all these approaches as some will be better suited than others to your specific needs. The best choice of therapies, be they traditional or alternative, is one that is made in an informed manner. Which therapies to choose and which to reject should be discussed with your physician, so as to plan the interventions most likely to be effective for your well-being and health.
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The causes of Parkinson’s disease
It is not known exactly what causes Parkinson’s disease. Some researchers claim that people in rural areas are more at risk of developing Parkinson’s, placing the blame on factors such as well water and pesticides.
The genetics theory stems from the discovery in recent years of genes involved in Parkinson’s disease. We know that people who have one parent with Parkinson’s present a higher risk of having the disease themselves. Recent studies have shown that the genetic contribution is particularly significant in those who develop Parkinson’s disease when they are young.
Who is right? Who is wrong? The truth lies probably in a combination of toxic and genetic factors. Moreover, the people most likely to develop Parkinson’s disease are perhaps those with a genetic predisposition who, once exposed to certain environmental toxins, will develop symptoms of Parkinson’s disease.
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Parkinson’s disease: Everyone has to learn a new way of life
The diagnosis of a chronic degenerative condition such as Parkinson’s disease causes emotional reactions both for the person with the disease and his/her loved ones. Living every day with a person suffering from this disease becomes a new challenge. You have to be familiar with and understand the other person’s disease and adapt to a future of uncertainty. This new situation becomes a shared experience. The physical, psychological and social changes which occur undeniably require the ability to adjust and adapt frequently.
This material is adapted from Societe Parkinson du Quebec’s “Le Guide Info PARKINSON”.
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