Moving on after Parkinson's disease
What do Muhammad Ali, Michael J. Fox, Adolf Hitler, Pope John Paul II, Salvador Dali, and Freddie Roach have in common?
Answer: They all have Parkinson’s disease, a neurological condition that affects that portion of the mid-brain called substantia nigra. This is characterized by the deterioration of cells containing dopamine, and results in movement-related manifestations. The symptoms include tremors that extend to the leg or foot on the same side, sometimes extending to the lip or jaw; hands shaking even when at rest; or slower movement (bradykinesia); and muscle stiffness or rigidity so that the patient has trouble with usual routines like buttoning up his shirt.
However, Dr. Raymond L. Rosales, professor of neurology and psychiatry and president of Movement Disorders Society of the Philippines (MDSP,) clarifies that there is a difference between Parkinson’s disease and parkinsonism. Parkinsonism is the general term that describes a number of movement disorders. While 77 percent of movement disorder cases are due to Parkinson’s disease, 12 percent are due to multiple-system degeneration and a smaller percentage of movement disorders are drug-induced.
“Parkinson’s disease (PD) starts with movement problems,” says Dr. Rosales who describes the condition as a “burning topic in neurology.” He explains, “It is the most common neurodegenerative disease after Alzheimer’s disease.” As a disease whose prevalence is related with advancing age, it affects more men than women with a ratio of 3:2.
In the Philippines, it is estimated that PD affects 120,000 people (or one percent of the 50–year-old and above bracket.) “But if you look at the data, only 30,000 (or 25 percent) seek treatment,” says Dr. Rosales. The remaining 75 percent do not seek treatment because they are not aware that they have PD; or are incapable of paying for medication. A recent study also showed that a spike in early-onset PD occurred in Regions 6 and 7 (Panay and Negros) islands. “We found that there are genetic markers for early onset PD in our country.” The disease is autosomal-recessive and linked to the X-chromosome, so that men whose mothers are carriers of the gene manifest the disease.
Dr. Rosales lists environmental risks that increase predisposition to PD. These include specific toxins such as manganese and carbon monoxide, and agrochemicals such as pesticides and herbicides. On the other hand, PD “protective” factors are caffeine, green tea, aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs.) Clinical manifestations of the disease become apparent when 60 percent of the cells in the mid-brain die.
How to detect PD at its onset?
Dr. Rosales advises patients to look out for these subtle signs: sleep problems (47 percent of patients), sensory symptoms such as the inability to smell (63 percent), anxiety (33 percent), fatigue (40 percent), depression (36 percent), and problems with bowel movement. However, since these are common symptoms that most people will usually disregard, it is easy to understand that, more often than not, PD is diagnosed at a later stage.
Dr Rosales mentions two major sub-types of PD. These are the tremor dominant form (TD-PD) and PD with postural instability and gait difficulty (PIGD.) “One finding is that patients with tremor dominant are relatively spared in terms of their cognition and memory. They have an early onset and the disease progresses more slowly,” continues Dr. Rosales. Predictors of poor prognosis are greater baseline impairment (where patients are greatly impaired at the onset), cognitive disturbance, old age, and lack of temors at the onset of the disease.
What is the treatment for PD?
“As much as possible, we keep the patient functioning independently,” says Dr. Rosales. “We encourage them to remain active and mobile, and we individualize therapy according to specific needs.”
To maintain a good quality of life, medicines such as dopamine agonists and levodopa are prescribed, alongside non-pharmacologic measures such as good patient education and support, exercise and proper nutrition. In extreme cases where a patient fails to respond, deep brain stimulation surgery is considered.
Dr Rosales notes, “The Quality Standards Subcommittee of the American Academy of Neurology identified eight studies with class II evidence suggesting that exercise modalities including music therapy, treadmill exercises, balance training, and cued training are “probably effective” in improving functional outcomes for patients with PD.” Likewise, dancing the tango and tai-chi exercises seem to be helpful and studies are underway to explain the correlation.
One interesting bit of trivia about Parkinson’s disease: “Those of you who are smokers will be happy to note that cigarette smoking is considered PD protective,” says Dr. Rosales. But he points out that smoking has also been implicated in various grave illnesses. On the subject of cigarette smoking to prevent Parkinson’s disease, it is like being caught between the devil and the deep blue sea.
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Dr. Rosales’ lay lecture for a media audience was through the efforts of GlaxoSmithKline (GSK) that has over 20 years of research and development experience in PD. The company recently launched a new therapy for people with PD in the Philippines. Ask your doctor about the first once-daily dopamine agonist that can be used as monotherapy for the early stage of PD, and in combination with other agents for PD’s advanced stage.
