Parkinson's (Parkinson's Disease, Parkinson's Plus Syndrome). Therapy

What types of treatment and therapies are there?

The options for treating Parkinson's syndromes become increasingly complex from year to year. Almost every year new drugs for treating Parkinson's are approved. It is the aim furthermore to draw up for each patient an individualised tailor-made treatment plan including non-medicamentous components such as physiotherapy and if applicable voice therapy integrated into a finely-tuned medication regimen as the cornerstone.

 

Parkinson's. Diagnostics, Therapy & Treatment

Diagnostics. How is Parkinson's identified?

How is Parkinson's detected?

There is no blood test or other procedure which can provide a 100% certain diagnosis of Parkinson's. The diagnosis and differentiation of individual Parkinson's syndromes must initially take place using purely clinical methods, i.e. the neurologist listens to the patient's or their relatives' description of their symptoms and examines the patient. You just need experience to be able to classify correctly a Parkinson's syndrome so that the treatment concept is consistent. It is not in vain that within the field of neurology a subspeciality called "Parkinson's and movement disorders" has developed together with corresponding clinics specialising in the field of Parkinson's.

 

Imaging procedures to detect Parkinson's.

Imaging procedures of the brain (Computed Tomography, Nuclear Spin Tomography, Sonography inter alia) have their significance primarily in terms of additional information in differentiating between the different Parkinson's syndromes. Findings for typical Parkinson's disease are normal from cranial computed tomography and nuclear spin tomography (MRT/MRI) of the brain. In the case of typical findings and disease progression therefore, an imaging procedure such as CCT or MRI are not absolutely necessary. However in the case of imposing gait disturbances, atypical symptoms and rapid progression, imaging procedures are essential

 

Imaging procedure - Computed Tomography.

A computed tomography (CT) of the head provides X-ray images of the brain, the bones and the blood vessels. Magnetic Resonance Tomography (MRT/MRI) is the method of choice. The CCT is purely helpful to provide evidence of larger structural lesions or a normal pressure hydrocephalus. Nuclear Spin Tomography/MRT/MRI

 

Imaging procedure - Magnetic Resonance Tomography (MRT).

Another option for brain imaging is nuclear spin tomography (Magnetic Resonance Tomography, MRT). The tomograms (images in sections) are produced by a strong magnetic field and provide more exact images than computed tomography thus allowing even the smallest changes to be detected. It is helpful for differentiating other Parkinson's syndromes from Parkinson's disease.

 

Imaging procedure - ultrasound examinations.

Other examination methods are ultrasound examinations (Doppler - sonography) of the blood vessel in the neck and head and of late also the brain tissue. In this way the doctor determines whether and how badly the vessels are blocked through arterial calcification or whether the flow of blood to the brain is normal. The examination is very helpful because many patients manifest a vascular type of Parkinson's syndrome, which must be treated differently. A particular pattern when examining the brain stem can provide valuable information for the overall evaluation in the early stages of diagnosis. An ultrasound examination of the heart (echocardiography shows changes to the heart, which may occur while taking dopamine agonists. With certain Parkinson's drugs it is a requirement that ultrasound examinations of the heart (echocardiograms) are carried out at yearly intervals. In the case of oedemas (accumulation of water) in the legs, echocardiograms are essential in order to differentiate between the side-effects from the Parkinson's medications and a heart disease.

 

Imaging procedure - Positron Emission Tomography (PET).

The PET allows, primarily in the framework of scientific research, the preclinical diagnosis of Parkinson's disease. However it is not available as a clinical application. However because of the high expenditure involved (radiochemists on locations, cyclotron equipment with high level of staff requirement, computer-intensive data evaluation etc.) there are no data available on the sensitivity and specificity for a broad clinical application.

 

Imaging procedure - Single-Photon-Emission-Computed-Tomography.

  • IBZM-SPECT
    The Single Photon Emission Computed Tomography (SPECT) is more common and less expensive when compared to PET. This type of examination has significance from a differential diagnostic perspective when it comes to differentiating Parkinson's disease from atypical Parkinson's syndromes. Unfortunately the diagnostic value of the findings is frequently limited because in each individual case they do not possess any absolute power of discrimination when it comes to the differential diagnosis of Parkinson's syndromes. Medications for Parkinson's must be discontinued depending on their half life up to 2 weeks before the examination.
  • DaTSCAN&™;
    In Europe in 2000 this radiopharmaceutical was approved for the differential diagnosis of essential tremor and Parkinson's syndromes. Another European approval exists for the differentiation of Alzheimer's and Lewy Body Dementia associated with a Parkinson's Plus Syndrome. This also allows the investigation of the presynaptic dopaminergic system. With the DaTSCAN&™ it was possible in 97 % of cases to differentiate between a Parkinson's Syndrome and essential tremor (ET). However there is no power of discrimination for differentiating the different Parkinson syndromes from each other. Unlike the PET the sensitivity and specificity in the early stages is not investigated. Discontinuing medication for Parkinson's prior to an examination is unnecessary unlike with the IBZM SPECT.
 

Neurophysiological examinations: Examinations of the speed of conduction of certain nerve paths.

  • Evoked potentials, transcranial magnetic stimulation
    With evoked potentials and Transcranial Magnetic Stimulation (through the skull) the nerve paths can be examined. In Parkinson's disease these are intact so that abnormal findings should make us think about Parkinson Plus Syndromes.
  • Posturography
    Posturography (measurement of balance when standing) together with a gait analysis help to objectify gait disorders and an unsteady standing position. These procedures are used especially for older patients in the differential diagnosis of "lower body Parkinsonism" (frontal gait disorder) and Parkinson's disease and are also very valuable for monitoring purposes.
  • Electromyography
    The EMG (Electromyography - Measurement of electrical activity in muscles) plays a part in tremor differentiation with a surface EMG (without needles).
  • Electroencephalogy
    The EEG (Electroencephalography - measurement of electrical activity in the brain) play a role in evaluating brain function, verifying the tolerability of medication and to ensure that medication does not cause increased susceptibility to seizures.
 

Therapy. Treatment options

Important: Individual treatment of Parkinson's

Where necessary complex forms of treatment such as deep brain stimulation or medicamentous pumps may be indicated as the disease progresses. Treatment must be adapted continuously to the individual disease progression and the subjective needs of the individual patient. Frequently it turns out that "less is more" when it comes to medication. Because if not strictly indicated, "cocktails" of Parkinson's drugs can have a negative effect especially in older patients.

The treatment of Parkinson's syndromes up to now has essentially been based on two mainstays:

  • Pharmacotherapy
  • activating therapies from the fields
    - physiotherapy
    - ergotherapy
    - voice therapy
    - speech therapy
    - swallowing therapy
    - as well as psychological procedures.

Added to this is deep brain stimulation (the "brain pacemaker") which is a special opportunity for many patients especially the younger ones, who experience considerable varying effects during the day while taking l-dopa medications.

 

Activating therapies for Parkinson's Physiotherapy, voice therapy, speech therapy, swallowing therapy and ergotherapy.

As measured by the treatment preferences of the patients, the activation procedure ranks very highly. This is because as Parkinson's disease and other Parkinson's syndromes progress, there are generally problems with the actions of standing, walking, posture, voice, speech and swallowing, which can barely be treated with medication alone or deep brain stimulation. It is even the case that deep brain stimulation and medication even make matters worse not to mention adverse side-effects. Traditionally physiotherapy is most frequently prescribed for Parkinson's patients but nevertheless with non-specific objectives. The symptoms being treated are primarily those which affect everyday living such as inadequate balance with a tendency to fall, gait disorders with motor blockades ("freezing") and festination, which frequently lead to the loss of independence and confinement in a home. New approaches in physiotherapy aim at physical training even in the early stages of Parkinson's disease with the greatest possible range of movements combined with muscular stretching

 

Drug therapy for Parkinson's.

Parkinson's was the first slowly progressing disease of the brain which could be explained in terms of its fundamental mechanisms and for which a therapeutically highly effective neurotransmitter substitution was possible with dopamine substitutes. If the dopamine substitutes are well adjusted it is possible to achieve astonishing improvements in symptoms for many Parkinson's patients, so that in many patients the signs of illness are no longer visible and for a few patients they even become free of symptoms. This has greatly improved both the quality of life as well as the life expectancy of those affected, at the same time modern treatment with anti-Parkinson's drugs has created new and complex problems, for instance varying effects (fluctuation in effect - with ON/OFF symptoms) and uncontrolled movements (dyskinesias) while taking dopaminergic drugs. This is because in the first instance there is sometimes difficulty in differentiating between Parkinson's disease itself and other Parkinsonian syndromes, so that patients just based on a suspicion are treated with anti-Parkinson's drugs.

 

What medications are there to treat Parkinson's?

The most important drugs for treating a Parkinson's syndrome are the dopamine substitutes. These are classified as follows:

  • "DOPA preparations" The dopamine precursor substance L-dopa, which is always taken in a fixed combination with a so-called decarboxylase inhibitor such as benseracid or carbidopa, is metabolised in the brain into the failing neurotransmitter dopamine.
  • COMT inhibitors (Catechol-O-methyltransferase inhibitors)
  • MAO-B inhibitors such as Rasagiline act even released from L-dopa and could also have a delaying action on the course of the disease.
  • Dopamine agonists are substances, which mimic the body's own dopamine in the brain. Unlike L-dopa, dopamine agonists do not have to be metabolised in the brain first, on the other hand these artificial substances similar to dopamine differ from the original substance.

There are 10 different dopamine agonists available:

Eight of these dopamine agonists are assimilated via the gastrointestinal tract. One dopamine agonist, Apomorphine, available on the market is injected under the skin (subcutaneously)- using a pen-like syringe and a pump. These syringes and pumps have been used for a long time now by many young diabetics for insulin treatment. Another dopamine agonist, Rotigotine, - is given as a transdermal patch (Parkinson plaster) and is the only Parkinson's medication that is absorbed through the skin.

Of the eight dopamine agonists which are absorbed via the gastrointestinal tract, one group is classified as belonging to the ergot or secale cornutum derivatives and another to the NON ergot derivatives.

  • Parkinson's drugs which do not act primarily using the dopamine system
  • Anticholinergics. These drugs, the synthetic successors of the first drugs ever used for treating Parkinson's - extracts from belladonna (deadly nightshade) only play a subordinate role today.

In addition various drugs are approved for specific non-motor problems in Parkinson's syndrome such as the atypical neuroleptic clozapine for pharmacogenetic psychosis and the cholinesterase inhibitor Rivastigmine for dementia associated with Parkinson's disease. Furthermore, many drugs are used without special approval for Parkinson's patients (so-called off-label use) such as botulinum toxin (BOTOX) for troublesome saliva flow.

 

Medications for atypical Parkinson's syndromes.

While treatment of Parkinson's disease with a suitable combination of dopaminergic medications (dopa preparations and dopamine agonists) frequently brings a 100% alleviation of symptoms during the first years of the disease, with patients who have atypical Parkinson's syndromes treatment with dopaminergic medications is by and large not as successful. For patients with atypical Parkinson's syndromes the following frequently applies: Less is more because the Parkinson's medications may even have an adverse effect by upsetting blood pressure regulation leading to cramps (dystonias) and above all else may trigger states of confusion. When trying out treatment with a dopa preparation, which is to be implemented purely based on diagnostic grounds, (with a gradual increase in dose over one to two weeks up to 1000 mg dopa of the appropriate name-brand medications to be taken at least 3 times a day,) it is important to ensure that the condition is not being made worse: In some patients who are taking dopaminergic medications there has to be acceptance of the fact that now and again there will be painful involuntary muscle cramps, which after discontinuing the medication will clear up

 

What do I have to be careful about when taking medication?

Many Parkinson's patients who have varying effects from L-dopa must take L-dopa medications more than four times a day try slavishly to adhere to the specified times. However more important than rigid adherence to these times for taking L-dopa is working around having a full stomach. L-dopa should always be taken no later than half an hour before and no sooner than 90 minutes after a main meal. It is worth observing how eating changes the effect of L-dopa preparations and discuss this with the neurologist. Protein-rich food hinders L-dopa's passage to the brain.

 

Social services for Parkinson's patients.

Because people with Parkinson's disease are suffering from a chronic disorder, they can claim various benefits, for instance exemption from additional payments for medication or healing aids ( such as physiotherapy, ergotherapy, speech therapy and swallowing therapy). If certain requirements are fulfilled, they can also apply for a severely handicapped pass, which also entitles them to various benefits (e.g. parking and using public transport).

 

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