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.

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.

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

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

Other treatment methods for Parkinson's

Over and beyond this there are different symptoms which can occur in Parkinson's disease. Read about these in the following pages and what treatment options there are.

Social services/benefits 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).

Professional care

Ceballos-Baumann

Prof. Dr. med.

Andres Ceballos-Baumann


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