Parkinson's and Movement Disorders
Yes, a new, highly specialized brain scan aid called DaTSCAN™ offers physicians the ability to definitively determine whether or not a patient’s symptoms are related to Parkinson’s disease or related syndromes. In 2011, Froedtert & The Medical College of Wisconsin became the first in the state to offer this diagnostic advantage to patients. The earlier an accurate diagnosis of a movement disorder can be made, the sooner effective treatment can begin. Learn more about DaTSCAN™ and other diagnostic services.
Is it possible to definitively diagnosis Parkinson’s disease?
The Parkinson’s and Movement Disorders Program at Froedtert & The Medical College of Wisconsin is the only program in the area to offer deep brain stimulation (DBS) surgery, a highly effective treatment in certain patients with Parkinson’s disease. Patients are selected for the procedure based on the best evidence available in medical literature and our extensive experience in performing DBS procedures.
Is Deep Brain Stimulation (DBS) surgery appropriate for me?
All patients must undergo an evaluation here at Froedtert and the Medical College of Wisconsin prior to being deemed a surgical candidate. This evaluation includes a review of past treatment efforts, thorough examinations by our neurologists and neurosurgeon to determine if symptoms will respond well to surgery, possible “on/off” medication testing, a brain MRI, a detailed neuropsychological evaluation and a detailed medical evaluation. Learn more about DBS.
Yes, more than two dozen drugs should not be taken by Parkinson’s patients because they alter the brain’s dopamine system. When in doubt, ask your neurologist.
Are there certain drugs that are “contraindicated” for Parkinson’s patients?
For the complete list, view: Drugs that Parkinson’s patients should not take.
Always let your neurologist know before you have surgery, so he or she can work with your medical team to keep your Parkinson’s in control.
What is the relationship between Parkinson’s disease and depression?It is estimated that up to half of people with PD may experience depression during their illness. Most have minor depression. Sometimes, depression is the first symptom of Parkinson’s. Major depression occurs in about 5 percent to 10 percent of cases.
Both psychological and biological factors are involved. Often, patients will experience a psychological reaction to having a chronic illness. But it is also possible that, just as the loss of dopamine affects movement, that loss (along with the changes in serotonin and norepinephrine) can cause chemical or biological depression.
Your neurologist will ask about your mood, interests, sleep and appetite and fatigue — all indicators for depression. Antidepressants are used commonly to help PD patients who suffer from depression. Psychotherapy can also be effective as can complementary treatment options — support groups, exercise, music therapy, massage and other options.
What is the relationship between Parkinson’s disease, stress and anxiety?Stress worsens the symptoms of Parkinson’s disease. Anxiety leads to stress. Anxiety is created by your thoughts. You may think people are staring at you. You think you may become “frozen” or are too slow in line at the grocery store. You think about the progression of Parkinson’s and worry about the future for you and your family.
You have the power to change your thoughts, reduce anxiety and limit stress. Stress reduction might mean you can get by with lower doses or less medication. It certainly will mean that the quality of your life is improved.
Meditation, relaxation techniques, massage and guided imagery are some ways to reduce anxiety and, therefore, reduce stress. Physical exercise that includes walking and some form of balance/stretching work (e.g., fundamental yoga or Tai Chi) has a direct impact on the motor symptoms of PD and stress and anxiety levels.
The Parkinson Program Coordinator at Froedtert & The Medical College of Wisconsin can provide resources for exercise and complementary medical practices. In some cases, patients may need to meet with a clinical psychologist or a psychiatrist for stress and anxiety issues. Both professionals are members of the Parkinson’s and Movement Disorders team. Learn more about patient resources.
Can anything be done to improve the voice of Parkinson’s patients?Most people with Parkinson’s disease will experience changes in speech, voice and swallowing at some point in their disease. The same PD symptoms that occur in the muscles of the body — tremor, stiffness and slow movement — can occur in the muscles used for speaking and swallowing. This can cause:
- A soft voice
- Mumbled or fast speech
- Loss of facial expression
- Problems communicating
- Trouble swallowing
While PD medications help improve most symptoms, they are not as helpful with improving speech and swallowing problems. Most people have the most improvement with speech and swallowing when medications are paired with a speech therapy program.
Ongoing research into a speech therapy program known as the Lee Silverman Voice Treatment® (LSVT) method is funded by the National Institutes of Health and the U.S. Office of Education. The LSVT method is effective in improving voice and speech in persons with PD. Froedtert & The Medical College of Wisconsin have speech-language pathologists certified in LSVT, and our movement disorder neurologists often refer patients for this therapy. Early intervention is key to maintaining and improving communication and swallowing function.
Collagen injections have been used in the treatment of voice and/or speech impairment in PD. The purpose of the injections is to build up vocal folds that do not close completely while talking. Ask your movement disorder neurologist if you are a candidate for this procedure.
Can Parkinson’s affect blood pressure?Orthostatic hypotension or “orthostasis” is caused by dysfunction in the autonomic nervous system. This part of the nervous system is responsible for various automatic functions in your body, such as your heartbeat, breathing, perspiration and blood pressure. Some people with Parkinson’s disease have problems with falling blood pressure when going from a sitting to standing position. That’s why the movement disorder neurologist takes your blood pressure reading from both positions. A rapid drop in blood pressure will cause lightheadedness and the possibility of passing out or falling. Orthostasis can be worsened by Parkinson’s medications.
If orthostatis isn’t too severe, it can sometimes be treated with a simple increase in salt intake. Your neurologist must analyze your condition, taking into account all your medications and the severity of your blood pressure drop. If you suffer from lightheadedness when you stand, or if you’ve ever passed out or fallen when you rise from a chair, be sure to inform your neurologist.
Is Parkinson’s disease inherited?There is a family history of Parkinson’s disease in 5 percent to 10 percent of patients. It may affect people of the same generation (e.g., a brother or sister) or in two generations, such as a father and son. Environmental toxins such as manganese, carbon monoxide and, rarely, certain pesticides cause diseases that resemble PD. However, most people with Parkinson’s disease have not been exposed to these toxins.
In less than 1 percent of cases, PD is clearly familial (tends to occur among members of a family). Several gene mutations have been shown to cause Parkinson’s disease in a few families, but these have not been found in most people with PD. Studies of identical twins in which one twin was known to have PD showed no increase in the incidence of PD in the other twin compared to the general population of patients over the age of 60 years. However, among identical twins younger than 50, if one twin has Parkinson’s disease, there is an increased risk of PD in the other twin. This indicates heredity may play a role in young-onset cases. Currently, researchers suspect that the cause of Parkinson’s disease in most people reflects a combination of genetic factors and environmental exposures.
Are vision problems a part of Parkinson’s disease?Some patients with PD and parkinsonism may have difficulty reading. After common problems such as cataracts and macular degeneration have been ruled out, it can be helpful to evaluate a patient’s ability to shift the eyes from the distant to the near. This evaluation may reveal that a patient’s capacity for converging eye movements is reduced. Convergence insufficiency makes it difficult to keep both eyes pointed together at a near target.
It is not known how many people with parkinsonism have this problem, but it is one of the most common eye movement disorders. People may only describe eye strain while they read, but more pronounced symptoms may appear, including a reduced ability to read, eye fatigue and sometimes double vision or a tendency to involuntarily close one eye while reading.
Convergence insufficiency, when identified as a cause of reading problems, may be improved with exercises designed to strengthen eye movements (the turning motion of the eyes toward or away from each other). In many cases, however, this will not suffice, and improving near vision may require the use of prisms in dedicated reading glasses. Prisms are optical devices that can be ground into regular eyeglasses. They bend the light so that the amount of convergence necessary for near vision is reduced. In severe cases, however, even this may not provide adequate relief, and the only remaining option is to cover one eye with a patch or cover glasses with occluding tape so the patient only reads with one eye.
Other eye movement disturbances have been described in parkinsonism. These include an impaired ability to pursue a moving target with the eyes, difficulty initiating gaze shifts or taking the eyes off a face. Also, the ability to maintain eccentric gaze is impaired, and the blink frequency tends to be reduced. Of these abnormalities, only the latter tends to show significant symptoms, as reduced blinking can cause a feeling of dry eyes. This may be further enhanced by reduction in tear secretion, which is not uncommon in parkinsonism. Management of dry eyes usually involves the use of artificial tears. It is rare that additional measures are needed to combat symptoms of dry eyes in patients with parkinsonism.
Patients with parkinsonism are also susceptible to visual hallucinations. These can be related to the underlying neurological illness or medications used for treatment. PD patients who have visual hallucinations respond well to antipsychotic medications such as quetiapine. Hallucinations should always be reported to the physician.
What about vision problems with PSP (Progressive Supranuclear Palsy?)Slowness in looking up or down with moving the head is a symptom in a severe parkinsonian disorder called progressive supranuclear palsy (PSP). Patients with PSP have trouble initiating gaze shifts in the up and downward direction, and the speed and extent of such gaze shifts reduce as the disease progresses.
The negative effects on vision and visual orientation are profound. Patients can eventually loose their ability to look down through the reading part of their glasses, causing an inability to read. In addition, they become susceptible to falls by not seeing where they step on level ground or on stairs. This adds greatly to mobility and balance problems, which are already prominent with PSP. Unfortunately, there is no treatment for this eye movement disorder. To make reading easier, special reading glasses that cover the entire field of vision can be prescribed, and reading material may have to be placed at eye level in a special stand.
Are there other, more serious, forms of parkinsonism?There are many atypical parkinsonian disorders that start out looking like Parkinson’s disease but then veer off into their own distinct disorders. These parkinsonisms affect motor functions, cognition, behavior and the autonomic system (blood pressure, potency and urinary disturbances). These include:
The common thread is that these disorders have a poor response to Sinemet and other antiparkinson drugs and, therefore, tend to evolve rapidly. While a definitive diagnosis is only available upon autopsy, a trained movement disorders neurologist can recognize these atypical disorders and assist the patient and family in understanding and treating the condition.
- Multiple system atrophy (MSA)
- Dementia with Lewy bodies
- Corticobasal degeneration
- Progressive supranuclear palsy (PSP)
Other conditions that can look like Parkinson’s are normal pressure hydrocephalus (NPH) and drug-induced Parkinson’s. Again, an experienced movement disorders neurologist should be consulted. Learn more about parkinsonian disorders.
Can a blow to the head cause Parkinson’s?Parkinsonism can be caused by repeated blows to the head, such as a professional boxer may experience. Chronic traumatic brain injury associated with boxing can also be associated with dementia (dementia pugilistica). Usually, this kind of parkinsonism is not as responsive to levodopa. The risk associated with a single head injury, such as in a car crash, and Parkinson’s disease has not been established, although one twin study reported that it may increase the risk of PD decades later.
What is on/off time and on/off testing? / What are motor fluctuations? / What is an L-DOPA /dopamine challenge?As Parkinson’s disease progresses, some individuals may need to increase the dosage of their medication to control symptoms. With time, patients may notice that, throughout their day, they have periods of good symptom control (“on” time), periods in which symptoms are much more noticeable (“off” time), and even periods in which peak medication levels produce involuntary movements (dyskinesias). When people experience these various states throughout the day, they are said to have motor fluctuations (sudden changes in the ability to move).
When assessing a patient’s response to medication, the Parkinson’s neurologist may ask the patient to come to the clinic “off meds,” usually foregoing their Parkinson medications for 12 to 24 hours. The doctor will then perform the usual exam utilizing the Unified Parkinson Disease Rating Scale (UPDRS), gaining valuable information on the patient’s baseline Parkinson’s disease in the drug-free state.
After this first exam, the neurologist will give a dose of medication (usually carbidopa-levodopa, thus the term “L-DOPA challenge,” but sometimes in combination with other medications), wait 30 to 60 minutes and re-examine the patient. At that point, the doctor may give another dose, followed by re-examination. This cycle repeats until the doctor can determine that a) the patient is a “responder” or b) a “non-responder” to medications. It also allows for monitoring of potential side effects, like nausea, dizziness, low blood pressure, etc. Furthermore, the doctor can get a feel for what the patient’s “best on” is, meaning how much improvement can be expected with a given dose of medication. This can help guide both medication adjustments as well as whether or not deep brain stimulation surgery might be an option.
The end result is that, over the course of a morning or afternoon (usually 2-3 hours), the neurologist is able to gain a better understanding of a patient’s Parkinson’s disease and how to best manage it.
Date: May 16, 2012
Online Editor(s): Richard Petre