Treatment

Once the diagnosis of Parkinson’s disease is made, then treatment options are considered.

Medical treatment 
Medical management is the mainstay of treatment for Parkinson’s disease. Medication adjustments must be individualized. The exact timeframe for initiation of drug treatment has not been clearly established. As the disease progresses, medications are less effective. It is important to know your medications and what doses you are taking. Many of the medications discussed below have significant interaction with other medications. Please make sure your doctor and pharmacist have a complete list of all your medications, including over-the-counter ones, to avoid any problems.

Levodopa/carbidopa (Sinemet):  Levodopa is the most effective medicine for Parkinson’s disease. Once inside the bloodstream, levodopa is converted into dopamine, the neurotransmitter that is low in PD. However, the medicine must cross the blood-brain barrier and reach the brain to be effective in treating symptoms. Carbidopa is added to decrease the conversion in the blood stream and increase the amount that is available in the brain. Nausea and vomiting can be side effects of levodopa therapy. After years of taking Levodopa therapy, patients can experience medication-induced dyskinesias, which are spontaneous, involuntary movements of parts of the body. You may also experience “on-off” periods when the medicine seems not to work or wears off quickly.

Carbidopa/levodopa/entacapone (Stalevo): This is a combination pill that includes entacapone, which extends the time the levodopa is active in the brain.

COMT (cathechol-O-methyl transferase) inhibitors: Enatcapone (Comtan) and tolcapone (Tasmar) are COMT inhibitors, which block an enzyme that breaks down dopamine. It must be taken with levodopa.

Dopamine agonist:  There are several medications in this drug class. These are medication that stimulate dopamine receptors and act like or mimic dopamine. Dopamine agonists available in the United States include bromocriptine (Parlodel), pramipexole (mirapex) and ropinirole (requip). Pergolide (Permax) was removed from the U.S. market in March 2007 secondary to concerns about damage to heart valves.

MAO-B (monoamine oxidase B) inhibitors: Selegiline and deprenyl (Eldepryl) are MAO-B inhibitors. These medicines block an enzyme that breaks down dopamine, thus allowing the available dopamine to last longer. These medicines have significant drug-drug and drug-food interaction.

Anticholinergics: This class of medications blocks the action of another neurotransmitter in the brain called acetylcholine. This neurotransmitter also controls movement, and by blocking its action, the medicine restores a balance between levels of dopamine and acetylcholine in the brain. Benztropine mesylate (Cogentin) and trihexyphenidyl (Artane) are examples of anticholinergics.

Amantadine: Amantadine (Symmetrel) is another medication that can help treat tremor and muscle rigidity.

Rivastigmine (Exelon):  This medicine is used to treat the dementia associated with Parkinson’s disease.

Supplements: There are supplements or natural products that may help with slowing the progression of Parkinson’s disease.  Some research suggests that there is oxidative damage to nerve cells in Parkinson’s, therefore implying that anti-oxidants may be helpful. There is no convincing scientific literature to support use of any specific supplements.

Coenzyme Q10, vitamin A, E, C, and creatine have all been studied.

Diet: A well balanced diet is recommended. Increased fiber in the diet can help treat or prevent constipation. Protein intake can interfere with absorption of some medications used to treat Parkinson’s disease. Consult you doctor or pharmacist about eating protein and timing of medication administration.

Symptom management: You may require multiple medications to manage the symptoms you experience. It is important to take the medication as prescribed, paying close attention to timing of medications and noting the effect on your symptoms. This response to medication or lack of response will help your doctor adjust your medications. Some medications over time may lose their effect, and you must work closely with your doctor to change your medicine regimen over time. Symptoms of Parkinson’s disease may be aggravated by medical illness, like pneumonia or urinary tract infection, and you may need to temporarily adjust your medication dosages.

Surgical treatment
Surgical treatments of Parkinson’s disease have had increased interest in recent years secondary to limitations of levodopa therapy, advances in stereotactic surgery and neurophysiology, and better understanding of the anatomy of the basal ganglia. It is very important that a person considering surgery be well informed of the potential benefit and limitations of any procedure. Appropriate patient selection is crucial to the success of surgical treatment.

Deep brain stimulation (DBS): This is the newest treatment for Parkinson’s disease. Overall, it is most effective for treating tremor and medication-induced dyskinesias. DBS involves the implantation of chronic stimulating electrodes that produce electrical impulses that stimulate areas deep in the brain. Depending on the clinical symptoms, there are several different areas in the brain that are the targets for DBS. Complication from the procedure itself can include intracerebral hemorrhage, seizures, and confusion. A second procedure implants a device called an impulse generator (IPG), much like a pacemaker, near the collarbone that connects the battery to the electrodes. When the stimulators are turned on, the person can experience side effects of stimulation that may include dysarthria, paresthesias, dystonia, ataxia, weakness, and headache. Adjustments of the settings can maximize intended treatment effect and minimize side effects.

Thalamotomy and Pallidotomy: These are irreversible lesions made by a neurosurgeon in the deep structures of the brain. They are named for the nucleus or area of the brain that are targeted. This procedure is most effective for treating dyskinesias on the opposite side of the body from the lesion. It is estimated that 70-90% of persons undergoing the procedure have clinical improvement in their symptoms. Since the advent of DBS, these surgical treatments are not used as often.

Rehabilitation Treatment

Basic principles:  Rehabilitation refers to the process of helping a person return to as much normal function as possible. There are many ways to help improve function. Some of the rehabilitation treatment is focused on regaining what is lost and other treatment focuses on compensating for lost function. Most patients with Parkinson’s disease will benefit from both. Neuroplasticity is the brain’s ability to re-wire or have another part of the brain take over the function. Research to understand this process is in the early stages, and we are not sure how it will apply to persons with Parkinson’s disease. Rehabilitation assumes that continued practice of certain tasks or function will maintain or delay loss of function.

Rehabilitation professionals:  Rehabilitation is provided by many different professional depending on your symptoms or problems. Often, these professionals work as a team to help coordinate the care they provide. 1. Physical Medicine and Rehabilitation doctor (physiatrist):  focuses on overall function and symptom complex to suggest treatment and make appropriate referrals for therapy.

2. Physical Therapist (PT): focuses on mobility and adaptive equipment used for mobility like cane, walker, and wheelchair.

3. Occupational Therapist (OT): focuses on activities of daily living or ability to perform certain tasks, including energy conservation and the use of adaptive equipment.

4. Speech Therapist (ST): focuses on cognition, language skills, speaking, and swallowing.

5. Neuropsychologist: focuses on in-depth evaluation of brain and brain functioning including administering extensive testing. They also provide treatment and support counseling to adjust and cope with your situation.

Therapy program: An individualized therapy program is very important for persons with Parkinson’s disease. Therapy programs are divided into skilled therapy treatment and maintenance home exercise program. Therapy is available in various settings including in a hospital, in a rehabilitation unit, in an outpatient clinic, or at home with home health services.

A course of therapy with a skilled therapist can improve mobility and ability to perform activities of daily living. Your doctor will need to write a prescription and refer you for therapy. It is usually covered by your health insurance. A therapy program seems to also give patients a greater sense of control, which is helpful in dealing with psychological effects and sense of well-being. Education is a big part of the treatment plan. Patients should be referred for evaluation at all stages of the disease process and should have periodic reevaluation as their clinical course progresses. Inactivity results in deconditioning; therapy and exercise can reverse the weakness associated with lack of use.

1. Exercise: A general exercise program is beneficial for a person with Parkinson’s disease. A complete program should include aerobic, strengthening, and stretching activities. Exercise is important for maintaining and even improving mobility, flexibility, balance, and range of motion. It can also help with depression and constipation. Typically, a person with Parkinson’s disease does not have true motor weakness but does have difficulty with moving.

2. Stretching: Stretching is critical to maintaining flexibility and range of joint motion. Loss of joint range of motion or tightness in the muscles can aggravate the underlying symptoms of Parkinson’s disease and worsen walking and ability to perform tasks.

3. Support groups: For many people, supports groups can be very helpful. They provide education, support, and advice for living with the disease and opportunities to meet others who have similar experiences. These groups can be a source of practical information for living better with Parkinson’s disease.