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Chapter: Diseases of The Brain and Nervous System(A Health Education Guide): Movement Disorders And Dystonia

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Parkinsonism: Symptoms, Treatment, Surgery

In the year 1817 Dr. James Parkinson described the symptoms of this brain disorder in detail for the first time, and therefore, this disease is now known as Parkinson’s disease.

PARKINSONISM

In the year 1817 Dr. James Parkinson described the symptoms of this brain disorder in detail for the first time, and therefore, this disease is now known as Parkinson’s disease. It is a common and troublesome disease affecting old people. In this disease; there is progressive cell degeneration in the region of the brain known as substantianigra reducing the formation of an extremely important bio-chemical substance, dopamine. Because of this, symptoms like lethargy, decrease in co-ordination, tremors, rigidity of muscles etc. occur. The beginning affects one side of the body, i.e. either the left or the right side. Usually it spreads to both the sides in a few years.


Symptoms :

1.        While at rest, the fingers of the hands and legs shake in a peculiar manner (pill-rolling movement or rhythmic movement as if the patient is counting money.)

2.        The patient stoops and his gait shuffles and there is poor arm swinging.

3.        All movements of the body become slow.

4.        The ‘muscles in the hands and the legs and the face gradually become rigid.

5.        Handwriting becomes smaller.

6.        The speed of walking becomes slow and while walking the patient suddenly stops.

7.        There is decrease in memory and depression with increased perspiration and body ache. The Voice reduces and becomes monotonous, facial expressions disappear, dribbling of saliva occurs from the mouth and frequency of eye blinking is reduced.

If such symptoms are seen, it is essential to consult a doctor and get the diagnosis done. Medically this disease is divided into five stages.

This disease occurs primarily due to aging effects on the brain, but the exact reasons are still unknown. Side effects of medicines, head injuries, injuries due to poisonous gas, or biochemicals, viral infections and in rare cases hereditary reasons may also be responsible for this disease. However, in majority of the cases the reason remains unknown (idiopathic).

Sometimes, it may also occur as a part of some other bigger disease like multisystem atrophy or progressive supranuclear palsy. In this many other symptoms are present along with tremors.

Parkinsonism can affect one person out of- every 500 people. 1.5% of the people in the age group of 60 or more suffer from Parkinson’s disease. However, it may sometimes be seen in young people. The symptoms of Parkinson’s disease occur when 80% of the cells producing dopamine are destroyed. There is no treatment or medicine available to -stop the destruction of the cells. Thus, this disease can never be cured completely. However, regular treatment can control the symptoms to a large extent. Modern treatment methods and exercise can give considerable relief in this disease and help live a long comfortable life.


Treatment :

Medical treatment consists of levodopa; dopamine agonists like bromocriptine, anticholinergic drugs like pacitane etc. Among these levodopa is the main drug, which directly introduces dopamine in the brain, the deficiency of which causes the disease. The dose is decided on the basis of the severity of the symptoms. It is essential to consult a specialist in this matter as this drug can cause serious side effects. This medicine can be given to the patient in different proportions and forms like tablets, liquids and pumps. Many specialists prefer to use Trihexyphenidyl, Amantadine,Bromocriptine, Pirebidil, etc in the initial stages of thedisease instead of levodopa and firmly believe that when the disease reaches the second and third stage (affects both sides of the body), only then levodopa should be used so that the patient can lead a long comfortable life without much side effects. If Selegiline is given in the first stage of the disease, further progression of the disease can be slowed down to some extent.

This disease is divided into five stages, for example in the first stage there is shaking or spasticity only on one side of the body and in the last stage the patient is totally bedridden. The treatment of each stage is decided by the neurophysician. The treatment of each and every patient may vary.

During the last few years there have been a lot of important discoveries for eradication of this disease which have instilled a new hope in the doctors as well as patients.

Premipexol, ropinirol, tolcapone, and entacaponearesome of the drugs, which are very effective and have veryless side effects. At present these drugs are not manufactured in our country and therefore are very expensive. Recently ropinirol is introduced in Indian market.

There is an opinion that vitamin-E and a few other elements help in reducing the intensity of the disease, however there is no consensus of opinion amongst neurologists about this issue.


Surgery :

Surgery has opened newer avenues in the treatment of Parkinsonism. Few decades ago, surgery was considered as a treatment option, but with the advent of the drug Levodopa which had significant beneficial effects, the surgical option took a back seat. However, long term and persistent side effects of Levodopa made doctors reconsider the therapeutic option of surgery. Over the last decade, there has been iminense progress and each new day, adds to the experience of surgical procedure in the patients of Parkinsonism. The procedure is becoming safer. The discussion as to when and what type of surgery should be done acquire prime significance in many medical conferences. Three types of surgery can be considered for Parkinsonism.

1. Ablation Surgery :

Ablation (literally means cuttingoff) at an appropriate spot in the neuronal circuit (responsible for Parkinsonism) is carried out using stereotactic method. This spot could be the thalamus, pallidum or subthalamic nucleus. Accordingly it is known as thalamotomy, pallidotomy etc. When tremors predominate and especially in young patients, thalamotomy is preferred. Pallidotomy can be done totreat levodopa induced dyskinesia. The results of surgery are good. However, once ablated the neuronal damage is permanent. Besides, occasional complications like hematoma (collection of blood at the site of surgery) or infections can occur, though the rate is very low. The cost of surgery comes to approximately Rs. 30,000 to Rs. 60,000. Surgery is done only in one hemisphere at a time.

2. Stimulation Technique :

Instead of permanently ablatingthe specific neurons, they can be stimulated (hyper excited) to the extent that they lose their functioning capacity. This is the basis of the stimulator technique. Hence, a stimulation electrode and circuit are fitted into the relevant part of brain. Hence, thalamic, pallidal or subthalamic stimulation can be done. However, at present results of subthalamic stimulation technique are excellent. This method does not cause permanent neuronal damage and for variable result the degree of excitability can be varied. Side effects are minimal. However, this is an expensive mode of treatment. For setting a stimulator in one hemisphere, the cost amounts to Rs.4 to 5 Lacs. Stimulator can be set in both the hemispheres. In some cases, ablation surgery in one hemisphere and stimulator electrode in the other can prove cost effective and thus bilateral symptoms can be controlled. These facilities are available in some centres in our country as well as in foreign countries. insurance facilities make it easier to avail the patients of these techniques.

3. Transplant Surgery: 

This is still in its experimentalstage. Here cells from the adrenal gland are transplanted into the brain. Some time back fetal cell transplant was tried, however, due to certain ethical issues and medicolegal problems, this did not gain momentum.

Besides, the medical and surgical treatment various factors like regular exercise, staying happy, meeting groups, yoga etc. prove very important in the treatment.

In short, now-a-days, Parkinson’s disease is not a disease to be scared of. Early diagnosis, appropriate treatment under the guidance of an expert physician or a neurophysician, group therapy, exercise, yoga and if necessary surgery can control this disease to a large extent. In the cities like Ahmedabad and Mumbai, there are associations of patients suffering from Parkinsonism, which give relevant information regarding the disease, teach exercises and yoga in groups and provide other services to the patients.

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