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Treatment Options

Treatment is very individualized with the goals of treatment being to relieve disabilities while minimizing side effects of medications. The decision to treat early PD with pharmacologic
agents often depends on the particular needs of the person and careful weighing of possible benefits, cost and adverse outcomes. There is no cure for Parkinson’s disease. However, there are therapies available to minimize symptoms and maximize function and quality of life. Before levodopa was introduced, the only agents that could relieve PD symptoms were anticholinergic drugs. Their primary benefits are the relief of rigidity and resting tremor. Levodopa brought about a revolution in PD treatment by reversing the neurochemical abnormality responsible for the symptoms. However, after a few years of treatment, symptoms responds less well to levodopa, requiring alterations or additions to the therapeutic regimen. For some, it is necessary only to extend increase the dose or frequency of levodopa. Others require the addition of medications as adjuncts to the levodopa action. A combination of levodopa and carbidopa (Sinemet) is usually used. The carbidopa decreases levodopa’s peripheral conversion to dopamine. This in turn reduces side effects and increases the amount of levodopa that enters the central nervous system (CNS).

Long-term drug therapy with levodopa is associated with motor complications that can be disabling. For this reason, younger persons with PD may be started on one of the alternative medications initially, reserving levodopa for later in the disease.

• Anticholinergics
• trihexyphenidyl, benztropine, symmetrel
• Levodopa
• carbidopa, levodopa, Sinemet
• Dopamine Agonists
• bromocriptine, pergolide, porinirol, pramipexole
• Monoamine oxidase (MAO) Inhibitors
• selegiline
• Catehol-O-methyltransferase (COMT) Inhibitors
• tolcapone

There are several other medications that may be used to help control various symptoms. For example, botulism toxin injections may be administered to reduce saliva production and drooling. Collagen injections may help voice and speech disorders by augmenting the vocal fold.

• Pallidotomy (unilateral): A surgical procedure performed on the globus pallidus portion of the brain to relieve involuntary movements or muscular rigidity.
• Thalamotomy: Destruction of a selected portion of the thalamus by sterotactic surgery to relieve involuntary movements.
• Radiosurgery: High energy beams of radiation are directed at a target in the brain with the intent of destroying the brain tissue in the area. The most common type of radiosurgery is focused beam radiation which can be accomplished by either linear accellerator radiosurgery or Gamma Knife radiosurgery.
• Neurostimulation (Deep Brain Stimulation): Surgeons implant a tiny electric pulse generator in a specific portion of the brain, such as the subthalamic nucleus or global pallidus to control the symptoms of PD.
• Tissue Implantation: Fetal brain cells which are rich in dopapine are implanted in the substantia nigra area of the brain. This procedure is still highly experimental and the use of fetal tissue is extremely controversial.

The development of PD is not related to stress, sleeping habits, exercise, diet or other aspects of everyday life. However, maximizing the quality of these issues certainly improves overall health and may therefore benefit the person who is coping with symptoms of PD. No special diets or natural foods have been shown to slow the progression of PD. High levels of protein are known to compete with levodopa for transport to the brain and to reduce its effectiveness. Some experts advise a low protein diet during the day with most protein eaten during the evening meal. However, this can cause problems upon awakening because of a severe “off” period during sleep that causes persons to awaken unable to move. A generally healthy diet containing fruits and vegetables help to preserve nerve cell function as well as general health. The fiber in these foods also helps to minimize problems from constipation. Exercise and physical rehabilitation are important in maintaining muscle strength, function and coordination. Therapists can teach new methods for standing, turning, and walking that can maximize function and reduce the risk for falls. There are a variety of techniques for managing the freezing phenomenon that can significantly improve mobility and safety.

No evidence exists that vitamins improve outcome in PD. Some persons believe that vitamin B6 is beneficial because of its role in the production and metabolism of dopamine. Co-enzyme Q10, a vitamin-like antioxidant substance may have protective benefits for persons with PD. Some think that antioxidant vitamins (C and E) may be helpful. However, high doses of vitamin E have shown no benefit and research has, in fact, begun to suggest that some antioxidant vitamins may be harmful in high doses. There are no studies to prove the efficacy or safety of most alternative therapies. It is important to notify your health care provider if you are using any alternative therapies, no matter how insignificant or benign they may seem.

The diagnosis and symptoms of PD can be devastating to an individual and family. However, there are several excellent resources available for education and support and ongoing research has lead to important developments in controlling symptoms and improving quality of life. Depression is extremely common in persons with PD as an emotional effect on the lives of both the individual and their loved ones. It is important to discuss this problem with the health care team so that therapy (including medications, if appropriate) can be provided to minimize its impact and improve quality of life. Dementia is about six times more common in the elderly person with PD than in the average older adult. The health care team can provide education and resources for managing difficult or unsafe behaviors that may develop.

• Transcranial magnetic stimulation (TMS) uses high frequency magnetic pulses that target affected areas of the brain. This noninvasive technique is currently being studied for its effectiveness.
• Bilateral pallidotomy is being studied for its safety and effectiveness in controlling the symptoms of PD.
• Researchers from the Department of Neurosurgery, University Medical Center Benjamin Franklin, Berlin, Germany, recently reported the effectiveness of deep brain stimulation (DBS) of the subthalamic nucleus in a series of 38 patients with advanced PD. The study was published in Surgical Neurology, May 2002; Vol. 57(5):306-13.
• The results of a recent study suggested that aerobic exercise may improve aerobic capacity and movement initiation in patients with PD. The study was published in NeuroRehabilitation, 2002; Vol. 17(2):161-8.
• Research is ongoing to evaluate the potential efficacy of stem cell transplantation for the treatment of PD.
• Researchers at Dalhousie University and Queen Elizabeth II Health Science Center, Halifax, Nova Scotia, are evaluating the efficacy of simultaneous intrastriatal and intranigral fetal tissue transplantation in patients with Parkinson’s Disease. The results of a recent study, that appear promising, were published in Journal of Neurosurgery, Mar. 2002; Vol. 96(3):589-96.
• Researchers from Newcastle General Hospital, Newcastle upon Tyne, UK, recently reported that rivastigmine was effective for the treatment of neuropsychiatric complications in a small series of patients with Parkinson’s Disease. The study was published in Movement Disorders, Nov. 2001; Vol. 16(6):1171-4.
• Researchers from the School of Pharmacy and Allied Health Professionals, Creighton Universtity, Omaha, NE, recently conducted a meta-analysis of 12 published studies involving patients with Parkinson’s Disease who were treated with unilateral pallidotomy. The results of this meta-analysis suggests that unilateral pallidotomy improves functional outcome in patients with Parkinson’s Disease. The study was published in Neuroscience Letters, Oct. 2001; Vol. 312(3):153-6.
• Information regarding ongoing clinical studies in your area can be obtained at the Clinical Trials Listing Service at http://www.centerwatch.com

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