4.  Treatment options for Parkinson's disease

While researchers continue to search for a cure to Parkinson's disease, there are highly effective treatments that may provide years of relief from the symptoms. Each treatment comes with its own side effects, and finding the right combination and sequence of treatments is a major challenge for physician and patient alike.

The non-motor symptoms, including impaired balance, sleep disturbance, constipation, and depression, are also important features of the disease. They also need to be treated, but in different ways. Some symptoms may be quite easy to treat with oral medication. Others, including impaired balance, often remain problematical.

In the earliest stages of Parkinson's, your doctor may decide that no medical treatment may be needed. You should focus on maintaining a balanced diet and using daily exercise to stay active. As the motor symptoms progress, your exercises will become an even more vital part of living with Parkinson's, since they will help to keep your muscles strong and joints flexible.

A formal physiotherapy program may be a good way to maintain strength and range of motion as your mobility decreases. And speech therapy is sometimes helpful to maintain adequate voice volume.

The four main options for the treatment and management of Parkinson's disease are:

  1. Drug therapy
  2. Deep brain stimulation
  3. Ablative neurosurgery
  4. Complementary Therapies

Drug therapy

When the symptoms of Parkinson's begin to interfere with your work or everyday life, it might be time to begin symptomatic medications.

The first medication prescribed for a person with Parkinson's will often be a dopaminergic drug. This drug is converted into dopamine within the brain, which helps the brain to control movements. Because the loss of dopamine-producing cells is what leads to Parkinson's symptoms, restoring dopamine levels this way can provide some relief.

Dopaminergic drugs may be administered as an injection rather than a pill, although this is normally only as a "rescue" therapy for later-stage patients when the effects of their oral medication wear off.

All dopaminergic drugs have similar side effects including nausea and excessive sleepiness. Some may cause hallucinations, whereas others lead to dyskinesias (uncontrolled excessive movements).

Another type of medication is called COMT inhibitors. These reduce the breakdown of dopaminergic drugs before they reach the brain. Adding a COMT inhibitor helps extend the duration and positive effects of each dopaminergic dose.

Over time, 'off times' increase markedly for many patients while dyskinesias accompanies more and more of their 'on time'. Pharmacological management becomes a difficult, frustrating, and increasingly less successful strategy for maintaining quality of life.

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Deep brain stimulation

Deep brain stimulation (DBS) uses an implantable medical device similar to a cardiac pacemaker, which treats the main symptoms of advanced Parkinson's disease by delivering electrical stimulation to a precisely targeted area deep within the brain. Fully reversible, this implant surgery helps control the main symptoms of Parkinson's Disease.

It is most suitable for patients whose symptoms are not well controlled by drug treatment, or who cannot tolerate the side-effects of medication. However, most physicians emphasise that the patient's best response to drugs will also indicate the level of improvement that can be expected from surgery.

The electrical signals delivered by DBS de-activate the target site within the brain without destroying any tissue. The goal is to restore the balance of electrical activity within brain, to offset the progressive loss of cells caused by Parkinson's.

The electrical signals are also adjustable, allowing more precise calibration and targeting of the effect. This can help improve your symptom control and reduce the risks of accidental damage to neighbouring areas.

The surgery is conducted under local, rather than general, anaesthesia, because the patient needs to provide feedback to help the neurosurgeon locate the exact target. The use of a rigid metal frame attached to the head ensures precise guidance of the instruments during surgery.

DBS requires repeated visits to the neurologist so that the electrodes can be programmed to deliver the maximum benefit to the patient.

You, your caregivers, and your neurologist must work together to determine if surgery is the right option for you. Your neurologist and a neurosurgeon will then help you choose the right procedure. When all of these factors are considered carefully, surgery does have the potential to significantly improve your quality of life with Parkinson's.

Any surgery for Parkinson's disease is a major procedure. The risks during and immediately after surgery include infection, haemorrhage, and even death. Complications from surgery may include cognitive impairment, swallowing difficulty, visual impairment, seizures, and headache. While many improve over time, these complications can persist without improvement for some patients.

There is also the chance that any part of the hardware - electrodes in the brain, a battery-powered pulse generator in the chest, and a wire connecting them under the skin - may malfunction or break. The equipment would then require surgical removal or replacement.

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Ablative neurosurgery

Ablative surgery destroys a select region of the brain. More specifically, pallidotomy, the lesioning or surgical destruction of specific cells of the brain's Globus Pallidus, has been used to control some of the symptoms of Parkinson's disease.

Ablative surgery may be a more suitable alternative for some patients. However, the lesioning is irreversible and non-adjustable, so the destroyed tissue cannot be replaced and the side effects cannot be adjusted. Ablating some sites also runs the risk of damaging brain cells that influence vision, swallowing, and verbal ability.

Any surgery for Parkinson's disease is a major procedure. The risks during and immediately after surgery include infection, haemorrhage, and even death. Complications from surgery may include cognitive impairment, swallowing difficulty, visual impairment, seizures, and headache. While many improve over time, these complications can persist without improvement for some patients.

You, your caregiver, and your neurologist must work together to determine if surgery is the right option. Your neurologist and neurosurgeon will then help you choose the right procedure.

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Complementary therapies

There is a wide range of alternative therapies, including massage, meditation and movement exercises, which can complement medical treatment. These therapies do not promise quick fixes for your Parkinson's disease. Rather, they are based on the common-sense notion that paying attention to the body's needs, and keeping in shape, are part of good self-care.

Aerobic exercise programs stress cardiovascular fitness as well as full range of motion, which is especially important in a movement-limiting disease like Parkinson's. Structured movement therapy programs, such as yoga and tai chi, may improve balance as well as promote your general feeling of well-being. And a good, relaxing massage can be a shortcut to simply feeling better about things.

If you are suffering from Parkinson's disease, discuss treatment options with your doctor, and ask for a referral to a movement disorder specialist near you.

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