Chances are you will benefit from a physical therapy (PT) evaluation and treatment if you have movement symptoms associated with Parkinson’s disease or other brain condition. However PT does more than simply treat movement symptoms. The objectives of PT vary with individual needs but do include these general goals:
- Evaluate movement problems and recommend therapy early in disease before problems and bad habits occur
- Reduce symptoms of disease associated with imbalance, rigidity, slowness, involuntary movements
- Reduce or delay symptoms of disease progression through targeted exercise such as balance and falls
- Optimize independence
- Optimize your home exercise program with a focus on general health, stamina, disease symptoms and long-term compliance
- Evaluate and recommend specific braces, orthotics, and ambulatory assist devices such as canes and walkers
- Improve safety, enhance confidence and reduce fear of activity such as fear of falling
- Neuro re-education designed to combat the abnormal movement associated with physiologic brain changes of disease, programs such as ‘Big and Loud’
- Promote neuroplasticity or enhanced brain activity through movement
- Promote healthy lifestyle changes to improve activity levels, quality of life and well-being both now and long-term
What is most important is that you advocate for yourself and take a proactive stance by seeking out a therapist even before you have problems. Most people wait until symptoms are significant or cause serious problems such as falls, pain or joint disease.
Advocate for your care.
Ask your doctor of healthcare provider if you can have a referral to a rehabilitation specialist.
Use this checklist to see how rehabilitation and other specialists can be of help to you and as a guide for discussion with your doctor or therapist.
Download and complete your Comprehensive-Care-Worksheet.
Carbidopa/Ldopa is one of the most commonly used medicines for Parkinson’s disease. Ldopa chemically resembles the amino acids or building blocks that make up protein. Because of this, Ldopa ‘competes’ with protein for absorption through the intestines and into the brain.
As the question suggests, optimal absorption of ldopa is important to avoid fluctuations in motor response. A dissolvable form of carbidopa/ldopa does exist but unfortunately it does not absorb through the mouth and still requires swallowing of medicine into the intestine for absorption. An infusion form of Ldopa gel was developed to deliver Ldopa directly to the intestine. This allows precise changes or titration of the amount delivered by using a pump to match the needs of the patient. This form of the medicine and pump delivery is still being studied in clinical research trials and requires that a feeding tube be placed by a surgical procedure into the stomach and advanced through to the small intestines where Ldopa is absorbed. Researchers are also studying different ways to deliver Ldopa using special techniques such as a patch formation. This mode of delivery is not currently available because Ldopa does not easily absorb through the skin requiring special technology to enhance its absorption.
The following tips can help:
- Treat constipation and bloating
- Be sure to get plenty of water, fiber and exercise to help transit of food through the GI tract
- Separate timing of Ldopa dosing from meals
- Eat the majority of your day’s protein when you are less active such as the endo of day
- Eat plant sources (nuts, beans, soy) over animal sources of protein
Click here to read more on this topic is available
Researchers at the University of Virginia are conducting a research study to investigate a new way of controlling tremor. The research study is designed to investigate the safety and feasibility of ultrasound waves targeted at the thalamus, a brain region important for tremor control. Similar to the thalamotomy of the past, this technique causes a lesion or destruction of brain cells that affect tremor.
Unlike traditional thalamotomy, this technique does not require brain surgery that includes drilling a hole in the skull to gain access to the brain and damage the cells but instead relies on MR guidance of these focused wave forms to precisely reach their target. In some ways it is similar to gamma knife thalamotomy, a technique that is sometimes used to treat tremor through focused gamma waves that when converging on a brain region can damage tissue (gamma knife is a common radiosurgery technique used for treating brain tumors and a condition called trigeminal neuralgia). These new techniques are promising and offer a less invasive approach to tremor control. It is important to note that research is just beginning and this current study is being conducted to investigate safety. If proven safe, larger studies will need to be done to test the benefit. Other considerations for this experimental procedure include
- Lesioning techniques (damaged cells) are not reversible since tissue is destroyed. If the wrong area of brain tissue is damaged it can not be restored.
- Focused ultrasound and gamma knife surgery does not have the same risk and recovery period associated with traditional neurosurgery offering a potential treatment for people in which standard surgery carries too much risk.
- Only unilateral thalamotomy at present is recommended for tremor on one side of the body due to concern of side effects with bilateral thalamotomy such as speech and walking problems.
- Research is for tremor predominant Parkinson’s disease, a condition in which other non-tremor movement symptoms are minimal compared with tremor. Non-tremor symptoms of Parkinson’s such as rigidity and bradykinesia are not treated with thalamotomy.
- There is limited experience about the combined effect of thalamotomy and other surgical techniques such as deep brain stimulation (DBS) if this were to be needed in the future.
- Like gamma knife thalamotomy, cells that are to be destroyed are located with MR imaging. Unlike thalamic DBS where a brain electrode is used to locate this precise area in the operating room by recording and stimulating actual brain cells involved in tremor, there is no ability to record the neuronal activity to further ensure that the area of tissue destruction is accurate for the individual.
Given these issues, researchers at the U of VA have designed a careful sham (placebo) controlled study to help effectively address these concerns. These new techniques show promise and offer hope for additional therapies in the future.
How Parkinson’s motor symptoms respond to dopaminergic medication changes over time. Although everyone is different the following stages can help you understand the role of medicines and expectations for their benefit:
Early Stage: Early in the disease, dopaminergic medications are effective and their effect on movement continues from one dose to the next. This results in a seamless control of motor symptoms and no clear fluctuation in response to each dose. In fact, many people do not notice that their next dose is due and must make the effort to take their medication on the schedule as directed by their healthcare provider. Of course people with Parkinson’s can still have ‘good’ and ‘bad’ days or find that their symptoms change in different situations such as stress, fatigue or illness.
Mid Stage: Over time, movement control with dopaminergic medical treatment can become more difficult as time progresses. The effects of each medication dose does not last from one dose to the next. However, medication doses continue to improve movement symptoms such as tremor, rigidity and slowed movement. Yet this improvement does not last from one dose to the next requiring medication change – these problems first appear as motor fluctuations often referred to as on and off periods.
- On – Off periods describe the change throughout the day in response to medication.
- On is when the medicine improves symptoms
- Off is when the medicine effect is worn off or is no longer working and symptoms worsen or return. It is first described prior to the next dose of medicine called end of dose wearing off.
- Dyskinesia or involuntary (unintentional) movements or jerky motions is a side effect of dopaminergic medication and usually occurs after it “peaks” in your system.
Advanced Disease Progression: Certain symptoms become less responsive to dopaminergic medicines and can increase in severity as the disease progresses. These motor symptoms include balance, freezing of gait, speech and swallowing. These symptoms do improve with rehabilitation therapy even if they do not improve with medication. It is important to review these problems with your healthcare provider so they can refer you to these specialists.
Talk with your healthcare provider to better understand how your symptoms are responding to medicine.
Rehabilitation therapy includes any of the following
Physical therapy- especially effective for gait, balance and mobility
Occupational therapy- especially helpful for daily activities, chores and hobbies
Speech and Swallowing therapy- focuses on speech and swallowing.
See Take Charge! Build your Team and print a copy of the Comprehensive care worksheet posted on NWPF wellncess site for more information on how these therapies can help you
Levodopa (carbidopa/levodopa or Sinemet) is an effective treatment for motor symptoms. Yet levodopa is associated with motor complications such as:
- Motor fluctuations – wearing off of medication effect between doses leading to re-emergence of movement symptoms
- Dyskinesia – uncontrolled involuntary movement
The risk of developing levodopa related motor complications increases in part with severity of the disease, type of Parkinson’s (greater risk in young onset individuals), duration of use and total levodopa daily dose. For this reason other dopaminergic medicines such as dopaminergic agonists or MAO inhibitors can be used first with the addition of levodopa when needed. Levodopa is the most effective medicine for movement with one of the lowest dopaminergic side effect profiles (nausea, lightheadedness, sedation, cognitive changes, hallucinations). For people who are at risk for these side effects (ie. elderly) levodopa is often considered the best choice.
So the decision on when to start levodopa depends on a person’s risk of side effects and the risk of developing motor complications. In general younger individuals are at greater risk of motor complications and a lower risk of side effect but this is not always the case. Which medication is best for you and when is a discussion each patient should have with their doctor.
Acupuncture is based on the belief that a certain life-force energy (“chi”) flows throughout your body along energy pathways called meridians. When the flow of chi becomes blocked or unbalanced at any point on a pathway this is what leads to illness. Acupuncture aims to ‘unblock’ these channels.
Little is known about the effect of acupuncture on Parkinson’s motor symptoms, mood, fatigue and well-being. Our understanding of the potential benefits is mostly from anecdotal reports such as simple observations from people about how they feel after this therapy. Because these reports often do not test the possible effect of placebo or the benefits of other therapies that are sometimes combined with acupuncture (such as relaxation techniques, physician or acupuncturist counseling, other lifestyle changes or changes in attitude), it is unclear how acupuncture truly affects Parkinson’s well-being. One study did evaluate the effect of acupuncture performed at a specific point termed GB34. Using fMRI imaging, researchers measured the specific effects of needling acupuncture point GB34 (Yanglingquan) on areas of the brain related to Parkinson’s Disease. Acupuncture activated brain centers that suffer excess deactivation in Parkinson’s Disease patients.
What this means for acupuncture and PD is unclear. However, controlled replicated research studies support the use of acupuncture for pain and headache suggesting this is a valid therapy for health and disease.
Follow these guidelines if you try acupuncture
- Talk to your healthcare provider about acupuncture and review any concerns and expectations together
- Research your acupuncturist’s training and credentials. Your state’s medical licensing board can provide certification information as many states require licensing. Visit the American Association of Acupuncture and Oriental Medicine website for more information, www.aaaom.org.
- Talk about your goals before treatment. Discuss how many treatments are needed, the associated cost and at what point treatment will be re-evaluated for its effect. Review when treatment be stopped if you do not notice a benefit?
- Ask about other modalities commonly practiced with acupuncture such as herbal medicine, massage or similar relaxation techniques. Will they be used during your sessions? What are the added risks or costs?
What is the one piece of advice you would give to others just diagnosed with Parkinson’s?
There is no doubt about it, getting a diagnosis of Parkinson’s can be life changing. People respond in different ways. Some seek out as much information about the disease as possible or take to the internet to find out about the latest treatment. Some people find comfort in support groups while others keep their diagnosis to themselves. A pledge to exercise more or eat healthier is the focus of many.
Think back to the time when you were diagnosed. What worked for you (or didn’t)? What advice do you wish that you were given? What advice would you give to others? How have your ideas about Parkinson’s changed over time. Share your own experience, advice and wisdom with people just recently diagnosed and with PDCommunity! by responding to this post.