Parkinson’s disease: Recognize it at an early stage and approach it in its entirety

In former times, the cerebral disease that was named after its discoverer in 1817 and whose most striking symptom is shaking was called the "shaking palsy". It is estimated that approx. 150,000 to 200,000 people in Germany suffer from Parkinson’s disease. By far, not every one of these patients is treated, indeed, although Parkinson’s disease has become one of the neurological diseases that can be treated best. Moreover: The right choice among the different therapies helps to widely maintain life quality at the beginning of the disease and to avoid most problems in long-time treatment or to considerably reduce them.

A metabolic disorder in the brain is responsible for the development of Parkinson’s disease. Without treatment it gradually leads to a decelerated and, in general, disturbed flow of movements, frequently also to shaking. Therefore Parkinson’s disease ranks among the group of movement disorders. At the bottom of the typical symptoms of Parkinson’s disease is a disorder in a small, strictly confined area deep inside the brain. Since the brain cells in that area contain black dye, it is called "black substance" (substantia nigra).

Dopamine transmits movement impulses

From the black substance nerve fibres lead to an area approx. 6 cm away which is situated also deep inside the brain but a bit more in the front and a bit more up. This area to which the nerve fibres lead is called striate body (striatum). The transmission of the movement impulses from the black substance to the striate body is accomplished by means of a chemical transmitting agent (messenger) named dopamine. Together with the brain cells of the black substance and the striate body, dopamine plays an important role in checking and controlling movements.

In every human being, the number of connective fibres from the black substance to the striate body and, thus, the content of dopamine gradually decrease in the course of a lifetime. In patients suffering from Parkinson’s disease, the cells of the black substance perish faster not that we have got to know the reasons for it. As a result, the dopamine concentration in the striate body decreases considerably and an imbalance with other transmitting agents is caused: The harmonic control of movements is disturbed and the typical symptoms of Parkinson’s disease occur.

Causes still unexplained

Even if the causes of the loss of cells in the black substance and of the messenger dopamine have not been clarified: We know that the reserve of the brain is big. More than half of the cells of the black substance, perhaps 60 to 70% must have perished before you perceive symptoms of the disease in your every-day life.

The span of time in which cells of the black substance perish unnoticed is estimated at approx. 5 years. Even when light early symptoms have already existed, another two to three years elapse in more than half the patients before the correct diagnosis "Parkinson’s syndrome" is made.

Indeed, the complete clinical picture of Parkinson’s disease is very typical and, in general, the physician can recognize it easily. The complete clinical picture exists if the main symptoms rigor (muscle stiffness), akinesia (immobility) and tremor (shaking) have developed. If you keep in mind the gradual mechanism of Parkinson’s disease, it is understandable that the symptoms are mainly atypical at the beginning and can easily be mistaken for other diseases.

If tying your shoes becomes difficult

Often the patients have difficulty in performing activities characterized by fine motor skills such as: tying one’s shoes, butting-up one’s clothes, threading a needle, writing. Looking at the handwriting you can notice that it becomes gradually smaller (micrography). At the beginning, the symptoms frequently occur only on one side of the body: The swing of one arm is reduced, one leg is dragged and one hand shakes although it is supported. The reduced mobility is not only seen in the changed gait pattern, the voice may change also. It can become quieter and less expressive. The imbalance of the transmitting agents in the brain results in a heightened muscle tone even if the muscle rests. For this reason already at an early stage of the disease, the patients often suffer from backache and pain in the neck and loin area that can be mistaken for pain as a result of arthrosis or rheumatism.

In combination with these early symptoms of the disease there may occur emotional complaints such as avolition, retreat and the feeling (sensation) not to be able to experience pleasure any more./to know any longer how to be (feel) really happy about something. Such a depressive disgruntlement often also represents an early symptom of the disease. Vice versa, restrictions in facial expression and mobility or even a bent forward posture may give an impression of apathy and misery to the outside although the person affected does not feel sad at all.

Recognize first signs

All the symptoms stated can be first signs of Parkinson’s disease. It is important to actually think of the possibility of having to do with Parkinson’s disease. Unambiguous routine examination methods, for example laboratory values in blood or urine with which an objective proof of the disease could be furnished do not exist yet. Imaging techniques such as computer or spiral scan computer tomography can only proof or rule out other contemplable disease patterns. They do, however, not enable direct proof of Parkinson’s disease. Technically very demanding imaging techniques from the field of nuclear medicine (e.g. PET, SPECT) are more conclusive, but, due to their technical complexity and price, they cannot be used in routine diagnostics. The diagnosis is, thus, still a clinical, i.e. the physician primarily makes a diagnosis based on the findings of physical examination.

Usually, when a diagnosis has been made, therapy starts. Since the disease originates from an imbalance of the messengers in the brain it is of major significance to bring the messengers back in a balanced proportion.

The most obvious solution is to directly replace the missing messenger. This can be done with a trick by administering a precursor of dopamine which, in the brain, is transformed to dopamine itself (so-called L-DOPA substitutes). Since L-DOPA substitutes are effective for a short time only, chemical substitutes for dopamine (so-called dopamine agonists) have been developed that are effective for a longer time and unfold a similar effect as dopamine. Another approach to prolong the relatively short effectiveness of dopamine or the artificially fed precursor L-DOPA is to delay the breakdown of dopamine and, thus, letting the messenger display its effectiveness longer and more efficiently (so-called COMT-inhibitors and MAO-B inhibitors).

New approach: "Brain pacemaker"

All these drug therapy approaches are aimed at intensifying the weakened part of dopamine and, thus, balancing the prevalence of other messengers. Additionally, you can weaken the antagonists of dopamine in order to indirectly bring the messengers in a harmonic balance (glutamate antagonists, anticholinergics).

In the last years, totally new treatment possibilities opened up particularly to patients suffering from distinct long-term complications of the disease: these are mainly neurosurgical therapy methods now being applied more gentle and having fewer side-effects than before.

Computer-controlled electrodes can be fitted in certain movement centres lying deep inside the brain and there they can balance, depending on their position, either therapy-resistant tremor or non-controllable fluctuations in the effectiveness of drugs. In general, we speak of "deep brain stimulation" or "brain pacemakers".

Long-term experience at the "Pfalzklinikum" and at other neurological hospitals shows that at all stages of Parkinson’s disease, an optimum treatment result can only be reached if drug therapy, physiotherapy and psycho-social support stand side-by-side having equal rights in a holistic therapy concept.

Do not avoid stress situations but handle them together

Depending on the patient’s age and the stage of the disease, physiotherapy can consist of sports and relaxation therapy as well as of active physical therapy (medical gymnastics), speech therapy and breath control.

Granting psycho-social support always means integrating the patient’s life partner and family - integrating them to accept the disease, to be in a position to openly talk about it and to handle every-day stress situations together, for example by simulating them beforehand and facing them then instead of avoiding them. Granting psycho-social support can mean having supportive talks with one’s doctor or exchanging ideas with one’s relatives or taking part in a self-help group. Behind all this at every stage of the disease, there should always be the idea of conveying help for self-help in order to accept the restrictions caused by the disease but also to fully exploit all remaining possibilities either by actively continuing one’s job, planning a holiday or participating in a public event.

Nowadays, there are a lot of established and increasingly new therapeutic possibilities for Parkinson’s patients. It is essential to tailor these possibilities to each patient’s requirements, especially with regard to his/her age and the stage of the disease and facilitate the handling of the disease. With this, there are good pre-requisites to successfully approach almost every stage of the disease.