James Parkinson (1755 - 1824)

The brain has neurons in a small area called substantia nigra. This area is located in the right and left side of the brain even though people are led to think its one section. The normal functions of these neurons are to produce dopamine. Dopamine is a chemical that allows signals to travel from the substantia nigra to the "relay station" of the brain which is called corpus striatum. When the signal has been made, the body is able to move smoothly. When the neurons start to die off the dopamine is lost, and the nerve signal becomes weak and movement is no longer smooth. This is the primary cause of Parkinson's disease. Many patients with this disease will start to develop what's called Lewy bodies. This is an unusual deposit of proteins that does not excrete from the body causing a build up in the substantia nigra. An interesting find that caught my eye was a study that was conducted on a large group of people with this disease. The study found that some people with this disease have never smoked a day in their life and a few of them were current smokers. It was led on that maybe smoking protected against the disease. Of course this is only a find not a fact.

As I mentioned before, the neurons die off and impaired movements occur. At this point in the process approximately 60-80% of the neurons have died and symptoms start to show. Something as simple as a mild tremor or difficulty getting out of a chair are some early symptoms. A patient with Parkinson's disease can speak a little softer or their handwriting becomes slower and looks cramped. With symptoms as small as these can last a very long time before the more serious symptoms start to show. In a rare case, people can show symptoms before the age of 20. This is called Juvenile Parkinsonism and is found commonly in Japan. A family may be the first to notice early symptoms. They notice a lack of expression on their face. A symptom commonly seen is Parkinsonian gait; a patient may have a tendency to lean forward and take small quick steps and a lack in swinging their arms. There happens to be four primary symptoms: 1. Tremor, the hand takes form of shaking back and forth. 2. Rigidity, is resistance in movement and a patients muscles tend to constantly be tensed and contracted so the patient will feel stiff and weak. 3. Bradykinesia, is a slowing down of random and automatic movement. 4. Postural instability, is impaired balance and causes the patient to fall easily. Other symptoms such as depression, sleep problems, and sexual dysfunction can occur. Some symptoms fluctuate in severity. Many patients have expressed that in the mornings the symptoms are milder.

This disease is so similar to many other diseases that it makes it very difficult to diagnose. A simple MRI or CAT scan will not do any good. Most patients that have these tests taken will get normal results. Doctors perform a differential diagnosis, which is where they listen to the patient and then examine them and decide what possibilities the symptoms can lead to. The next step is for the doctor to order tests that are designed to confirm the diagnosis.
These tests include blood tests, x-rays, and of course the MRI and CAT scan. Most physicians will call for a neurological exam. A neurologist will look for things such as 1. Slowness in movement of the hands, fingers, and toes. 2. Can the patient swing their arms when they walk? 3. Does the patient have a hard time turning or a size difference in their stride? When this shows no diagnosis of being Parkinson's disease a physician must rely on his own judgment. A physician has a lot of knowledge in the history and signs and symptoms of Parkinson's disease and can call good judgment. When examining a patient. They call this a clinical diagnosis. With a disease such as this one, some doctors have to wait several months for more signs to show to properly diagnose a patient. This is a bad thing for many reasons: 1. The longer undiagnosed, the longer treatment has to wait. 2. It leaves the family in limbo and doesn't allow the diagnosis to set in for the patient and the family. Knowing as soon as possible can start the process of accepting and adjusting to whether work, finances, and daily duties will be affected.

A person with Parkinson's disease will not die from this disease. In fact, Parkinson's patients live as long as any other healthy person. As time goes by Parkinson's disease can cause problems such as choking, and with a loss of balance a patient could fall and die.

A cure has not yet been found, there is medication that can help with the symptoms of this disease. In the 1960's, a drug called Levodopa was administered to patients. Levodopa was found to control the symptoms if they were given in a large enough dose. Levodopa came in tablet form at the strength of 500mg per tablet. A daily dose could consist of 100-1000mg. Levodopa is the most effective drug available still today. It was seen as a miracle drug and is used for "replacement" therapy. It compensates for the dopamine, Levodopa can get across the blood-brain barrier and converts into dopamine for the brain. Levodopa is made up off hydrogen, oxygen, carbon, and nitrogen atoms. Levodopa converts to dopamine by dopa-decarboxylase; this is an enzyme that regulates a chemical change in the body. This enzyme is also present in the gut, liver, kidneys, and blood vessels. Over the years, research came to a more sophisticated method of drugs called Sinemet; it is a controlled-release tablet. It allows the Levodopa to stay in the brain for a longer period of time. As much as Parkinson's disease patients love Levodopa, it does have its side
effects. They can be the most undesirable side effects that can occur immediately or shortly after starting treatment.

1. Patients have complained about nausea and vomiting. This can occur when the dopamine triggers the vomiting center in the brainstem. After long use of dopamine, the vomiting center gets used to it and will no longer affect it.

2. Levodopa can also affect the sympathetic nervous system, allowing postural hypotension to occur. An example of this is when a patient stands up and the blood pressure drops. It could drop so low that the person can feel dizzy.

3. A very small portion of Parkinson's disease patients will experience hallucinations, delusions, and confusion while taking this drug. It may only be 20% of Parkinson's disease patients that have these side effects, but it's seen more in older people who had the late onset of the disease.

4. Another common complaint is insomnia, it occurs mainly when the medication is taken after the evening meal. It helps to miss that dosage to get some sleep or take Valium or Serax to overcome the restlessness of the insomnia. A side effect of these drugs can be increased slowness and dizziness. This is where risk vs. benefit comes into play. Taking the risk to experience some increased slowness and maybe some dizziness might include the benefits of getting sleep. Another risk to using drugs such as Serax and Valium can lead to developing a dependency.

Another treatment option is neurological surgery. Surgical procedures began in the 1930's, before Levodopa. Neurosurgeons have managed to accomplish reducing a person's symptoms of tremor, slowness, and
postural problems by creating a lesion in the brain. Of course the results were not expected to cure the disease, but doctor's hoped that it would delay the symptoms and improve the quality of one's life that has advanced Parkinson's disease. This kind of procedure is good for maybe two years without the symptoms is worth it. There at two different procedures that can be done. One is called a Thalamotomy and that is where a selective destruction of a portion of the thalamus. The other procedure is called a Pallidotomy, this is where a selective destruction of a portion of the pallidus. During surgery, a hole is made in the skull and probes that have electrodes are passed through to a target area. At the same time the doctor is performing this task the patient is kept awake and alert. The doctor will ask the patient to perform small tasks such as open and closing the hand or talking.
This way the doctor knows if the targeted region has been reached. At this point, the doctor will heat up the tip of the electrode and it permanently injures a small amount of the brain tissue in that targeted area allowing the symptoms to subside. New research has made an important new surgical approach, Deep Brain Stimulation. Deep Brain Stimulation is similar to the Thalamotomy and Pallidotomy except the DBS is electrically stimulated and not destroyed. If the procedure has bad side effects or doesn't have the expected outcome, the electrodes can be turned off or the stimulus can be adjusted. Patients are most likely to go for this procedure considering the other procedures are irreversible and can cause other problems such as a person losing their sight. The procedure consists of making a hole in the skull and placing a probe in its path just like the Thalamotomy surgery. There is a second part to the DBS procedure, this can happen immediately or up to a week after the initial surgery. The patient will be placed under general anesthesia, and then the doctor attaches the electrode to a wire that goes under the skin to a small stimulating box. This box is placed in a pouch under the skin on the chest wall. The placement is very similar to a cardiac pacemaker. The benefit of such a surgery is the patient can adjust or simply shut the device off. The way this procedure minimizes the symptoms of Parkinson's disease is when the stimulation is turned on it sends an
electrical current from the electrode to the target region and disrupts the function of that specific area of the brain. So far today, the only approved surgery for DBS is of the thalamus for relief of the tremor that Parkinson's disease causes. The risks that are considered with this surgery can be brain hemorrhage, stroke, partial loss of vision, infection and all for good reason. A hole is being cut into a patient's skull that allows for infection to form around the lesion. A procedure being performed on a skull is always a very serious matter, and can have serious outcomes.

Dealing with this kind of disease changes a person's entire life. When one hears of a procedure that can be done that will help with not only the tremor, but their daily tasks they want to jump on the schedule as fast as possible. There a lot of evaluations that needs to be done to see if the patient is the right candidate for the surgery. Sidney Dorros is a patient that suffers from Parkinson's disease. When he heard about this procedure, he was very interested in finding out what his life could be like after a surgery of this degree. "When I completed all the evaluations and the doctor agreed that I was a good candidate for this surgery they made plans for the procedure." Sidney talks about what he felt in the surgery. "When I went into the operating room I was told that no anesthetic would be used because neither the skull nor the brain can feel pain." After knowing that he would be awake through the whole procedure he kept very alert. Before the procedure the anesthesiologist explained that the head needed to be immobile in order to have control over the instruments. "I felt four prongs dig painfully into my skull until there was solid pressure and my head could not move." The only pain felt after that was small needle pricks from administering the local anesthetic needed to make the lesion on the skull. The noise from the drill that was actually cutting the hole into the skull was a little scary to hear. Once the probes were positioned in the right place, and the liquid nitrogen was pumped into the tip of the probe, Sidney felt a relaxing wave flow through his body. The tension in his fingers and in his left side seemed to loosen. The doctor asked for a small task in counting from one to ten and then backwards. This task was easily achieved! The next task was to hold up the left hand, open and close it. We so easily lose touch of how important it really is that we have control over our body. After a very successful operation, Sidney said that he had so many thoughts going through his mind such taking a walk with his wife and children, being able to talk to friends. Something so small for people without Parkinson's disease is so major for people who suffer from Parkinson's disease.

The world wouldn't be where it is today if it wasn't for James Parkinson taking the time to research something that interested him. James took a big step for the world and now people who are diagnosed with Parkinson's disease have something to look forward to. They all know that it will only take time to improve on the accomplishments that have already been made. A patient will never lose to the Parkinson's disease; it will only make their journey in this world a little more challenging. Treatments have been found in the form of medication such as Levodopa, and surgeries such as a Thalamotomy. With these options, a person who suffers from this disease can get help as well as having something to look forward to. A normal life with mild symptoms!