Parkinson’s Disease

Here’s a Tip: A Good Exercise Program Can Slow Parkinson’s Progression

Before we get into Parkinson’s treatment… If you’ve been diagnosed with Parkinson’s and you want to do everything you can to slow its progression, here’s a tip. A good, active set of exercises that you do every day (or almost every day) can make Parkinson’s get worse more slowly. It only takes about 30 minutes a day to be effective. It seems that almost any type of exercise will do, as long as it’s “real” exercise. It’s often said, and it really is true, that the best exercise is the exercise that you’ll keep doing. So if you have Parkinson’s and you don’t exercise, find something you like doing to get you moving, and get started today.

There Are Many Good Medications for Parkinson’s Treatment

Here’s the good news, right up front. Parkinson’s research has continually found new medications for Parkinson’s treatment ever since the approval of Sinemet in the 1960s. In addition, new formulations of existing medications are continuously being made and are extremely helpful, making each medication dose last longer. These new formulations enable a person to take meds less frequently through each day. According to a recent report (10/12/2021) there are 64 drugs in development for Parkinson’s (and 85 for Alzheimer’s and 33 for multiple sclerosis). Beyond medications, there are other non-pharmaceutical treatments that come into play. (See our main page on Parkinson’s for a more general discussion.) 

Parkinson’s Treatment – The Right Balance Does It

Treating Parkinson’s safely and effectively is all just a matter of medication balance, tracking disease progression, clinical effectiveness, and side effects. It’s a collaborative effort, patient and doctor working together, to pursue this balancing from the first day of treatment. Here’s why. It’s not just today’s medicine benefits and side effects. Having the right balance from the start can affect how long a person stays more well and less ill. Too much of a medication too soon in the course can allow disabling symptoms to come earlier in the progression of Parkinson’s. And, as anyone with Parkinson’s knows, it’s best for any disabling symptoms to start as far in the future as possible. But today also matters, that is, with too little medication Parkinson’s symptoms won’t change, and, of course, too much can overwhelm with side effects.

Understanding Parkinson’s Treatment is a Learning Process

As you might guess, there’s a whole educational process involved in a person learning to treat his or her own Parkinson’s. First to learn the medications, what each one does and how it works. Then to learn and put into practice how they control muscles, coordinated movements, and how they help with overall coordination and balance. This learning about the dose and timing is why new formulations of existing medications are so useful. Better formulations make the whole process easier.

A Reader Asks: Why aren’t there any drugs to cure Parkinson’s?

Sadly, this is a good question, because it’s true. There are no medications that change the deterioration of Parkinson’s in a meaningful way. There are no “disease-modifying” drugs for Parkinson’s. Here’s the problem. Both the muscle movement symptoms of Parkinson’s and the symptoms of other areas (emotions, thinking) happen because the nerves in those brain circuits stop working correctly and then die. We haven’t yet found a way to keep these dying nerve cells healthy and alive, and no way to grow new nerves to replace the ones that are gone.

The First Medication for Parkinson’s Treatment is Usually a Combination Tablet

The usual starting point in Parkinson’s disease treatment is a single tablet that is a combination of two medications, levodopa plus carbidopa. Most people find that this combination works the best at the start with the fewest side effects. This combo tablet and the effective way it works is often called the “gold standard” for treating Parkinson’s. Anything new would have to work better, or work at least as well with fewer side effects.

There Are Many Other Medications for Parkinson’s Treatment

After getting started with the levodopa/carbidopa tablet, there are several other medications that might be added as needed. To name a few, there are the “dopamine agonists”, pramipexole, ropinirole, rotigotine, and apomorphine, and the “anti-viral” amantadine. More on these later. Getting the medication dose right is part of the balance that needs to be achieved. Part of this exploration is working out which medications to take. It’s often the case that two or more medications are used together. You and your doctor will need to do a bit of trial and error to find the best ones for you, and the best fit might well change over time. The medications need to work well and also need to cause the fewest possible side effects. It’s all personalized medicine. There is no one best medication or mix of medicines that works for everyone throughout their course of Parkinson’s.

Finding Your Best Medications for Parkinson’s Treatment

You doctor tells you that, yes, you have Parkinson’s.  Then the search for the best medications for you begins. Pramipexole and ropinirole are medications that might be used by themselves, at least early on. Later either one of them might be added to a mix of two or more medications if the Parkinson’s gets worse. Ropinirole or pramipexole might also be useful as an add-on medication to the levodopa if the levodopa starts to work less well. Or, if levodopa starts working better at some times and less well at other times.

Getting Control of Muscle Movements – The “Dopamine Agonists”

Pramipexole (Mirapex®) and ropinirole (Requip XL®) are two oral medications in the medicine family known as “dopamine agonists”. By themselves they don’t work as well as the carbidopa/levodopa combination for the muscle symptoms. But, they’re less likely to contribute to on again/off again medicine effects or movement side effects. They’re more likely to work by themselves early on, with early, mild Parkinson’s. But as the years roll by at some point the carbidopa/levodopa combination will work better. Even later, in more advanced Parkinson’s, one or the other might be added back in to help.

Other Formulations of the “Dopamine Agonists”

There’s a transdermal patch form of dopamine agonist medicine, rotigotine (Neupro®). There’s another dopamine agonist medicine that comes as a subcutaneous (under the skin) injection, apomorphine (Apokyn®). It’s useful as a rapidly-effective medication for quick treatment of “off episodes” during motor fluctuations. The apomorphine is also available as a sublingual film (Kynmobi®) but many people don’t tend to like it.

More Solutions to Parkinson’s Treatment

There are other medications that can be added only if needed to treat new situations as they come up. For example, the COMTs. The names of the COMTs are entacapone (Comtan®) and tolcapone (Tasmar®). They’re used as add-on medications if the benefit of levodopa seems to wear off too soon. (COMT stand for catechol-O-methyltransferase.)

Treating Tremor and Other Movement Problems

Amantadine was originally used to treat influenza, so became known as an antiviral drug. But it’s no longer used for influenza and it’s real value is in treating some symptoms of Parkinson’s. As with the dopamine agonists, amantadine might work by itself in early, mild Parkinson’s. In later Parkinson’s it can be added to treat some movement side effects from the levodopa. It’s often used to reduce the Parkinson’s tremor because the dopamine agonists don’t work on tremor. If it works it’s hard to predict how long amantadine will keep working, sometimes for months or years, sometimes only a few weeks. There are extended-release formulations of amantadine, like Osmolex ER® and Gocovri®. But these are more expensive than immediate-release amantadine and it’s unclear if they work any better.

Medications to Help in Specific Parkinson’s-Related Situations

Along the way in Parkinson’s treatment one begins to find that meds work less well, or work sometimes and not at other times. If during this part of treatment you suddenly are less able to be steady and smooth in your movements and less able to get things done, the MAOBs might help. Examples of MAOBs are rasagiline, safinamide, and selegiline. Sometimes, early on, a MAOB is added to your levodopa. (MAOB stands for monoamine oxidase B inhibitor.)

More Medications for Specific Situations in Parkinson’s Treatment

If a hand, arm, or leg starts to show a tremor-at-rest and the tremor is not helped by just levodopa, adding benztropine (Cogentin®) or trihexyphenidyl (Artane®) might help. (A tremor-at-rest is when you are resting the arm or leg, with no muscle tone, and there’s a tremor.) Neither of these two medications will help with your walking smoothly or other Parkinson’s symptoms. And, they only help the tremor that occurs when a hand, arm, or leg are at rest. These two meds aren’t used that much because they can make a person feel mildly confused.

Coping with Psychosis in Parkinson’s

People with Parkinson’s can have a change in their thinking, a confusion that comes over them. Parkinson’s is a brain disorder, after all, so it’s reasonable that the workings of the brain can be upset. Here we’re referring to brain changes that are called psychosis. Psychosis is when the new change is seeing, hearing, or believing what is not real, what is not true. When what the person thinks he actually sees or hears is really an illusion. It’s an hallucination. What the person believes is real is not real. It’s a delusion. What’s understood about a social situation is not correct. One thinks things are happening that are not really happening. Again, a delusion.

Psychosis in Parkinson’s is a Real Medical Challenge

This brain change that results in psychosis is a problem, and a big one. Psychosis in Parkinson’s disease presents a real medical conflict on what to do. The medications that are the best and that are always needed to treat psychosis push the opposite way of the medications used to treat Parkinson’s. Treating one makes the other one worse.

Pimavanserin (Nuplazid) for Psychosis in Parkinson’s

It feels like a medical miracle that such a medication as pimavanserin (Nuplazid®) was found. It’s the one medicine that works in a way that gets around the “opposite medication actions” problem. It makes the psychosis better but does not make the Parkinson’s worse. It’s so helpful in this situation that the FDA even approved it for Parkinson’s psychosis. It’s the first medication to get this approval.

Parkinson’s Can Become an Even More Complicated Condition

As someone lives with Parkinson’s for years and years more symptoms can appear. It seems that more and more keeps happening as time goes by, added to the symptoms that are already there. Fortunately, there is usually a medication that can help. Here are a few more things that can go wrong.

• Fatigue and sleepiness during the day
• Constipation
• Erectile dysfunction

Modafinil (Provigil®) might help with the daytime sleepiness and methylphenidate (Ritalin®) could be useful to treat the fatigue.

A type of laxative, the brand names Miralax® and Glycolax®, can usually help the constipation. These are called polyethylene glycol laxatives.

The usual medications, sildenafil (Viagra®), tadalafil (Cialis®), or vardenafil (Levitra®) can help men with erectile difficulties.

Deep Brain Stimulation Surgery for Parkinson’s

Yes, we know, it’s surgery. Surgery is not the first choice most people would want. But it might help. Deep Brain Stimulation surgery is a treatment for Parkinson’s that’s not a medication. It’s not a cure, just as none of the medications can cure Parkinson’s. Also, it does not slow the progression of Parkinson’s. And, it doesn’t help everyone. But, for some individuals who are not doing well with trying so many medications, it can be really useful. The benefits can last for up to 5 years. A successful surgery might stop really bad tremors, help with medication wearing off, and ease muscle movement side effects from the medications. One piece of good news is that it’s a surgery that doesn’t harm any brain tissue and the surgical changes can be reversed. If medications are not helping enough with Parkinson’s this surgery might be the next choice.

Helpful links:

Parkinson’s Clinical Studies – ClinicalTrials.gov

National Institute of Neurological Disease and Stroke – Parkinson’s Disease: Hope Through Research

National Institutes of Health PubMed Central – Current approaches to the treatment of Parkinson’s disease

Parkinson’s Foundation on Parkinson’s Treatment

The Michael J. Fox Foundation for Parkinson’s Research – Parkinson’s 101

The Mayo Clinic on Parkinson’s Disease

Over 260 Drugs in Development for Neurodegenerative Diseases

Drugs for Parkinson’s Disease. The Medical Letter on Drugs and Therapeutics, Vol. 63 Issue 1618, February 22, 2021.

Now is a Time of Great Progress for Parkinson’s Disease

This is a time of great progress in the diagnosis and treatment of Parkinson’s. Both major and minor technological advances add together to paint a brighter future for understanding and treating it. One area is several breakthroughs toward the ability to diagnose it earlier, allowing early treatment to slow its progression. Targeted, personalized treatment are in development, moved forward by brain imaging techniques like positron emission tomography (PET scans) and magnetic resonance imaging (MRI). Higher resolution scans can aid in pinpointing those brain areas that are most affected as the places to focus treatment. New treatments are planned, such as stem cell transplants and immunotherapies. Immunotherapies would use antibodies that are designed to seek out the relevant brain areas and slow or halt Parkinson’s progression. There are refinements in bioelectric medicine, that is, deep brain stimulation, to stimulate or to inhibit identified brain circuits.

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Parkinson’s – Slow, Progressive Neurodegeneration

Parkinson’s is a medical disorder, a brain-based movement disorder, with brain changes that affect how one moves, walks, stands, reaches for objects, and holds objects. It starts with minimal changes, as we describe below. Then gradually it progresses. An area deep in the brain, the basal ganglia, slowly loses nerve cells that make a signaling molecule called dopamine. As cells die and too little dopamine is made, the condition progresses. At first it affects mainly muscle movement that is seen as stiffness, rigidity, tremor, slowed movement, and difficulty with walking. Later it affects one’s mood, sleep, and thinking ability, and eventually it progresses to dementia.

The First Signs of Parkinson’s

In 1817 a London physician, James Parkinson, wrote “An Essay on the Shaking Palsy.” But that wasn’t really the beginning. Physicians had known about this medical condition for several thousand years. And during these millennia the disorder remains the same. The first change people feel is a bit of a tremor, a mild shakiness, usually of one hand. Or, the shakiness might be in an arm or a leg. In the hand, the Parkinson’s tremor is called a “tremor at rest”. The hand only shakes when it’s relaxed. The shaking stops if the person uses his hand. When his hand is once again resting and relaxed, the tremor comes back. The hand tremor is sometimes called a “pill-rolling” tremor because when the hand is relaxed the thumb and forefinger move as though the person is rolling a pill between them.

One of our readers in Newark, New Jersey (USA) commented:

If you’re taking care of a spouse with Parkinson’s you have to get into some sort of Parkinson’s caregivers support group. I was having all kinds of problems with my husband and it was because I was doing everything wrong. After I got into a group and learned how to do things right it got much better. He’s gone now, God rest his soul, and it was tough. It was awful. But it would have been much worse if I hadn’t learned the right things to do.

This is good advice. There are so many approaches to caring for someone with Parkinson’s and learning and pursuing the better ways of doing it can make a huge difference. Like, yes, go to their doctor visits with them, and yes, track their medication to make sure they’re taking it. Don’t keep changing their schedule day-to-day, keep it consistent. Some people keep planning new things for fear that the person with Parkinson’s will get bored. Not so. Schedule changes disorient them. There are dozens of these tips and participating in a Parkinson’s caregivers support group can teach one a lot.

Beyond That Early Parkinson’s Tremor

Gradually the situation changes. The way a person steps while walking changes. His posture when he is standing still is different, too. It’s a stooped posture. The way his face looks changes because his face muscles move less.

The Easily Recognized Parkinsonian Gait – How He Walks

As Parkinson’s progresses, a person’s walk changes. It can change in a few different ways. One is called a “shuffling gait”, where he seems to drag his feet when he walks, taking smaller steps and not swinging his arms much. Another type of walking is the “freezing gait”, where he starts to take a step but then stops. It’s like his foot is stuck to the floor. After a step or two he walks more normally. Finally, there’s the “festinating gait”, taking quick, short little steps. (Festinate means to hurry.) But it’s a slow walk because, though the steps are quick, they’re so small, there’s not much progress across the room.

Parkinson’s Posture – How He Stands

Maybe the best word to describe the way a person with Parkinson’s stands is “stooped”. The brain doesn’t send the right “stand up straight” signals. The result is rounded shoulders with his head and upper body leaning forward. The stiff muscles that come with Parkinson’s don’t help the situation. (Good news: Physical therapy can help a person overcome Parkinson’s posture. You can read more about it on our Parkinson’s Treatment page.)

The Frozen Face of Parkinson’s

It’s the stiff muscles problem again. With Parkinson’s a person’s face muscles are less able to move to show emotions on his face. It becomes hard to smile or frown. It’s as though he’s wearing a mask of his own face, and it’s called “facial masking”. Without smiling, frowning, or other facial expressions of emotion it makes it look as though he doesn’t have any emotions.

What Happens and How Fast It Gets Worse is Unpredictable

What happens, when it happens, and how quickly things get worse is different for each person. Your personal physician doesn’t have the ability to predict what will happen next and how fast everything will move along. Some people are lucky in that they have only minor signs like a bit of a tremor. The right medications at the right time, regular exercise, and physical and occupational therapy can slow it down. However, it’s important to understand that It’s an ongoing condition that can be treated but cannot be cured. Sadly, there’s just no way to completely stop it. Not yet. Once Parkinson’s starts it continues for the rest of the person’s life. And it does gradually change over time, continually even if slowly getting worse.

The 5 Stages of Parkinson’s

As time goes by more signs appear. His arms don’t swing in quite the same relaxed way when he walks. His voice gets quieter. The changes over time are consistent enough that physicians have been able to divide them into 5 stages.

Stage 1 of Parkinson’s – No Problems

In this earliest Stage 1 of Parkinson’s the movements are only altered on one side of the body. The symptoms are mild and the person can do anything he wants to do. He can move as he needs for tasks and jobs, hobbies and sports. Often at this stage he doesn’t even realize a medical problem has started. And if he did, the signs are so minimal that his physician might not be able to make the right diagnosis. No physician would to guess wrong and have the patient feel that he has Parkinson’s if that’s not what’s wrong. There might be a bit of a tremor now and then in one hand. Or just a bit of not-quite-right feeling or movement in an arm or a leg. He might feel his muscles are just a bit stiff.

Stage 2 of Parkinson’s – The First Hints of Things to Come

Months, or even years, after Stage 1 has appeared, the person might start having the signs of Stage 2. This second stage is still mild Parkinson’s but it’s more noticeable. In Stage 2 his physician might be able to make the diagnosis, especially if there’s a tremor. Both sides of his body might be involved. There might not be any difficulties with balance but his trunk muscles might feel stiff. There might be neck or back pain with a start of the stooped posture of Parkinson’s. It’s in Stage 2 that the changes in his face might start, with his face appearing stiff, with less blinking. His voice might get softer, quieter, as he talks, and what he says might be slurred at times. While all his movements are slowed he can still get everything done, all the usual tasks of daily life.

More on Stages 1 & 2 – Parkinson’s Signs You Don’t See

In addition to the changes you can see in these early stages there are changes with the individual that you can’t see.  For example, he might lose some or all of his sense of smell. His thinking might slow down. He might have been quick-minded before Parkinson’s, but no longer. Though previously a strong person, he might start to feel physically weak. He used to be a vigorous, robust individual but now he starts to feel just a bit sick all the time. Life might slowly drift toward being a burden, with no fun at all, which then could slide into a depression.

Stage 3 of Parkinson’s – Here Comes Trouble

Stage 3 is when the diagnosis becomes clear and the feeling of disability really starts. The individual can still do everything even though disability is starting. He can do all the tasks of daily living like taking showers, brushing his teeth, getting dressed, and eating. So, in Stage 3 the individual can still live alone. However, at this point all the signs of Parkinson’s are there. A physician can make the diagnosis without a doubt. His movements are obviously slowed and there are problems with keeping his balance. The balance problem is there because, without knowing it or thinking about it, we all keep our balance with little muscle and position changes all the time, moment to moment. As Parkinson’s gets worse these little balance fixes are slower or not there at all. Because of this, falling is more common.

Stage 4 of Parkinson’s- Trouble Is Here

Stage 4 is when the real difficult times start. He can no longer live independently by himself. For some of those tasks of daily living, like bathing, dressing, and eating, he needs someone’s help. This need for help is what marks him as in Stage 4. The Parkinson’s disease has become really disabling. Even if he can stand by himself and walk along alone it’s clearly a struggle. A walker can help.

Stage 5 of Parkinson’s – Some Never Make It This Far

Stage 5 is the worst. In fact, some people never make it to Stage 5. In Stage 5 he can’t stand up from a chair or get out of bed by himself. He might fall just with standing. Even when walking with a walker he might freeze in place or stumble as he tries to walk. As you can imagine, at this point he needs seven days a week, twenty-four hours a day, around-the-clock assistance so that he doesn’t fall and to help him eat, bathe, and dress. He might even start to test reality poorly, having hallucinations (seeing or hearing what’s not there) and delusions (believing something that’s just not true).

Parkinson’s Disease is a Really Common Condition

It’s heartbreaking to say, but in truth Parkinson’s is a really common medical condition. It’s so common that each of us probably knows someone who had it or has it now. Worldwide, it’s one of the most common disorders of the nervous system. About 1 out of every 100 people over age 60 will eventually get it.

Younger People, Under Age 50, Can Get Parkinson’s

Parkinson’s is usually viewed as a condition of the elderly. And while this is true for the most part, younger individuals can get it. For every 20 people who have Parkinson’s it’s likely that one will be under age 50. To put it another way, about 5% of people with Parkinson’s had it start before age 50.

The Intense International Push for Research on Parkinson’s Treatments and Cures

The major worldwide effort is in progress. People with Parkinson’s (including some well-known celebrities like Michael J. Fox, Linda Ronstadt, and Alan Alda), their families, and the physicians who treat them are all pushing public opinion to support more research on Parkinson’s. Everyone wants answers. And a lot of public interest helps drive fund raising for research and patient care. The research is across many areas, like the types of exercise one can do to slow it so that it progresses much more slowly. Drug companies and universities search for new medications. Medical technology companies are working to invent new non-drug devices and treatments. To help speed research along, genetically-modified animals have been made that behave physiologically as people do when they have Parkinson’s. The animals allow researchers to test trial medicines to see if they are safe and might help people.

Helpful links:

Clinical Trials for Parkinson’s Treatments – CllinicalTrials.gov

Parkinson’s Information Page – National Institutes of Health

More on Parkinson’s – National Institute on Aging

Parkinson’s – MedlinePlus – U.S. National Library of Medicine

Understanding Parkinson’s – Parkinson’s Foundation

About Parkinson’s – The Michael J. Fox Foundation

Parkinson’s – The Mayo Clinic