Diagnosis and treatment of Parkinson’s disease

Professor F Stocchi, Rome, Italy

Introduction

The symptoms of Parkinson’s can be divided into two types: those related to movement and those not related to movement (motor and non-motor).¹ Motor symptoms include tremor, slowness of movement (bradykinesia), rigidity of muscles, inability to move (akinesia), a shuffling gait and a stooped posture.² Non-motor symptoms include sleep disturbances, constipation, loss of sense of smell, depression, sexual dysfunction and anxiety.¹ Parkinson’s is different for everyone and each person with Parkinson’s will have different symptoms. Symptoms can appear at any age, but the average age at which people develop Parkinson’s is 60. It is rare in people under 30.³

The symptoms of Parkinson’s can have an impact on quality of life.⁴ Parkinson’s is a progressive disease, which means that the symptoms will get worse as time goes on.⁵ However, with the correct treatment, most people will be able to continue with their normal lives for many years. It is important that medical advice is sought as soon as the early signs and symptoms of Parkinson’s are detected, so that treatment options can be explored.⁶

Early symptoms of Parkinson’s to look out for

In the early stages of Parkinson’s, symptoms vary from person-to-person and so will the way the symptoms progress. Slowness of movement in one hand is often one of the earliest symptoms to appear, and there may also be a reduction in arm swing while walking. This can be accompanied by pain in the shoulder.^7,8 Most people initially experience tremors, which are slight at first and most noticeable at rest. The tremors often occur in the hand, but the arms and legs may also be affected.⁵ However, up to 15% of people with Parkinson’s never experience tremor throughout the course of their disease.⁹

Often the symptoms start on one side of the body.³ When the dominant side is affected; the symptoms are more noticeable when performing common tasks such as writing. Those who experience tremor and have symptoms affecting their dominant side are the most likely to visit their doctor and benefit from early diagnosis and treatment. Therefore, it is important not to ignore symptoms that affect the non-dominant side however slight.

People in the early stages of Parkinson’s may also have problems with balance; for example, they might be unstable when standing or have difficulty turning or making abrupt movements.¹⁰ People with Parkinson’s often use less facial expression and may speak in a soft voice. Non-motor symptoms such as sleep disturbances, depression and anxiety can also occur, often before the motor symptoms.

Parkinson’s is usually diagnosed by a neurologist who can evaluate symptoms and their severity. There is no specific test to clearly identify the disease; Parkinson’s is diagnosed when other conditions with similar symptoms have been ruled out or if the person responds to medication for Parkinson’s. It can be difficult to pinpoint when the first signs and symptoms begin to show; many people can remember noticing their first tremor but close questioning reveals that the signs and symptoms were there before the tremor became noticeable. Following is a list of some of the symptoms to look out for:

change in facial expression (staring, lack of blinking)
failure to swing one arm when walking
flexion (stooped) posture
frozen, painful shoulder
limping or dragging of one leg
numbness, tingling, aching or discomfort in the neck or limbs
softness of voice
sensation of internal trembling.

How Parkinson’s can affect day-to-day life

If untreated, Parkinson’s can have an effect on a person’s quality of life. Symptoms can be particularly hard to cope with when the person affected is young, as younger people will have to live with their symptoms for longer than an older person. Around five to 10% of people with Parkinson’s are under 45. This is called young onset Parkinson’s.

In those of working age, Parkinson’s may affect a person’s ability to do their job if it goes untreated. For example, as symptoms progress it may become too difficult to use a computer, operate machinery or drive. For some people, their symptoms may progress to the point that they are no longer able to work at all.

Outside of work, there are several factors that contribute to the quality of life of those with Parkinson’s. Around 30 to 40% of those with Parkinson’s have depression.¹¹ The person’s ability to cope with the symptoms of Parkinson’s, their self-esteem and their level of social support can all have a bearing on depression. People with Parkinson’s can feel socially isolated because they feel their friends and family do not understand their condition and they may not be able to participate in the social activities that they used to. Lack of sleep can also affect a person’s quality of life and ability to function. However, with the correct medication, the symptoms of Parkinson’s can be controlled and the person can continue with a normal life for longer.

Benefits of early treatment

Currently there is no cure for Parkinson’s, however, a number of treatments are effective in improving symptoms of Parkinson’s. Therefore it is very important to raise people’s awareness to the symptoms and get early treatment. The medications that are most commonly used work by replacing or mimicking the effects of dopamine, the chemical produced in the brain that controls the body’s muscles and movement. These medicines improve the motor signs of Parkinson’s, for example rigidity, tremor and slowness.¹²

More effective treatments are evolving all the time. In particular, there are medicines being investigated that can help slow the progression of the disease. These treatments should be started as early as possible and continued throughout the course of the disease.⁶ ^,13 By slowing down the progression of the disease, people with Parkinson’s can maintain a good quality of life for longer.

A recent clinical trial (ADAGIO) showed that people who received early treatment with rasagiline showed slower progression of their disease, as measured on the Unified Parkinson’s Disease Rating Scale (UPDRS), than those who were diagnosed at the same time but started the same treatment nine months later.⁶ Similar studies with other Parkinson’s medicines are underway but results are not yet available. ADAGIO is one of the most important studies of the last few years, with a large study population and a rigorous design and provides promising evidence that early intervention with rasagiline slows the course of the disease.⁶

Early treatment largely depends on early diagnosis, therefore, it is vital to be aware of the early signs of Parkinson’s and seek medical advice as soon as possible.^13,14

Complementary therapy

Several complementary therapies may be used alongside conventional medicine. Massage can help relax muscles; herbal remedies and acupuncture can help non-motor symptoms such as depression and sleep-lessness.^14,15 Exercise, such as Tai Chi, has been shown to improve balance and postural stability.¹⁵

Other complementary therapies include art therapy, reflexology, yoga, hydrotherapy, musicotherapy and hypnotherapy.¹⁵ These techniques and therapies have all been shown to benefit people with Parkinson’s by helping to relieve the motor and non-motor symptoms. However, complementary therapy should be just that – practiced in addition to, not instead of, conventional treatment.¹⁵

Conclusion

The motor and non-motor symptoms of Parkinson’s can impact on the quality of life of those affected, particularly as the disease progresses and the symptoms worsen. Parkinson’s is a highly individual disease and different people will be affected by different symptoms. However, Parkinson’s is a progressive disease with no cure available and symptoms gradually worsen as time goes on. As soon as early signs of Parkinson’s are detected, medical advice should be sought as there is evidence that early treatment of Parkinson’s can help delay the progression of the disease and prolong a good quality of life.⁶ ^, ¹³

Receiving a diagnosis of Parkinson’s can be very difficult and many people delay visiting their doctor through fear, however, providing action is taken at the earliest stages, the most appropriate treatment options can be explored. This will give people the best chance of controlling their symptoms and slowing the progression of the disease.

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