Parkinson’s Disease for Rural Patients

What is Parkinson’s disease?

Parkinson’s disease is a disease of movement that arises from malfunction of nerve cells in the brain. Generally the cause of the disease is unknown and it is a chronic disease that needs constant medication and treatment. It affects the cells in the brain that produce Dopamine and when the cells become less then there is less production of Dopamine in the brain.

The common symptoms or signs are the following:

1. Tremors: These are repetitive movements that occur in the hands, legs, jaws and face
2. Bradykinesia: Slowness of movement
3. Rigidity: Stiffness of the trunk or limbs
4. Postural instability: Impaired balance or posture of the body
5. Parkinsonism: These occur with progression and include anxiety, depression, sleep disorders, thinking disorders and emotional disturbances

What causes Parkinson’s disease?

As mentioned earlier most of the time the cause is unknown. However both genetic and environmental factors could be involved. People exposed to certain pesticides and those who have head injuries have higher risk of having the disease. Heavy metal and insecticide exposure have also been implicated.

How is Parkinson’s disease diagnosed?

Symptoms and clinical testing lead to the diagnosis easily.

1. Tremors: Although one third of the patients might not have it at the onset of disease it is the most important diagnostic tool. It is found at rest and disappears with voluntary movement and sleep. It commonly occurs in the distal part of the leg or hand and occurs at a speed of 4 to 6 times a second. The classical example is the Pill–rolling movement.
2. Hypokinesia: This is the medical word for slowness of movement. It might start as difficulty in writing, sewing and getting dressed. Performing two or three actions at the same time becomes very difficult. The speed of movement is different for different limbs. Sometimes there would be what is called Gait Freezing or sudden inability to move while walking.
3. Rigidity: The stiffness of the muscles is due to continuous contractions. Later it can become what is called Cog wheel rigidity in which the movement is ratchety. The rigidity often starts in the neck and shoulder muscles and then spreads to the face muscles and then to the extremities. At later stages the entire body could become rigid.
4. Other symptoms: These can occur in later stages because of Dopamine and include a variety of symptoms like indifference, quiet speech, craving and binge eating, hypersexuality, pathological gambling, hallucinations, etc which come during later stages because of inadequate dosage of treatment methods. Other autonomic nerve dysfunction like oily skin, low blood pressure on standing, excessive sweating, urinary incontinence, constipation, automatic eye movements, etc can also occur at later stages.

There is no laboratory or scan test that will clearly identify the disease in early stages. Hence in rural areas response to the primary medicine levodopa is used as a diagnostic test. Sometimes eye doctors can detect what are called Lewy bodies in the eye. Plain CT scan, MRI, etc could be normal but special ones like DaT scan, DOPA scan etc use radiotracers with PET and SPECT scans could give more information on early diagnosis. However, these scans are available in only very few places in the World.

Hence in rural areas clinical diagnosis and trial with medication is the best option. Unless one is going to a specialist center going to other higher centers are not productive and would be expensive.

How is Parkinson’s disease treated?

The treatment of Parkinson’s disease is complex and multidisciplinary and needs constant evaluation. In general plenty of water and warm baths and physical activity help. Physiotherapy is useful for maintaining the movement of joints and reducing the stiffness. Antioxidants and vitamins are helpful especially Vitamin E. Exercise is the safe, effective and easy to way for improvement. Biofeed back is very helpful.

1. The first line of treatment could be what is called Dopamine agonists or medicines that mimic Dopamine in the brain. Mirapex is a common medicine in this group. They are well tolerated and do not have long term side effects but in some can cause nausea, vomiting or light headedness and hallucinations in some people.
2. A group called anticholinergics could be used to decrease levels of acetylcholine in the brain so that the balance between dopamine and acetylcholine is maintained in the brain. These are useful for those with tremors as the primary problem.
3. The conventional treatment especially for those with stiffness and Bradykinesia is Sinemet a combination of LevoDopa and Carbidopa. L Dopa is converted in the brain to Dopamine that is lacking. Carbidopa increases the efficiency of L Dopa and decreases the side effects. The medicine is taken on an empty Stomach as food and vitamins interfere with its absorption. It is better to start it as late as possible because it loses it’s effectiveness over a period of time. However it is the most effective medicine and there are other ways of offsetting the loss of effectiveness.
4. Stem cell therapy is the latest research focus and if successful could help in a great way.
5. Curcumin found in Turmeric is a powerful antioxidant and also increases the level of glutathione in the brain. Studies from NIMHANS in India have shown significant benefit from many Indian dishes with turmeric.

Exercise regime is the most important treatment in addition to the medicines as it naturally corrects many of the problems. It prevents depression, maintains mobility and increases dopamine levels in the brain.

What are the options for rural Patients with Parkinson’s disease?

The important points to note are:

1. The diagnosis is clinical and expensive, tests do not add much to clinical diagnosis except in few advanced centers in the World
2. Trial with a course of LevoDopa is almost as good as a diagnosis at the very expensive centers
3. Medicines, physiotherapy and exercises form the mainstay of treatment
4. Indian dishes with Turmeric are useful especially in early disease

What are the facilities available at SEESHA?

SEESHA has facilities for clinical testing and a very good physiotherapy department to teach relevant exercises.

Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore currently working as Director of Medical Services of the charitable organization SEESHA and Adjunct Professor in Karunya University. He has special interest in rural surgery and during the last three decades of service in rural areas helped 23 rural hospitals start minimally invasive surgeries. Karunya is now recognized as center for excellence in innovation for rural surgery by Lancet Commission on Global Surgery. He has over 200 publications. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. Recently, he was awarded the Lockheed Martin innovations award by the Department of Science and Technology of Indian Government and the Lockheed Martin Group (USA)

Image: Ball-and-stick model of the dopamine molecule, a neurotransmitter that affects the brain's reward and pleasure centers. Source/Author: Jynto. Date: 25 June 2011. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Dopamine_3D_ball.png