A Clinician’s Guide to Parkinson’s Pathology and Treatment

By Beth Olson, PT, DPT, LSVT BIG Certified, RQAL

Physical Therapist

Parkinson’s Disease is a chronic, progressive neurologic disease that affects an estimated 800,000 people in the United States. It is caused by a loss of certain neurons that affect a specific part of the brain, called the substantia nigra.

Essentially, there is a loss of dopamine, a neurotransmitter made by the brain, that helps to control and regulate movement. When enough dopamine is lost, this creates problems with being able to move normally. With Parkinson’s disease, this can be seen as slowness or complete absence of movement as a person tries to perform normal daily activities.

Parkinson’s disease is the most common of all central nervous system diseases. It is more prevalent in men and in those of advanced age (85 years and older.) Researchers continue to be unsure about the exact cause of Parkinson’s disease. However, it may be linked to living in certain rural areas, the use of pesticides and/or insecticides and possibly drinking contaminated well water.

How to Stage Parkinson’s Disease

The first method of staging Parkinson’s Disease is the Hoehn & Yahr Rating Scale. This scale uses a more simple rating system from 1-5. Each level is based on the progression of motor or physical symptoms. The higher the rating, the more advanced the disease process.

The second method is the Unified Parkinson’s Disease Rating Scale (UPDRS). The UPDRS is a more comprehensive scale, looking at both motor/physical and non-motor symptoms, such as mental functions, mood, social interactions, and even loss of the sense of smell. It is scored from zero or no disability to 199, which is considered total disability.

Both methods are good at determining how a person’s motor/physical symptoms progress, as well as a person’s level of disability. The UPDRS may provide more insight into a person’s quality of life and ability to cope with the disease, as it takes into account the non-motor symptoms.

Symptoms & Behaviors of Parkinson’s disease

Motor or physical symptoms usually begin as a resting tremor on just one side of the body. Often, this begins in one hand or foot, eventually progressing into both sides of the body. A condition called micrographia, where handwriting gets smaller and smaller is also common. Progression of symptoms includes

• Rigidity and a forward flexed posture at the trunk muscles
• Difficulty with walking
• Difficulty maintaining balance and a more upright posture
• Increased energy use, leading to fatigue
• Loss of the sense of smell

Non-motor symptoms or behaviors can include the following:

• Quickly changing moods
• Decreased ability to learn new or more complicated tasks
• Sleeping issues, including daytime sleepiness and difficulty sleeping at night
• Bowel and bladder problems
• Sexual dysfunction
• Restless leg syndrome
• Changes in blood pressure when moving from one position to another
• Hallucinations and/or delusions

Pharmacological Treatment Options

There are several different medications that are commonly used to treat Parkinson’s disease. Carbidopa-levodopa or L-dopa is one of the most effective and earliest medications given. It helps to increase dopamine levels, leading to more normal movement. Researchers first found levodopa to be very helpful to decrease the slowed or absent movement, as well as decreasing tremors. When paired with carbidopa, the effects of the drug combination last longer.

While very effective, after long term use and larger doses of L-dopa, several side effects can occur. One of these is an on/off cycle, where a person will have periods of normal movement, followed by periods of slowed or complete absence of movement.

MAO-I inhibitors are medications that block certain enzymes from breaking down dopamine. This allows the brain to have more available dopamine for more normal movement.

COMT-inhibitors also block certain enzymes, specifically those that break down levodopa. When levodopa is able to stay in the body for longer periods of time, less of the on/off cycle occurs.

Anticholinergics are medications that block the action of acetylcholine, a neurotransmitter that carries information from the brain to the muscles. By blocking this neurotransmitter, anticholinergics are able to boost the working potential of the basal ganglia, a specific part of the brain affected by Parkinson’s disease. They are especially helpful to decrease tremors.

All of these medications work to decrease the symptoms of Parkinson’s disease, including rigidity and tremors. Implantation of a deep brain stimulator is a surgical option to help with very bad tremors that affect a person’s ability to eat and/or participate in other activities of daily living.

Non-Pharmacological Treatment

Along with medication, non-pharmacological treatments can be very effective to treat the symptoms of Parkinson’s disease. Exercises prescribed by a physical therapist, occupational therapist, and/or speech-language pathologist can be very beneficial. These can include high-intensity resistance training, flexibility training, aerobic conditioning, and rhythmic exercises. Voice exercises are especially helpful to combat low speech volume and the ability to be better understood when speaking.

Cognitive or mental exercises are also helpful to address some of the memory and processing difficulties associated with Parkinson’s disease. These exercises may include using specific routines to complete activities of daily living without missing a step or the ability to divide more complicated tasks into smaller, easier to complete steps. Coping strategies to deal with depression and hallucinations are also commonly taught.

Balance and walking programs are frequently used to combat the rigidity and postural issues commonly found with Parkinson’s disease. Decreasing a person’s risk of falls, as well as allowing them to be more active and engaged in their life, is very important.

Learning compensatory strategies can help to address any physical issues that can’t be well controlled by medications. This can also help to decrease someone’s risk of falling and improve the overall quality of life.

Several formal programs have been created and more information on these programs can be found below:

• LSVT BIG and LOUD stand for Lou Silverman Voice Training. Both programs were developed based on research that began in 1987. LSVT LOUD was developed first and focuses on improving a person’s ability to speak, swallow, and communicate more effectively. After seeing the success of LSVT LOUD, LSVT BIG was created. This program focuses on recalibrating a person’s body movements to a more normal baseline. These programs are performed one on one by a certified therapist, helping to develop healthy exercise habits for life.
• PWR 4 LIFE is another program focusing on returning a person to a more normal ability to move and live with research-based exercises and strategies, addressing the decreased endurance, motor issues, and other symptoms of Parkinson’s disease.
• Rock Steady Boxing programs are locally owned gyms catering to people with Parkinson’s disease and other movement disorders. The programs are monitored by certified trainers and can be changed to fit all levels of ability. This program works to return a person to a more normal baseline. It also provides support from a social standpoint, as it allows multiple people with Parkinson’s disease, as well as their loved ones, to work together and learn from one another.