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‘Pre-motor Phase of Parkinson’s Disease’ explained by Neurologist Dr Paul Silberstein.

Next in our series of blogs on Parkinson’s disease, Movement Disorder Neurologist, Dr Paul Silberstein explains the pre-motor phase of Parkinson’s disease. Dr Silberstein discusses how researchers now understand that abnormalities in the nervous system of people living with Parkinson’s disease begin long before physical symptoms are manifest.

The diagnosis of Parkinson’s disease is made on the basis of the motor features of the condition:  slowness of movement, stiffness, tremor, walking and balance impairment.  Whilst these physical symptoms are critical in making a diagnosis, we now understand that abnormalities in the nervous system of people living with Parkinson’s disease begin long before physical symptoms are manifest.

When the brains of people with Parkinson’s disease are examined post mortem under the microscope, typical abnormal inclusions are seen within neurons (brain cells).  These inclusions, known as Lewy bodies, consist of abnormal accumulations of a naturally occurring protein known as alpha synuclein.  These abnormal protein clusters are thought to result in brain cell dysfunction and ultimately in premature brain cell death.

Notably, long before Lewy bodies can be found in the brain of people living with PD, they develop in the nerve cells of the nose and the intestine.  These changes result in loss of sense of smell and constipation, symptoms which are commonly recalled by people living with PD to have been present long before motor symptoms. 

How Lewy bodies, or the processes that result in abnormal protein accumulation  might travel from the nasal and intestinal nerve cells to the brain is not known, but current theories suggest that transport through nerves themselves may be an important mechanism.

Many of the Motor features of Parkinson’s disease (see ‘Motor Features of Parkinson’s Disease‘ blog) relate to a gradual reduction in the ability of the brain to produce a critical brain chemical known as dopamine.  Motor features of PD occur when Lewy bodies are found in the brain’s main dopamine production site – the Substantia Nigra, located at the top of the brain stem.

Prior to involvement of the Substantia Nigra however, pathologic studies have often noted Lewy bodies deposits in even deeper structures in the brain stem.  These structures are involved in regulation of mood and sleep, and likely underscore the common report of patients that they experienced mood or sleep disturbance months or years before they first developed the motor symptoms of PD.

Specific pre-motor features of Parkinson’s disease include Depression and Anxiety.

On the sleep front, common pre-motor symptoms include Restless leg syndrome and REM sleep behaviour disorder, the latter a condition in which patients enact their dreams whilst asleep, leading to movements such punching, kicking or throwing themselves out of bed, all occurring whilst completely asleep.

Pre-motor manifestations of PD including constipation, sleep and mood disturbance commonly respond to symptomatic treatments but are often only linked to the diagnosis of Parkinson’s disease once motor symptoms become manifest.

Understanding the abnormal processes that result in the formation of Lewy bodies and exploration of therapies that might slow or stop this process are a major focus of current research in Parkinson’s disease.

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‘Non-motor Features of Parkinson’s Disease’ explained by Neurologist Dr Paul Silberstein

Next in our series of blogs on Parkinson’s disease, Movement Disorder Neurologist, Dr Paul Silberstein explains the non-motor features of Parkinson’s disease, which include anxiety, changes in speech and bladder difficulties.

Parkinson’s disease is best known for the physical manifestations of the condition which include slowness and stiffness of movement, tremor and walking difficulty.  Indeed, these physical symptoms continue to form the basis for the diagnosis of the condition.

In addition to these physical symptoms, we now recognise that Parkinson’s disease can cause a variety of additional difficulties in non-motor domains.  These non-motor features include anxiety, changes in mood, speech and swallowing impairment, bowel and bladder difficulties and sleep impairment.  After many years of PD, some patients experience changes in their thinking or cognitive ability.

These non- motor features of Parkinson’s disease can have a major impact on wellbeing.  Fortunately, many non-motor symptoms can be treated effectively with medical therapy.  Some, like anxiety and sleep impairment may respond to the same treatments used for motor symptoms.  Others, like mood alteration may respond to exercise, psychologic interventions or different classes of medication such as antidepressants.

Non-motor symptoms can wax and wane in their intensity through the course of PD, but often remain treatment responsive many years after the diagnosis.

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‘Motor Features of Parkinson’s Disease’ explained by Neurologist Dr Paul Silberstein

Next in our series of blogs on Parkinson’s disease, Movement Disorder Neurologist, Dr Paul Silberstein, explains the motor features of Parkinson’s disease.

Parkinson’s disease (PD) is a neurologic disorder characterised by slowness of movement, stiffness, tremor and gait or walking impairment.  The condition is typically asymmetric – that is, it affects one side of the body more than the other.

Slowness of movement, termed bradykinesia, is the hallmark of the condition.  Bradykinesia often manifests initially with smaller handwriting or an impaired ability to attend to fine motor tasks such as doing up buttons.  Sometimes it is recognised by relatives or friends as reduced arm swing when walking

The muscular rigidity associated with Parkinson’s disease, manifests as a feeling of stiffness.  Typically, stiffness will first be evident in one limb, more commonly an arm.

Tremor is common in Parkinson’s disease, but, contrary to general opinion, tremor is not a universal finding in PD.  Overall, approximately 75% of people with PD will experience tremor at some stage.  PD Tremor is more common in the upper limbs than lower limbs, typically occurs at rest, such as when seated quietly, and resolves at least transiently with movement of the affected limb.  Tremor can be made worse with stress or anxiety and can vary spontaneously in severity over minutes or hours.

Walking and balance impairment can occur either early, or after many years of Parkinson’s disease.

Motor, or physical difficulties related to PD typically respond well to medication and exercise therapy. Most patients treated with medications and exercise achieve consistent control of physical symptoms of PD for many years after the initial diagnosis.

Motor symptom control can become less consistent over years, or even more than a decade after the diagnosis of PD.  Here a second tier of therapies including surgical treatment can be very effective in re-achieving consistent physical symptom control and improving quality of life. 

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‘What is Parkinson’s disease?’ explained by Neurologist Dr Paul Silberstein

In this first blog in a series of informative blogs about Parkinson’s disease, Movement Disorder Neurologist, Dr Paul Silberstein, explains ‘What is Parkinson’s disease?’

Parkinson’s disease (PD) is a slowly progressive Neurologic condition. It was first described by the British Neurologist James Parkinson in 1817 in his monograph “The Shaking Palsy”, where he described the physical symptoms experienced by patients with the condition.  These include stiffness and slowness of movement, tremor and gait or walking impairment.  These physical manifestations are referred to as the motor features of PD.

We now recognise that Parkinson’s disease can also result in changes in a variety of other domains including mood, sleep, bladder and bowel function and, after many years, cognitive performance.  These clinical manifestations are considered the “non-motor” features of PD.

The average age of onset for Parkinson’s disease is 60, but patients can present with the condition at a younger age.  More commonly PD is a condition of older people with a notably increasing prevalence with advancing age.

At present, there are no treatments that alter the course of Parkinson’s disease. Existing therapies focus on management of symptoms. 

The good news is that there is an excellent suite of therapies that improve symptom control.  Coupled with exercise and a focus on well-being, these treatments allow most patients to enjoy good quality of life for many years after the diagnosis.

In the research space there have been major advances in understanding the pathologic abnormalities which underly Parkinson’s disease.  There are many trials currently underway internationally, examining therapies that may slow the progression or ultimately cure Parkinson’s disease. This provides an optimistic outlook for major future advances in Parkinson’s treatment.

Follow our social media pages and look out for when our next blog, ‘Motor features of PD’, is published

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The New YOP-X app Is For People Newly Diagnosed With Parkinson’s Disease

Parkinson’s Australia have just launched YOP-X, a free app for people newly diagnosed with Parkinson’s disease. This app is a world first, and includes tools which have been uniquely shaped by the first-hand experiences of people living with Young Onset Parkinson’s.

In this article by Alexandra De Vylder at Aged Care Weekly, Geoff, who is committed to positivity throughout daily battles with his Parkinson’s Disease, talks about how’s he’s determined to share his knowledge through the YOP-X app.

Geoff had a big smile on his face when he was diagnosed with Parkinson’s disease. He was just 50 years old.

“It was the first time in six years I actually had an answer,” he told me 14 years later. “I actually apologised to the doctor. I said, “I’m not happy that I have Parkinson’s, but I’m happy I’ve got a name I can now work with”.”

Geoff had spent the last six years with severe balance issues so that he could barely walk down the street. Finally, he knew what he was dealing with.

But he soon realised what he was in for. His doctor prescribed him drugs and told him what to expect for the rest of his life.

“All that was very negative. It was like, within three years you’ll be looking at early retirement, within four or five years you won’t be driving a car, within 8 years you’ll be needing mobility devices to get around. Within eight years you’ll have maxed out on drugs and you’ll be looking at alternatives like Deep Brain Stimulation.

“I haven’t ticked any of those boxes.”

Now, at 64, Geoff cycles between 200 and 450 km every week. He’s a team leader at his design job and gives presentations about living with Parkinson’s as a Parkinson’s Victoria ambassador.

Parkinson’s app helps people like Geoff

Experts are now more aware of ways to manage Parkison’s so people can live full and productive lives. Now there’s a free app that helps people navigate the condition.

The app, called YOP-X, focuses on key aspects of life with Parkinson’s Disease, including exercise, nutrition, mental health tools, relationships, and work. Neurologist Dr Paul Silberstein worked on the app other experts to support people post-diagnosis.

“We know that most patients with typical Parkinson’s disease will have a very robust response to medical treatment,” Dr Silberstein said.

“Generally speaking, for newly diagnosed patients, we would expect their physical function to improve by 60 to 80% (with treatment). Again, that effect can be further augmented by things like exercise and mental health strategies.

So most people with Parkinson’s disease will live very well with the condition for many years.”

Dr Silberstein said the app is relevant to anyone with Parkinson’s, even though it’s tailored to people with Younger Onset Parkinson’s Disease.

Is exercise a Parkinson’s Disease treatment?

At first, Geoff didn’t know that exercise could help him. It was only after a trip to the gym a year after diagnosis that he realised cycling on a stationary bike relieved his symptoms.

“I found that riding on those for twenty to thirty minutes, released all the stress and rigidity of my legs and the pain disappeared. I could actually walk a lot better for a few hours afterwards.

He progressed to road bikes with big tyres to help him balance. Now he rides voraciously on an “almost normal” bike as well as doing regular gym sessions, tai chi, and yoga.  

“It gave ownership back to me a little bit.”

Research

shows that exercise improves mobility and balance, mood, sleep, and relieves pain and constipation. Parkinson’s researcher Professor Colleen Canning writes that “high intensity exercise and exercise that challenges thinking and movement” can directly impact brain function. She recommends at least 30 minutes of “at least somewhat hard exercise on most days” to reap the benefits.

Dr Silberstein said mental health management is another major part of living well with Parkinson’s.

“About 50% of people with Parkinson’s disease will experience at some stage a clinically diagnoseable depressive illness. And typically, about 50% of people will suffer anxiety. And so, management of those aspects of the condition is very important to people’s overall health and quality of life.

“Certainly for mental health, both within and outside of Parkinson’s, exercise also clearly has beneficial effects.”

It’s not easy, but attitude is key

Coping strategies are key for Geoff, who is committed to positivity throughout daily battles with his condition.

“Each day you get up, and you just check yourself in, as in what sort of day is this going to be? and you know very quickly.

“In a lot of ways you’ve just got to accept that it’s never going to be constant, it’s never going to be the same as yesterday or tomorrow.”

Geoff had to find answers on his own, and now he’s determined to share his knowledge with others through the YOP-X app.

“Everything I’ve learned about Parkinson’s is through research. Ploughing in. And it was dogged. I had to really fight to try and get as much information as I could.

“There was so much I learned along the way. I just want to short cut it so that people don’t lose that drive and that initiative.”

The YOP-X app is free to download.

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Parkinson’s Disease – Back to Basics

There is such a dizzying amount of information about Parkinson’s disease available on the internet and at large.  For people living with PD, their carers and clinicians, it’s increasingly difficult to know where to start and sometimes more difficult to know where to stop, let alone work out what a lot of it means. 

We are all anxious to see major improvements in the field, and particularly keen to see the development of treatments that do more than control the symptoms of Parkinson’s disease.   Indeed, perhaps most importantly, therapies that might slow, stop or cure PD.

In all of our searching however, its easy to forget that we already have at our disposal many strategies that help people living with PD feel a lot better, sometimes remarkably better.  Some of these therapies like tablets are relatively simple to deliver, and others, like Deep Brain Stimulation, more complex, but coupled with exercise and a clear focus on mental health and wellbeing, existing therapies can make a big difference for most people living with PD.

So…its this kind of thinking that inspired us to write ‘Back to Basics’, a series of posts starting with what we know about Parkinson’s disease and moving on to a discussion of what we are currently able to do to improve the wellbeing of people living with PD.  Of course, we’ll talk about the medical treatments, but you’ll also see a big focus on the motherhood stuff too: diet, sleep, exercise, mental wellbeing, bowel function and strategies to help with taking medications regularly and on time.  We hope you find them helpful!