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Parkinson's Disease Management & Treatment Options

Online Health Chat with Dr. Michal Gostkowski

October 4, 2011


Introduction

Cleveland_Clinic_Host: Approximately 1 million Americans have Parkinson's disease. More than 50,000 Americans are diagnosed with Parkinson's disease each year. Men after the age of 60 are more likely to develop the disease than women. The average age at the onset of symptoms is 60. However, 10 percent of patients are diagnosed before age 40. There is increasing evidence that Parkinson's disease may be inherited.

Parkinson's disease is a chronic, progressive neurological disease that affects nerve cells (neurons) in an area of the brain near the neck, known as the substantia nigra. These cells normally produce dopamine, a chemical (neurotransmitter) that transmits signals between areas in the brain. These signals, when working normally, coordinate smooth and balanced muscle movement. Parkinson's disease, however, causes neurons in the substantia nigra cells to die, leading to a lack of dopamine in the brain, especially in the part of the brain known as the basal ganglia. The basal ganglia are responsible for organizing movement commands from other parts of the brain. The loss of dopamine causes patients to lose the ability to control their body movements.

The major symptoms of Parkinson’s disease include:
  • Muscle stiffness (rigidity)
  • Tremors
  • Bradykinesia (the slowing down of movement and the gradual loss of spontaneous activity)
  • Changes in walking pattern and posture
  • Changes in speech and handwriting
  • Loss of balance and increased falls

Dr. Michal Gostkowski and the physicians in the Center for Neurological Restoration at Cleveland Clinic offer expertise in the latest treatments for Parkinson’s disease and other movement disorders to help people improve function and quality of life. Common treatment options include medication, therapy, and surgical management.

Michal Gostkowski, DO, is a neurologist at Cleveland Clinic. His specialties include Parkinson’s disease, movement disorders, dystonia, botulinum toxin injection for dystonia, and medical treatment for movement disorders. He completed his medical degree at Philadelphia College of Osteopathic Medicine and completed a residency in neurology at Botsford Hospital in Farmington Hills, MI. He then completed his first fellowship in movement disorders at Barrow Neurological Institute in Phoenix, AZ, and his second fellowship in microelectrode recording for deep brain stimulation at Cleveland Clinic.

To make an appointment with Michal Gostkowski, DO, or any of the specialists in the Center for Neurological Restoration at Cleveland Clinic, please call 216.636.5860 or call toll-free at 866.588.2264. You can also visit us online at www.clevelandclinic.org/neurorestoration.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Michal Gostkowski. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Definitions

steele63: What is a parkinsonism?

Dr__Michal_Gostkowski: The simple answer is stiffness (rigidity) and slowness (bradykinesia). To be diagnosed with PD (Parkinson’s disease), one needs a rest tremor. Roughly 80 percent of parkinsonism patients are PD, and the remaining 20 percent are different forms of PD.

steele63: Are essential tremors and resting tremors both considered Parkinson’s?

Dr__Michal_Gostkowski: Rest tremors are seen in PD, but essential tremors are different. They are action tremors that have different causes and treatments.


Symptoms

babs: I’ve read that unexpected weight loss can be an early indication of Parkinson’s. What specifically should someone look for to determine if PD might be a cause?

Dr__Michal_Gostkowski: Some people may experience weight loss, although some patients have weight gain. Unintended weight loss is a serious issue and needs to be worked up thoroughly with a PCP (primary care physician) and a neurologist.

robbiea: I've been experiencing frozen ankles/toes for almost a year now. Is this a symptom of Parkinson’s or a side effect of medication? I take Stalevo® 100 (2x day) and trihexyphenidyl (3x day).

Dr__Michal_Gostkowski: That is difficult to say. It may be that you might require additional medication to see if this improves. It may be a dystonia that is occurring as well. Trihexyphenidyl is used for tremor and dystonias. Speaking to your physician about increasing Stalevo® (carbidopa/levodopa with entacapone) may be fruitful.

steele63: Does PD progress at different rates for everyone. I was just diagnosed about six months ago but noticed tremors about a year and a half ago.

Dr__Michal_Gostkowski: Tremor is usually the first feature for many people.

Nova1: I am newly diagnosed with PD but went into the initial appointment exhibiting many symptoms, which have displayed over the past year or so to some extent. Am I already past the preliminary stage? In addition, I do have balance problems and have read that this is thought to be an indicator of future dementia. Your insight is appreciated. (I am with a movement specialist who started me on medications in early summer, and I begin PT with a PD specialist this week.)

Dr__Michal_Gostkowski: The fact that you are being treated is beneficial. I would not concern myself with stages. The goal is to improve your function through medication and exercise. Balance issues are complicated, but may be helped through physical therapy and assistive devices (walkers).


Genetic Factor and Early Diagnosis

Whiskey: Are there any preventive methods for avoiding Parkinson's disease, or is it purely genetics?

Dr__Michal_Gostkowski: There is a lot of effort and research toward a preventive treatment. There seems to be no way to avoid PD. Genes play a role, though it's not as large as we thought. Environment and other issues may play a very large role in its development.

Braemg: Is the Cleveland Clinic Center a site for genetic testing? Because my mother has Parkinson’s, I’m interested in testing myself for the gene.

Dr__Michal_Gostkowski: I do not recommend genetic testing. Less than 2 percent of PD is caused by genetics. A general rule of thumb: normal healthy people are not tested if there is no treatment or cure available. Even though a person may have the gene for Parkinson's, they may not develop the disease.

nutzy: If my mother was diagnosed with Parkinson disease after age 60, what are my chances of getting this disease at this age? Is there is a new procedure to diagnose an early Parkinson’s? Thanks for your answer.

Dr__Michal_Gostkowski: There is no definite reason to suspect you will develop PD. There is a slightly higher risk. There is no imaging or test to diagnose PD before symptoms start.


Medications

pdbob: Isn't too much medication as bad as too little?

Dr__Michal_Gostkowski: True. Too much medication can give people side-effects, and too little may provide no benefit. I frequently need to increase medications to see if they are helpful. My personal preference is to give the least amount possible while making sure that it’s still effective.

steele63: My biggest issue is the essential tremors that interfere with my work on the computer. I know I need medication for this, but I need to be able to focus and be sharp at work.

Dr__Michal_Gostkowski: Treating essential tremors is frustrating because there are no medications just for tremor. We use other medications (blood pressure pills, seizure medications, and sedatives), so there is not a lot of improvement expected with medication. Deep brain stimulation may be a very good option (if done properly).

jamcin: My dad has PD and is currently taking carbidopa levo 1 tablet 3 times a day. What other medications can you recommend that we can ask his doctor about? He also is diabetic.

Dr__Michal_Gostkowski: Sinemet (carbidopa levo) needs to be taken with care. Your father may require a larger dose or more frequent dosing. PD medications such as Comtan® (entacapone)/Tasmar® (tolcapone)/Stalevo® may be helpful. Diabetic medications are generally safe and can be used in PD patients.

Mattie: At what stage of Parkinson’s should you begin taking medication?

Dr__Michal_Gostkowski: There is no specific stage to start. I tend to start treatment earlier and at the lowest dose that is possible, yet effective. Any treatment tends to have an improved course.


Surgical Issues

phineas: I see that Cleveland Clinic now offers and option for being asleep during DBS (deep brain stimulation) surgery. What are the benefits to surgery with this new technology?

Dr__Michal_Gostkowski: It allows more people access to DBS. If someone is anxious or has significant medical reasons (cardiac, breathing), then it may be an option.

momom: My husband had DBS stimulators placed for PD last year and now needs knee replacement. Will the surgeons know how to handle this properly?

Dr__Michal_Gostkowski: If he is working with his movement disorder team (neurologist, surgeon, and programmer), this should not be an issue. There are some limitations to imaging. Your orthopaedic surgeon (not the patient) should speak to Medtronic directly through their patient assistance line about the technique used in surgery.


Movement

steele63: My resting tremors are not a significant problem, but essential tremors affect my work at the computer. What type of medication is best for this issue? I am taking Requip® (ropinirole) for the resting tremors.

Dr__Michal_Gostkowski: That is generally true about the resting tremors. Action tremors are usually more problematic. There are some medications such as Mysoline® (primidone) and Inderal (propranolol) that can be used along with benzodiazepines. These medications can be taken in conjunction with your PD medicines.

tamia2003: I hate the freeze spells. What or how can I prevent these spells?

Dr__Michal_Gostkowski: Freezing is a really frustrating part of the disease for some people. There are not a lot of options with medications. I urge patients to use a walker with assistive devices (lasers). Freezing is very interesting because it can be overcome with "tricks," such as shining a laser on the ground or thinking about something in one's head. I had one patient who was able to stop freezing by singing "Happy Birthday" to herself!


Mental Health

BL62: Is it common for patients with Parkinson’s disease to develop psychological problems? If so, what types of medications can treat this?

Dr__Michal_Gostkowski: It depends on the problem. We are lucky to have a multitude of medications for many different issues (depression, fatigue, anxiety, motivation, hallucinations).

steele63: Does stress make the disease progress any faster?

Dr__Michal_Gostkowski: Stress will make the symptoms appear worse for a time. This will also happen if you are ill or are post-surgery. It shouldn't make the disease progress much faster than it ordinarily would.

pdbob: Can you discuss hallucinations, the cause and effects?

Dr__Michal_Gostkowski: Hallucinations can be a symptom of the disease in advanced cases. The medications, since they involve dopamine, can make people more likely to have them when taken in higher doses and for longer courses. This is true of medications such as Mirapex® (pramipexole) and Requip®, but levodopa can do it, too.

pdbob: I'm taking several medications to combat symptoms of PD, and find that my hallucinations are becoming more frequent. Any connection?

Dr__Michal_Gostkowski: There is a potential association. As I said, both the medications and the disease can cause hallucinations. Bring this up with your physician, since your medications may need to be altered, or you may need to have other medications started.

Spartan: When I get nervous or under pressure, my stomach distends and I need to take deep breathes. I did not have this problem prior to PD. Is this PD related?

Dr__Michal_Gostkowski: PD has a strong association with anxiety (nervousness). It is unlikely that the stomach distension is directly linked to the medications or PD. Some patients can get some rigidity of intercostal muscles (ribcage), but this is rare.

Alba: My wife was diagnosed with PD at a young age. I have noticed new problems occurring, specifically not being able to focus. Are problems with concentration common with Parkinson’s?

Dr__Michal_Gostkowski: The important step is to find the cause of the concentration issues: depression, anxiety, pain. Then we would treat it appropriately.


Exercise

robbiea: Do you recommend any specific exercises to reduce symptoms? Is working out with weights OK?

Dr__Michal_Gostkowski: There are multiple PD exercise regimens. I have been trained and my experience is that patients benefit from stretching and extension exercises. I do not recommend weights since they can make some patients become more bent over.

Marthy: What are 'extension' exercises?

Dr__Michal_Gostkowski: Stretching exercises, extension of the spine and extremities.

Curious: I have read about Dr. Albert’s research in regard to treating PD symptoms with forced exercise. Can you explain the difference between regular exercise and ‘forced’ exercise benefits?

Dr__Michal_Gostkowski: The results of Dr. Albert’s research focus on the fact that forced exercise has potentially more benefits than voluntary exercise. It is a very interesting study.

Orchidman: What is the difference between "forced" exercise and normal exercise?

Dr__Michal_Gostkowski: Forced exercise in Dr. Alberts' research is exercise to a predetermined rate/time, which would exert the patient past what they would typically do. Think continuing to sprint instead of jogging.

Marthy: Can you 'be more specific’ as to 'what' exercises to 'extend' and 'stretch' the spine and extremities? (Yoga? Other?)

Dr__Michal_Gostkowski: Yes. Yoga, Pilates -- any exercise that involves stretching has been found to be beneficial.


Non-Traditional Therapy

coffeelover: Do you ever suggest that your PD patients receive acupuncture to help relieve symptoms?

Dr__Michal_Gostkowski: I do not recommend this, but I will not discourage it. There have not been many studies regarding the effectiveness; and if the option was between medical treatment and acupuncture, I would only consider acupuncture as a supplement.

robbiea: Do you recommend any natural supplements that might help ease some of the symptoms (i.e. glucosamine)?

Dr__Michal_Gostkowski: Since the FDA does not regulate supplements, there is not one that is interchangeable between brands like an aspirin. There is research on some supplements like coenzyme Q10 and creatinine, but they are still looking into it. Herbal supplements can be dangerous, but some of those for anxiety may be helpful. However, I would recommend you speak to your physician before starting them.


Future

tamia2003: What causes this disease to take over the body?

Dr__Michal_Gostkowski: That is the billion dollar question. We know it's a progressive disease so we expect patients to get worse with time. There will likely be different reasons for each person.

Om: What are best actions we can do to slow progression of disease?

Dr__Michal_Gostkowski: Exercise, healthy living, and medications help with the disease as it progresses.

GRAMMYRUTH: My nephew has been diagnosed with Parkinson's plus syndrome. We are very concerned for him and his family. They do not have immediate family support where they live. Will they be able to care for him at home in the latter stages of this disease? He's had this for five years already and is in his early 40s.

Dr__Michal_Gostkowski: I am sorry to hear about that. There are many different types of Parkinson's plus syndromes, so I cannot answer that specifically. The treatment is usually supportive, so we are unable to treat it really effectively.


Research

Marthy: Are the Cleveland Clinic Neurology Institute doctors aware of study findings published in the 9/8/11 Neurology International medical journal about a procedure by Pittsburgh, PA, Dr. P. Jannetta whereby he 'repositioned' an 'offending artery pressing against the cerebral peduncle' of a woman who had Parkinson's, rendering her symptom-free after the 'procedure'? A subsequent control-study found that 78 percent of participants having Parkinson's also had the same 'arterial problem.' Dr Jannetta plans to further the study using other institutions. Would Cleveland Clinic Neurology Institute possibly consider participating?

Dr__Michal_Gostkowski: Yes, I am aware of this case report, which is interesting. Skull-base surgery is used for hemifacial spasm and trigeminal neuralgia in extreme cases. The neurosurgeons I work with are hesitant since there are severe and permanent side-effects (deafness), and the results are usually not complete and permanent.

sein3892: I feel as if I have exhausted all possibilities with medication options for treating my PD symptoms. How can I find out if I am eligible for clinical trials that Cleveland Clinic offers?

Dr__Michal_Gostkowski: Meet with a Cleveland Clinic Foundation movement disorders neurologist and discuss what studies you may qualify for. There are different criteria for each study.

We do have a listing of our current trials at this website http://my.clevelandclinic.org/research/clinical_trials/ns_neurological_restoration.aspx

Marthy: Are you aware of a clinical trial, 'CERE-120' involving 'introducing' the 'gene' cere-120 (neurturin)?

Dr__Michal_Gostkowski: The trial had to be redone. The results are not out yet, but there is some encouraging news. It is not available yet to the general public


General Questions

quiddichplayer: Does Cleveland Clinic offer any type of support groups for patients and family members with Parkinson’s disease?

Dr__Michal_Gostkowski: There is a young-onset support group. There is excellent information available on our website (http://my.clevelandclinic.org/Documents/Neurological_Restoration/Young-Onset-PD-Fact-Sheet-FINAL.pdf)

For questions about our Northeast Ohio Young Onset Parkinson’s Support Group, call 216.445.0267 or e-mail us at youngparkinsonsgroup@ccf.org.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Michal Gostkowski is now over. Thank you again Dr. Gostkowski for taking the time to answer our questions today about the treatment and management of Parkinson's disease.

Dr__Michal_Gostkowski: Thank you for the interesting questions.


More Information

To make an appointment with Michal Gostkowski, DO, or any of the specialists in the Center for Neurological Restoration at Cleveland Clinic, please call 216.636.5860 or call toll-free at 866.588.2264. You can also visit us online at www.clevelandclinic.org/neurorestoration.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.

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This chat occurred on 10.4.2011

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