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Managing Parkinson's Disease&Other Movement Disorders

Introduction

Cleveland_Clinic_Host: Parkinson’s disease is a chronic, progressive neurological disorder that affects a small area of nerve cells deep within the brain. Approximately 1.5 million Americans have Parkinson’s disease, including one out of every 100 people over the age of 60.

More than 50,000 Americans are diagnosed with Parkinson’s disease each year. Other types of movement disorders, including essential tremor (uncontrollable shaking or tremors in different parts of the body) and dystonia (forceful sustained muscle contractions cause twisting and repetitive movements or abnormal postures) also affect thousands people throughout the United States and around the world.

Take advantage of this opportunity to chat live in a secure, online setting with medical and surgical experts in the treatment and management of Parkinson’s disease, essential tremor and other types of movement disorders. Dr. Andre Machado and Dr. Anwar Ahmed will be available to answer your questions regarding the management and treatment options associated with these conditions. Bring your own questions to the chat. This is your time to ask!


Andre Machado, MD, PhD

Andre Machado, MD, PhD, is the director of the Center for Neurological Restoration and associate staff in the department of neurosciences, the department of biomedical engineering and department of neurological surgery, all located on Cleveland Clinic’s main campus. He earned a doctorate in medicine and a PhD in experimental neurology from the University of Sao Paulo in Sao Paulo, Brazil. He then completed a neurology internship and residency at the same institution. Dr. Machado also completed a fellowship at Cleveland Clinic in stereotactic and functional neurosurgery and was co-investigator of a NIH study to assess the safety of using MRIs for deep brain stimulation.

Dr. Machado has published his research in many peer-reviewed journals.  In 2006, the American Association of Neurological Surgeons (Stereotactic and Functional Neurosurgery Section) awarded Dr. Machado the Philip L. Guildenberg Award for published research, determining the optimal cathode location for deep brain stimulation as a treatment for refractory obsessive-compulsive disorder. He was a co-author of a 2007 Nature article titled “Behavioral improvements with thalamic stimulation after severe traumatic brain injury.” Dr. Machado was recently awarded the Cleveland Clinic’s Innovator Award.


Anwar Ahmed, MD

Anwar Ahmed, MD is a neurologist and a staff member of Cleveland Clinic’s Center for Neurological Restoration. He specializes in movement disorders, tremor analysis, Parkinson’s disease and related neurodegenerative disorders, dystonia and botulinum toxin injection for dystonia, and deep brain stimulation for movement disorders.

He received his medical degree from Dow Medical College in Karachi, Pakistan. Following a medicine internship at Mount Sinai Medical Center in New York, Dr. Ahmed completed a clinical research fellowship in movement disorders at Cleveland Clinic, a fellowship in surgical approaches to movement disorders and motor physiology at Columbia University Medical Center/New York Presbyterian Hospital, and a residency in neurology at Detroit Receiving Hospital/University Health Center. Dr. Ahmed has conducted a number of research studies and has presented and published on topics such as unusual movement disorders, treatment of tremor caused by multiple sclerosis, and brain stimulation.

Cleveland_Clinic_Host: To make an appointment with Dr. Andre Machado, Dr. Anwar Ahmed or any of our other specialists in the Center for Neurological Restoration in the Neurological Institute at Cleveland Clinic, call 216.636.5860 or toll-free at 866.588.2264; visit us online at clevelandclinic.org/neurorestoration.


Parkinson’s Disease Overview

Cleveland_Clinic_Host:  Welcome to our Online Health Chat with Andre Machado, MD, PhD and Anwar Ahmed, MD. We are thrilled to have Dr. Ahmed and Dr. Machado here today for this chat. They are considered experts in the Parkinson’s disease and other movement disorders. Let’s begin with some general questions.

tentonj: What causes Parkinson’s disease?

Speaker_- Dr__Anwar_Ahmed: The cause of Parkinson’s disease is unknown. It probably is multifactorial such as hereditary predisposition, environmental toxins, and aging.

paller2_18: Is Cerebellar Atrophy a part of Parkinson’s disease?

Speaker_s__-_Dr__Anwar_Ahmed: No. There are other forms of Parkinson’s, such as Multiple System Atrophy which can cause Cerebellar Atrophy.

century1: Does Parkinson’s always get progressively worse or can medication halt its regression or worsening? Any side effects from brain surgery?

Speaker_- Dr__Anwar_Ahmed: Parkinson’s disease is a chronic neurodegenerative disease. Usually progression is slow in many patients and symptoms usually get progressively worse over the years. To date, there are no medications available to halt its regression or worsening. However, recent clinical studies have shown that starting early Parkinson medication may be helpful to modify the course of the disease, particularly delaying the onset of long term complications.

bankers_box: Should children of Parkinson’s patients have DNA testing to check if they could develop Parkinson’s in their lifetime?

Speaker_- Dr__Anwar_Ahmed: Parkinson’s could be genetic in some families when there are cluster of people that manifest Parkinson’s symptoms in the same family. There are gene mutations responsible for young onset and Juvenile Onset Parkinson’s disease. However, late onset Parkinson’s is less likely to be associated with genetic mutations. So we usually recommend genetic testing for young onset Parkinson’s disease patients and also those with strong family history of this disease.

At this time it is not recommended to check children’s of Parkinson’s patient for known mutations if the patient himself is not tested and secondly genetic testing would not be helpful to treat or cure the disease before it starts.


Diagnosing Parkinson’s

ptt_298: How do you get early detection of Parkinson’s disease – what type of tests?

Speaker_- Dr__Anwar_Ahmed: There are no specific laboratory tests available to detect early Parkinson’s disease. Parkinson’s disease is a clinical diagnosis and at least two clinical signs should be present to make a diagnosis.

eahls: What tests do you use to determine Parkinson’s, is a brain scan one of them?

Speaker_- Dr__Anwar_Ahmed: Parkinson's is a clinical diagnosis and at least two clinical signs should be present to make the diagnosis.

Clinical signs to make correct diagnosis includes: presence of tremor at rest, slowness of movement, muscle stiffness or rigidity and walking difficulty. Presence of at least two of these clinical signs is needed to diagnosis PD. Again, there is no specific laboratory test available for making a diagnosis.

eahls: What does a brain CT scan reveal about Parkinson’s?

Speaker_- Dr__Anwar_Ahmed: The only finding on the CT scan would be non-specific brain atrophy.

hallerjohn: My father was diagnosed with Parkinson’s disease (Frontal Lobe) and Dementia about 10 yrs. ago. He has tremors, balance problems, hoarse voice, rigidity, confusion. He sees a top Cleveland Clinic specialist who has not put him on any real Parkinson’s meds because he doesn’t feel he needs them yet. He takes ARICEPT ® (donepezil HCl) and I assume that is more for the memory. He is not severe and seems to be slowly progressing. Do Parkinson’s and dementia go hand in hand? Are there long term effects to medications and are the side effects severe?

Speaker_- Dr__Anwar_Ahmed: From the description, it is possible that your father may not be suffering from the most common form of Parkinson’s disease (Idiopathic Parkinson’s disease). Usually dementia starts in Parkinson’s disease in late stages, and after 10 years, at least 25-30% may have some degree of dementia. If dementia and balance difficulty are initial manifestations, then other diagnosis should be considered, such as Lewy Body Disease, Progressive Supranuclear Palsy, Corticobasal Ganglionic Degeneration and Fragile X Tremor Ataxia Syndrome. In these conditions Parkinson’s medications are minimally effective and have a high risk of side effects such as hallucinations, confusion, low blood pressure and symptoms worsening can occur.

triedbuttrue: Would balance have any connection to Parkinson’s? I am experiencing balance issues: feeling top heavy, moving fast or get up from sitting or rising in the morning having to be careful from falling.

Speaker_- Dr__Anwar_Ahmed: Balance difficulty is one of the symptoms of Parkinson’s disease. In many patients, balance difficulty starts to occur as the disease progresses. Parkinson’s medication might be helpful if it is related to medications wearing off. In some Parkinson’s patients, blood pressure drops upon standing and cause them to loose balance. You should discuss this with your health care provider.

Q2B: Can a simple tremor (left thumb) and weakness in a limb (left leg) lead one to think they have Parkinson’s?

Speaker_- Dr__Anwar_Ahmed: Parkinson’s disease may start with mild clinical symptoms including thumb tremor at rest, slowness of movement in limbs (not weakness), rigidity or muscle stiffness. Some time slowness of movement can be taken as weakness. I would suggest seeking a neurologist's opinion for your symptoms.

bbtrent: Are TIA’s a factor in getting Parkinson’s?

Speaker_- Dr__Anwar_Ahmed: TIA’s are not risk factor in developing Parkinson’s disease.


Tremor: Essential and Non-Essential

cappy: Would you explain the difference between Essential Tremor, Non-essential tremor and Parkinson’s disease?

Speaker_- Dr__Anwar_Ahmed: Essential tremor is also called familial tremor. It usually begins in early life but some patients can develop later in life.

  • It can be distinguished from Parkinson’s disease by 1) its low amplitude and higher frequency 2) Essential tremor manifests during posture and action as opposed to rest tremor of Parkinson’s disease 3) Lack of slowness of movement and rigidity in Essential tremor versus presence of these features in Parkinson’s disease.
  • Non essential tremor could be any type such as:
  • Dystonic tremor: Tremor with abnormal muscle pulling or posture.
  • Medication induced tremor: History of using Antipsychotic, Lithium, Depakote, Nausea medications.
  • Physiological tremor: tremor due to stress or anxiety
  • Psychogenic tremor: tremor due subconscious conflict

RT97: Please explain the cellular mechanism that causes essential tremor. Is there a correlation of cause between heart arrhythmias, such as SVT or A-FIB, and essential tremor?

Speaker_- Dr__Anwar_Ahmed: The cellular mechanisms in essential tremor is not fully understood. However recording of tremors cells in the brain can be seen in the thalamus of essential tremor patients.

In response to your 2nd questions, there is no relationship to Afib or SVT.


Diffuse Lewy-Body Disease

pattyrosier5: Is diffuse lewy body disease hereditary and what causes it? Can it be from toxic fumes?

Speaker_- Dr__Anwar_Ahmed: No, it is not hereditary and no toxic fumes have been known to cause this disease. The cause of Lewy body disease is unknown.

pattyrosier5: What can we expect to be the progression of diffuse lewy body disease?

Speaker_- Dr__Anwar_Ahmed: Diffuse lewy-body disease is a chronic progressive neuro degenerative disease which affects patient's cognition, gait, balance and autonomic nervous system. Symptoms gradually get worse particularly memory decline occurs over the years and walking and balance difficulty becomes worse as well.

Progression is usually very slow and takes many years to get worse to the point where the patient requires significant assistance and help.

In many patients, symptoms can persist in a mild degree before the eventual diagnosis can be made.

concernedfriend: Would the use of ubiquinol help with symptoms of Diffuse Lewy-body disease?

Speaker_- Dr__Anwar_Ahmed: Ubiquinol is the active antioxidant form of Coenzyme Q10 (CoQ10). CoQ10, a vitamin-like substance found in every cell in the body plays a vital role in cellular energy production and protects cells from free radical damage. In one study, low levels of Coenzyme Q10 was found in patients with Lewy body disease. Unfortunately there are no clinical studies done on Lewy-body disease patients to study the benefit of Ubiquinol (Co Q10). However in Parkinson’s disease, one study has shown the benefit of using CoQ10 in early patients.

concernedfriend: Are there any clinical trials available for people with DLBD?

Speaker_- Dr__Anwar_Ahmed: There are no clinical trials that are being conducted at Cleveland Clinic at this time for DLBD. You may check the NIH Clinical Trial website which is clinicaltrials.gov for more information.


Treatment Options

plankton: What are the treatment options for Parkinson’s disease?

Speaker_- Dr__Anwar_Ahmed: There are many treatment options, including medications available for symptomatic control in Parkinson’s disease.

  • Dopamine Agonist: Mirapex® and Requip®
  • Sinemet® (Carbidopa/Levodopa)
  • MAOB inhibitors: Azilect® and Eldepryl®
  • COMT inhibitors: Tasmar® and Comtan®
  • Amantadine®
  • Anticholinergics: Artane®

mastersk: Is Vitamin E used in the treatment of Parkinson’s disease?

Speaker_- Dr__Anwar_Ahmed: Vitamin E has been studied in the treatment of Parkinson’s disease but not proven to be effective in the treatment of Parkinson’s disease.

hattrick: Do hallucinations/fixed delusions or other side effects of medicines for Parkinson’s disease last forever?

Speaker_- Dr__Anwar_Ahmed: Hallucination’s and fixed delusions are not permanent side effects of Parkinson’s medications. Any Parkinson’s medication can cause hallucinations. Usually hallucinations improve after stopping the offending drug. But in some cases a combination therapy has been used to treat Parkinson’s symptoms and stopping all Parkinson’s medications is not possible or safe in these patients. There are many other side effects including nausea, dizziness, confusion and compulsive behavior which are reversible upon stopping Parkinson’s medication. The motor complications of Parkinson’s disease such as wearing off medications and dyskinesia are more permanent and develop due to progression of the disease itself.

eahls: Is Azilect® effective for Parkinsons? What are its side effects?

Speaker_- Dr__Anwar_Ahmed: Azilect® is effective to treat Parkinson's symptoms when they are mild and also can be used in advanced disease to improve the wearing off problem.

Side effects include nausea, dizziness (high or low blood pressure), feeling tired, insomnia and anxiousness are the more common side effects.

queenie: If someone is being treated for another disease like Schizophrenia, can drugs used to treat this cause drug induce Parkinson’s? Should they see a Neurologist?

Speaker_- Dr__Anwar_Ahmed: In the treatment of schizophrenia, a psychiatrist has to use an antipsychotic which blocks dopamine in the brain and this may lead to drug induced Parkinsonism. Patients should see a neurologist to check if patient has progressive Parkinson’s disease versus drug induced symptoms.

RT97: Is botox effective in treating familial tremors and if so what is the duration of relief per treatment?

Speaker_- Dr__Anwar_Ahmed: Clinical trials have shown that the effectiveness of Botox is minimal in essential tremor except if the tremor involves the head, it may be more beneficial.

For limb tremors, the benefit of Botox is very limited and not recommended.


Deep Brain Stimulation (DBS)

benandgert: When considering treatment for familial tremors our options seem limited. I prefer treatment that is safe but also gives relief. What is the safest longstanding med for familial tremors which has the best effect? Instead of meds what other therapy with effectiveness is available?

Speaker_s__-_Dr__Andre_Machado: If medications fail, the deep brain stimulation surgery can be an option for patient's who are affected by significant tremors.

howards: Can you briefly explain how DBS treats Parkinson’s.

Speaker_s__-_Dr__Andre_Machado: DBS is a brain pacemaker. It sends small electrical signals to the brain to modulate the activity of a part of the brain that is involved in PD. DBS does not cure PD, it may alleviate the symptoms of PD.

jackd: I have heard that not everyone is a candidate for DBS surgery. What is the criteria and is there an age limit?

Speaker_s__-_Dr__Andre_Machado: Great question. It is true that not everyone is a candidate. There are many factors that influence a patient's candidacy for surgery. Patients who are possible candidates are seen by a multidisciplinary group of doctors at our center including a neurologist, neurosurgeon and a neuropsychologist. Usually an MRI of the brain is also done. The groups of doctors then meet in a multidisciplinary conference and discuss each patient's indications and risks individually.

There is no absolute age cut off for surgery. Older patients are likely to have a higher surgical risk. However, even older patients can be good surgical candidates, depending on their health status.

tryharder: Are you using DBS to treat Tourette’s?

Speaker_s__-_Dr__Andre_Machado: DBS is currently not FDA approved for Tourette's. Sometimes, "OFF label" use of DBS can be considered for a patient with refractory Tourette's. This depends on the patient's age, individual characteristics and specific diagnosis and co-morbidities.

plants2: DBS – some feel surgery has hastened memory impairment? What does follow-up study show?

Speaker_s__-_Dr__Andre_Machado: DBS can precipitate memory and cognitive impairment. These are concerns that are taken into consideration at the time of evaluation for surgery. Neuropsychological evaluation can help identify patients who at higher risk for cognitive decline.

centered: What other conditions are treated with DBS? Schizophrenia? Dementia? Bipolar Disorder?

Speaker_s__-_Dr__Andre_Machado: DBS is currently FDA approved to treat Parkinson's disease and essential tremor. There ia a humanitarian device exemption for patients with dystonia and severe forms of OCD.

There is research going on in other neurological and psychiatric disorders such as severe refractory depression and epilepsy. DBS is currently not standard of care for bipolar disorder or schizophrenia.

kdd_915: Are there known predictive factors for success of DBS?

Speaker_s__-_Dr__Andre_Machado: There are some factors that may indicate a good response. No factor is absolute. In general, patients who responded well to medication but now have side effects (like dyskinesias) related to a higher medication dose are possibly good candidates for surgery. Patients who continue to respond well to a dose of medication (compared to the OFF state) can, in general, be good candidates. Patients who have secondary parkinsonism (not Parkinson's disease) are usually not considered candidates.

quick_feet: Any downsides to DBS? Do some devices intervene with signal?

Speaker_s__-_Dr__Andre_Machado: Deep brain stimulation surgery is a brain surgery and has risks including the risk of hemorrhage (stroke) and infection.

Large magnetic fields can interfere with the device and even impose a risk to the patient. MRI usually cannot be done for patients implanted with DBS, with few exceptions under specific guidelines.

hardyharhar: Should a person diagnosed at Stage 3 be considered for continuous deep brain stimulation?

Speaker_s__-_Dr__Andre_Machado: A person with stage 3 PD can be considered a candidate for DBS. The patient can be seen by our multidisciplinary team and be evaluated for candidacy regarding DBS.


Parkinson’s and Diet

proudgramps: Do certain food and/or diet affect Parkinson’s or essential tremors? What about a high protein diet?

Speaker_- Dr__Anwar_Ahmed: Caffeine containing beverages make essential tremor worse. High protein diet interferes with Parkinson’s medications, particularly Levodopa delivery to the brain. High protein directly can not affect Parkinson’s symptoms. There is no effect of high protein on essential tremor.


Exercise and Movement Disorders

kellerj: What’s the difference between forced & voluntary exercise?

Speaker_- Dr__Anwar_Ahmed: Voluntary exercise means the patient is doing exercise at his own pace. During forced exercise, the patient is being assisted mechanically or by a trainer to achieve higher rates of pedaling a bicycle or walking on a treadmill.

There is emerging evidence in medical literature in healthy older adults and individuals with Alzheimer’s disease, which indicates voluntary exercise results in structural and functional changes in the brain. These alterations suggest that brain function can be modified via voluntary exercise in individuals with relatively normal patterns of activation within the motor areas of the brain. However, because Parkinson patients have decreased motor cortical activation therefore limiting their motor output, their ability to induce changes in brain function may be diminished when engaging in exercise under voluntary control.

Preliminary data at Dr. Jay Albert’s research lab in Cleveland Clinic have demonstrated increased activation within the supplementary motor area of the brain after forced exercise. This pattern of increased brain activity is similar to that observed following the administration of the Parkinson medication Levodopa.

finnegan: Is tandem cycling the only methods for forced exercise? Can running produce the same results as pedaling? Fast walking?

Speaker_- Dr__Anwar_Ahmed: At this time, we are studying a tandem bicycle method. Assisted running on treadmill with higher rates may produce similar results as produced by forced bicycling. We need more studies to compare different methods of exercises and symptoms improvement in Parkinson’s disease.


Environmental Toxins

concernedfriend: What tests would be needed to determine environmental toxins and are there specific toxins that could be a factor?

Speaker_- Dr__Anwar_Ahmed: Usually heavy metals in the environment may be associated with Parkinson's like symptoms. Heavy metals such as manganese exposure in welders and in the mining industry may lead to Parkinsonism. Serum and urine manganese levels usually can be checked.


Caregivers

concernedfriend: What advise can you give to friends and family to help both the patient and his spouse(caregiver), especially since they are unable to get any long-term in home health aide?

Speaker_- Dr__Anwar_Ahmed: Caregivers, family, and friends should try to keep eye on changes in a patient symptoms and the patient’s ability to perform daily activities independently. Patient safety should be assessed in terms of walking, balance, swallowing and cognitive functions.
Decisions about keeping a patient at home should be made on the basis of the above mentioned factors. If a caregiver is unable to care for the patient at home, then other alternatives should be explored.


Parkinson’s Research

LSJR: To both doctors - do either of you see a realistic timeframe as to when the PD world may see relief in the form of stem cell research?

Speaker_s__-_Dr__Andre_Machado: We do not have a realistic time frame for whether / when stem cells will have a significant impact on the lives of patients with PD.

lunkin: Is there any research showing a link between metal exposure and Parkinson’s disease?

Dr__Anwar_Ahmed: Occupational exposure to specific metals (manganese, copper, lead, iron, mercury, zinc, aluminum and others) appears to be a risk factor for Parkinson's disease (PD) in some, but not all, case-control studies.


Seeking Second Opinions

goodtimes: My Neurologist has diagnosed me with early-stage Parkinson’s but I am not 100% convinced that I really have it. Are there doctors at Cleveland Clinic who can give me a second opinion and tell me if I am getting the proper treatment?

Speaker_- Dr__Anwar_Ahmed: You are most welcome to come for second opinion regarding your diagnosis and treatment. 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 eclevelandclinic.org/myConsult


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Ahmed and Dr. Machado is now over. Thank you again for taking the time to answer our questions about Managing Parkinson’s disease and Other Movement Disorders today.


More Information

  • To make an appointment with Dr. Andre Machado, Dr. Anwar Ahmed or any of our other specialists in the Center for Neurological Restoration in the Neurological Institute at Cleveland Clinic, call 216.636.5860 or toll-free at 866.588.2264; visit us online at 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 eclevelandclinic.org/myConsult
  • If you need more information, contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!
  • Some participants have asked about upcoming web chat topics. If you would like to suggest topics for 2009, please use our contact link clevelandclinic.org/webcontact.

This chat occurred on September 14, 2009.  

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This information is provided by Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.