Physical Therapy for PD

Exercise should be part of the daily routine of a patient with Parkinson’s disease (PD). Exercise and regular activity improve mobility, dexterity, and balance, and may even slow the progression of PD. Exercise, especially outdoors, also helps to alleviate depression, which is a common accompaniment of parkinsonism. Finally, there is a growing belief in the medical community that regular exercise improves or preserves cognitive function. For most PD patients, it is not necessary to consult with their primary care provider (PCP) before starting a low-impact exercise regimen, such as taking a daily walk for 30 minutes. However, for a PD patient with heart or pulmonary disease, in particular, it is important for the PCP to determine what exercise can be done safely.

For a more focused program, patients may want to consult with a physical therapist on specific exercises that can be done to keep muscles, joints, and limbs in an optimal state. Neurologic Clinical Specialists (NCS) are physical therapists who specialize in movement disorders, such as PD. However, a patient should not delay starting a program in order to meet with an NCS, as all physical therapists are trained movement professionals and will be able to assist in creating an exercise plan.

A physical therapy (PT) program ideally should focus on improving posture and balance and on maintaining dexterity and functional ability in the limbs. Such programs can be tailored to emphasize exercises that may reduce the risks of falling. It is common for patients with PD to have disturbances of gait, and certain exercises can help to maintain good strides, improve arm swing, and counter freezing episodes.

PD motor symptoms are usually asymmetric, affecting one side of the body more than the other. Some patients with PD show a reticence to use their affected side. Seeking to hide their tremor, they will attempt to stay the tremor by clasping hands or sitting on the tremulous hand. Others, knowing that one hand is slower and clumsier, will favor the “better” hand for most activities. Patients with PD who have predominantly lower limb symptoms often reduce the amount of walking they do, or rely increasingly on a cane or walker. If an assistive device is necessary to protect the patient from repeated falls, it should be employed —however, the danger in neglecting an affected limb is that the less the limb is used, the less usable it becomes. Patients must actively strive to do more with affected limbs. “Forced” use of an affected limb leads to neural adaptation. In other words, the limb becomes more responsive because the neural pathways that control it are activated more fully. Neural adaptation has been shown to occur in patients who have undergone forced use rehabilitative strategies after a stroke.

In the daily routine of a patient with PD, time should be spent on improving range of motion, task performance, and coordination, particularly of the more symptomatic limb. For the hands, practice precise repetitive movements: drumming or tapping the fingers, turning the palm up and down, throwing, catching, and squeezing a ball, putting small objects in small containers, using a finger to quickly touch mobile and stationary objects, and so on. Exercises to practice with the legs include: marching and stepping in place while occasionally changing directions, and toe tapping. When walking, keep the head up, the shoulders back, and swing the arms purposefully. The point is to challenge the limbs to be as active as possible.

After a PT program has been outlined and followed for a while, periodic re-evaluation by the physical therapist will help to confirm that the program is providing some benefit. PD is a disease that tends to worsen over time, and exercise programs may need to be adjusted with disease progression.

Keeping the mind limber is also important. Learning-based exercises can help maintain multi-tasking capabilities, which may —in turn— have a positive effect on work and inter-personal interactions. Solving puzzles, playing board games, and exploring new hobbies are all things that PD patients can do to challenge the mind and keep it nimble. Other activities like dance, tai chi, and yoga are especially beneficial, pairing relatively low-impact movement with learning, memory, and repetition. In addition, these activities provide pleasure and increase opportunities to socialize. Physical therapy offers the opportunity to collaborate with a movement professional to create a regimen that is unique to the patient, and will help the patient keep the body and mind durable, flexible, and resilient.

Bay Area NPF 2016 Moving Day, 2 dates!

In case you haven't heard, the National Parkinson Foundation is having its second annual Moving Day® in San Francisco (May1) and Silicon Valley (June 4) and we would love to see you there!

UCSF is a National Parkinson Foundation Center of Excellence and the UCSF Parkinson’s Disease and Movement Disorders Clinic (Parnassus Campus) and the UCSF Movement Disorder and Neuromodulation Center (Mt Zion Campus) are working with the NPF to produce another successful event.  We are currently establishing the UCSF PD Center walking team and hope you will be inspired to create your own team and join with the hundreds of other people walking and celebrating together!

Moving Day® is a fun and inspiring fundraising event that will unite families, friends, and communities in the fight against Parkinson’s disease. More than just a walk, Moving Day highlights NPF’s belief in a better life until we have a cure for PD.  It focuses on “movement” and exercise as a symbol of hope and progress because of its essential role in treating the disease.   The funds raised by this event help support NPF programs vital to the advancement of PD research and outreach at the national and local level.  Last year, support from the NPF helped to expand our community outreach in San Francisco.

REGISTER TODAY for either:  San Francisco - Sunday, May 1, 2016 or Silicon Valley (San Jose) – Saturday, June 4, 2016.  You can find additional information at www.MovingDayBayArea.org.

Moving Day® features a unique Movement Pavilion, with stations such as yoga, Pilates, Tai Chi, PWR, LSVT Big, boxing, and dance — all proven to help manage the symptoms of Parkinson’s disease. The walks also feature a Resource Pavilion, which will include local medical and paramedical professionals like neurologists, physical therapists, social workers, and other community resources for patients and caregivers.  Included in the festivities are family-friendly walk routes of 1, 2, or 3 miles, a kids’ area, music, entertainment and much more. 

Thank you for your support and if you have any questions concerning Moving Day®, please reach out to walk coordinator, Colleen Fischer at 925-421-6737 or email her at cfischer@parkinson.org. 

Hope you can make it out for a day of movement and exercise and support for the fight against PD.

Aaron (Team Captain, UCSF PDCRC)

The History of Levodopa

Levodopa is the “gold standard” for the medical treatment of the motor symptoms of Parkinson’s disease (PD) [1].  How levodopa was discovered and the process by which it was found to have anti-parkinsonian effects is an interesting scientific story.

Levodopa is the precursor to the neurotransmitter dopamine, i.e., it is converted to dopamine in the body.  A neurotransmitter is a chemical that “transmits” information from one neuron (nerve cell) to another [2].   Dopamine is involved in the ability to move, form memories and learn, experience pleasure, sleep, and keep stable emotional states.   It was first synthesized in 1911, by Casimir Funk in London [3].  At the same time, an Italian pharmacologist, Torquato Torquati, isolated and crystallized levodopa from the seeds of a broad bean plant (Vicia faba), while researching naturally occurring compounds in plants [4].  

In 1913, Swiss biochemist Marcus Guggenheim discovered that the compound that Torquati had produced was levodopa [3, 4].  Guggenheim used himself as a test subject and ingested 2.5 g of levodopa (the equivalent of taking 25 Sinemet 25/100 pills at once) and recorded his body’s reaction.  He became nauseous and began to vomit, which he assumed incorrectly was due to an irritation of the mucus membrane layer of his stomach [5]. 

Four years after Guggenheim’s work with levodopa, Swiss dermatologist Bruno Bloch correctly postulated that levodopa was the parent compound—a chemical composite from which derivatives can be created—of melanin [3].  Melanin is responsible for determining skin and hair color, i.e., their pigmentation [6].   This discovery showed that levodopa occurred naturally in human skin cells.

For many years it was not realized that levodopa had any useful biological functions.  In the early 1940s, however, it was found that the body converted levodopa into dopamine and in the 1950s dopamine was also found to occur naturally in the body [7].  Swedish scientist Arvid Carlsson discovered that dopamine was a neurotransmitter in the brain [8] and established a scientific method for measuring dopamine levels in brain tissue [9].  Subsequent analysis showed that the basal ganglia, an area of the brain essential for movement, normally contained high levels of dopamine [10]. By giving animals a drug called reserpine—which reduces the levels of dopamine—Carlsson induced a loss of spontaneous movements [11]. In 2000, he was awarded the Nobel Prize in Physiology or Medicine for his work.

In 1959 two Austrian doctors, Ehringer and Hornykiewicz, measured dopamine levels in the brains of deceased patients. Using 17 human control brains, they compared dopamine levels to those in the brains of 2 patients with Huntington’s disease, 6 patients with movement disorders of unknown origin, and 6 brains of patients with PD. Compared to the controls and the patients with other neurodegenerative diseases, only the brains of the 6 PD patients showed severe dopamine loss [12]. 

A treatment hypothesis was soon formed: PD patients suffer from a loss of dopamine; therefore, the introduction of dopamine to the body should have a beneficial effect.  Certain substances, including dopamine, are unable to penetrate from the blood into the brain. Accordingly, levodopa —which does penetrate this blood-brain barrier —was used instead as the therapeutic agent.  In 1961, two independent medical studies found that levodopa led to significantly improved motor function of PD patients [13, 14].  Seven years later, neurologist George Cotzias outlined a high-dose levodopa treatment for PD patients that is still in use today [15, 16].

While levodopa can cross the blood-brain barrier, researchers discovered that the majority of levodopa administered was being metabolized by the body before it reached the brain.  The inclusion of the compound carbidopa to the levodopa inhibited this extra-cerebral breakdown of levodopa, so that more levodopa was able to get into the brain.  An added benefit of slowing the extra-cerebral breakdown of levodopa was a significant reduction in the nausea experienced by patients.  Consequently, patients were able to take much smaller doses of levodopa with the same (or more) therapeutic benefit. 

In 1972 a combination carbidopa/levodopa treatment was approved in the United States under the trade name Sinemet© (a Latin combination of Sin-“without” and Emet-“vomiting”) in four different dose strengths, 10/100, 25/100, 25/250 and 50/250.  Madopar© was created for distribution in Europe and other countries, using a combination of levodopa and benserazide (a compound with the same inhibitory capability as carbidopa).  Over forty years have passed since symptomatic levodopa treatment was introduced for PD, and to this day it remains the most widely used course of treatment for combatting the motor symptoms of PD.

References

1. Aminoff MJ. Parkinson's disease. Neurol Clin. 2001;19(1):119-28, vi.
2. National Institute of Health. Brain Basics. Available at http://www.nimh.nih.gov/health/educational-resources/brain-basics/brain-basics.shtml. Accessed on March 23, 2016
3. Hornykiewicz O. L-Dopa: A historical perspective. In: Yoshimi Misu, Yoshio Goshima, eds. Neurobiology of DOPA as a Neurotransmitter. Boca Raton, FL: CRC Press; 2005: 3-16
4. Hauser RA. Levodopa: past, present, and future. Eur Neurol. 2009;62(1):1-8.
5. Hornykiewicz O. A brief history of levodopa. J Neurol. 2010;257(Suppl 2):S249-52.
6. Mandal, A. What is Melanin? http://www.news-medical.net/health/What-is-Melanin.aspx Accessed 12/17/2015
7. Carlsson A, Lindqvist M, Magnusson T, Waldeck B. On the presence of 3-hydroxytyramine in brain. Science. 1958;127(3296):471.
8. Carlsson A. The occurrence, distribution, and physiological role of catecholamines in the nervous system. Pharmacol Rev. 1959;11(2, Part 2):490-3.
9. Carlsson A, Waldeck B. A fluorimetric method for the determination of dopamine (3-hydroxytyramine). Acta Physiol Scand. 1958;44(3-4):293-8.
10. Lees AJ, Tolosa E, Olanow CW. Four pioneers of L-dopa treatment: Arvid Carlsson, Oleh Hornykiewicz, George Cotzias, and Melvin Yahr. Mov Disord. 2015;30(1):19-36.
11. Carlsson A. A half century of neurotransmitter research: impact on neurology and psychiatry. In: Hans Jornvall, ed. Nobel Lectures in Physiology or Medicine 1996-2000. River Edge, NJ: World Scientific; 2003: 303-322.
12. Ehringer H, Hornykiewicz O. [Distribution of noradrenaline and dopamine (3-hydroxytyramine) in the human brain and their behavior in diseases of the extrapyramidal system]. Klin Wochenschr. 1960;38:1236-9.
13. Birkmayer W, Hornykiewicz O. [The L-3,4-dioxyphenylalanine (DOPA)-effect in Parkinson-akinesia.]. Wien Klin Wochenschr. 1961;73:787-788.
14. Barbeau A, Sourkes TL, Murphy GF. Les catécholamines dans la maladie de Parkinson. In: de Ajuriaguerra J (ed) Monoamines et système nerveux central. Georg & Cie SA; Geneva: 1962: 247–262
15. Cotzias GC, Van woert MH, Schiffer LM. Aromatic amino acids and modification of parkinsonism. N Engl J Med. 1967;276(7):374-9.
16. Cotzias GC, Papavasiliou PS, Gellene R. Modification of Parkinsonism--chronic treatment with L-dopa. N Engl J Med. 1969;280(7):337-45.