Medications have long been in use for Parkinson’s disease. Use of different medications has resulted in the betterment of the life of the patient with the disease. All the symptoms of the Parkinson’s disease like tremors, bradykinesia, and rigidity are controlled to some extent for some period of time by the medications available.

But after a period of time, medications become ineffective to control the progression of the disease. The symptoms worsen. Then other modalities of treatment are considered. Surgical treatment is one option. A new mode of treatment which has come up for the treatment is deep brain stimulation.

What is deep brain stimulation?

Deep brain stimulation is a surgical procedure for the treatment of Parkinson’s disease. It involves placing a small electrode within the brain surgically. The area of the brain for the electrode insertion is chosen carefully. The area in the brain with the maximum amount of active cells of Parkinson’s disease is chosen for the procedure. The electrode is connected to a pulse generator and gives intermittent electric stimulus to the cells. The stimulus would control the excessive brain activity in the area and in effect control the symptoms of the disease.

Is the procedure helpful?

Deep brain stimulation is an advanced procedure and is commonly seen to control the symptoms of the disease. The use of the oral medication in the patients is reduced after the surgery. It also reduces the dyskinesias which are often associated with levodopa use. In several patients of Parkinson’s disease, it is seen that the as the disease progresses, patients experience a fluctuation of the symptoms. With the progression of the disease, the patient experience a time when the amount of the medication becomes inadequate to control the symptoms. When deep brain stimulation is done, the patient experiences a medication like state even when off medication.

Are there risks involved with the surgery?

As any surgery, there are risks involved with deep brain stimulation as well. Bleeding may occur in some patients and might turn fatal. In some patients, stroke also occurred post operatively. Infection also may occur in some patients, but with advanced modern medicine, it is easily controlled.

The outcome of the procedure depends on the patient’s condition at the time of the surgery. The presentation of the Parkinson’s disease itself varies in every individual patient; hence the effect of the treatment also may be different for different patients.

There are several medications available for the treatment of Parkinson’s disease. Levodopa is the most common medication used for a patient with Parkinson’s disease. Levodopa is given to the patients with the intention of reducing the symptoms of the disease such as stiffness, tremor and slowing of the movements. But since the medication is taken orally, very little amount of it reaches the brain. The mechanism of action of levodopa is stimulating the brain cells to convert it into dopamine. Advances in modern technology discovered other medications when given along with levodopa, allows slow release of the medication and hence an optimal amount of the drug to reach the brain.

Anticholenergics are used along with levodopa. Amantadine may also be used along with levodopa and helps in the reduction of fatigue, tremor and bradykinesia.

Neuroprotective treatments aid in the protection of the brain cells and is seen to be helpful in the patients with early stages of Parkinson’s disease. Selegiline is a drug which inhibits the enzyme monoamine oxidase B. the enzyme breaks down the dopamine in the brain and reduces the time dopamine is available in the brain. Inhibition of this enzyme would increase the time when dopamine is available in the brain and thereby reduces the progression of the disease.

There are surgical treatments also available for Parkinson’s disease. They come into the picture at a very later stage in the progression of the disease. In the earlier stages of the disease, it is attempted to delay the progression, then the symptoms are reduced with the aid of medications, but at a later stage when the patient starts experiencing wearing off, of the medication, surgery may provide some relief.

Pallidotomy and is an ablative procedures where a small area in the brain, which produces the symptoms of Parkinson’s disease, is destroyed surgically. This would immediately reduce the symptoms of the disease.

Deep brain stimulation procedures are also conducted in an effort to reduce the symptoms of Parkinson’s disease. In this procedure, an electrode is placed within the brain and intermittent stimulation of the abnormal cells which result in the symptoms of Parkinson’s disease is done. It is aimed at restricting the activity of these abnormal cells.

With all these treatment modalities, the quality of life of the patient of Parkinson’s disease might be improved.

What is Parkinson’s disease?

Parkinson’s disease is a slowly progressive neurological condition occurring due to the lack of dopamine in the brain cells. Dopamine is one of the neurotransmitters involved in the transmission of information through the nerves. Movement, muscle control and balance are commonly affected if there is a deficiency of dopamine; hence the symptoms of Parkinson’s disease are related to these.

What are the signs and symptoms of Parkinson’s disease?

The most common signs are

1. Tremor- uncontrolled shaking of the body while atnrest. This is especially noted at the hands.

2. Bradykinesia- Slowness & difficulty beginning a voluntary movement. Simple movements like standing up from a sitting position, turning to one side etc may become difficult, as the disease progresses.

3. Muscle stiffness

4. Imbalance. The patient frequently loses balance and there is a high risk of falls. In elderly people, the bones are extremely fragile, hence any fall might add to the complications already present.

The symptoms presented are

1. Hypomimia- a lack of expression on the face. This occurs due to the damage of the nerves controlling the facial movements.

2. Hypophonia- the voice becomes softened. Other people may find it difficult to hear when the person with Parkinson’s disease is speaking.

3. Microgrpahia- handwriting becomes smaller.

4. Depression.

5. Constipation.

Management of Parkinson’s disease

The treatment of Parkinson’s disease is aimed at improvement of the daily living of the patient. No definitive treatment modality has been developed till now. It is better to start the treatment for the disease at the earliest, once the diagnosis is made, as there might be adverse effects in the later stages of the disease, if treatment is not given.

Medications used in the treatment of Parkinson’s disease

Levodopa is the most commonly used medication for managing Parkinson’s disease. This is used in combination with other medications, thereby improving the condition of the patient.

Mechanism of action of Levodopa

Levodopa is a naturally present substance in animals and plants. But taken orally the dopamine from these products might not reach the brain. This is being done by the medication. Levodopa, taken in the form of medication, reaches the brain cells where it is converted into dopamine. The dopamine producing brain cells, take in the dopamine and the symptoms of Parkinson’s disease is reduced.

Levodopa used in combination treatment

Levodopa alone is not commonly used for the treatment of Parkinson’s disease. it is always used in conjunction with other medications like carbidopa or benserazide. The combination therapy is more effective because carbidopa or benserazide if used along with levodopa would restrict the conversion of levodopa into dopamine outside the brain. This results in the optimal amount of dopamine in the brain.
Levodopa is most effective against rigidity and slowness present in the Parkinson’s disease. It is not as effective against the imbalance or tremor.

Side effects of Levodopa

1. Nausea and vomiting- in the initial stages of the treatment. As doses are increased, the dose of carbidopa or benserazide is adequate in controlling this side effect.

2. Dyskinesias- involuntary movements like jerking, writhing, nodding might occur.

3. Low blood pressure- in the initial stages if the dosage is higher than required.

4. Arrythmia

5. Hairloss

6. Confusion

7. Visual and auditory hallucinations.

8. Wearing off effect- if the dose of levodopa is not adequate to control the symptoms, or if adequate levodopa has not reached the brain, the symptoms might be evident before it is time for the second dose. This is called wearing off effect and most people think it is a worsening of the disease because of the medication. The progression of the disease might be a reason for this effect.

For each patient, the disease manifests in a different way. The treatment of the disease and the dosage of the drugs are also individual.
There are other newer drugs also included in the treatment of Parkinson’s disease, used in combination with levodopa.