Parkinson's Disorder:

A total of 1.5 million Americans have Parkinson's Disorder, more than are afflicted with multiple sclerosis and muscular dystrophy combined. Parkinsons, a degenerative disorder of the brain, results from the destruction of substantia nigra cells that produce dopamine. Typical Parkinsons symptoms include rigid muscles, tremor, bradykinesia (slow movement), gait disturbance, and postural instability.

In the last decade or so, great strides have been made in the treatment of Parkinson disease (PD). New dopamine agonists and COMT inhibitors have improved motor function, and several new medications will soon become available. The treatment of other symptoms that may be present in PD, such as depression and sleep disorders, also has improved.

A select group of patients may benefit from surgical therapy for PD. At a minimum, the addition of an exercise program is vital to maintaining good health.

Though significant, these developments are insufficient in treating every aspect of the disease. Unfortunately, there still exist many symptoms and medication side effects for which current “traditional” treatments are unsatisfactory or incomplete.

Because persons with PD generally tend to be well-educated and quite proactive about the care they receive, many have chosen to explore treatment options outside the realm of “Western” medicine. Alternative therapies have been slow to gain favor with some practitioners of more traditional medicine because there is little research to demonstrate their effectiveness. This is beginning to change, due in part to the establishment of The National Center for Complementary and Alternative Medicine, a government organization that will fund and carry out such studies. Many universities have established similar departments.

For some patients and caregivers, alternative or complementary approaches to treatment are completely novel. Others have been raised in cultures where the use of herbal medicines or acupuncture are commonplace. In fact, many of these modalities have been in use for thousands of years. In the treatment of PD, a number of complementary therapies, such as Yoga and Tai Chi, are well-established companions to traditional medications. Acupuncture and therapeutic massage also have become popular in some PD centers, as have herbal therapies and dietary supplements (though self-prescription of supplements can be dangerous in some cases).

The intention of this article is to provide a summary overview of various complementary therapies, and how some can be useful in the treatment of PD.

Diet

The choices we make about food – what we consume, its quality and quantity – are crucial to our health and well-being. Of course, conflicting information abounds concerning what constitutes a healthy diet: Are fats and carbohydrates “good” or “bad” dietary components? This may depend on which fad diet is currently in vogue. There is some agreement that it is generally wise to consume a varied diet high in fruits and vegetables and to avoid excessive saturated fats, especially trans-fats. There is also some evidence that the so-called Mediterranean diet, a diet high in monounsaturated fats, such as olive oil, may be beneficial in reducing blood pressure and cardiovascular disease. The diet also emphasizes fish, especially those high in Omega-3 fatty acids, such as salmon, and foods containing antioxidants.

Persons with PD are often particularly concerned about the possibility that protein intake can decrease the effectiveness of carbidopa/levodopa, one of the common medications used to treat PD. While it is true that levodopa absorption into the brain can be slowed by a high protein meal, most patients do not notice that their motor function varies along with their diet. Since PD can affect digestive function, many patients do notice symptoms such as constipation and early satiety (the sensation of feeling very full after consuming a small amount of food). Since these changes can be of long-term duration, it may be advisable to treat them with dietary modifications such as frequent, small meals and increased fiber intake to avoid or delay the need for additional medications.

THE LDL-PARKINSON'S CONNECTION FROM THE DAILY HEALTH NEWS (March 2, 2006)

Link Found Between Low LDL CHOLESTEROL and Parkinson's Disease.

The mantra in many medical circles concerning LDL cholesterol continues to be "the lower the better," which is understandable because LDL cholesterol, under certain circumstances, is the one that can clog arteries, leading to heart attacks and strokes. But our bodies need LDL because, among other things, it is critical for cellular membrane walls, it forms a protective sheath around the peripheral nerves and it is a precursor for a number of the body's hormones. Some medical professionals have serious concerns about the drive to lower LDL through statin medications, as I have written about before. They point out that possible repercussions of very low LDL (that found in a total cholesterol level of less than 160 mg/dl) include impaired mental functioning, such as depression and anxiety. Now another worrisome link between low LDLs and possible neurological impairment has emerged via a study from the University of North Carolina, Chapel Hill.

The study found that men with LDL levels between 91 and 135 were six times more likely to have Parkinson's disease (PD) than men with LDL levels higher than 135... men with LDL levels below 91 were four times more likely. This is particularly startling because many doctors consider LDLs of 130 as the point at which statin treatment should begin. I spoke with Xuemei Huang, MD, PhD, lead author of the study, about the possible causes for this increased risk. She theorizes about several possible explanations, including that the body uses cholesterol to help rid itself of environmental toxins that may be contributory to PD. Furthermore, she says, as a precursor of hormones and chemical modulators, cholesterol may contribute to a variety of central nervous system functions.

The study results did not find a correlation between lowered LDLs and PD in women, but Dr. Huang points out interesting gender considerations about PD in general. The onset of PD is usually after people turn 60, and two-thirds of those affected people are male. Men's LDL cholesterol begins to drop naturally around age 65 while women's natural decrease doesn't start until age 75. Perhaps, she says, the naturally lower LDL levels in men at a younger age relates to why more men develop PD.

Future studies will have to examine that issue, but in the meantime Dr. Huang has advice based on her study. Specifically, she says that people who do not have a family risk of cardiovascular disease but who do have PD in the family, especially if it is a sibling, should think carefully before taking statins or beginning treatment strategies to lower cholesterol. She does not suggest that people who already have PD and are on statin therapy stop it, however, because the study suggests that lower LDLs came before onset of PD. As for general advice, she reminds people that the cultural belief in her native China supports the idea of balance in all things and it might be time to reconsider the belief that promoting low, lower and lowest LDL levels isn't optimal, at least for some groups, after all.

Antioxidants

Antioxidants are substances that can detoxify free radicals, which are reactive particles involved in certain types of cell death. Since there is evidence that free radical damage is involved to some extent in PD, Vitamin E, a moderately potent antioxidant, was studied in people with early PD in a large study in the 1980s. The study did not demonstrate benefit in slowing the disease or “neuroprotection.” However, it is possible that dietary Vitamin E may be used more easily by the body than the supplements used in the study. This might be another reason to consider the Mediterranean diet. Another antioxidant substance that has achieved importance in PD treatment is Coenzyme Q10. In a relatively small but well-designed study in early PD, CoQ10 appeared to have some effect on disease progression at doses of 1200mg/day. This is a much larger dose than most people were taking prior to the release of the study data, a deliberate choice designed to avoid the risk of missing a significant effect by giving too low a dose. In fact, the study showed no benefit from the lower doses, possibly because only a small amount of the ingested dose (10-15 percent) is actually absorbed by the body. The researchers involved in the study did not recommend that all persons with PD begin taking this compound and, in fact, there is no information on the effects of CoQ10 in more advanced disease. It is also very expensive and, as a nonprescription agent, is not covered by insurance, although it is covered by Health Saving Accounts. However, it does appear to be safe and well-tolerated.

Ayurvedic Medicine

One of the oldest systems of medicine is Ayurveda, which has been practiced in India for thousands of years. The practice is concerned more with establishing and maintaining one’s health in terms of body, mind and spirit than in treating a particular disease entity. However, the principles of Ayurveda have been found to be useful by some practitioners for treating various conditions. The initial step is to determine the metabolic type of an individual. Then the practitioner looks at environmental factors, such as season and time of day. Diseases are diagnosed by assessing various pulse points and their relationship to internal organs.

Treatment of disease consists of detoxification (shodan) through various cleansing therapies, then restoring balance through palliation (shaman) with such modalities as yoga and meditation. Finally, a process of tonification, called rasayana, is initiated. Interestingly, one of the medications used in Ayurveda was derived from a legume, Mucuna pruriens, which has been found to contain levodopa. The condition for which it was used, as described many centuries ago, most likely was Parkinson disease.

Yoga

Yoga is an ancient practice associated with Ayurvedic medicine. A complete practice of yoga integrates mind, body and spirit in a process involving one’s complete lifestyle. The most popular form of yoga is asana or Hatha yoga, which involves execution of a series of postures with attention to breathing (pranayama), meditation and proper execution of the poses. Like Tai Chi, the practice of yoga has been shown to improve various aspects of health such as blood pressure, digestion and asthma. Most yoga centers offer a range of classes and list them as to level of experience required. Yoga classes are also offered at many senior centers, park districts and fitness enters. Most instructors inquire about any physical limitations at the beginning of the class. As with any form of exercise, it is important to start slowly and build up gradually to a more advanced level to avoid injury.

Since exercise is so important in the treatment of PD, patients are seeking to improve their strength, balance and flexibility. Yoga and Tai Chi are both excellent for this. In addition to more traditional fitness programs such as walking and weight lifting, classes in yoga and Tai Chi have become standard offerings in senior centers, gyms and park districts.

Traditional Chinese Medicine (TCM)

Like Ayurveda, Chinese or Oriental Medicine has been in practice for thousands of years and also is concerned with maintaining health instead of just reacting to disease. Much emphasis is placed on maintaining a balance between opposites within the body as well as with the natural world. These opposites are termed the yin and the yang. According to Roger Jahnke, O.M.D., Chairperson of the National Qigong Association (quoted in Alternative Medicine; The Definitive Guide, 2nd Edition, edited by Burton Goldberg), “yin refers to the organ, while yang refers to its activity.” Disease results from a disturbance in this balance. The concept of Qi (pronounced “chee”) is also important; this refers to life force and energy within the body. The energy flows in channels or “meridians” along the surface of the body and through the internal organs for which they are named.

A condition described in the text Principles of Medicine, written in 1565, sounds very much like PD; “Wind tremors are (caused by) by Wind entering the Liver and the Qi of the channels rebelling upward, (causing) tics of the face and tremors of the limbs.” In this context, Liver refers to the organ itself as well as the associated meridian and sphere of influence. The Liver is believed to rule coordination and smooth movement. Parkinson disease is thought to represent a defective Liver (yin) and the invasion of Wind (yang), which is thought to result in tremor. Imbalances between yin and yang are treated with modalities such as acupuncture and herbal medicine. There are many variants of TCM practices, some involving the practice of martial arts such as Tai Chi.

Tai Chi

Tai Chi, both a form of martial arts and a system of meditation, is part of an ancient Chinese system of healing called Qigong. In Tai Chi classes, participants follow a teacher in performing a choreographed series of movements. There are various styles and levels of difficulty, including some classes performed while practitioners are seated. Tai Chi has been shown in several studies to improve balance in older patients as well as persons with PD. There may be other benefits as well, including reduction of stress and improvements in digestion and arthritis pain.

Acupuncture

One of the methods used to help restore the balance of yin and yang is acupuncture, a technique developed over 2,500 years ago in China. The treatment involves inserting hair-like needles into certain points on the body, known as acupoints. This is done to restore the flow of Qi to the organ system associated with that acupoint. It is important to choose a practitioner who is licensed in acupuncture and is recommended either by another trusted physician or by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). As with most areas of complementary medicine, there is a paucity of data in the use of acupuncture in PD. Some persons with PD describe temporary relief from symptoms such as tremor and rigidity.

Herbal Medicine

Herbal medicine refers to compounds made from plants or plant components such as flowers, leaves or roots. In addition to being an important component of TCM, herbal medicine exists in many forms in many cultures. In many Spanish-speaking countries, for example, it is common to visit the local herbal practitioner for an infusion designed to treat a particular ailment. Symptoms of PD might be treated with a preparation to treat “nerves.” Consulting a traditional physician such as a neurologist might happen later, or not at all. It has also become relatively common for people to self-prescribe herbal remedies based upon their own research on the Internet or the advice of the sales staff at a health food store. This can be expensive and is potentially dangerous. These products are not regulated by the FDA, and many of them are imported from countries where there may be no quality control or guarantee of purity. It is also important to realize that many of these agents have distinct pharmacologic properties with the potential to be harmful on their own or to interact with medications the patient is already taking. Therefore, it is strongly recommended that the use of herbal treatments be supervised by a competent specialist and that all prescribing physicians be informed of these additions.

In TCM, herbs are chosen by a trained practitioner as part of a comprehensive treatment plan and prescribed in combination based on their properties related to specific organ systems.

Body Work/Massage Therapy

Body work comprises a group of “touch therapies” such as reflexology, Rolfing, and therapeutic massage. Massage therapy in particular has become very popular because of its beneficial effects on the muscle stiffness and aching that may accompany PD. Massage may also help with associated conditions such as arthritis, and sleep and digestive disorders. In addition, a well-executed massage can be an extremely relaxing and enjoyable experience.

Of the many different styles of massage therapy, two in particular may be useful in PD. Shiatsu, or acupressure, uses touch rather than needles to treat the same pressure points as acupuncture. Swedish massage consists of gently kneading the muscles of the back, neck, scalp and limbs. It is not uncommon for people to feel a bit awkward about letting a stranger touch their bodies, especially if they are asked to disrobe for the treatment.

It is worth noting that the client will be covered by a sheet or blanket; only the part of the body being massaged will be uncovered at any one time. If this is still an intimidating concept, it might be helpful to start out by having a chair massage first. This is done while the client is seated in a specially designed chair while fully clothed. This may allow one to experience the benefits of the massage in a less stressful setting while getting to know the therapist. Some therapists are able to do a full body massage on a person who is wearing clothes, but it is wise to ask in advance, if this is an issue.

This is another treatment that should only be performed by a licensed massage therapist or by a physical therapist with training in this area. In some cases, massage therapy will be reimbursed by insurance or Medicare, especially when performed as part of a physical therapy program.

In summary, many of these therapies are becoming accepted by patients and practitioners in the contemporary treatment of Parkinson disease and can work well in complement with medications and other so-called traditional treatments. Diet and exercise are proving to be extremely important in maintaining good health, and this may be augmented by practices such as yoga, Tai Chi or the addition of appropriate supplements or herbs. It is important to find practitioners who are well-trained and appropriately certified, and who have been recommended by a trusted source, such as one’s primary care physician, neurologist or the regulatory board for that discipline. Herbal agents and supplements should be used cautiously, preferably under the supervision of a trained professional in the use of these drugs.

The author wishes to thank Patrick Massey, M.D., Ph.D., and David Bates for their assistance in writing this article.

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