Article from June 2018 E-Newsletter

Why Does Balance Break in Parkinson’s Disease?
Balance and postural control are some of the most challenging areas to deal with in Parkinson’s Disease (PD). Dopaminergic treatments that are typically given for PD have not shown much benefit for the stooped posture and unsteady feeling that PD patients commonly experience. This suggests that other parts of the brain may be causing these balance problems, and that other forms of therapy may be required to improve balance and posture in PD patients.

The good news is that basic exercise programs that simply get the body moving have been shown to have lasting improvements in patients with PD. This includes things like Tai Chi, resistance training, and even boxing training have been shown to have positive lasting effects in people with early to moderate symptoms.

How does something as simple as exercise improve the symptoms of a brain disease like PD? How can we use some of these concepts to help patients with PD overcome plateaus in their improvement?

Proprioception: The Underdog of the Senses
It’s hard to appreciate just how complicated balance is until you start to lose it. The maintenance of posture and balance is so important and complex in the human body that some of the largest and fastest tracts in your spinal cord are dedicated to the use of your back muscles.  In order for balance to work properly, it requires the use of 3 super important sensory systems. This includes your vision from your eyes, the vestibular system from your inner ears, and your proprioceptive system from your skin and joints.

Proprioception is a sense dictated by movement detected by your skin, muscles, and joints. If you were to close your eyes and raise your hand over your head, you can reach up with your other hand and touch that body part without looking at it. How does your body know? Because there are sensors in your skin and joints telling your brain where it is in space all of the time.  When it comes to balance, these same sensors that exist in your spine and in your ankles play an enormous role in keeping you upright, and it is the breakdown in this system that commonly leads to balance and posture problems in people with PD.

When Proprioception Breaks Down
Research has shown that patients with Parkinson’s Disease typically have a balance system that is overly reliant on vision and has mostly normal inner ear function. This implies that it is the proprioceptive system that breaks down leading to a heavier reliance on vision to compensate.   Why does this break down? Because the basal ganglia (the area of the brain affected by Parkinson’s) plays a really important role in your body’s joint position awareness. The basal ganglia is a really important relay station for proprioceptive information to get to the higher parts of the brain in the cortex. When the brain can’t integrate this proprioception, then it can’t provide feedback to the muscular system to make appropriate adjustments.  This can be problematic.  People without balance problems need proprioception to stay upright and balanced with stability. If you can’t make adjustments to your muscular system, especially in the dark, then your likelihood for falling increases dramatically with a little push from an unexpected source.

Teaching an Old Brain New Tricks
Proprioception is a big fancy word that sounds like it requires tools and advanced therapies, but in reality it is generated by simple movement. Every time your muscles contract or a joint moves, you are increasing proprioception into the brain!  That’s why exercise of all shapes and sizes tends to help patients with Parkinson’s Disease.  In addition to standard exercise programs, patients with PD may benefit from therapies that help their brain better integrate sensory stimuli. This can include different types of proprioceptive therapies that include visual feedback training, eye movement training, and vestibular rehabilitation from a functional neurology perspective.

The right combination of therapies may help patients with PD improve posture, gait, and general difficulties with movement. While we can’t fix the area of the brain that is damaged, because the brain has the ability to change itself, we can teach different parts of the brain new tricks to help the brain better adapt to the environment.

Article written by Dr. Jon Chung, Structural Chiropractor from Keystone Chiropractic

Article from May 2018 E-Newsletter

Big News About Access to Therapy
The opportunity for the Parkinson’s community to get access to the care they need has recently changed for the better! Elimination of the Medicare Therapy Caps and access to maintenance therapy are now effective ways for the Parkinson’s patients to maximize their functional ability through Medicare rehabilitation services. The law that created the financial limitation on how much therapy a beneficiary could receive per year was repealed as of February 9, 2018, and the guidelines on the maintenance therapy benefit have been clarified.

“Millions of Medicare beneficiaries can now—finally—breathe a bit easier when it comes to getting access to critical rehabilitation services they require following a serious health episode,” said Elise Davis- McFarland, PhD, CCC-SLP, 2018 ASHA President. “The last thing these patients need in the face of serious illness or injury is to have to choose between financial ruin or forgoing much-needed care that has a strong potential to transform their life. We are grateful that Congress has taken action on the therapy caps.”

“Stopping the hard cap is a victory for our patients, and for our dedicated advocates,” said APTA President Sharon L. Dunn, PT, PhD, board-certified orthopedic clinical specialist. “For 2 decades we have held back the hard cap through repeated short-term fixes—17 in total—that were achieved each time only through significant lobbying efforts by APTA and other members of the Therapy Cap Coalition. In that time, the hard cap was a genuine and persistent threat to our most vulnerable patients, a threat we saw realized earlier this year when Congress failed to extend the therapy cap exceptions process. Today that threat has been eliminated.”

In summary, patients that meet the Medicare requirements of medically necessary skilled therapy for Physical therapy, Occupational therapy, and Speech therapy no longer need to worry about getting the care necessary to meet their therapy goals. It also means that patients no longer need to worry about getting therapy later in the same year if they require skilled therapy for any reason.

Along with the repeal of the therapy cap is the clarification by Medicare and instructions for the maintenance therapy program benefit. CMS has issued a Fact Sheet outlining the Jimmo v. Sebelius settlement. Use this fact sheet as evidence that skilled maintenance services are coverable for skilled outpatient therapy. The Center for Medicare Advocacy has Self-help Packets to help pursue Medicare coverage, including for skilled maintenance nursing and therapy. This shows that patients not expected to make recovery or progress may still be able to receive skilled therapy in maintenance when, “Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program.”

Article written by Matthew Green, M.S. Esq., from LifeCare Therapy Services

Article from April 2018 E-Newsletter

Parkinson Psychosis, Hallucinations, and Delusions
Parkinson’s disease is a neurodegenerative disorder that robs patients of coordination and movement. It has four cardinal motor symptoms; tremor, bradykinesia, rigidity and postural instability. However, all patients have some type of non-motor manifestations. These non-motor symptoms can be as disabling as the motor symptoms. Non-motor symptoms include dysautonomia, sleep disturbance, cognition difficulties, mood disorder or psychosis. Progression of motor and non-motor complications increases morbidity, mortality, and caregiver stress. Early recognition and treatment of these complications will improve quality of life.

Psychosis has been estimated to occur in 20-60% of persons living with Parkinson’s disease (PD). Psychosis associated with PD can be difficult to diagnose and treat. There must be a primary diagnosis of idiopathic PD, recurrent episodes ongoing for longer than one month, and occur after the onset of PD. Other causes of psychosis can be due to dementia, metabolic disorders, and medications. PD psychosis is associated with length of dopaminergic drugs, age of onset of disease, and severity of disease. There is an increased risk of psychosis with Hoehn Yahr score>4, MMSE<24, and age>70 years old. Use of anticholinergics can increase risk. Use of donepezil can decrease risk. (1) It is associated with sleep impairment, depression and dementia (2).

Psychosis is an abnormal condition of the mind in which there is an impaired sense of reality. It usually involves hallucinations or delusions. Hallucinations are the perception of visual, auditory, olfactory or tactile stimulus that is not present or real. Visual hallucinations occur in 39% of patients with psychosis. Visual illusions are present in 72% of patients (3). This is the visual distortion or perception of movement, form, size or color of an object. This is commonly the misinterpretation of bushes or trees as children or animals outside the house. Another common visual illusion is seeing bugs on the floor. Auditory, olfactory, tactile hallucinations are less common.

The treatment of psychosis can be complicated. It must be individualized and follows a slow, methodical process which includes medication analysis and assessment of PD and comorbid diseases. PD psychosis is triggered by dopamine (D2) receptor activation. Decreasing dopaminergic medications may lead to improve psychosis but decrease motor function (4). The first step is to rule out infection, metabolic or structural abnormality causing the onset of psychosis. The next step is tapering medications such as antispasmodic, anticholinergic, benzodiazepine, muscle relaxants and opioids. Then, gradually tapering dopaminergic medications such as amantadine, selegiline, rasageline, dopamine agonists, and levodopa should be considered. The last step is considering use of atypical antipsychotic medications. There has been an increased risk of death in the elderly with use of antipsychotics.

Atypical antipsychotics use in PD psychosis is effective. The goal of treatment is to minimize dopamine D2 receptor blockade while increasing serotonin 5HT2A antagonism. Clozapine may stimulate D2 receptors and block 5HT2A. It may improve REM sleep as well. It does affect adrenergic, histamine, and cholinergic receptors. It has many side effects and requires frequent blood work. Quetiapine also has minimal D2 receptor blockade with 5HT2A blockade but also affects other receptors. Sedation and orthostatic hypotension are the most common side effects. Pimavanserin is more selective to 5HT2A receptor. It is the first medication approved for PD psychosis. It can cause QT prolongation and requires decrease dosing in hepatic and renal impairment.

PD psychosis is a common late symptom of Parkinson’s disease. Early diagnosis and treatment is complicated. Treatment must balance the motor and emotional complications of PD. The goal of treatment is to improve quality of life, lessen caregiver stress, and decrease the need for hospitalization.

1 “Trigger medications and patient related risk factors for Parkinson Disease Psychosis requiring anti-psychotic drugs: a retrospective cohort study”, BMC Neurology, 2013; 12: 145.
2 “Cognitive correlates of psychosis in patients with Parkinson’s disease”, Cognitive Neuropsychiatry, 2014; 19(5): 381-398.
3 “Characteristics, correlates, and assessment of psychosis in Parkinson’s Disease without dementia”, Parkinsonism Related Disorders, 2017; 43: 56-60.
4 “12 year population based study of psychosis in Parkinson’s Disease”, Archives of Neurology, 2010; 67(8): 996-1001.

Article written by Linda Pao, MD, PA | Comprehensive Neurological Care

Article from March 2018 E-Newsletter

Impulse Control Disorders
Parkinson Disease (PD) motor symptoms occur due to a loss of dopamine stimulation of the deep brain nuclei called the striatum. Nerve fibers that originate in the midbrain nucleus, the substantia nigra, which carry the dopamine to the striatum die off. Greater than 60% of these cells have been lost by the time a patient exhibits the first clinical signs of PD such as resting hand tremor or diminished facial expression.
Since the late 1960s the principal strategies for treating PD have been directed at restoring the dopamine deficiency. Levodopa, given as carbidopa/levodopa (Sinemet), is the oldest and most effective therapy for restoring brain dopamine levels and improving movement and decreasing tremor in PD. Dopamine agonist (DA) drugs pharmacologically look like dopamine and stimulate dopamine receptors in the brain and will significantly improve PD symptoms. The DA drugs include oral ropinirole (Requip), pramipexole (Mirapex), and rotigotine (Neupro transdermal patch).

One of the unwanted side effects from using the dopamine stimulating drugs has been the appearance of Impulse Control disorders (ICDs). The most common ICDs include 4 behaviors: excessive gambling, compulsive shopping, compulsive sexual behavior, and compulsive eating. Less frequent ICD behaviors include punding which is repetitive, non-goal directed behavior or nonsensical hobbies, and dopamine dysregulation syndrome in which there is compulsive PD medication use. The ICDs may start slowly and seem quite benign at first, such as an increased interest in going to the casino, or an interest in pornography, or an inappropriate enthusiasm for shopping with purchasing more items than are needed. These ICD behaviors may overtime have devastating consequences as some patients uncontrollably gamble away family savings and others get involved in inappropriate sexual relations and ruin their marriage.

Dopamine plays a significant role in the brain reward circuitry. Increased dopamine stimulation in the amygdala, and in the frontal lobe behavior control networks may lead to decisional impulsivity (making bad decisions quickly). The DA drugs are most often the cause for ICDs. These drugs will stimulate dopamine brain receptors other than the motor control receptors which levodopa effects. The rapid acting formulations of ropinirole and pramipexole are more likely to cause ICD than the extended release forms or than the transdermal form, Neupro.

Carbidopa/Levodopa alone rarely causes ICDs. These behaviors can emerge after a patient has been on the drug for quite some time, so vigilance regarding the development of ICDs is needed. Treatment of ICDs requires first that they be recognized, and secondly that the offending drug (usually a DA) be tapered and discontinued. Patients often will struggle with worsened motor function when the drugs are removed. Antidepressant medications may be needed to help mood disorders which can arise as the behaviors and DA drug withdrawal have their consequences. A low dose of quetiapine, an antipsychotic drug, may be needed to help patients resist impulses. Behavioral strategies such as limiting bank account access and 12 step programs may be needed. Awareness of this problem is the key to successful management and outcomes.

Article written by Thomas C. Hammond MD, FAAN | Marcus Neuroscience Institute and member of the APDA South Florida

Article from February 2018 E-Newsletter

Can Ultrasound Waves Be Used To Treat Parkinson’s Disease?
Patients with Parkinson’s disease for some years may have a fluctuating response to medications, significant dyskinesias, or severe tremor. Surgical treatment is a consideration for such patients. The current FDA approved surgical treatment is deep brain stimulation. There is over 20 years of experience with DBS and it is covered by Medicare and most insurances for appropriate patients.

A new surgical technique is being developed called MRI-focused ultrasound (MRI-FUS). In this method a deep area in the brain called the thalamus is targeted with ultrasound waves using high quality brain MRI imaging. This makes a small stroke-like lesion that suppresses abnormal brain activity that can lead to tremor. Small numbers of patients with essential tremor have been treated with relatively good control of tremor and minor side effects. The ExAblate system manufactured by Insightec earned FDA approval to treat essential tremor in July 2016. Though FDA approved it is not covered by insurance and is available from a few centers in the US on a cash pay basis.

There is an interest in extending the indication to Parkinson’s disease. Advantages of MRI-FUS include the less invasive nature of the procedure and there is no need for hardware to be installed in the body. A few words of caution must be kept in mind. The deep brain target for this MRI-FUS is the thalamus and the technique resembles an old method called thalamotomy used in the pre-DBS era. While this target is good for tremor control it is not the optimal target for control of overall symptoms of Parkinson’s disease. Most centers performing DBS choose the subthalamic nucleus or the globus pallidus as the ideal target, not the thalamus. Secondly, while we have over two decades of experience with DBS, we do not have long-term data with the newer technique. Further clinical trials with long-term follow-up are required before MRI-FUS becomes an accepted part of care for Parkinson’s disease.

Article written by Arif Dalvi, MD, MBA | Palm Beach Neuroscience Institute and Medical Director of the APDA South Florida Chapter.

Article from January 2018 E-Newsletter

Caregiver Burnout
Taking care of yourself is not a symptom of being selfish. It’s important to remember that you cannot serve from an empty vessel. However, all too often, those caring for a loved one forget to take care of themselves, significantly increasing the risk of caregiver burnout. Here are a few signs and symptoms to look for that could indicate you are suffering from caregiver burnout and may need some help:

  • You’re feeling stressed
  • You are using alcohol or drugs more than you did before
  • You are exhausted from losing sleep
  • You often have a short fuse and feel agitated
  • You are self-medicating and potentially overusing prescription medications
  • You’re missing appointments
  • You’re experiencing a lack of interest in social activities and/or seeing your friends
  • You feel angry and/or resent your partner

According to a recent CNN Report, 70 percent of all caregivers over the age of 70 will pre-decease the person they are caring for. It’s critical for family caregivers to seek help and respite care so they can take care of themselves and be the best caregiver they can be to their loved one. Here are just a few steps you can take to help minimize the risk of caregiver burnout:

  • Accept your feelings and understand that it is completely normal to have negative feelings like anger or frustration at times. It doesn’t make you a bad person. Consider talking to a professional who is trained in dealing with physical and emotional issues.
  • Educate yourself on the condition. The more you know, the more effective a caregiver you will be.
  • Remember the importance of taking care of yourself. Maintain a healthy diet, find time to exercise and try to maintain healthy sleep habits.
  • Look for caregiver support services in your area. Support groups where people can talk and share with others who are having a similar experience can be very comforting and helpful. Also, local chapters of national organizations as well as your local Area Agency on Aging can offer additional resources and information.
  • Remember, it takes a village. Do not be afraid to ask for help. Respite care can provide a temporary break for caregivers. It can be anything from a few hours of in-home care to an adult day care center.

Remember, the goal is to seek help before stress affects your health and well-being. If you are caring for a loved one and think you may be experiencing caregiver burnout or any of the signs discussed above, please reach out for help.

Article written by Melissa Morante | ComForcare Senior Services