May/June 2015

Parkinson's Disease Treatment: Tried, True, And New
By Laura D. Dunnick, PT, DPT, and James S. Dunnick, MD, FACC, CPC, CHCQM, CMDP
Today's Geriatric Medicine
Vol. 8 No. 3 P. 18

Parkinson's disease takes a toll on patients and their families in terms of physical limitations, financial costs, and emotional fallout. But treatments hold some promise for symptom management and slowing disease progression.

The cost of Parkinson's disease (PD) must be recognized as both economic and emotional. The financial aspects include medical costs such as those related to diagnosis, medications, surgeries, home care, counseling, physical therapy, and frequent hospitalizations. They also include lost wages from employment that's no longer possible and increased use of tax dollar-funded disability programs.

The emotional cost may be more difficult to quantify. It is important in its own right as well as in its influence on increased health care resource utilization. In the United States there are currently approximately 1 million patients with the diagnosis of PD. Nearly 60,000 new cases are diagnosed each year, and some estimates suggest that for each patient who is officially diagnosed with PD, there are 20 patients with the disease who have not been diagnosed.1,2

PD patients average more than 40% more hospital admissions per year than their non-PD counterparts. Longer hospital stays are noted as well as nearly a 2.5 times greater complication-of-care rate. When hospitalized, more than 20% of admitted PD patients worsen, and 44% of those fail to return to their original baseline status.3 With hospitals no longer being reimbursed by third-party payers for hospital-acquired conditions, this creates an even greater economic impact as well as an emotional burden for the patient and family.

Medications for the treatment of PD can reach $2,500 per year per patient (not including experimental medicines that may have no insurance coverage), and surgeries can cost as much as $100,000 per patient.2 In addition to these costs, social security and other disability payments reach $25 billion per year.2

PD Diagnosis
The diagnosis of PD is predominantly made by clinical means. No laboratory biomarkers are currently known, and both CT scans and MRIs can be unremarkable. According to Hauser et al, the "two major neuropathologic findings in PD are loss of pigmented dopaminergic neurons of the substantia nigra pars compacta and the presence of Lewy bodies and Lewy neurites."4

Dopamine receptors are membrane receptors that are members of the G-protein coupled family. Five subtypes are known, and these are found in the cerebral cortex and limbic system. Dopamine binds to the receptor and starts a signaling pathway that ultimately is stimulatory or inhibitory.5

When dopamine neurons degenerate, voluntary motor control is interrupted, and the PD symptoms are manifest. Initial treatment with levodopa can produce some motor function improvement.6

Some neurologists have subspecialties in PD. This subspecialization allows a neurologist to focus purely on PD, along with its newest medications and research. Research goals focus on disease etiology, new medicines, and surgical interventions at the forefront. Unfortunately, many families live in communities with smaller hospitals and no access to specialty centers.

There is currently no cure for PD; however, treatments focus on symptom management, slowing disease progression, and allowing patients to maintain an optimal level of community participation with quality of life. Depression and anxiety associated with PD must be recognized and treated. Sleep disturbances are common and lead to mood alteration and a less alert daytime status.6

Death is most often due to immobility and its complications of infection, aspiration pneumonia, or blood clot with embolism.7 Falls and the complications resulting from falls can also be fatal.

PD Medications
All medicines have side effects and PD medicines are no different. Each medicine class has side effects that are unique to that group of drugs. Some medicines that can be used for PD treatment include levodopa, dopamine agonists, monoamine oxidase (MAO)-B inhibitors, catechol O-methyltransferase (COMT) inhibitors, anticholinergics, and apomorphine.8,9

Patients may experience nausea with levodopa that usually dissipates as they adjust to the medicine. A larger side effect concern is dyskinesia, which is an involuntary movement of the arms, legs, or even the entire body.8,9 These side effects can worsen over time.

Other potential side effects include confusion, hallucinations, psychological changes, mood swings, and sleepiness.8 Sometimes the illness itself can cause these problems, and it can be difficult to discern a disease symptom from a drug side effect.

Dopamine agonists are drugs that mimic the function of dopamine in the brain and therefore activate the dopamine receptor. Dopamine agonists are often the first drug choice for treatment of PD as they appear not to have as many long-term side effects as levodopa.8

The short-term side effect risks include nausea and vomiting, dizziness, confusion, and hallucinations. Patients may exhibit compulsive behaviors, such as sex, gambling, and eating.8,9

MAO-B inhibitors increase dopamine by inhibiting the enzyme involved in the breakdown process. Side effects are nausea and headaches, and if MAO-B inhibitors are used with carbidopa/levodopa, there is a risk of hallucinations. A rare but serious reaction can occur if MAO-B inhibitors are used with antidepressants and some narcotics.

COMT inhibitors also block the enzyme that breaks down dopamine and this can, to a degree, prolong the effect of levodopa. The augmented levodopa effect can lead to involuntary movements. One drug of this class is no longer in significant use because of the risk of serious liver damage and failure.

While anticholinergics produce modest benefits, these can be offset by side effects such as constipation, dry mouth, and impaired urination. And like other drug classes, they may be accompanied by symptoms of impaired memory, confusion, and hallucinations.9

Surgical Treatment
Surgery as a PD treatment was initially employed in the late 1930s.10 It does not offer a cure, and patients often remain on medicines, though typically fewer medicines, after a surgical procedure. Patients in a more advanced disease stage or who have other significant comorbidities are less attractive as surgical candidates.

Brain surgeries for PD treatment include deep brain stimulation (DBS), pallidotomy, and thalamotomy.10 DBS targets specific areas with electrical stimulation. Its purpose is to attempt to improve motor symptoms such as tremors, rigidity, and walking difficulty. It is most helpful in patients who have improved to some degree with prior medication use.

In DBS, an implantable pulse generator (IPG) is surgically placed into the brain. The device delivers electrical stimulation, usually to the thalamus, subthalamic nucleus, and globus pallidus, blocking abnormal nerve signals. The surgery can be performed while the patient is awake or asleep, with specific advantages in both scenarios.

The device is battery powered and although there are no external features (ie, nothing protrudes through the skin), the battery must be replaced every three to four years.

DBS offers several attractive features. No brain tissue is destroyed and the IPG can be adjusted as a patient's response or disease progression warrants. If new treatments become available that are more attractive, the entire process can be stopped, including removal of the device. The complication rate is low, quoted as 2% resulting in stroke and 5% leading to infection.

Both pallidotomy and thalamotomy procedures make an effort to destroy brain tissue that is assessed as producing symptoms. This differs from DBS in which no tissue is destroyed.

In thalamotomy, the best candidates are patients who have severe tremor-based symptoms. The most common complications, bleeding and infection, fall into the 2% to 5% range with a mortality rate of below 1%.10

With pallidotomy, the patient group that appears to realize the greatest benefit is those with treatment-resistant idiopathic PD but who have responded to dopamine replacement therapy in the past. The symptoms that appear to be most responsive are drug-induced dyskinesias, bradykinesias, and rigidity. Speech, tremor, and walking improve to a much lesser degree. Patients with early onset PD (ie, before the age of 50) are viewed as better candidates, though the procedure is performed on older PD patients as well.10

Dementia, severe walking issues, other health-related conditions, and older age (ie, over the age of 75) provide a relative contraindication for the procedure.10

Peripheral Impact
In considering the emotional impact, the effects of PD are not limited to the patient. PD has an impact on the family and friends of the patient, many of whom may become caregivers over the course of the disease progression. Family members observe such changes as decreased gait speed, softer voice, and stooped posture. As a patient's physical and cognitive abilities worsen, depression increases. Family members must take a greater role in patient care.

Fall injuries and illnesses directly related to immobility add to both the economical and emotional toll on everyone involved. A spouse may be forced to provide the primary income; the family may need to leave their home and neighborhood for a home without stairs or one that's less expensive. Future plans may have to change entirely, with a couple's expectations of traveling the world in their retirement years or traveling to visit children and grandchildren becoming impossible.

PD patients often cite their own immobility and dependence on others as the greatest worries and sources of concern they face. Patients realize that PD is a progressive disease, and suffer knowing that their condition and symptoms will continue to worsen. They understand the increased burden this places on the family, and the loss of freedom greatly impacts their daily lives, leading to depression and withdrawal from society. A key factor in fighting this depression is offering patients hope and empowering them to fight against the disease.

Movement-Based Therapy
Physical therapy is an active way for patients to take a role in fighting PD and its symptoms. Among physical therapists, recognized specialties include neurology,11 although a neurology specialty is not necessary for a therapist to specialize in Parkinson's treatment. With the development of a Parkinson's-specific treatment protocol, therapists without a neurology specialty are able to take a more concentrated approach to PD, using a disease-specific researched therapy program to obtain optimal functional outcomes.12-15

One of the most successful nonpharmacological treatments for PD is an intense movement-based therapy program known as the Lee Silverman Voice Treatment (LSVT). It has been gaining popularity as research and patient testimonials continue to demonstrate the effectiveness of the program.12 With its origin as a voice program administered by speech-language pathologists, it has spawned the movement-based program administered by physical or occupational therapists. LSVT BIG focuses on increasing the amplitude of movement in order to recalibrate a patient's understanding of "normal" movements.12

This recalibration is essential because it focuses on minimizing the negative effect PD exerts on a patient's movements. Microphonia, micrographia, stooped posture, and small shuffling steps are a few examples of the "smallness" that characterizes Parkinson's movements. These small movements are caused by the brain's inability to correctly interpret the scale of a movement. This leads patients to perform movements they perceive as "normal" when in actuality they are too small. The inherent solution to this problem is to recalibrate patients' understanding of "normal" movements, which is exactly the goal of the LSVT BIG program.13

Teaching patients to incorporate "bigness" into everyday life enables them to reproduce "normal" movements. The LSVT BIG program is an intense specialty-certified and therapist-driven program. It involves a four-week protocol of 16 one-hour sessions.12 Each session is conducted with a one-to-one patient-to-therapist ratio. Daily patient-driven home practice sessions, sometimes assisted by family members or caregivers, follow the therapist-patient sessions. The intensity and patients' responsibility to follow through must be emphasized and accepted as agreeable to patients, as they are vital components of the treatment. With compliance to the program, patients can expect to see improvements in gait speed, balance, trunk mobility, and decreased fall risk.13

Patients achieve greater independence through a daily physical therapy home exercise program, focusing on muscle strength, amplitude of movement, and balance as the therapeutic goals. A reduced fall risk and increased mobility diminish patient fears, lessening depression. Overall health care costs decrease through a reduction in outpatient visits, fewer hospitalizations, and potential elimination of the complication of care rate seen in hospitalized PD patients.

Completion of the program empowers both patients and family members with the tools, knowledge, and actions they can take to help fight the disease, providing a much needed morale boost. Initial positive results provide motivation to continue with home exercises from the initial physical therapy sessions. The newly found self-ability to influence the future of the illness cycles upon itself and leads to conserving more energy and effort that are available to invest in staying upright and healthy.

Prior to LSVT BIG, there was no disease-specific physical therapy treatment plan for PD. Instead, general physical therapy targeted improving gait, posture, and balance with varying degrees of success.14,15 The positive outcomes and patient success associated with program completion have resulted in the LSVT BIG protocol's increasing popularity as an essential nonpharmacological treatment.

The goal of each provider and facility is to improve outcomes. Equally important in today's health care environment is the cost of care. As physician treatment options improve, outcomes improve, as is the case for physical therapy and specialty physical therapy. The specialty therapist with unique skills brings within reach the goal of keeping a patient at home, increasing independence, and reducing the need for hospitalization.

New physical therapy specialty techniques offer disease-focused treatments. Augmenting the number of specialty physical therapists can make these highly skilled professionals available to more communities of all sizes. Achieving optimal clinical outcomes and independence through participation in the home program contributes to the specific goal of health care cost reduction. Perhaps more importantly, improvement in the emotional status and quality of life of both the patient with PD and family members can be realized.

— Laura D. Dunnick, PT, DPT, licensed through the Federation of State Boards of Physical Therapy, specializes in Parkinson's disease treatment with a certification in LSVT BIG from LSVT Global, Inc. She is a physical therapist in Washington, D.C.

— James S. Dunnick, MD, FACC, CPC, CHCQM, CMDP, is founder and CEO of The Dunnick Group, a health care consultant firm. He is certified in coding, quality assurance, and compliance.

References
1. Parkinson's disease overview. National Parkinson Foundation website. http://www.parkinson.org/parkinson-s-disease.aspx. Accessed January 18, 2015.

2. Statistics on Parkinson's. Parkinson's Disease Foundation website. http://www.pdf.org/en/parkinson_statistics. Accessed January 18, 2015.

3. Okun MS, Hassan A. Hospitalization in Parkinson's disease: an NPF-QII study. National Parkinson Foundation website. http://www.parkinson.org/NationalParkinsonFoundation/files/fc/fc84496c-231f-4b76-9712-35cc3eaa5df0.pdf. Accessed January 24, 2015.

4. Hauser RA, Lyons KE, McClain TA, et al. Parkinson disease. Medscape website. http://emedicine.medscape.com/article/1831191-overview. Updated January 23, 2015. Accessed January 24, 2015.

5. Parkinson's disease: dopaminergic receptors systems. CNS Forum website. https://www.cnsforum.com/educationalresources/imagebank/pd_dopaminergic.  Updated July 4, 2014. Accessed January 18, 2015.

6. Pathophysiology of Parkinson's disease. ATrain Education website. https://www.atrainceu.com/course-module/2441043-143_parkinsons-module-02. Accessed January 15, 2015.

7. Scott DM, Brown DA. Parkinson's disease: a review. Drug Topics. 2009;153(8):40-47.

8. Drug treatment for Parkinson's disease. WebMD website. http://www.webmd.com/parkinsons-disease/guide/drug-treatments?page=2. Accessed January 8, 2015.

9. Parkinson's disease treatments and drugs. Mayo Clinic website. http://www.mayoclinic.org/diseases-conditions/parkinsons-disease/basics/treatment/con-20028488. Updated May 28, 2014. Accessed January 8, 2015.

10. Cosgrove GR, Eskandar E. Thalamotomy and pallidotomy. Massachusetts General Hospital Neurosurgery website. http://neurosurgery.mgh.harvard.edu/functional/pallidt.htm. Updated May 11, 2005. Accessed January 8, 2015.

11. Specialist certification: neurology. American Board of Physical Therapist Specialties website. http://www.abpts.org/Certification/Neurology/. Accessed January 8, 2015.

12. What is LSVT BIG? LSVT Global website. http://www.lsvtglobal.com/patient-resources/what-is-lsvt-big. Accessed January 20, 2015.

13. Fox C, Ebersbach G, Ramig L, Sapir S. LSVT LOUD and LSVT BIG: behavioral treatment programs for speech and body movement in Parkinson disease. Parkinson's Dis. 2012;2012:391946.

14. Ellis T, de Goede CJ, Feldman RG, Wolters EC, Kwakkel G, Wagenaar RC. Efficacy of a physical therapy program in patients with Parkinson's disease: a randomized controlled trial. Arch Phys Med Rehabil. 2005;86(4):626-632.

15. Keus SH, Bloem BR, Hendriks EJ, Bredero-Cohen AB, Munneke M, Practice Reommendations Development Group. Evidence based analysis of physical therapy in Parkinson's disease with recommendations for practice and research. Mov Disord. 2007;22(4):451-460.