This includes physical therapy: gait training, strengthening, balance, LSVT-BIG, exercise, exercise bicycle, aerobic exercise, Tai Chi; occupational therapy – home safety evaluation; speech therapy – swallow study, Lee Silverman voice training (LSVT).
This includes balance and falls- avoidance of ladders, safety with ADLs, orthostatic hypotension, daytime sleepiness. Driving safety can become an issue for many reasons, both physical and cognitive. Visuospatial difficulties can be problematic when a PD patient misjudges his landing on attempting to sit in a chair. This can be catastrophic when it involves the momentum of a several ton vehicle. “The responsibility for determination of driving competence in early to mid duration patients with PD is the responsibility of patients, family and physicians. Driving should be discussed and referral to a driver RHB specialist considered if necessary.”23
This has been the classic focus of attention in therapeutic intervention. As alluded to above, following the administration of L –Dopa the majority of PD patients develop over several years a pharmacodynamic change in their response to the drug. Continued loss of DA cells and alterations in downstream processing of striatal signal in the globus pallidus result in diminished duration of action of L-dopa and the re-emergence of PD symptoms prior to the next scheduled dose (wearing off) as well as the appearance of dyskinesias.24 Early morning painful foot dystonias may signal the first evidence of wearing off. Protein ingestion with meals may compete with L-dopa for transport across the jejunal mucosa and blood brain barrier causing loss of dose efficacy. The pattern of the PD patient’s response to medication throughout the course of the day (and night) is assessed. Based upon this information the practitioner applies the appropriate knowledge of pharmacology and pharmacokinetics to attempt to achieve as smooth a response to medication as possible with maximal on time, minimal off time and minimal side effects. The therapeutic armamentarium includes immediate release and sustained release L-dopa, DA agonists (oral, injectable, transcutaneous), L-dopa catabolic enzyme inhibitors (COMT and MAOB), amantadine and anticholinergics.
When optimal control of motor symptoms can no longer be obtained by use of oral medications other options can be considered. This is usually in the setting of a patient with motor fluctuations whose off periods can only be controlled at the expense of intolerable dyskinesias. Continuous enteral L-dopa infusion has been found to ameliorate motor fluctuations. L-dopa gel (DUODOPA) for jejunal infusion is currently available in Europe and Canada( not currently available in US). Deep Brain Stimulation has proven a valuable therapeutic option for patients with uncontrollable motor fluctuations25.DBS is also of benefit for patients with PD in whom severe tremor is a predominant symptom not adequately responsive to medications. Both the Subthalamic nucleus(STN) as well as the Globus Pallidus interna (GPi) have been successfully targeted in PD. Careful patient selection is critical.
Thus, of the 10 quality measures discussed, five of the ten address non-motor symptoms and seven of the ten address quality of life issues. In a recent multicenter study26 to assess the impact of non-motor symptoms on quality of life it was found that the most prevalent symptoms of which patients complained were nocturia (68%), fatigue (66%) and sialorrhea (57%). Non-motor symptom scales showed higher correlation with diminished perception of health related quality of life (HRQoL) than did motor scales. The authors questioned why it might be so that non-motor symptoms were better predictors of HRQol than motor symptoms and proposed three possible explanations.
1) We do a better job at treating DA symptoms than non DA symptoms.
2) Patients are unaware of nonDA symptoms as related to their disease and don’t tell us about them. They consequently go unattended.
3) Physicians are unaware of non-motor symptoms as related to PD or don’t have time to deal with them.
Hopefully this article will help to increase physician awareness of the many difficulties faced by the patient with PD that go beyond the traditional tremor, bradykinesia, and rigidity. Awareness of these many non-motor aspects of the disease will enable us to significantly improve the quality of life of PD patients. The management of PD will now require two more advances – the development of drugs that will halt or definitively slow disease progression and a socioeconomic environment which can make feasible our paying adequate attention to the many problems faced by our patients with this most fascinating and debilitating disorder.
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