PARKINSON'S DISEASE AND MOVEMENT DISORDERS
Parkinson's Disease (PD) affects more than 1,000,000 people in the United States. The mainstay and sole treatment until the 1960s was surgery. In 1939, Meyers resected the caudate head stopping tremor and rigidity. Cooper & Leksell performed well over 5000 operations for PD in the 1950s relieving tremor, sometimes rigidity and rarely bradykinesia; the mortality was 10-30%. Therefore, it was not surprising that when L-Dopa was introduced, surgery was nearly eliminated. However, as with most medicines, side effects developed. L-Dopa was no exception. Patients became intolerant to the medicine, 50% in 5 years and nearly 100% in 10 years. Thus new methods were needed. Then in the 1990s Laitinen published his own work, and that of Leksell, and PD surgery was reborn.
Tremors are the most widely acknowledged symptoms. PD tremors are bi-modal, 4 Hz rest tremor and 7-8 Hz tremor with action. Tremor is seen in other diseases such as familial essential tremor in which there is a fine voluntary tremor alleviated with rest and not associated with bradykinesia. Tremors also occur after CVA and are a late sequel although less curable with MS. Other symptoms of PD include dyskinesias from medication, rigidity, akinesia & bradykinesia and postural/gait instability. Movement disorders not associated with PD include dystonia. These are involuntary rigid movements of the trunk and limbs. Spasticity is the velocity dependent increase in tonic stretch reflexes. These movement disorders may also be treated.
For PD patients to respond to surgery they should be less than 75, they must initially respond to L-Dopa and they may not be demented (mini-mental score >25) or severely depressed. They should have a Hoehn and Yahr score of 3 or less, a UPDRS scale less than 100, not have any of the Parkinson's Plus syndromes and have reasonable expectations. Surgery does not cure PD. Patients probably will need medication, although far less. However, their symptoms should be less, allowing return of some function and therefore improvement in quality of life. Candidates must have been placed on medication and maximally adjusted. They do not have to have dyskinesia from the medication. This is unlike patients with essential tremor, dystonia, and spasticity, these patients should no longer tolerate their medicine or the medicine should be ineffective.
A team approach to movement disorders yields the best results. It takes the cooperation between the primary care physician, neurologist, neurosurgeon and sometimes the neuropsychology doctor to affect the best treatment.
There is a plethora of medicine to treat PD. Medications should be reviewed by the neurologist. The use of drugs requires micro- manipulation as the disease advances. Sometimes the pills have to be adjusted for meals, for side- effects and definitely for the time of day. Parkison's is treated with amantadine, apomorphine,
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