Parkinson’s disease is one of the neurological disorders referred to as motor system disorders considering that these conditions are implicated in the loss of brain cells, particularly dopamine-producing cells. As a result, Parkinson’s disease is recognized by four primary symptoms including stiffness or rigidity (of the trunk and limbs), bradykinesia, tremor or trembling (in the hands, arms, face, legs, and jaw), and postural instability.
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On the other hand, progression of the primary symptoms leads to more pronounced symptoms such as difficulties in carrying out simple tasks, talking, or walking. Additionally, PD is common among the elderly people above the age of 50 years, with the early symptoms being subtle and gradual while individual differences are obvious in terms of disease progression.
Here, progression of the primary symptoms results into more pronounced effects such as interference with normal physiological activities in the patient’s body. Moreover, PD is associated with depression; emotional changes; skin problems; constipation; sleep disruptions; and difficulties in speaking, swallowing, and chewing (National Institute of Neurological Disorders and Stroke [NINDS], 2012a).
Currently, there are no known diagnostic tests for PD, and hence, many doctors rely on medical histories and other neurological examinations for diagnosis. As a result, many challenges are encountered during PD diagnosis, and the accuracy of tests is not guaranteed. Moreover, differential diagnosis may be initiated to rule out the presence of other related conditions.
On the other hand, there is no known cure for Parkinson’s disease, but various medications and therapeutic interventions, which provide remarkable symptomatic relief, are available (NINDS, 2012a; Claassen, van den Wildenberg, & Ridderinkhof, 2011; Wilkinson, Beigi, Lagnado, & Jahanshahi, 2011; Tiihonen, Lankinen, & Viemero, 2008).
This research paper compares and contrasts the effectiveness of pharmacological interventions such as the administration of Levodopa, Carbidopa, anticholinergics, and other drugs; the deep brain stimulation (DBS) surgical therapy, and the cognitive-behavioral patient education programs in the reduction or management of symptoms in PD.
Additionally, this paper will recommend the most appropriate approach to treating PD in addition to examining the neuro-physiological foundations of diseases and/or disorders, and the contemporary attitudes toward the three therapeutic interventions listed above.
Approaches to the Treatment of Parkinson’s disease
Amid enormous progress in the treatment of PD in the last few years, Levodopa has been the most effective medical therapy for controlling symptoms in PD. Additionally, other drugs such as dopamine agonists (DA), non-dopaminergic agents, and catechol-o-methyl-transferase (COMT) inhibitors have shown considerable success in controlling PD symptoms (Jankovic & Aguilar, 2008; Claassen et al., 2011).
However, it is important to note that before initiating any form of medical therapy, there is the need to assess the levels of motor, sensory, autonomic, and mental impairment through correct diagnosis. Additionally, the medical interventions should be individualized for each patient.
Accordingly, Levodopa is very effective in ameliorating bradykinesia-related symptoms in PD patients. Despite its efficacy, studies indicate that Levodopa is implicated in the development of motor complications (fluctuations and dyskinesias).
However, the conventional preparation of Levodopa and Carbidopa improves the therapeutic efficacy of Levodopa. In addition, it is recommended that the onset of Levodopa therapy should be delayed to avoid the underlying motor complications associated with the drug (Jankovic & Aguilar, 2008).
In addition to the duration and cumulative dose of Levodopa therapy, other risk factors such as the genetic predispositions to PD have been implicated in the development of Levodopa-induced dyskinesias. As a result, reduction of the cumulative dosage, the use of antidyskinetic drugs, and surgery improves Levodopa-induced dyskinesias.
Despite the effectiveness of Levodopa in controlling PD symptoms, studies indicate that the drug may be neurotoxic. Additionally, the duration of treatment with Levodopa has been implicated in the development of Levodopa-induced complications, which underlie delays in the initiation of Levodopa therapy until the PD symptoms start to interfere with the body functions and patient’s lifestyles (Jankovic & Aguilar, 2008).
As a result, it is recommended to use dopamine agonists (DA) prior to initiating Levodopa therapy considering that DA agonists can improve PD symptoms, and hence, becoming an alternative to delaying the initiation of Levodopa therapy. The efficacy of DA agents depends on their ability to activate DA receptors by circumventing the synthesis of DA in the presynaptic membrane.
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As a result, studies indicate that the activation of D2 receptors in concurrence with D1 stimulation mediates the effects of DA agonists in terms of improving physiological and behavioral effects associated with PD.
Among the DA agonists in use, Pramipexole is the most effective and safe drug, which can be administered as monotherapy, and hence, achieving Levodopa sparing, exerting neuroprotective effects, and improving PD clinical symptoms.
However, studies indicate that Levodopa remains superior to DA agonists in terms of providing prolonged motor control; longer life expectancy; and lower levels of hallucinations, edema, and vomiting in comparison to DA agonists (Jankovic & Aguilar, 2008).
In the early stages of PD treatment, non-dopaminergic drugs, including anticholinergics and amantadine, have been shown to provide similar levels of symptomatic relief as their dopaminergic counterparts. Most importantly, anticholinergics are effective in controlling tremors among young PD patients.
However, the usefulness of anticholinergics in controlling PD symptoms has been limited by various side effects such as urinary complications, dry mouth, and cognitive impairment.
Generally, pharmacological approaches to the treatment of PD are quite effective despite the underlying side effects. Additionally, it is important to individualize therapies on the basis of scientific rationale, which should aim at controlling symptoms and disease progression (Jankovic & Aguilar, 2008).
Deep Brain Stimulation (DBS) Therapy
Due to the underlying side effects associated with pharmacological approaches to PD treatment, contemporary studies aided by technological advancements have increased the understanding of the mechanisms regarding neurodegeneration, and therefore, providing effective therapeutic strategies to PD treatment such as DBS.
Unlike the use of pharmacological agents for controlling PD symptoms, DBS employs surgical procedures to treat neurological symptoms such as tremor, walking problems, stiffness or rigidity, and slowed movement (National Institute of Neurological Disorder and Stroke [NINDS], 2012b; Wilkinson et al., 2011).
However, despite DBS providing an alternative approach to controlling many debilitating symptoms in comparison to pharmacological agents, its current use is limited to patients whose response to medications is inadequate.
Basically, DBS is a cognitive approach to treating PD, which utilizes a surgically implanted neurostimulator to send electrical signals to specific sections of the brain, mainly the areas controlling movement. As a result, the artificial signals block the abnormal signals implicated in the development of essential tremor and other PD symptoms.
In comparison to pharmacological agents whose administration is aided by diagnostic tests, which may be inaccurate and unreliable, DBS surgical therapy is aided by magnetic resonance imaging (MRI) or Computed Tomography (CT) techniques for initial PD diagnosis.
These techniques are used to scan the brain in order to locate the exact position of nerve signals, which produce PD symptoms (NINDS, 2012b; Jankovic & Aguilar, 2008; Wilkinson et al., 2011).
Additionally, DBS surgical therapy may involve the use of microelectrode recording devices to monitor nerve cells within a specific area to identify and locate precise brain targets more accurately. In most cases, initial PD diagnosis identifies and locates the globus pallidus, thalamus, and subthalamic nucleus as the target areas within the brain, which are subject to abnormal nerve functioning.
Therefore, it is evident that the initiation of DBS surgical therapy is founded on accurate determination of specific brain regions exhibiting abnormal nervous functioning in order to administer correct symptomatic interventions.
Compared to pharmacological agents whose targets are non-specific, DBS surgical therapy is more specific, and achieves remarkable symptomatic relief in real-time (Jankovic & Aguilar, 2008; Wilkinson et al., 2011). Accordingly, the basic DBS system includes the lead, the extension, and the neurostimulator.
After identifying and locating the target area, the lead (electrode) is inserted through the skull with the tip of the lead reaching the target area. The extension (electrical wire) connects the lead to the neurostimulator, and in most cases, it passes under the skin around the head, neck, and shoulders. The neurostimulator is a battery-operated device inserted under the skin around the collarbone, chest, or the abdomen.
Upon installation, artificial electrical impulses are delivered right from the neurostimulator through the extension to the lead, and finally to the targeted areas in the brain. As the impulses reach the brain, they interfere or block the activities of abnormal nerve signals, which produce PD symptoms, and hence providing immediate and prolonged symptomatic relief.
In comparison to pharmacological agents, DBS surgical therapy is an effective PD treatment strategy that achieves symptomatic relief with minimal or no side effects. Furthermore, DBS does not cause damage to brain tissues or nerve cells, as opposed to earlier surgical procedures (NINDS, 2012b).
Most importantly, the stimulation generated by the neurostimulator can be adjusted whenever the patients begin to show remarkable improvement.
However, most PD patients are required to take their medications post-DBS treatment, but studies indicate that a good number of patients experience low levels of PD symptoms after undergoing DBS surgery, and therefore, the frequency of taking medications is greatly reduced. Consequently, the reduced frequency of medication intake improves the associated side effects, including dyskinesias (NINDS, 2012b).
Cognitive-Behavioral Patient Education Programs
From the foregoing discussions, it is apparent that both the pharmacological agents and surgical therapies improve various PD symptoms with remarkable effectiveness.
However, none of the two therapeutic interventions seeks to address other aspects of PD, such as the patients’ quality of life, psychosocial welfare, and depression.
As a result, the cognitive-behavioral patient education programs for persons with PD are alternative symptom management approaches to treating PD through evaluating the patients’ capacity to adjust to the disease symptoms, training the patients to cope with symptoms, and providing supportive services (Tiihonen et al., 2008).
Therefore, the initial approaches to these programs entail measuring the psychosocial effects of disease symptoms.
For example, it is recognized that PD affects both the primary motor functions of patients and the psychological/social functions of patients through the physical symptoms, which influence the patients’ normal activities. Therefore, the primary symptoms may lead to other secondary symptoms such as depression, social stress, lack of motivation, and lack of emotions.
The prevalence of depression among PD patients ranges from 7-70%. Additionally, the motor symptoms associated with PD have been associated with social stigmatization. Subsequently, the behavioral symptoms may as well worsen the primary motor symptoms.
For instance, studies indicate that stress increases the adverse effects of motor symptoms in patients with PD. As a result, the synergistic association between the primary and secondary PD symptoms is a matter of concern for many scientists.
Consequently, many researchers have recommended various intervention approaches aiming at reducing the psychosocial consequences of PD. Here, patient education forms the basis for supporting patients through their efforts to improve their lives. Therefore, patient education complements the work of medical and surgical treatments.
Moreover, patient education disseminates knowledge and instrumental skills to persons with PD in order to increase capacity in terms of self-management (managing behavioral and emotional stressors).
Basically, the programs utilize stress resistance training, relaxation training, cognitive restructuring, and social skills training to achieve various goals, particularly improving self-management skills among the patients (Tiihonen et al., 2008).
Therefore, compared to the other two therapeutic interventions, cognitive-behavioral programs employ different approaches toward reducing psychosocial consequences of PD, which are directly associated with motor symptoms. Overall, this is a very effective therapeutic strategy compared to the other two in ameliorating the psychosocial symptoms of PD such as depression and social stigmatization.
Hence, it is obvious from the preceding discussions that no one therapeutic intervention is effective in controlling all the symptoms associated with PD.
This is because pharmacological agents have side effects despite their remarkable efficacy in controlling some of the PD symptoms. On the other hand, DBS surgical therapy is quite effective in reducing a good number of PD symptoms, but it must be used concurrently with other medical therapies.
Further, cognitive-behavioral approaches to treating PD are very effective in reducing psychosocial consequences of PD with minimal or no effect to motor symptoms of PD. As a result, the most effective approach to treating PD should entail the use of all the three treatment options. The reason why the three treatment options will work together is that they complement one another.
For example, pharmacological agents cannot achieve complete treatment due to inherent limitations and side effects, and thus, DBS surgical therapy may compensate for these limitations. Conversely, the two treatment options may not be effective in controlling psychosocial symptoms of PD, and therefore, cognitive-behavioral therapies should come into play.
The Neurophysiological underpinnings of Diseases and Disorders
The discussions above highlight different approaches to diagnosing and treating PD, which is a neurological disorder or disease. Therefore, it is important to analyze the scientific foundations underlying these approaches.
Over the years, scientists in the field of clinical neurophysiology have been involved in neurophysiological studies with the aim of providing insights into the diagnosis and treatment of neurological diseases and disorders.
Here, these scientists measure and assess the activities of the central nervous system, the peripheral nervous system, and the skeletal muscles using various neuro-physiological procedures. The most common methods underlying various neurophysiological studies include polysomnography, EMG, EEG, MEG, movement monitoring, and intraoperative monitoring, among others (Walton, 2001).
Some of these procedures, such as EEG and EMG are employed in the measurement of direct signals or potentials originating from the body systems or muscles. These mechanisms underlie the process of identifying and locating specific target areas exhibiting abnormal functions, as noted earlier.
On the other hand, chemical and mechanical techniques are used in measuring various parameters such as respiratory effort, blood pressure, behavioral monitoring, oxygen saturation, and body motion, among others. Moreover, these techniques may be used together or separately for epilepsy monitoring, neonatal EEG recording, and movement analysis (Walton, 2003).
Therefore, the correct selection and application of the procedures described above require that one understands the scientific foundations of clinical neurology and normal neurophysiology in order to identify and locate abnormal functions associated with different neurological diseases and disorders under investigation.
Here, it is essential to note that the specialty of clinical neurophysiology deals with many diseases and disorders such as Parkinson’s disease, polyneuropathies, myopathies, epilepsy, dementia, sleep disorders, developmental or genetic disorders, and many more (Walton, 2003).
On the other hand, with the advent of the current technological advancements, more accurate and faster procedures of diagnosis are becoming available to the field of neurophysiology. As a result, there is the need to embrace the efficiency and effectiveness that comes with the new technologies by incorporating them into the existing procedures in order to realize the full benefits of both.
Currently, many people are of the opinion that the current diagnostic procedures and even the therapeutic interventions for different diseases and disorders are not adequate or effective in one way or another. Consequently, these contemporary attitudes toward the current procedures and treatment options will guide the future of diagnosis and treatment of various neurological diseases/disorders, including Parkinson’s disease.
Ultimately, the future of treatment approaches for PD will be marked by the advent of more advanced procedures, which will utilize the neurophysiological foundations underlying the three treatment options described in the previous discussions. Besides, the future treatment strategies will be tailored to fit into the requirements of individualized therapies.
Claassen, D.O., van den Wildenberg, W.P.M., & Ridderinkhof, K.R. (2011). The risky business of dopamine agonists in Parkinson Disease and impulse control disorders. Behavioral Neuroscience, 125(4), 492-500.
Jankovic, J., & Aguilar, L.G. (2008). Current approaches to the treatment of Parkinson’s disease. Neuropsychiatr Dis Treat., 4(4), 743-757.
National Institute of Neurological Disorders and Stroke [NINDS]. (2012a). NINDS Parkinson’s disease. USA: National Institutes of Health.
National Institute of Neurological Disorders and Stroke [NINDS]. (2012b). NINDS Deep Brain Stimulation for Parkinson’s disease. USA: National Institutes of Health.
Tiihonen, S., Lankinen, A., & Viemero, V. (2008). An evaluation of a cognitive behavioral patient education program for persons with Parkinson’s disease in Finland. Nordic Psychology, 60(4), 316-331.
Walton, J. (2001). Neurology-history: The oxford companion to medicine. New York: Oxford University Press.
Wilkinson, L., Beigi, M., Lagnado, D.A., Jahanshahi, M. (2011). Deep Brain Stimulation of the subthalamic nucleus selectively improves learning of weakly associated cue combinations during probabilistic classification learning in Parkinson’s disease. Neuropsychology, 25(3), 286-294.