World Parkinson's Day: How Treatment Of The Disease Has Evolved Over The Years

Several therapeutic options are now available to treat Parkinson's but Levodopa remains the cornerstone of medical management.

The cardinal symptoms of PD consist of bradykinesia (slowness of movements)

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World Parkinson’s Day takes place on 11 April every year to raise awareness about Parkinson's disease (PD).

PD is the second most common neurodegenerative disorder in the world, and it leads to significant morbidity unless treated early and appropriately. Although described as early as Ayurveda, the first clear medical description of PD in English literature was written in 1817 by James Parkinson in his Essay on the Shaking Palsy. Its widespread recognition is credited to Jean-Martin Charcot who refined and spread the knowledge regarding this disorder. Since then, scientific advancements in the field have furthered the understanding of the disease to achieve the best possible therapeutic response to enable patients to lead active and productive life. 

The cardinal symptoms of PD consist of bradykinesia (slowness of movements), rigidity, rest tremor, and impaired posture. In the beginning, the symptoms are mild and may manifest as tremor of the hands or legs in some patients, while others may present with the slowness of activities without significant tremor. However, as the disease progresses other symptoms also become prominent, and without treatment, it becomes difficult for the person to carry out the activities of daily living. Additionally, PD is often accompanied by non-motor symptoms such as anxiety, depression, constipation, and pain. 

Indeed, it is not uncommon for patients with PD to be diagnosed initially as having ‘frozen shoulder’ or low back pain. The course of the disease usually pans out over several years with gradual accrual and aggravation of symptoms requiring assistance from caregivers.

It is important to diagnose PD at an early stage and initiate appropriate treatment. Several therapeutic options are now available, but Levodopa remains the cornerstone of medical management. Introduced in the 1960s, Levodopa, aimed at mitigating dopaminergic dysfunction, has shown the best and most consistent effect in reducing the symptoms of PD. A good response to Levodopa is considered to be a diagnostic criterion. 

Other medications include dopamine agonists (pramipexole, ropinirole), MAO-B inhibitors (rasagiline), COMT inhibitors (entacapone), Amantadine, and anticholinergic (trihexyphenidyl). Sometimes a rational combination of these medications is used in varying dosages depending on the clinical condition of the patient. Along with the various medications, non-pharmacological strategies such as regular exercise, proper diet, and a healthy lifestyle are also important.         

Despite a good initial response, patients on prolonged dopaminergic therapy develop a gradual decline in the effect of Levodopa. This can be addressed by increasing the dosage, however, gradually the effect of the medication wears off and the patient enters into increasing ‘OFF’ states.

Moreover, patients may develop excessive involuntary movements known as ‘dyskinesia’ related to the dose of Levodopa. These symptoms are often difficult to manage with the usual medications, and at this stage advanced therapeutics such as deep brain stimulation (DBS) surgery becomes useful. DBS is an effective option that helps to improve the symptoms of PD and reduces Levodopa-induced dyskinesia with an overall reduction in the dose of dopaminergic medication.

It is essential to increase the awareness of PD in the general population to ensure early detection of the disease, initiation of appropriate management, and involvement of various sections of society to provide an adequate support structure for people with PD.

Dr Sanjay Pandey is the head of Department of Neurology, Amrita Hospital, Faridabad

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