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Friday, 28 October 2011

Treatment and Therapy of Parkinson's Disease

Governance of Parkinson's disease
Parkinson's disease is a chronic disease that requires treatment in a holistic manner covering various fields. At this time there is no treatment to cure this disease, but treatment and surgery can overcome the symptoms that arise. Individualized treatment of Parkinson's disease and symptomatic, medication is usually given for the treatment of disease or to replace or mimic dopamine which will improve tremor, rigidity, and slowness.
 Treatment in patients with Parkinson's disease aims to slow and inhibit the progression of the disease. This treatment can be performed by administering medication and physical therapy such as walking therapy, sound therapy / speech and the patient is expected to keep doing daily activities.

1. Therapeutic Medicines
          Some medicines given to people with Parkinson's disease:
a. Anticholinergic Benzotropine (Cogentin), trihexyphenidyl (Artane).
Useful for controlling symptoms of Parkinson's disease. To smooth the movement.
b. Carbidopa / levodopa
Levodopa is the main treatment for Parkinson's disease.
In the brain levodopa is converted to dopamine. L-dopa is converted to dopamine in dopaminergic neurons by L-aromatic amino acid decarboxylase (dopadekarboksilase). However, only 1-5% of L-Dopa into dopaminergic neurons, the remainder is metabolized in any place, resulting in extensive side effects. Because the feedback mechanism, there would be inhibition of endogenous formation of L-Dopa. Carbidopa and benserazide are dopa-decarboxylase inhibitor, helps prevent the metabolism of L-Dopa before it reaches the dopaminergic neurons. Levodopa to reduce tremor, stiffness of muscles and improve movement. Patients with mild Parkinson's disease can return to normal activity medicine is administered with carbidopa to enhance their effectiveness and reduce side effects. Since its introduction late 1960s, levodopa is considered one of the most widely used medicines to date. Levodopa is considered the backbone of the treatment of Parkinson's disease. Thanks to levodopa, a Parkinson's patient can return to normal activities. Many physicians delay treatment with levodopa symptomatic until it is needed. If the patient's symptoms are mild and do not interfere, with levodopa therapy should not be done. It is given that the effectiveness of levodopa is associated with long time usage. Levodopa across the blood-brain-barrier and enters the central nervous system and enzymatic changes into dopamine. Inhibit the activity of dopamine neurons in the basal ganglia. Side effects of levodopa can be:
1) Nausea, vomiting, abdominal distress
2) Postural hypotension
3) Once in a while will get cardiac arrhythmias, especially in patients who are elderly. This effect is caused by beta-adrenergic effects of dopamine on the cardiac conduction system. This bias treated with beta blockers such as propranolol.
4) dyskinesia. Dyskinesias are most commonly found involving the limbs, neck or face. Dyskinesia often occur in patients who respond well to levodopa therapy. Some patients showing symptoms of an on-off which is very annoying because people do not know when a sudden movement to a standstill, frozen, hard. So the movement for a moment interrupted.
5) laboratory abnormalities. Granulocytopenia, abnormal liver function and increased blood urea is a rare complication of levodopa therapy. Side effects of levodopa on the use of many years is dyskinesia is not controlled motor movements in the limbs and body. Response of patients who take levodopa also progressively reduced. To eliminate the side effects of levodopa, the schedule of regulated and increased the dose, also by providing additional medicines that have different mechanisms such as dopamine agonists, COMT inhibitors or MAO-Binhibitor. If the combination of these medicines also not helping here considered the treatment of surgery.
Surgery is not a standard treatment for Parkinson's disease is also not as a replacement therapy to medication taken.
c. COMT inhibitors Entacapone (Comtan), tolcapone (Tasmar).
To control the motor fluctuations in patients taking the medicine levodopa. Tolcapone is a COMT enzyme inhibitor, prolonging the effects of L-Dopa. But because of excessive side effects such as liver toxic, it is rarely used. The same type, entacapone, does not cause decreased liver function.
d. Dopamine agonists.
Dopamine agonists such as bromocriptine (Parlodel), pergolid (Permax), pramipexol (Mirapex), ropinirol, cabergoline, and lisurid apomorfin considered effective enough to treat symptoms of Parkinson's. This medicine works by stimulating dopamine receptors, but this medicine also causes a progressive decrease in dopamine receptors which in turn will lead to increased symptoms of Parkinson's.
These medicines can be useful for treating patients who have experienced attacks and dyskinesia fluctuate as a result of high doses of levodopa. Apomorfin can be injected subcutaneously. Low dose is given every day can reduce the fluctuations in motor symptoms.
e. MAO-B inhibitors selegiline (Eldepryl), Rasagaline (Azilect).
MAO inhibitors are thought to be useful in Parkinson's disease because dopamine neuotransmisi can be improved by preventing damaging. Selegiline can also slow the worsening of Parkinson's syndrome, levodopa therapy thus may be deferred for some time. Useful for controlling symptoms of Parkinson's disease. That is to smooth the movement.
 Selegilin and rasagilin menginhibisi reduce symptoms with a monoamine oxidase B (MAO-B), thereby inhibiting dopamine released by the destruction of dopaminergic neurons. Metabolites contain L-L-amphetaminand methamphetamines. The side effects are insomnia. Combination with L-dopa can increase mortality, which until now has not explained clearly biased. Another effect of this combination is stomatitis.
 f.Amantadine (Symmetrel)
Useful for the treatment of akinesia, dyskinesia, rigidity, tremor.
g. Inhibitor of dopa and levodopa decarboxylation
To prevent the levodopa is changed into dopamine outside the brain, levodopa combined with dopa decarboxylase enzyme inhibitor. For this purpose can be used karbidopa or benserazide (madopar). Dopamine and karbidopa can not penetrate the blood-brain-barrier. Thus, more levodopa that can penetrate the blood-brain-barrier, and then converted into dopamine in the brain. The side effects generally similar to side effects caused by levodopa.

2.Deep Brain Stimulation (DBS)
           In 1987, the treatment was introduced by inserting an electrode that emits a high frequency electrical impulses continuously into the brain. This therapy called deep brain stimulation (DBS). DBS is a minimally invasive disurgerykan actions through guidance computer with minimal damage to graft a medical device called a neurostimulator to generate electrical stimulation to targeted areas in the brain involved in controlling movement.
        This therapy provides a low electrical stimulation in the thalamus. This stimulation is driven by implantable medical devices that suppress tremor. This therapy offers the possibility of an emphasis on all the symptoms and side effects, doctors target areas subthalamic nucleus (STN) and globus pallidus (GP) as the electrical stimulation. Choice of target areas, depending on clinical assessment. DBS is now offering new hope for a better life with the latest surgical advances to patients with Parkinson's disease. DBS is recommended for patients with advanced Parkinson's disease (stage 3 or 4) that deliver the response to levodopa. Control of parkinsonism with DBS therapy showed 90% success. Based on research, as many as 8 or 9 out of 10 people using DBS therapy to achieve an increase in the ability to perform normal daily activities.
In addition to medicine therapy is given, feeding should really be considered, because it can cause muscle stiffness sufferers have difficulty swallowing so that it can happen malnutrition (malnutrition) in patients. Fiber foods will help reduce digestive disorders caused by lack of activity, fluids and some medications.

3. Physical Therapy
             The vast majority of people with Parkinson's will feel good effects of physical therapy. Patients will be motivated so that this therapy can be done at home, with examples given instructions or training in physical therapy clinics. Program of physical therapy in Parkinson's disease is a long-term program and the type of therapy tailored to the development or worsening of disease, such as changes in rigidity, tremor and other obstacles. Regular physical exercise, including yoga, tai chi, or dance can be beneficial in maintaining and improving mobility, flexibility, balance, and range of motion. Basic training is always recommended, such as carrying bags, wearing a tie, chewing hard and move the food in the mouth.

4. Sound therapy
        The greatest care for the sound mess caused by Parkinson's disease is the Lee Silverman Voice Treatment (LSVT). LSVT focus to increase the volume. One study found that electronic devices that provide sensory feedback listener or frequency auditory feedback (FAF) to improve the clarity of sound.

5. gene Therapy
          At this present time, investigations have been carried out up to the stage of gene therapy that involves using a harmless virus that is sent to the brain called the subthalamic nucleus (STN). Genes used for mempoduksi ordered an enzyme called glutamic acid decarboxylase (GAD), which accelerates the production of neurotransmitters (GABA). GABA acts as a direct inhibitor of cell that is too active in other STN.Terapi being developed is GDNF. Infusion of GDNF (glial-derived neurotrophic factor) in the basal ganglia using kathether implants through surgery. With a variety of biochemical reactions, GDNF stimulates the formation of L-dopa.

6. nerve grafting
           Stem cell grafts genetically to produce dopamine or stem cells turn into dopamine producing cells have begun to do. The first experiment was conducted randomized double-blind sham-placebo with dopaminergic transplants that failed to demonstrate improved quality of life for patients under age.

7. Surgery
           Surgery for Parkinson's sufferers rarely done since the discovery of levodopa. Surgery performed on patients with Parkinson's who have severe where medicine therapy is inadequate. Surgery performed thalamik thalatotomi and stimulation.

8. neuroprotective therapy

           Neuroprotective therapy may protect neurons from cell death induced disease progression. Which is being developed as a neuroprotective agent is apoptotic medicines (CEP 1347 and CTCT346), lazaroids, bioenergetics, anti-glutamatergic agents, and dopamine receptors. As for which is often used in clinics are monoamine oxidase inhibitors (selegiline and rasagiline), dopamine agonists, and complek I mitochondrial fortifier coenzyme Q10.

         Some nutrients have been tested in a clinical study clinic to then widely used to treat Parkinson's patients. For example, L-tyrosine, which is an L-dopa perkusor mennjukkan effectiveness of about 70% dalammengurangi symptoms of this disease. Iron (Fe), an essential cofactor in the biosynthesis of L-dopa reduced 10% - 60% of symptoms in a study of 110 patients.
 THFA, NADH, and piridoxin perkusor which is a coenzyme and coenzyme in the biosynthesis of dopamine showed a lower efficacy than L-tyrosine and iron. Vitamin C and vitamin E high doses can theoretically reduce cell damage that occurs in Parkinson's patients. Both vitamins are required in the enzyme activity of superoxide dismutase and catalase to neutralize superoxide anions that can damage cells. Not long ago, Coenzyme Q10 has also been used in a manner similar to working with vitamin A and E. MitoQ is a new synthetic substance that has a similar structure and function of coenzyme Q10.

10. qigong
         There are two studies of qigong in Parkinson's disease. In experiments in Bonn, a study of 56 patients found an increase in non-motor symptoms and motor skills among patients who did qigong structured 1 time a week for 8 weeks.
  However, both studies showed no effective qigong in Parkinson's disease. In the study, researchers used a randomized cross-over trial comparing aerobic exercise with qigong in advanced stages of Parkinson's disease. two groups of PD patients were assessed, then do 20 sessions both aeronik and qigong exercises, graded again, then after a lapse of 2 months, exchanged with 20 other sessions, and then assessed again. Authors obtain an increase in motor skills and function cardiopulmonal after following aerobic exercise, but do not have the benefit after attending qigong.

         More recently, Botox injections are being investigated as one of the treatment of non-FDA in the future

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