Parkinson’s disease: An incurable and lifelong condition

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As we age, quite a few ailments tend to become more prevalent; one is Parkinson’s disease (PD). It has been around since ancient civilizations, but it was first medically described by English physician James Parkinson in 1817 as “shaking palsy”. In 1872, it was termed Parkinson’s disease. اضافة اعلان

The World Health Organization (WHO) estimates that by 2019 over 8.5 million people were living with the condition. While there are no updated estimates of PD in Jordan, a 2009 study estimated PD to affect 59 people per 100,000 Jordanians.

The rate of PD has been on the rise globally due to a whole host of factors, including an increase in the number of the older population. With this trend in mind, it is safe to assume that the prevalence has also been rising in Jordan.

What is PD
PD is a neurodegenerative disease, which means that in time, the neurons in the brain cease to function. It is the second most common age-related degenerative brain disease and most common movement-related brain disease. Another common neurodegenerative condition, especially in the older population, is Alzheimer’s disease. Both conditions affect the brain, but each affects different areas, which results in different manifestations. Whereas Alzheimer’s most commonly causes memory impairment, PD causes mostly movement impairment.

The brain is composed of billions of little wires known as neurons, which use little chemical messengers known as neurotransmitters. One such neurotransmitter is dopamine. Dopamine is commonly known as the “feel good” chemical, since it plays an important role in the reward system of the brain. However, dopamine also plays a crucial role in movement.

In PD, a specific portion of the brain, known as the basal ganglia, experiences degeneration. The basal ganglia includes a specific region known as the substantia nigra, which is responsible for movement. As the disease progresses, the neurons that produce dopamine begin to die. Once roughly 80 percent of dopamine is lost, symptoms of PD begin to occur.

Symptoms of PD
Symptoms of PD are progressive. The majority of cases do not develop symptoms until after the age of 60, but roughly 5–10 percent of cases may present themselves before 50.

Typically, PD has four main symptoms. One is known as bradykinesia or slowed movements. This symptom is essential in the diagnosis of PD; when having it, the individual may report muscle weakness. There is no actual loss of muscle strength, only an impairment in muscle control. Bradykinesia manifests itself as more than slow movement; it can include impaired dexterity, decreased blinking, drooling, and difficulty with facial expressions.

Another symptom is tremors at rest. These are involuntary, rhythmic shaking movements. In PD, the tremors only occur at rest, known as resting tremors, and seemingly disappear with voluntary movement. Generally, tremors will begin on one side of the body and may progress, but they commonly start in the hands.

A third symptom of PD is rigidity or stiffness, caused by an involuntary increase in muscle tone, which makes fluid movements difficult. It can take two shapes: lead-pipe rigidity and cogwheel stiffness. Lead-pipe rigidity is a constant and unchanging stiffness when moving a body part; cogwheel stiffness appear more as stop-and-go movements that resemble jerking.

The fourth and final main symptom is impaired posture and unstable gait. This is the result of an impaired sense of balance combined with rigidity. Walking becomes impaired, and this will be compensated by lowering the center of gravity. Ultimately, the result is a stooped posture while walking, as well as shorter and shuffling strides.

These four main symptoms are combined with other motor and non-motor symptoms. Other motor related symptoms include micrographia (small handwriting), dysphagia (difficulty swallowing), and hypophonia (unusually soft speaking voice). Non-motor symptoms were once thought to be risk factors for PD, but as research into the condition has advanced, it is more likely that they serve as early indicators of the disease.
The condition itself is not fatal, and generally does not affect life expectancy. In 1967, the life expectancy for someone with PD was under 10 years.
One of the most important set of non-motor related symptoms is autonomic nervous system impairment. This can include orthostatic hypotension (low blood pressure when standing up), constipation and other gastrointestinal issues, urinary incontinence (loss of bladder control), and sexual dysfunction. Other non-motor related symptoms include depression, anosmia (loss of sense of smell), sleep disorders, and Parkinson’s related dementia.

Causes and risk factors
Parkinson’s disease is a complex condition that is still being investigated. Its exact cause is not fully understood, but by current understanding, there are two main causes. One is familial PD, when the condition is inherited from one or both parents, but only makes up approximately 10 percent of all cases. So far, at least seven different genes have been linked to PD and three of them are linked to early-onset manifestations of the condition (i.e., developing symptoms before the age of 50).

The second main cause is known as idiopathic PD, and is the result of a specific protein known as α-synuclein. Proteins take on very specific configurations and shapes in order to be properly utilized and disposed of. However, in PD, for unknown reasons, this protein becomes misfolded, which makes disposal difficult. As a result, α-synuclein builds up in the brain and forms clumps known as Lewy bodies, which ultimately have toxic effects and cause cell damage.

Other conditions may cause Parkinson’s-like symptoms parkinsonism. For example, certain medications, encephalitis, toxins and poisons, and brain injury can result in Parkinsonism. Depending on the case, the symptoms may be temporary or permanent, but even in cases of permanent Parkinsonism, if there is no degeneration of the basal ganglia, it is not considered PD. Unfortunately, by current understanding, PD is either caused by genetics (i.e., familial) or unpredictably (i.e., idiopathic). This means that there is no clear way to prevent the disease.

PD in Jordan
Unfortunately, to date PD is an incurable and lifelong condition, and treatment manages its symptoms. In the early stages of the condition, living independently will still be manageable, but as the disease progresses, independent living will become increasingly difficult.

The condition itself is not fatal, and generally does not affect life expectancy. In 1967, the life expectancy for someone with PD was under 10 years. However, as our understanding and management of the condition improved, so too has the life expectancy, to roughly 14.5 years.

The quality of life for individuals with PD can be greatly improved with proper education and management, through pharmacological and non-pharmacological intervention. Unfortunately, Jordan is ill equipped for the increase in the number of PD patients, and a 2016 study may have identified several barriers.

The study was quite simple in nature; it consisted of 13 Jordanian PD patients who were interviewed about potential barriers to treatment in Jordan. Three of the main complaints by participants were: it is difficult to diagnose,  there is a lack of information provided by neurologists, and a lack of referrals to physiotherapy.

If Jordan has any hope of properly managing cases of PD, there must be reform on multiple fronts, including how healthcare providers approach management of PD, public awareness and education, research into prevalence, and effective management interventions.

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