Summer Can Be A SAD Season for Parkinson's Disease

Hear the Music of Life While Travelling the PD Journey

In the Northern Hemisphere 'tis the season of the year when it's normally easy to be happy and optimistic. The weather is fantastic. Beautiful flowers and trees have bloomed and budded. This year, however, optimism is not such a sure thing what with the global fiscal crisis, several countries threatening to use missiles or nuclear bombs. The weather is weird with earthquakes and other bleak natural disasters. Gasoline seems headed to new price highs while families are spread out all over the globe......and oh yes, those of us who had Parkinson's still do.

Parkinson's disease still isn't fully understood and there is no cure yet. PD is a disease where the only certainly is progression, no matter the speed. It's not just situational depression but depression as part of PD itself. And don't forget summer SAD. I don't think I am affected by it all the time, but when I am it becomes very hard to begin projects, organize or complete things.

I have learned a few things about countering depression: If you have sleeping problems deal with them first, you won't get very far dealing with any PD problem until you are sleeping well. Try to acknowledge the depression. Denial just makes it more difficult for you and certainly for your family.

As difficult as it is, continue to be social. From volunteering to joining an online or offline support group. Don't sit at home, if at all possible, get out to be with people you like, people with whom you can communicate or share an activity. You need to generate your own positive feedback for yourself. You need to affirm that you still have a place in the world.

Exercise as often as possible using exercises designed for Parkinson's. Since every PWP is different, it may not work for you as well as it did for me or it may work better. I work out one hour a day, 6 days a week. I use exercise machines, a program designed for my needs and my own personal routine.

When you begin exercise get your doctor's advice and even better, the advice and program of a good exercise therapist. Begin slowly, you will find your pace, plateau and then exceed it.

Make listening to music something you do all day long especially when you work out. Music and exercising to music whether on a machine, dancing or sitting in a chair helps restore some homeostasis to the PD brain. And Chocolate for you but not your pets.

Enjoy your pets. Get out in the yard to soak up the sun with them, talk to them, smile with them, pet them, let them love you. And do the same for the rest of your family. Join the rhythm of life.

Transcranial Magnetic Stimulation - a future treatment for Parkinson's Disease

Exciting the Neurons - a potential noninvasive treatment for PD

Will Transcranial Magnetic Stimulation (TMS) using pulsating low electrical currents be a future treatment of PD motor impairment symptoms? Will it hold the line or slightly reduce symptoms?

Essentially TMS causes a group of neurons in the brain to depolarize and discharge an action potential. We're already familiar with that from what we know about Spinal Cord Stimulation. "rTMS can increase or decrease the excitability of corticalspinal or corticocortical pathways depending on the intensity of stimulation, coil orientation and frequency of stimulation." There are two types of TMS: rTMS, repetitive transcranial stimulation and tDCS which is transcranial direct current stimulation.

TMS hardware varies but the basics are coils of varying shapes of plastic encasing wires with either a magnetically inert inner layer or a ferromagneticlly active solid core. The shape varience my result in changes in the focus, shape and depth of the magnetic field cortical penetration. There are several designs to move the electrical current across the scalp and skull. The most discomfort has been some pain from the scalp and related muscles or a loud audio click caused by the TMS pulse.

The patient sits in a chair similar to a dental chair but without anethesia while the coils are placed. In the case of the TMS device which received FDA approval for use in treating non-medication responsive depression, the coils are located to stimulate the area of the brain responsible for mood regulation. In treating depression the short MRI strength magnetic pulses continue for about 40 minutes. The patient returns over the next month and a half for at least 20 to 30 sessions. At the end of each session, the patient can return to routine activity.

It is felt that for Parkinson's disease motor function 15-20 sessions will have a positive effect for six to eight months. Aften that time fewer sessions will be needed to sustain the effects. The sessions are always carried out by a team which includes a Biological Psychologist and an rTMS Specialist.

The whys of how it can work for PD are still unclear but it does seem to have an effect on the presynaptic inhibition of the motor cortex. TMS appears to help balance neural network activity and to stimulate dopamine release.

There aren't many diseases where the patient would simply want to stop the progression or simply eliminate just a few symptoms but Parkinson's disease happens to be one of these diseases because until a cure is found, that is the option.

Transcranial Magnetic Stimulation is a noninvasive brain stimulation to treat Parkinson's disease symptoms and dystonia. There are several studies in underway.
What have the researchers been studying for the last few years?
Sleep disorders: which may be may be partially reversed without affecting mood or motor symptoms.
Dyskinesia: slight reduction of symptoms with no negative effects upon motor function using low frequency rTMS.
Motor function: significant improvement in UPDRS with stimulation of the motor cortex resulting in increased dopamine in the striatum which was maintained for three days following the rTMS.
Depression: improved scores were observed at three days and three weeks after treatment. An improvement was also seen in anxiety scores and movement.

Some stimulating reading:Beneficial effect of transcranial magnetic stimulation on sleep in Parkinson's disease 2/17/09
http://www.ncbi.nlm.nih.gov/pubmed/19224604
KD van Dijk, EI Most, EJ Van Someren, HW Berendse, YD van der Werk, Dept of Neurology Medical Center, Amsterdam, The Netherlands

Repetitive transcranial magnetic stimulation for levadopa induced dyskinesias in Parkinson's disease 1/30/09
http://www.ncbi.nlm.nih.gov/pubmed/18951540
SR Filipovic, JC Rothwell, BP van de Warenburg, K Bhatia

Dopamine levels after repetitive transcranial magnetic stimulation Dept of Neurology: Assiut University Hospital, Assuit, Egypt
Sobell Research Dept of Motor Neuroscience and Movement disorders, National Hospital for Neurology and Neurosurgery, Queen Square, London - 2007
http://cat.inist.fr/?aModele=afficheN&cpsidt=18817071

More Abstracts on topic:
http://www.ncbi.nlm.nih.gov/pubmed/19255412?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/19255412?dopt=Abstract
http://74.125.93.104/search?q=cache:51PhTWpmWsUJ:www.bioportfolio.com/indepth/Transcranial_Magnetic_Stimulation.pdf+magnetic+stimulation+parkinson%27s+disease&cd=16&hl=en&ct=clnk&gl=us Link to trancranial magnetic stimulation info
http://www.ncbi.nlm.nih.gov/pubmed/15464863?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Patent Applications:
http://patft.uspto.gov/netacgi/nph-Parser?Sect2=PTO1&Sect2=HITOFF&p=1&u=%2Fnetahtml%2FPTO%2Fsearch-bool.html&r=1&f=G&l=50&d=PALL&RefSrch=yes&Query=PN%2F7236830 2002 Patent info on systems and methods for enhancing or optimizing neural stimulation therapy for treating symptoms of Parkinson's disease and/or other movement disorders
http://patft.uspto.gov/netacgi/nph-Parser?Sect2=PTO1&Sect2=HITOFF&p=1&u=%2Fnetahtml%2FPTO%2Fsearch-bool.html&r=1&f=G&l=50&d=PALL&RefSrch=yes&Query=PN%2F7277758 2004 Patent info
http://patft.uspto.gov/netacgi/nph-Parser?Sect2=PTO1&Sect2=HITOFF&p=1&u=%2Fnetahtml%2FPTO%2Fsearch-bool.html&r=1&f=G&l=50&d=PALL&RefSrch=yes&Query=PN%2F7437196 2006 Systems and methods for selecting stimulation sites and applying treatment, including treatment of symptoms of Parkinson's disease, other movement disorders, and/or drug side effects
Patent info: North Neuroscience, Inc

Clinical Trials of Transcranial Magnetic Stimulation:

TMS intermittent theta-burst (ITBS) Transcranial Magnetic Stimulation to treat Parkinson's Disease.Accepted age range: 40-80 years
Accepted gender: male and female with Dopa responsive PD
Trial location: appears to be Rockville, MD only
http://clinicaltrials.gov/ct2/show/NCT00753519?term=NCT00753519&rank=1
Contact: Patient Recruitment and Public Liason Office (800)411-1122 National Institute of Health in Rockville, MD identifier #NCT00753519 email contact

Study on the Effect of External Magnetic Stimulation on Patients with Parkinson's Disease
Accepted age range: 40-80 years
Accepted gender: male and female
Therapeutic restrictions: none seen
For more information about study #1EA-0000071
Government identifier: NCT00841464
http://clinicaltrials.gov/ct2/show/NCT00841464
Contact: Eileen Hummel or Cassandra Brasile

Transcranial Magnetic Stimulation to Treat Parkinson's Disease
http://clinicaltrials.gov/ct2/show/NCT00753519

http://clinicaltrials.gov/ct2/results?term=transcranial+magnetic+stimulation+Parkinson%27s+disease&recr=Open

FYI: Other PD Clinical Trials
To view all Parkinson's Clinical Trials:
http://www.pdtrials.org/en/browse/all
To view Parkinson's Clinical Trials by location:
http://www.pdtrials.org/en/browse/location
To view Parkinson's clinical trials by symptomCan be movement or non-movement or both:
http://www.pdtrials.org/en/browse/location

Questions About Parkinson's Disease Part V - Depression & PD

Parkinson's Depression and the three molecules of depression: serotonin, norepinephrine and dopamine

Depression is a common problem for many people - we hear those ads on television every day along with the side effect warnings. Parkinson's patients, their families and caregivers alike may go through periods of depression. The remedies and treatments for PDer and the carer may differ because of medication and supplement interactions and the disease itself.

Some research has indicated that the chemical changes in the brain caused by depression might actually be a trigger for PD. We know that Parkinson's shows itself after a significant loss of the neurotransmitters dopamine and norepinephrine; is serotonin deficiency occurring at the same time or earlier? One view is that synaptic depletion of serotonin allows a fall in norepinephrine levels. Which might mean that manipulating serotonin levels would increase norepinephrine levels if the norepinephrine depletion hadn't occurred because of the dopamine depletion. Which is why depression treatment can be different in Parkinson's disease.

Depression is often one of the 1st symptoms of PD - long before any obvious ones. Older patients can also manifest confusion, memory loss and apathy. PD is not the only disease associated with depression; Alzheimer's disease, kidney failure, stroke, AIDS, chronic fatigue, fibromyalgia, cancer and hypothyroidism patients also suffer from depression.

The PD symptoms for depression range from lack of energy, a struggle to arise to begin the new day, sleep disturbances, feeling irritable and anxious, have a sense of the loss of self-worth, feeling of self-guilt and loss of appetite. Because depression often manifests early it may seem to everyone that it is an extension of the appearance of Parkinson's Disease symptoms and the diagnosis. The depression may come and go. In the late stages depression may actually be caused by a chemical imbalance.

It is understandable that people would be depressed by having any disease because there is the shock, the grief and the sometimes not so subtle physical changes. There are differences in PD. A primary difference is that the depression over loss of mobility and appearance of other motor symptoms may actually acerbate the symptoms.

Psychological therapy such as cognitive-behavioral therapy as opposed to psychotherapy can be of benefit to PD patients because it can help restore a more positive self image which can assist in improving caregiver and family relations as well. It can also help the patient focus on problem-solving rather than the loss.

There are also medications which help. Be aware, however, the Cleveland Clinic information suggested that amoxipine (Ascendin) can make PD symptoms worse. And there are others which can cause low blood pressure. Selective serotonin uptake inhibitors (SSRIs) are among the more recent, safer meds. However, recent a study showed that nortriptyline, a tricyclic antidepressant (TCA) which targets both serotonin and norepinephrine receptors was more effective in PD patients than paroxetine (Paxil) an SSRI. Tricyclics are older antidepressants which must be monitored closely for overdose

If you are taking Zelapar or Zydis selegiline, Eldepryl, Cipro (Ciprofloxacin) there are cautions about taking antidepressants, SSRIs and tricyclic antidepressants because of interactions and side effects. Prozac and Zoloft may cause anxiety, tremor and insomnia.

Much to our surprise, we read that electroconvulsive therapy ("shock" therapy) works more rapidly than medication and may actually help improve other PD symptoms in some cases.

Another important treatment is exercise. It will help both the the depression and the PD symptoms.

There are also supplements which can help. Remember that medications are not the only substances which can cause side effects. Food and dietary supplements also have side effects.

Most of us are familiar with St John's Wort. You can also find St John's Wort in combination with 5-HTP and vitamin B-6. L-5-Hydroxytryptophan crosses the blood brain barrier and is said to help relieve anxiety and depression as well as being a natural relaxant which also aids in insomnia. There is some evidence that 5-HTP should not be used with carbidopa. If you are taking Azilect, if you are combining with MAO1 inhibitors, you should make sure to consult your doctor before taking ST John's Wort or 5-HTP. (Currently Teva, manufacturer of Azilect, is working with the FDA to change the description to MAO-B inhibitor which can be more broadly prescribed.)

Because of the impact upon the three molecules, the big 3 monoamines of Parkinson's, it is important to discuss any supplements you are considering with your neurologist. Melatonin is another supplement which is used in low doses to treat depression because it is known to raise serotonin levels and to help adjust the sleep cycle. Supplements should not be taken without a discussion with your physician.
It is important to keep in mind that everything you take into your body, including the foods you eat, will interact with everything else you take. Some combinations are synergistic, they work well together and may amplify the benefits while combining others can cause serious side effects.

One last area to discuss is Seasonal Affective Disorder - SAD.
It isn't just the winter blues because you feel cooped in even when you have to go out and about. SAD is more serious than that. It affects patients and caregivers alike. Some people have SAD even in the spring and summer.

We'll talk more about SAD in the next post - better late than never.

Yoga as Exercise for Parkinson's Disease and PD Depression

Let's start with a few words about doing Yoga as an exercise for Parkinson's disease and Parkinson's depression:

First of all these exercises are best read aloud slowly and calmly by another person. If you have no one with whom to practice, read them aloud step by step yourself. You should be able to print the article either printing the page or by cutting and pasting this article onto a word-pad or some other docs program or even an email and then printing in the your favorite type face and size for reading.

If you are working with another person, ask them if they will do each exercise first as YOU read it aloud to them. Then it will be your turn. The advantage to seeing the exercise performed first is that of the kinetic experience you can achieve by watching.

If you like to exercise to music, these asanas should be done to calming, slow, soothing sounds. You might choose nature sounds.

It is important to remember that the stiffness of Parkinson's and the tremors may make the simplest of poses seem difficult. That's okay. The benefits accrue with the repetition. As you learn each step, as the muscle stiffness does not impair movement as much with each repetition, the movements will begin to flow from one step to the next. Soon you will be able to reach your version of the pose.

Your reader needs to be aware of your pace and not attempt to move you too rapidly from step to step. The reader should allow time for the practitioner to achieve the step before moving on for the complete pose.

Remember that breathing is an integral part of the exercise and important for the relaxation which will ultimately be felt. Breathing better is very important to help with the depression which is so symptomatic of PD. The exercises themselves are significant in their focus on the relaxation needed for helping with depression.

All floor exercises should be done on a carpet or mat. Bare wood or tile is uncomfortable. Have at least one cushion or pillow available.

Not all positions are possible for all people. You have two options: you can do the best you can do without pain to achieve the pose or you can simply perform the ones which are possible.

Please do not be upset by the Shava Asana title: the corpse pose. It is definitive of a body in repose. It should also be your first and last pose for a session.

About the Asanas: they should be steady and comfortable. Your body should be poised and relaxed. Breathing should be controlled (Pranayama) Do not use force or pressure. And do not exercise immediately after a meal. The purpose is to develop muscle flexibility, tendon strength, better respiratory function, improve the circulatory system, improve sex life and concentration, aid in weight loss. The asanas are designed to aid the flow of prana (vital energy or qi in Chinese) and to help balance the physical and metaphysical body.

Let us begin

SHAVA-ASANA or MRTA-ASANA, The Corpse Pose1. Lie on your back
2. Spread your arms at a 45 degree angle from your body, hands and fingers open
3. Let your legs relax to an open posture - no tension - no toe point - head comfortable
4. Close your eyes
5. Breathe deeply from the diaphragm - through the ribcage - and the upper chest
6. Let your body feel heavy and pliant - relax into the carpet or mat.
7. Sense your body - be aware of where your body is holding tension and send your focus there
8. You may wiggle your toes and your fingers to shake out stress
9. Continue to inhale from the diaphragm - through the ribcage and the upper chest.
10. Exhale in the same pattern
11. Clear your mind and continue to inhale and exhale - slowly and deeply.
Shava-Asana is not a fall asleep exercise although it can be used in that way at bedtime.
In this exercise you are moving to a conscious state of relaxation.

Bala-Sana The Child's Pose
1. Kneel on the mat with the tops of your feet on the floor.
2. Sit back on your heels
3. Adjust your position so that your knees are about 1 foot apart
4. Your hands should rest on your thighs (Vajar-asana or Thunderbolt pose)
5. Bend forward from your hips, bringing your chest to rest on the floor between your thighs.
If this is uncomfortable or if you do not have that much flexibility, rest your head on a cushion or two instead.
6. Stretch your arms full out in front of you on either side of your head.
7. Stretch you spine, your arms, your hips.
8. Relax as you inhale slowly - through your nose and from your diaphragm, your rib cage and upper chest.
9. And slowly exhale
10. Remain in this pose for about 2 mnutes.
11. Now slide your arms back to your sides, palms up and onto your thighs palms down.
Repeat at least once more.
This is a comforting and peaceful pose. It will stretch and relax your shoulders, thighs, neck and back muscles.

If you have Parkinson's constipation you can vary the child's pose by bending first over one leg, holding that pose and then returning to an upright position.
Repeat over the other thigh if you are kneeling.
You can also do this in a chair. It should relieve some of the discomfort as well as helping those smooth muscles of the intestinal tract.

We will be adding more exercises over the next few days.