Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Parkinson's Disease
- Sameer Chadha, Shikha Mehta, Sumeet Chadha Medical Students (4 September 2007)
-
Parkinson’s disease – What about voice?
- Gordana Ninkovic, Meredydd Harries (12 September 2007)
-
Treatment of Parkinson's Disease in Gauchers Disease.
- Noor-ul-Ain Mughal (18 September 2007)
|
|
|||
|
Sameer Chadha, Medical Student Maulana Azad Medical College, New Delhi, India, Shikha Mehta, Sumeet Chadha Medical Students
Send response to journal:
|
Surgical Care in Parkinson's Disease (PD) Stereotactic surgery has made a resurgence in the treatment of PD, largely due to long-term complications of levodopa therapy resulting in significant disability despite optimal medical management. Lesion surgeries involve the destruction of targeted areas of the brain to control the symptoms of PD. 1) Thalamotomy involves destruction of a part of the thalamus to relieve tremor. Thalamotomy has little effect on bradykinesia, rigidity, motor fluctuations, or dyskinesia. But More than 90% have significant improvement in tremor of the limbs contralateral to the side of the lesin. Complications from bilateral thalamotomy are common, more than 25% of patients experience speech impairment. 2)Pallidotomy involves destruction of a part of the globus pallidus interna (GPi), which is overactive in PD. Results demonstrate significant improvements in each of the cardinal symptoms of PD (tremor, rigidity, bradykinesia) as well as a significant reduction in dyskinesia. 3)Subthalamotomy involves destruction of a part of the subthalamic nucleus (STN), which is also hyperactive in PD. It has shown significant improvements in the cardinal features of PD as well as the reduction of motor fluctuations and dyskinesia. Lesion surgeries for PD have largely been replaced by deep brain stimulation (DBS) that does not involve a permanent lesion in the brain making the procedure reversible and the device can be adjusted to accommodate for disease progression and side effects. Deep brain stimulation The DBS system consists of a lead that is implanted into the targeted brain structure (thalamus, GPi, STN) respectively called Thalamic, Pallidal or Subthalamic stimulation. DBS has been proposed to work by resetting abnormal firing patterns in the brain leading to a reduction in parkinsonian symptoms. Subthalamic stimulation Subthalamic stimulation is currently the most common surgical procedure for PD and involves implantation of a DBS lead in the subthalamic nucleus (STN). STN DBS controls all of the cardinal symptoms of PD as well as motor fluctuations and dyskinesia. Competing interests: None declared |
|||
|
|
|||
|
Gordana Ninkovic, ENT ST2 Guy's Hospital, Meredydd Harries
Send response to journal:
|
Clarke CE gives a comprehensive overview of Parkinson’s disease with the emphasis on early diagnosis. In the review the author failed to mention dysarthria experienced by Parkinson’s patients and its significance both diagnostically and socially. Evidence suggests that speech disorder may be one of the early presenting features of the disease and with that in mind could be used to aid early detection of the disease. Stewart(1) identified at least two characteristics of dysarthria in all of his early Parkinson’s disease patients including vocal tremor in 4/12 patients. Sewall(2) et al found that nearly a third of Parkinson’s disease patients find speech impairment to be their most disabling symptom leading to communication difficulties and social isolation. However, only 3-4% receive speech therapy(3). Significant speech disorder is also common in advanced Parkinson’s disease(4). Dysarthria in Parkinson’s disease sufferers results from laryngeal changes, alteration in the cerebral function and changes in four components of speech production: respiration, phonation, articulation and prosody5. Different treatment modalities are used with varying success ranging from pharmacotherapy, surgical interventions (thalamotomy, pallidotomy, subthalamotomy, deep brain stimulation and laryngeal framework surgery) to speech therapy (Lee Silverman Voice therapy)6. Due to complexity of its pathogenesis, Parkinson’s dysarthria should be managed by multidisciplinary teams including speech and language therapists, laryngologists and neurologists. Whilst the review was excellent in almost every other aspect of Parkinson’s, we hope this letter will draw attention to the importance of voice and communication in this disease and aid its earlier diagnosis and management. 1. Stewart C, Winfield L, Hunt A, Bressman SB, Fahn S, Blitzer A, Brin MF Speech dysfunction in early Parkinson's disease, Movement Disorder 1995 Sep;10(5):562-5 2. Sewall GK, Jiang J, Ford CN Clinical Evaluation of Parkinson’s-Related Dysphonia, Laryngoscope Oct 2006;116: 1740-1744 3. Delyski D, Petrushev P Methods of objective assessment of high speed videoendoscopy, proceedings from the 6th international conference: Advances in quantitative laryngology, voice and speech research, April 2003, Hamberg, germany 4. Blumin JH, Pcolinsky DE, Atkins JP Laryngeal Findings in Advanced Parkinson’s Disease, Ann Oto Rhino Laryngo April 2006; 113: 253-258 5. Scott S, Caird FI, Williams BO Communication in Parkinson’s Disease, Aspen Publisher, Rockville, Maryland, 1985 6. Schulz GM The Effects of Speech Therapy and Pharmacological Treatments on Voice and Speech in Parkinson’s Disease: A Review of the Literature, Curr Med Chem 2002; 9: 1359-1366 Competing interests: None declared |
|||
|
|
|||
|
Noor-ul-Ain Mughal, FY2 M46 9DE
Send response to journal:
|
Parkinson's disease is a degenerative disease of the nervous system associated with trembling of the arms and legs, stiffness and rigidity of the muscles and slowness of movement (bradykinesia).it is one of the motor system disorders, which are the result of the loss of dopamine-producing brain cells. The four primary symptoms of PD are tremor, or trembling in hands, arms, legs, jaw, and face; rigidity, or stiffness of the limbs and trunk; bradykinesia, or slowness of movement; and postural instability, or impaired balance and coordination. Association between Gauchers disease and Parkinsonism has been a point of interest for a long time.The clinical picture is characterized by the predominance of bilateral akinetic-rigid signs and poor response to levodopa therapy.However the nature of the association is still a mystery.In type 1 Gauchers Disease which is more common in Ashkenzi jews, the risk of Parkinson's disease is sevenfold higher among those with glucocerebrosidase gene mutations than in those with normal genotype. Various trials have shown evidence in favour of misglustat. Relatively mild Gauchers Disease (mean age of diagnosis of 35 years) and early onset treatment-refractory Parkinsonian syndrome (mean age at diagnosis of 48 years) have been shown to be associated.However few patients have been found to have Parkinsonism before they had Gauchers Disease, therefore showing that various Phenotypes of Gauchers Disease are associated with Parkinson’s disease.None the less the molecular link between the two remains to be established. Clinical studies on animal have shown that miglustat crosses the blood–brain barrier with beneficial effects on neuronal glycosphingolipid storage.In one trial which was conducted for 24 months the patient who was given misglustat did not experience any reported side effects especially bowel disturbances. Also as far as the haematological peripheries and the biological markers;i.e. chitotriosidase were concerned, they remained stable or improved over the period when the Substance reduction therapy i.e. Misglustat was used. Therefore Oral Substance Reduction Therapy should be considered as an effective therapeutic alternative in patients with type I Gauchers Disease and concurrent movement disorders who are unsuitable for Enzyme Reduction Therapy. References; 1. “Clinical Review: Parkinson’s Disease” C.E.Clark et al.BMJ, Sep 2007; 335: 441 - 445 ;doi:10.1136/bmj.39289.437454.AD 2. “Gaucher’s disease with Parkinson’s disease: Clinical and pathological aspects.” B. Bembi, MD, S. Zambito Marsala, MD,et al.American Academy of Neurology, Neurology 2003;61:99-101. 3. “Mutations in the Glucocerebrosidase Gene and Parkinson's Disease in Ashkenazi Jews.” Judith Aharon-Peretz, M.D., Hanna Rosenbaum, M.D. et al.National England Journal of Medicine. Volume 351:1972-1977 4. “Oxford handbook of General Practise.” Chantal Simon et al. July 2005: 2: 610-611. Competing interests: None declared |
|||