Parkinson's disease and parkinsonism( trembling paralysis)

Parkinson's disease, or parkinsonism is a slowly progressive condition that manifests itself by slow motion, muscle stiffness and restless tremor. The disease was first described by the English physician James Parkinson, who called it the trembling paralysis. In 1877,

identifies idiopathic parkinsonism( Parkinson's disease) and parkinsonism syndrome caused by various causes and often serves as a manifestation of other degenerative diseases of the nervous system. Parkinson's disease or parkinsonism occurs in 60-140 per 100 000 population;its frequency increases dramatically with age. According to statistical data, parkinsonism occurs in 1% of the population up to 60 years and in 5% of older persons. Men get sick more often than women.

Causes of Parkinson's Disease

Parkinson's disease and parkinsonism are based on a decrease in the number of neurons of the black substance and the formation of inclusions in them - Lewy bodies. Its development is promoted by hereditary predisposition, elderly and senile age, influence of exogenous factors. In the onset of akinetic-rigid syndrome, a hereditary conditioned disruption of catecholamine metabolism in the brain or inferiority of the enzyme systems controlling this metabolism may be important. Often, a family burden on this disease is revealed in the autosomal dominant type of inheritance. Such cases are attributed to Parkinson's disease. Various exo- and endogenous factors( atherosclerosis, infections, intoxications, traumas) contribute to the manifestation of genetic defects in the mechanisms of catecholamine metabolism in the subcortical nuclei and the onset of the disease.

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Parkinsonism syndrome occurs as a result of acute and chronic infections of the nervous system( tick and other encephalitis).The causes of Parkinson's disease and parkinsonism can be acute and chronic disorders of cerebral circulation, cerebral atherosclerosis, cerebral vascular diseases, tumors, trauma and tumors of the nervous system. It is possible to develop parkinsonism due to drug intoxications with long-term use of phenothiazine series drugs( aminazine, trifazine), methyldopa, some narcotic drugs - drug Parkinsonism. Parkinsonism can develop with acute or chronic intoxication with carbon monoxide and manganese.

The main pathogenetic link of the trembling paralysis and Parkinson's syndrome is the disruption of the exchange of catecholamines( dopamine, norepinephrine) in the extrapyramidal system. Dopamine performs an independent mediator function in the implementation of motor acts. Normally, the concentration of dopamine in the basal nodes is many times greater than its content in other structures of the nervous system. Acetylcholine is a mediator of excitation between the striatum body, the pale sphere and the black substance. Dopamine is its antagonist, acting inhibitoryly. When the black matter and pale ball hit, the level of dopamine in the caudate nucleus and the shell decreases, the ratio between dopamine and norepinephrine disrupted, and the extrapyramidal system disrupts function. Normally, the impulse is modulated toward suppression of the caudate nucleus, the shell, the black matter and stimulation of the pale ball. When the function of black matter is turned off, a blockade of impulses arriving from the extrapyramidal zones of the cerebral cortex and the striatum to the anterior horns of the spinal cord occurs. At the same time, the pathological impulses from the pale sphere and the black substance enter the cells of the anterior horns. As a result, the circulation of impulses in the alpha and gamma motor neuron system of the spinal cord increases with the predominance of alpha activity, which leads to pallidarno-nigral rigidity of muscle fibers and tremor, the main signs of parkinsonism.

Pathomorphology of Parkinson's Disease and Parkinsonism.

The main pathoanatomical changes in parkinsonism are observed in black matter and a pale ball in the form of degenerative changes and death of nerve cells. On the site of dead cells, foci of growth of glial elements or void remain.

Forms of parkinsonism:

trembling, trembling - rigid, rigid - trembling, akinetic - rigid, mixed.

The degree of severity distinguishes five stages of Parkinson's disease. The most common classification was proposed in 1967 by Hyon and Yar:
• 0 stage - no motor manifestations
• Stage I - unilateral manifestations of
• Stage II - bilateral symptoms without postural disorders
• Stage III - moderate postural instability but patientdoes not need outside assistance
• Stage IV - significant loss of motor activity, but the patient is able to stand and move without the support of
• V stage - in the absence of outsidersit help the patient chained to a chair or bed

symptoms of Parkinson's disease and parkinsonism

symptoms of Parkinsonism - a movement disorders and muscle tone, and combinations thereof. Stiffness of movements, increase of tone, tremor of hands and head, movement of the lower jaw like "chewing", handwriting and accuracy of movements, gait "bent", small steps, "shuffling", poverty of facial movements - "frozen face", decreased emotional behavior, depression. Symptoms of the disease, at first unilateral, in the future progress, in severe cases lead to disability, immobility, cognitive impairment.

Symptoms of parkinsonism

The main clinical syndrome in Parkinson's disease and Parkinson's disease is akinetic-rigid or hypertonic-hypokinetic. The trembling paralysis and parkinsonism are characterized by hypo- and akinesia. A peculiar flexing posture appears: the head and trunk are tilted forward, the arms are bent in the elbow, wrist and phalangeal joints, they are often tightly brought to the lateral surfaces of the thorax, the trunk, and the legs are bent at the knee joints. Poverty of facial expressions is noted. The rate of voluntary movements with the development of the disease gradually slows down, and sometimes immobility may occur quite early. The gait is characterized by small shuffling steps. Often there is a tendency to involuntary run forward( propulsion).If you push the patient forward, he runs to avoid falling, as if "catching up with his center of gravity."Often a push in the chest leads to a run back( retropulse), to the side( lateropulsesia).These movements are also observed when you try to sit up, stand up, throw your head back. Often, with a pronounced parkinsonism syndrome, the patient's postures resemble cataleptic ones. Akinesis and plastic hypertension are especially pronounced in the musculature of the face, the masticatory and occipital muscles, and the limb muscles. When walking, there are no friendly hand movements( aheyrokeznez).Speech is quiet, monotonous, without modulation, with a tendency to fade at the end of the phrase.

With passive limb movement, there is a kind of muscular resistance due to an increase in the tone of the antagonist muscles, the phenomenon of the "cogwheel"( it seems that the articular surface consists of the coupling of two gears).The increase in the tone of the antagonist muscles with passive movements can be determined by the following method: if you raise the head of a lying person and then release your hand sharply, the head does not fall on the pillow, but descends relatively smoothly. Sometimes the head in a supine position is slightly elevated - the phenomenon of an "imaginary pillow".

Tremor is a characteristic symptom, although not mandatory for Parkinson's syndrome. This rhythmic, regular, involuntary trembling of limbs, facial musculature, head, lower jaw, tongue, more pronounced at rest, diminishing with active movements. The oscillation frequency is 4-8 per second. Sometimes there are movements of the fingers in the form of "rolling down pills", "counting coins".Tremor increases with excitement, almost disappears in a dream.

Mental disturbances are manifested in the loss of initiative, activity, narrowing of horizons and interests, a sharp decrease in various emotional reactions and affects, as well as some surface and slowness of thinking( bradyphrenia).Bradypsychia is observed - a difficult active switching from one thought to another, acaiya - stickiness, viscosity, egocentrism. Sometimes there are paroxysms of mental arousal.

Vegetative disorders are manifested in the form of greasiness of the face and scalp, seborrhea, hypersalivation, hyperhidrosis, trophic disorders in the distal parts of the limbs. There is a violation of postural reflexes. Sometimes special methods of research determine irregular in frequency and depth of breathing. Tendon reflexes, as a rule, without deviations. Atherosclerotic and postencephalitic parkinsonism, an increase in tendon reflexes and other signs of pyramidal insufficiency can be determined. In post-encephalitic parkinsonism, there are so-called oculogic crises - fixing the gaze upward for several minutes or hours;sometimes the head is thrown back. Crises can be combined with a violation of convergence and accommodation( progressive supranuclear palsy).

It is accepted to distinguish several clinical forms of trembling paralysis and parkinsonism;rigid, bradykinetic, trembling-rigid and tremulous. Rigid-bradykinetic form is characterized by an increase in muscle tone by plastic type, progressive slowing of active movements down to immobility;there are muscular contractures, flexor posture of patients. This form of parkinsonism, the most unfavorable in the course of the course, is more often observed with atherosclerotic and less frequent in postencephalitic parkinsonism. The trembling-rigid form is characterized by a tremor of extremities, mainly of their distal sections, to which, with the development of the disease, the stiffness of arbitrary movements joins. The trembling form of parkinsonism is characterized by the presence of a constant or almost constant medium- and large-amplitude tremor of the limbs, tongue, head, and lower jaw. Muscle tone normal or slightly elevated. The rate of arbitrary movements is saved. This form is more common in postencephalitic and posttraumatic parkinsonism.

A person is disturbed by movement, muscle control and body balance in space. This state is formed as time due to the destruction of a cluster of nerve cells( black substance) of the brain stem. These nerve cells are connected by their fibers to both hemispheres of the brain. They produce and release special substances( neurotransmitters), which help control the movement and coordination of the body in space. Their absence leads to appearance of outwardly visible signs of parkinsonism, such as a decrease in the volume of movements with an increase in muscle tone, trembling of the limbs, masklike facial expression, walking with small steps and similar symptoms.

Laboratory and functional research data.

In posttraumatic parkinsonism, an increase in cerebrospinal fluid pressure is detected with normal cellular and protein composition. In Parkinsonism, which is due to carbon monoxide poisoning, the blood shows carboxyhemoglobin, in manganese parkinsonism - traces of manganese in the blood, urine, cerebrospinal fluid. Global electromyography in the case of trembling paralysis and parkinsonism reveals a violation of the electrogenesis of muscles - an increase in the bioelectrical activity of the muscles at rest and the presence of rhythmic group discharges of potentials. With electroencephalography, mainly diffuse, non-rough changes in the bioelectrical activity of the brain are detected.

Diagnosis and differential diagnosis of parkinsonism.

First of all, the doctor conducts an examination of the patient and already on these data can make a preliminary diagnosis. It is necessary to differentiate Parkinson's disease from Parkinson's syndrome. For postencephalitic parkinsonism, oculomotor symptoms are characteristic;can be observed torticollis, phenomena of torsion dystonia, which are never observed in a tremor paralysis. There are violations of sleep, respiratory dyskinesia with bouts of yawning, coughing, adiposogenital disorders, autonomic paroxysms. Posttraumatic Parkinsonism can be reliably diagnosed in patients of young and middle age. The disease develops after a severe, sometimes repeated craniocerebral injury. For posttraumatic parkinsonism, anteretropulsions, spasm of the eyes, mastication disorders, swallowing, breathing, cataleptoid phenomena are uncharacteristic. At the same time, often there are vestibular disorders, a violation of intelligence and memory, visual hallucinations( due to damage to the cerebral cortex).It is often noted that the pathogenetic process is regentred or stabilized. For the diagnosis of manganese parkinsonism, anamnesis( information on work in contact with manganese or its oxides), detection of manganese in biological fluids is important. Diagnosis of oxy-carbon parkinsonism is based on the determination of carboxyhemoglobin in the blood.

In atherosclerotic parkinsonism, tremor and rigidity are combined with signs of cerebral atherosclerosis or occur after acute disorders of cerebral circulation. Focal neurological symptoms are revealed in the form of pyramidal insufficiency, expressed pseudobulbar symptoms. Often, the unilaterality of stiffness and stiffness is determined. Dyslipidemia, characteristic of atherosclerosis, is found in the blood. Certain changes in the REG are recorded as flattening of pulse waves.

A clinical picture reminiscent of Parkinson's disease can be observed with senile atherosclerotic dementia, for which the most common are psychiatric disorders up to dementia. Stiffness and stiffness are moderately expressed, tremor, as a rule, is absent. Individual clinical manifestations of parkinsonism can be found in other hereditary degenerative diseases of the nervous system: Friedreich ataxia, olivopontocerebellar atrophy, orthostatic hypokinesia, Creutzfeldt-Jakob disease. In these diseases, along with akinetic-rigid symptoms, there are progressive phenomena of cerebellar ataxia.

If the neurologic examination is insufficient, the following methods can be used to clarify the diagnosis:

REG, UZDG vessels of the neck and brain
X-ray of the cervical spine with functional tests
MRI of the brain and its vessels
MRI of the cervical spine, etc.

begins Parkinsonism in 45-52 years, when the activity of dopaminergic structures is significantly reduced. It is a disease of neurotransmitter metabolism - dopamine is not produced enough in the basal ganglia and with the loss of 70% of dopamine in the striatum( caudate nucleus and shell), clinical signs of parkinsonism appear. The only reliable criterion for diagnosis is positron emission tomography. In practice, a specific reaction to levodopa is used, the reception of which leads to the disappearance of the symptoms of the disease.

Course and prognosis of Parkinson's and Parkinson's disease.

The disease is progressing steadily. Exception is made by some forms caused by drug intoxication( with the cancellation of drugs, there may be an improvement in the condition).It is generally accepted that the treatment in the initial stage can reduce the severity of symptoms, slow the progression of the disease. In the later stages of treatment is less effective. The disease leads to disability for several years. Even levodopa treatment is currently slowing the flow for a short time. This confirms the thesis that the disease is based not only on the primary biochemical defect, but also on the neuropathological process, which has not yet been studied.

Treatment of Parkinson's Disease and Parkinsonism.

Treatment of patients with trembling paralysis and parkinsonism syndrome should be complex, long-term and include specific antiparkinsonian drugs, sedatives, physiotherapy procedures, therapeutic physical therapy, psychotherapy taking into account the etiologic factor, the age of the patients, the clinical form and stage of the disease, and the presence of concomitant diseases. With mild forms, amantadine( midantan) and parasympatholytics are first prescribed, since they cause fewer side effects. Apply central parasympatholytics( cyclodol, drug), pyridoxine, amantadine, dopamine receptor agonists( bromocriptine, lizard).

At the expressed clinical displays of a parkinsonism now the basic preparation is levodopa, usually in a combination with the inhibitor decarboxylase. Doses are increased slowly, for several weeks, until a clinical effect is obtained. Side effects of the drug - dystonic disorders and psychoses. Levodopa, getting into the central nervous system, is decarboxylated into dopamine, which is necessary for the normal function of the basal ganglia. The drug affects primarily akinesia and, to a lesser extent, other symptoms. When levodopa is combined with a decarboxylase inhibitor, the dose of levodopa can be reduced and, thus, the risk of side effects can be reduced.

In the arsenal of symptomatic anti-Parkinsonics, holinolitic drugs take a big place, which, blocking m- and n-cholinergic receptors, help to relax the striated and smooth muscles, reduce violent movements and the phenomenon of bradykinesia. These are natural and synthetic atropine-like drugs: bellazone( romparkin), norakin, combi park. Also used are preparations of the phenothiazine series: dinezine, deparcoll, parsidol, diprazine. The main reason for the variety of medications used to treat Parkinson's disease is inadequate therapeutic effectiveness, side effects, individual intolerance and rapid addiction to them.

Morphological and biochemical changes in Parkinson's disease are so complex, and the course of the disease and its consequences are so severe, and also aggravated by the effects of substitution therapy - levodopa, that treatment of such patients is considered the top of medical skill and subject to virtuosos - neurologists. Therefore, special centers for the treatment of parkinsonism are opened and operate, where the diagnosis is clarified, the observation is conducted, the doses of the necessary drugs and the treatment regimen are selected. It is impossible to prescribe and take medication independently.

For replacement therapy use levodopa, carbidopa, nakom. Stimulates the release of dopamine adamantine, memantine, bromocriptine, inhibit the process of reuptake of dopamine - anticholinesterase drugs and tricyclic antidepressants( amitriptyline), inhibits the decay of dopamine selegiline, neuroprotectors of DA neurons use antioxidants - selegiline, tocopherol, calcium channel blockers - nifidipine. In the early stages, the use of pramipexole( mirapex) has been proven to preserve the quality of life. It is the first line treatment of Parkinson's disease with a high level of efficacy and safety. The treatment uses yumeks, neomidantan, neuroprotectors, antioxidants. Patients need therapeutic gymnastics on an individual program - move as much as possible and stay active longer.

Surgical treatment of Parkinson's disease and Parkinson's.

Despite the great successes achieved in drug treatment of parkinsonism, its possibilities are limited in some cases.

The most widely used drug of levodopa is more conducive to the elimination of symptoms such as akinesia, general stiffness, to a lesser extent it affects the rigidity of muscles and tremors. Approximately in 25% of patients this drug is practically ineffective or poorly tolerated.

In these cases, there are indications for a stereotaxic operation on the subcortical nodes. Usually, local destruction of the ventrolateral nucleus of the visual hillock, subthalamic structures or pallid sphere is performed.

With the help of the operation it is possible in most cases to achieve a positive effect - reducing muscle tone, relaxing or stopping tremors, reducing hypokinesia.

The operation is usually performed on the side opposite to that on which parkinsonian symptoms predominate. With indications, bilateral destruction of subcortical structures is performed.

In recent years for the treatment of parkinsonism is also used implantation of embryonic adrenal tissue in the striped body. It is too early to speak about the clinical effectiveness of such operations.

Stereotactic operations on subcortical structures are also used for other diseases accompanied by violent movements( hemiballism, choreoathetosis, torticollis and some others).

The ability to work with Parkinsonism depends on the severity of motor disorders, the type of professional activity. For mild and moderate impairments of motor functions, patients remain permanently able to work with various types of mental work, as well as work not related to physical stress and the performance of precise and coordinated movements. With severe manifestations of the disease, patients are unable to work and need outside help.

Physiotherapy

Patients can develop articular contractures as a result of impaired tonus and hypokinesia, for example, shoulder - scapular periarthrosis. Patients are recommended low-cholesterol diet and low-protein diet. For normal absorption of levodopa, protein foods should be taken no sooner than an hour after taking the medication. Psychotherapy, reflexotherapy is shown. Preservation of motor activity stimulates the production of internal( endogenous) neurotransmitters. There are scientific researches on the treatment of parkinsonism: these are stem and dopamine-producing cells, a vaccine against Parkinson's disease, surgical treatment - thalamotomy, pallidotomy, high-frequency deep stimulation of the subtalamic nucleus or internal segment of the pale sphere and new pharmacological preparations.

Physiotherapy for Parkinson's Disease and Parkinsonism

In addition to the conservative treatment of Parkinson's disease and Parkinson's disease, physiotherapy, manual therapy and reflexology are widely practiced, allowing to partially or completely eliminate the symptom of rehydration of neck and arm muscles and restore muscle tone. Also, patients with Parkinson's disease are recommended exercise therapy( exercise therapy), classes for the effectiveness of treatment must be systematically carried out.

Prevention of Parkinson's disease

* Berries can reduce the risk of developing Parkinson's disease

A new study shows that men and women who regularly eat berries may have a lower risk of developing Parkinson's disease, while men can also further reduce the risk,regularly eating apples, oranges and other foods rich in nutrients, called flavonoids.

This study will be presented at the 63rd meeting of the American Academy of Neurology in Honolulu from April 9 to April 16,

Flavonoids are found in plants and fruits and are also known collectively as vitamin P and citrine. They are also found in berries, chocolate, and in citrus fruits, such as grapefruit.

The study involved 49,281 men and 80,336 women. Researchers distributed the questionnaire to participants and used a database to calculate the amount of flavonoid consumption. They then analyzed the relationship between the consumption of flavonoids and the risk of developing Parkinson's disease. They also analyzed the consumption of five staple foods rich in flavonoids: tea, berries, apples, red wine and oranges or orange juice. Participants were observed for 20 to 22 years.

During this time, 805 people developed Parkinson's disease. Among men, the top 20 percent who consumed flavonoids the most, had about 40 percent less chance of developing Parkinson's disease than the lower 20 percent of male participants who consumed the least amount of flavonoids. In women, there was no correlation between the total number of flavonoids consumed and the development of Parkinson's disease. However, when subclasses of flavonoids were considered, it was found that regular consumption of anthocyanins, which are found mainly in berries, is associated with a lower risk of developing Parkinson's disease in men and women.

Doctor's consultation on Parkinson's disease

Question: When should I start treatment for Parkinson's disease?
Answer: the approach is individual. The main goal is to restore and preserve the social, everyday, psychological, and professional adaptation of the patient as long as possible. In the early stages of this can be achieved.

Question: What are the earliest signs of Parkinson's disease?
Answer: the disease begins for 7 to 10 years before the appearance of motor disorders. Non-motorized early manifestations include a decrease in smell( sensation of smells), depression, anxiety, constipation, sleep disturbances, pain, more often in the shoulder joints, discomfort in the legs, apathy( decreased interest in life and everything that happens around), increased fatigue, unrelatedwith loads.

Question: Is cyclolol used to treat Parkinson's disease?
Answer: it is used less and less often because of its side effects, but sometimes, for example, when it is salivated strongly.

Doctor neurologist Kobzeva S.V.