Parkinson's disease is a progressive disorder of the nervous system that affects

your movement. It develops gradually, sometimes starting with a barely noticeab

le tremor in just one hand. But while a tremor may be the most well-known sign o
f Parkinson's disease, the disorder also commonly causes stiffness or slowing of
movement.
In the early stages of Parkinson's disease, your face may show little or no expr
ession or your arms may not swing when you walk. Your speech may become soft or
slurred. Parkinson's disease symptoms worsen as your condition progresses over t
ime.
Although Parkinson's disease can't be cured, medications may markedly improve yo
ur symptoms. In occasional cases, your doctor may suggest surgery to regulate ce
rtain regions of your brain and improve your symptoms.Symptoms
By Mayo Clinic Staff
Parkinson's disease symptoms and signs may vary from person to person. Early sig
ns may be mild and may go unnoticed. Symptoms often begin on one side of your bo
dy and usually remain worse on that side, even after symptoms begin to affect bo
th sides.
Parkinson's signs and symptoms may include:
Tremor. Your tremor, or shaking, usually begins in a limb, often your hand or fi
ngers. You may notice a back-and-forth rubbing of your thumb and forefinger know
n as a pill-rolling tremor. One characteristic of Parkinson's disease is a tremo
r of your hand when it is relaxed (at rest).
Slowed movement (bradykinesia). Over time, Parkinson's disease may reduce your a
bility to move and slow your movement, making simple tasks difficult and time-co
nsuming. Your steps may become shorter when you walk, or you may find it difficu
lt to get out of a chair. Also, you may drag your feet as you try to walk, makin
g it difficult to move.
Rigid muscles. Muscle stiffness may occur in any part of your body. The stiff mu
scles can limit your range of motion and cause you pain.
Impaired posture and balance. Your posture may become stooped, or you may have b
alance problems as a result of Parkinson's disease.
Loss of automatic movements. In Parkinson's disease, you may have a decreased ab
ility to perform unconscious movements, including blinking, smiling or swinging
your arms when you walk. You may no longer gesture when talking.
Speech changes. You may have speech problems as a result of Parkinson's disease.
You may speak softly, quickly, slur or hesitate before talking. Your speech may
be more of a monotone rather than with the usual inflections. A speech-language
pathologist may help improve your speech problems.
Writing changes. Writing may appear small and become difficult.
Medications may greatly reduce many of these symptoms. These medications increas
e or substitute for dopamine, a specific signaling chemical (neurotransmitter) i
n your brain. People with Parkinson's disease have low brain dopamine concentrat
ions.
Symptoms
By Mayo Clinic Staff
Parkinson's disease symptoms and signs may vary from person to person. Early sig
ns may be mild and may go unnoticed. Symptoms often begin on one side of your bo
dy and usually remain worse on that side, even after symptoms begin to affect bo
th sides.
Parkinson's signs and symptoms may include:
Tremor. Your tremor, or shaking, usually begins in a limb, often your hand or fi
ngers. You may notice a back-and-forth rubbing of your thumb and forefinger know
n as a pill-rolling tremor. One characteristic of Parkinson's disease is a tremo
r of your hand when it is relaxed (at rest).
Slowed movement (bradykinesia). Over time, Parkinson's disease may reduce your a
bility to move and slow your movement, making simple tasks difficult and time-co
nsuming. Your steps may become shorter when you walk, or you may find it difficu
lt to get out of a chair. Also, you may drag your feet as you try to walk, makin
g it difficult to move.
Rigid muscles. Muscle stiffness may occur in any part of your body. The stiff mu
scles can limit your range of motion and cause you pain.
Impaired posture and balance. Your posture may become stooped, or you may have b
alance problems as a result of Parkinson's disease.
Loss of automatic movements. In Parkinson's disease, you may have a decreased ab
ility to perform unconscious movements, including blinking, smiling or swinging
your arms when you walk. You may no longer gesture when talking.
Speech changes. You may have speech problems as a result of Parkinson's disease.
You may speak softly, quickly, slur or hesitate before talking. Your speech may
be more of a monotone rather than with the usual inflections. A speech-language
pathologist may help improve your speech problems.
Writing changes. Writing may appear small and become difficult.
Medications may greatly reduce many of these symptoms. These medications increas
e or substitute for dopamine, a specific signaling chemical (neurotransmitter) i
n your brain. People with Parkinson's disease have low brain dopamine concentrat
ions.
Risk factors
By Mayo Clinic Staff
Risk factors for Parkinson's disease include:
Age. Young adults rarely experience Parkinson's disease. It ordinarily begins in
middle or late life, and the risk increases with age. People usually develop th
e disease around age 60 or older.
Heredity. Having a close relative with Parkinson's disease increases the chances
that you'll develop the disease. However, your risks are still small unless you
have many relatives in your family with Parkinson's disease.
Sex. Men are more likely to develop Parkinson's disease than are women.
Exposure to toxins. Ongoing exposure to herbicides and pesticides may put you at
a slightly increased risk of Parkinson's disease.
Complications
By Mayo Clinic Staff
Parkinson's disease is often accompanied by these additional problems, which may
be treatable:
Thinking difficulties. You may experience cognitive problems (dementia) and thin
king difficulties, which usually occur in the later stages of Parkinson's diseas
e. Such cognitive problems aren't very responsive to medications.
Depression and emotional changes. People with Parkinson's disease may experience
depression. Receiving treatment for depression can make it easier to handle the
other challenges of Parkinson's disease.
You may also experience other emotional changes, such as fear, anxiety or loss o
f motivation. Doctors may give you medications to treat these symptoms.
Swallowing problems. You may develop difficulties with swallowing as your condit
ion progresses. In typical Parkinson's disease, this is rarely a severe problem.
Saliva may accumulate in your mouth due to slowed swallow, leading to drooling.
Sleep problems and sleep disorders. People with Parkinson's disease often have s
leep problems, including waking up frequently throughout the night, waking up ea
rly or falling asleep during the day.
People may also experience rapid eye movement sleep behavior disorder, which inv
olves acting out your dreams. Medications may help your sleep problems.
Bladder problems. Parkinson's disease may cause bladder problems, including bein
g unable to control urine or having difficulty urinating.
Constipation. Many people with Parkinson's disease develop constipation, mainly
due to a slower digestive tract.
You may also experience:
Blood pressure changes. You may feel dizzy or lightheaded when you stand due to
a sudden drop in blood pressure (orthostatic hypotension).
Smell dysfunction. You may experience problems with your sense of smell. You may
have difficulty identifying certain odors or the difference between odors.
Fatigue. Many people with Parkinson's disease lose energy and experience fatigue
, and the cause isn't always known.
Pain. Many people with Parkinson's disease experience pain, either in specific a
reas of their bodies or throughout their bodies.
Sexual dysfunction. Some people with Parkinson's disease notice a decrease in se
xual desire or performance.
TEST AND DIAGNOSIS
No tests exist to diagnose Parkinson's disease. Your doctor trained in nervous s
ystem conditions (neurologist) will diagnose Parkinson's disease based on your m
edical history, a review of your signs and symptoms, and a neurological and phys
ical examination.
Your doctor may order tests to rule out other conditions that may be causing you
r symptoms.
In addition to your examination, your doctor may give you carbidopa-levodopa, a
Parkinson's disease medication. Significant improvement with this medication wil
l often confirm your diagnosis of Parkinson's disease. You must be given a suffi
cient dose to show the benefit, as low doses for a day or two aren't reliable. T
o assure an optimum response, the drug must be taken on an empty stomach at leas
t an hour before meals.
Sometimes it takes time to diagnose Parkinson's disease. Doctors may recommend r
egular follow-up appointments with neurologists trained in movement disorders to
evaluate your condition and symptoms over time and diagnose Parkinson's disease
.
TREATMENT AND DRUGS
Parkinson's disease can't be cured, but medications can help control your sympto
ms, often dramatically. In some later cases, surgery may be advised.
Your doctor may also recommend lifestyle changes, especially ongoing aerobic exe
rcise. In some cases, physical therapy that focuses on balance and stretching al
so is important.
Medications
Medications can help you manage problems with walking, movement and tremor by in
creasing your brain's supply of dopamine. However, dopamine can't be given direc
tly, as it can't enter your brain.
You may have significant improvement of your symptoms after beginning Parkinson'
s disease treatment. Over time, however, the benefits of drugs frequently dimini
sh or become less consistent, although symptoms usually can continue to be fairl
y well controlled.
Your doctor may prescribe medications, which may include:
Carbidopa-levodopa. Levodopa, the most effective Parkinson's disease medication,
is a natural chemical that passes into your brain and is converted to dopamine.
Levodopa is combined with carbidopa (Parcopa, Sinemet), which protects levodopa
from premature conversion to dopamine outside your brain, which prevents or less
ens side effects such as nausea. In Europe, levodopa is combined with a similar
substance, benserazide (Madopar).
Side effects may include nausea or lightheadedness (orthostatic hypotension).
After years, as your disease progresses, the benefit from levodopa may become le
ss stable with a tendency to wax and wane ("wearing off").
Also, you may experience involuntary movements (dyskinesia) after taking higher
doses of levodopa. Your doctor may lessen your dose or adjust the times of your
doses to control these effects.
Dopamine agonists. Unlike levodopa, dopamine agonists don't change into dopamine
. Instead, they mimic dopamine effects in your brain.
They aren't as effective as levodopa in treating your symptoms. However, they la
st longer and may be used with levodopa to smooth the sometimes off-and-on effec
t of levodopa.
Dopamine agonists include pramipexole (Mirapex), ropinirole (Requip) and rotigot
ine (given as a patch, Neupro). A short-acting injectable dopamine agonist, apom
orphine (Apokyn), is used for quick relief.
Some of the side effects of dopamine agonists are similar to the side effects of
carbidopa-levodopa, but also include hallucinations, swelling, sleepiness and c
ompulsive behaviors such as hypersexuality, gambling and eating. If you're takin
g these medications and you behave in a way that's out of character for you, tal
k to your doctor.
MAO-B inhibitors. These medications include selegiline (Eldepryl, Zelapar) and r
asagiline (Azilect). They help prevent the breakdown of brain dopamine by inhibi
ting the brain enzyme monoamine oxidase B (MAO-B). This enzyme metabolizes brain
dopamine. Side effects may include nausea or headaches.
When added to carbidopa-levodopa, these medications increase the risk of halluci
nations.
These medications are not often used in combination with most antidepressants or
certain narcotics due to potentially serious but rare reactions. Check with you
r doctor before taking any additional medications with a MAO-B inhibitor.
Catechol O-methyltransferase (COMT) inhibitors. Entacapone (Comtan) is the prima
ry medication from this class. This medication mildly prolongs the effect of lev
odopa therapy by blocking an enzyme that breaks down dopamine.
Side effects, including an increased risk of involuntary movements (dyskinesias)
, mainly result from an enhanced levodopa effect. Other side effects include dia
rrhea or other enhanced levodopa side effects.
Tolcapone (Tasmar) is another COMT inhibitor that is rarely prescribed due to a
risk of serious liver damage and liver failure.
Anticholinergics. These medications were used for many years to help control the
tremor associated with Parkinson's disease. Several anticholinergic medications
are available, including benztropine (Cogentin) or trihexyphenidyl.
However, their modest benefits are often offset by side effects such as impaired
memory, confusion, hallucinations, constipation, dry mouth and impaired urinati
on.
Amantadine. Doctors may prescribe amantadine alone to provide short-term relief
of symptoms of mild, early-stage Parkinson's disease. It may also be given with
carbidopa-levodopa therapy during the later stages of Parkinson's disease to con
trol involuntary movements (dyskinesias) induced by carbidopa-levodopa.
Side effects may include a purple mottling of the skin, ankle swelling or halluc
inations.
Surgical procedures
Deep brain stimulation. In deep brain stimulation (DBS), surgeons implant electr
odes into a specific part of your brain. The electrodes are connected to a gener
ator implanted in your chest near your collarbone that sends electrical pulses t
o your brain and may reduce your Parkinson's disease symptoms.
Your doctor may adjust your settings as necessary to treat your condition. Surge
ry involves risks, including infections, stroke or brain hemorrhage. Some people
experience problems with the DBS system or have complications due to stimulatio
n, and your doctor may need to adjust or replace some parts of the system.
Deep brain stimulation is most often offered to people with advanced Parkinson's
disease who have unstable medication (levodopa) responses.
DBS can stabilize medication fluctuations, reduce or halt involuntary movements
(dyskinesias), reduce tremor, reduce rigidity, and improve slowing of movement.
DBS is effective in controlling erratic and fluctuating responses to levodopa or
for controlling dyskinesias that don't improve with medication adjustments.
However, DBS isn't helpful for problems that don't respond to levodopa therapy a
part from tremor. A tremor may be controlled by DBS even if the tremor isn't ver
y responsive to levodopa.
DBS may provide a sustained benefit to Parkinson's symptoms persisting for years
after the procedure. However, DBS doesn't keep Parkinson's disease from progres
sing.
LIFESTYLE AND HOME REMEDIES
Healthy eating
Eat a nutritionally balanced diet that contains plenty of fruits, vegetables and
whole grains. Eating foods high in fiber and drinking an adequate amount of flu
ids can help prevent constipation that is common in Parkinson's disease.
A balanced diet also provides nutrients, such as omega-3 fatty acids, that may b
e beneficial for people with Parkinson's disease.
Exercise
Exercising may increase your muscle strength, flexibility and balance. Exercise
can also improve your well-being and reduce depression or anxiety.
Your doctor may suggest you work with a physical therapist to learn an exercise
program that works for you. You may also try exercises such as walking, swimming
, dancing, water aerobics or stretching.
Parkinson's disease can disturb your sense of balance, making it difficult to wa
lk with a normal gait. Exercise may improve your balance. These suggestions may
also help:
Try not to move too quickly.
Aim for your heel to strike the floor first when you're walking.
If you notice yourself shuffling, stop and check your posture. It's best to stan
d up straight.
Look in front of you, not directly down, while walking.
Avoiding falls
In the later stages of the disease, you may fall more easily. In fact, you may b
e thrown off balance by just a small push or bump. The following suggestions may
help:
Make a U-turn instead of pivoting your body over your feet.
Keep your center of gravity over your feet without leaning or reaching.
Avoid carrying things while you walk.
Avoid walking backward.
Daily living activities
Daily living activities such as dressing, eating, bathing and writing can be dif
ficult for people with Parkinson's disease. An occupational therapist can show y
ou techniques that make daily life easier.
Alternative medicine
By Mayo Clinic Staff
Some types of alternative medicine may help people with Parkinson's disease, inc
luding:
Coenzyme Q10. Early research suggested that coenzyme Q10 in high doses may be be
neficial for people in the early stages of Parkinson's disease. Unfortunately, l
arger studies haven't confirmed this. Coenzyme Q10 appears to be safe.
You can buy coenzyme Q10 without a prescription in drugstores and natural food s
tores.
Massage. Massage therapy can reduce muscle tension and promote relaxation. These
services, however, are rarely covered by health insurance.
Acupuncture. During an acupuncture session, a trained practitioner inserts tiny
needles into many specific points on your body, which may reduce your pain.
Tai chi. An ancient form of Chinese exercise, tai chi employs slow, flowing moti
ons that may improve flexibility, balance and muscle strength. Tai chi may also
prevent falls. Several forms of tai chi are tailored for people of any age or ph
ysical condition.
A study showed tai chi may improve the balance of people with mild to moderate P
arkinson's disease more than stretching and resistance training.
Yoga. In yoga, gentle stretching movements and poses may increase your flexibili
ty and balance. You may modify most poses to fit your physical abilities.
Alexander technique. This technique which focuses on muscle posture, balance and
thinking about how you use muscles may reduce muscle tension and pain.
Meditation. In meditation, you quietly reflect and focus your mind on an idea or
image. Meditation may reduce stress and pain and improve your sense of well-bei
ng.
Music or art therapy. Music or art therapy may help you to relax. Music therapy
helps some people with Parkinson's disease to improve their walking and speech.
Participating in art therapy, such as painting or ceramics, may improve your fin
e motor skills and strength and help you express your emotions.
Pet therapy. Having a dog or cat may increase your flexibility and movement and
improve your emotional health.
Coping and support
By Mayo Clinic Staff
Living with any chronic illness can be difficult, and it's normal to feel angry,
depressed or discouraged at times.
Parkinson's disease presents special problems because it can cause chemical chan
ges in your brain that make you feel anxious or depressed. Parkinson's disease c
an be profoundly frustrating, as walking, talking and even eating become more di
fficult and time-consuming.
Although friends and family can be your best allies, the understanding of people
who know what you're going through can be especially helpful. Support groups ar
en't for everyone. However, for many people with Parkinson's disease and their f
amilies, support groups can be a good resource for practical information about P
arkinson's disease.
Also, groups offer a place for you to find people who are going through similar
situations and can support you.
To learn about support groups in your community, talk to your doctor, a Parkinso
n's disease social worker or a local public health nurse. Or contact the Nationa
l Parkinson Foundation or the American Parkinson Disease Association.
You and your family may also benefit from talking to a mental health professiona
l (psychologist) or social worker trained in working with people with chronic co
nditions.
Prevention
By Mayo Clinic Staff
Because the cause of Parkinson's is unknown, proven ways to prevent the disease
also remain a mystery. However, some research has shown that caffeine which is f
ound in coffee, tea and cola may reduce the risk of developing Parkinson's disea
se. Green tea also may reduce the risk of developing Parkinson's disease.
Some research has shown that regular aerobic exercise may reduce the risk of Par
kinson's disease.
Pathology
Several brain cells stained in blue. The largest one, a neurone, with an approxi
mately circular form, has a brown circular body inside it. The brown body is abo
ut 40% the diameter of the cell in which it appears.
A Lewy body (stained brown) in a brain cell of the substantia nigra in Parkinson
's disease. The brown colour is positive immunohistochemistry staining for alpha
-synuclein.
Anatomical
The basal ganglia, a group of "brain structures" innervated by the dopaminergic
system, are the most seriously affected brain areas in PD.[36] The main patholog
ical characteristic of PD is cell death in the substantia nigra and, more specif
ically, the ventral (front) part of the pars compacta, affecting up to 70% of th
e cells by the time death occurs.[8]
Macroscopic alterations can be noticed on cut surfaces of the brainstem, where n
euronal loss can be inferred from a reduction of neuromelanin pigmentation in th
e substantia nigra and locus coeruleus.[37] The histopathology (microscopic anat
omy) of the substantia nigra and several other brain regions shows neuronal loss
and Lewy bodies in many of the remaining nerve cells. Neuronal loss is accompan
ied by death of astrocytes (star-shaped glial cells) and activation of the micro
glia (another type of glial cell). Lewy bodies are a key pathological feature of
PD.[37]
Pathophysiology
Composite of three images, one in top row (referred to in caption as A), two in
second row (referred to as B). Top shows a mid-line sagittal plane of the brains
tem and cerebellum. There are three circles superimposed along the brainstem and
an arrow linking them from bottom to top and continuing upward and forward towa
rds the frontal lobes of the brain. A line of text accompanies each circle: lowe
r is "1. Dorsal Motor X Nucleus", middle is "2. Gain Setting Nuclei" and upper i
s "3. Substantia Nigra/Amygdala". A fourth line of text above the others says "4
. ...". The two images at the bottom of the composite are magnetic resonance ima
ging (MRI) scans, one saggital and the other transverse, centred at the same bra
in coordinates (x=-1, y=-36, z=-49). A colored blob marking volume reduction cov
ers most of the brainstem.
A. Schematic initial progression of Lewy body deposits in the first stages of Pa
rkinson's disease, as proposed by Braak and colleagues
B. Localization of the area of significant brain volume reduction in initial PD
compared with a group of participants without the disease in a neuroimaging stud
y, which concluded that brain stem damage may be the first identifiable stage of
PD neuropathology[38]
The primary symptoms of Parkinson's disease result from greatly reduced activity
of dopamine-secreting cells caused by cell death in the pars compacta region of
the substantia nigra.[36]
There are five major pathways in the brain connecting other brain areas with the
basal ganglia. These are known as the motor, oculo-motor, associative, limbic a
nd orbitofrontal circuits, with names indicating the main projection area of eac
h circuit.[36] All of them are affected in PD, and their disruption explains man
y of the symptoms of the disease since these circuits are involved in a wide var
iety of functions including movement, attention and learning.[36] Scientifically
, the motor circuit has been examined the most intensively.[36]
A particular conceptual model of the motor circuit and its alteration with PD ha
s been of great influence since 1980, although some limitations have been pointe
d out which have led to modifications.[36] In this model, the basal ganglia norm
ally exert a constant inhibitory influence on a wide range of motor systems, pre
venting them from becoming active at inappropriate times. When a decision is mad
e to perform a particular action, inhibition is reduced for the required motor s
ystem, thereby releasing it for activation. Dopamine acts to facilitate this rel
ease of inhibition, so high levels of dopamine function tend to promote motor ac
tivity, while low levels of dopamine function, such as occur in PD, demand great
er exertions of effort for any given movement. Thus the net effect of dopamine d
epletion is to produce hypokinesia, an overall reduction in motor output.[36] Dr
ugs that are used to treat PD, conversely, may produce excessive dopamine activi
ty, allowing motor systems to be activated at inappropriate times and thereby pr
oducing dyskinesias.[36]