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How To Slow Down Parkinson’s Disease



Experts Explore Which Of The Existing Strategies To Slow Down Or Stop The Processes Of Parkinsons Disease Are Most Likely To Be Successful Over The Next 20 Years

How Cycling Helps to Slow Down Parkinson’s Disease

Understanding of the processes involved in Parkinson’s disease degeneration has vastly improved over the last 20 years. Published in the Journal of Parkinson’s Disease, authors Tom Foltynie, MBBS, PhD, Department of Clinical and Movement Neurosciences, UCL Institute of Neurology & The National Hospital for Neurology and Neurosurgery, UK, and J. William Langston, MD, Associate Director, Stanford Udall Center, Department of Pathology, Stanford University, USA, explain the progress of research.

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Parkinson’s Disease Progression Can Be Slowed With Vigorous Exercise Study Shows

His friends noticed the tremor before he did. It started in his left hand, Geoffrey Rogers said, but before long the trembling affected his right too.

The cause, doctors found, was Parkinson’s disease.

At Rush University Medical Center, where Rogers, then 64, received a second opinion, the father of three learned he could join a new clinical trial for those with the neurodegenerative condition.

A team of researchers at Northwestern Medicine and the University of Colorado School of Medicine wanted to find out whether high- or moderate-intensity exercise was safe for patients with Parkinson’s disease. Would it help with the disease’s symptoms, the progressive loss of muscle control, tremors, stiffness?

Five years later, those scientists have an answer: Yes. Increasing disease severity in early-stage Parkinson’s disease patients can be slowed with a few days of exercise weekly. The results of their trial, published Monday in JAMA Neurology, found vigorous exercise is a safe way to potentially delay the progression of Parkinson’s disease.

“The real question is: Is there any disease or any disorder for which exercise is not good?” said Daniel Corcos, one of the lead authors of the study and a professor of physical therapy and human movement sciences at Northwestern’s Feinberg School of Medicine. “I haven’t found any.”

The onset of symptoms can be distressing for families, especially because the causes of Parkinson’s disease are not fully understood.

eolumhense@chicagotribune.com

Rutgers Collaborates With Scripps Research Hoping To Develop New Drug Treatment

A collaboration between scientists at Rutgers University and Scripps Research  led to the discovery of a small molecule that may slow down or stop the progression of Parkinson’s disease.

Parkinson’s, which affects 1 million people in the United States and over 10 million worldwide according to the Parkinson’s Foundation, is a neurodegenerative disorder with no cure. Symptoms develop slowly over time and can be debilitating to patients, who most recognizably develop tremor, slow movements and a shuffling gait.

A key feature of Parkinson’s disease is a protein named ?-synuclein, which accumulates in an abnormal form in brain cells causing them to degenerate and die. However, it has been difficult to target ?-synuclein because it does not have a fixed structure and keeps changing its shape, making it very difficult for drugs to target. Because higher levels of the protein in the brain speed the degeneration of brain cells, scientists have been looking for ways to decrease the protein production as a form of treatment.

In 2014, Parkinson’s disease expert and scientist M. Maral Mouradian, William Dow Lovett Professor of Neurology and director of the Rutgers Robert Wood Johnson Medical School Institute for Neurological Therapeutics, contacted Matthew D. Disney, chemistry professor at Scripps Research in Florida, to explore a novel idea for treating Parkinson’s disease using a new technology developed by Disney.

New Treatment May Have The Potential To Slow Stop Or Reverse Parkinson Disease

This discovery could help slow down progression of ...

Wallace Stephens

Results from a recent study suggest that a revolutionary treatment may have the potential to slow, stop, or even reverse the progression of Parkinson disease.

Results from a February study of a revolutionary treatment suggest that it may be possible to slow, stop, or even reverse the progression of Parkinson disease, according to findings in the Journal of Parkinson’s Disease.

The 3-part, experimental study investigated whether using a novel delivery system to increase levels of glial cell line-derived neurotrophic factor can regenerate dying dopamine brain cells in patients with Parkinson disease and even reverse their condition. GDNF is a naturally occurring protein that promotes the survival of many types of neurons.

“I believe that this approach could be the first neuro-restorative treatment for people living with Parkinson’s, which is, of course, an extremely exciting prospect,” Steven Gill, MB, MS, FRCS, who designed the infusion device used in the study, said in a statement.

Initially, 6 patients enrolled in a pilot study which evaluated the safety of the treatment approach. After the pilot study, 35 additional individuals participated in a subsequent 9-month double-blind trial. Half of the participants were randomly assigned to receive monthly infusions of GDNF while the other half received placebos.

Reference

Research Field:proteins Central To The Development Of Parkinsons Disease

In a treatment room at the Parkinson’s Clinic at Karolinska University Hospital, Svenningsson, who is a professor and neurologist, is talking to research nurse Lisa Hainke. They are working together in a clinical study, in which a new drug is being tested on patients with Parkinson’s.

“There are drugs that can inhibit early-stage symptoms, particularly motor function symptoms, but we can’t slow down the progress of the disease. This new drug is a step in that direction,” Svenningsson says.

Parkinson’s disease is a neurological disease affecting the central or peripheral nervous system. Sufferers become slow, stiff and experience tremors. Many also suffer from depression and dementia. Age is the main risk factor. Svenningsson elaborates:

“Most people develop the disease in their sixties, more men than women, but I also meet younger patients. By the time patients arrive at the clinic, they may have had symptoms for years without seeking or receiving help.”

It often only takes Svenningsson a few seconds to see whether a patient has Parkinson’s.

“We do check for symptoms, but we also have the support of brain scans, which reveal whether the patient has reduced levels of dopamine, a neural transmitter, which plays a central role in the brain’s ability to control bodily movements.”

How Do You Know If Youre Doing Moderate Or Vigorous Aerobic Activity

One of my trainers would definitely say that if you have to ask, you’re not exercising hard enough.

Obviously, everyone has a different level of fitness, so brisk walking may be vigorous intensity for some and moderate for others.

How do you measure this intensity?

According to the American Heart Association, for most people, increased heart rate correlates directly with the level of exercise intensity. For this reason, using a heart rate monitor to track your heart rate during exercise is the best way to measure your exercise effort. Your maximum heart rate is approximately 220 minus your age. Moderate intensity exercise raises the heart rate to approximately 50-69% of your maximum, and vigorous intensity exercise raises the heart rate to roughly 70%-89% of your maximum.

The following table provides rough guidelines:

Age
98-125 bpm140 bpm

When starting an exercise program, aim for the lower ranger of your heart rate target zone and gradually build up to the higher range . After six months or more, you may be able to exercise comfortably at the 70-89% range of your maximum heart rate.

Everyone’s fitness level is different. This means that walking may feel like a moderately intense activity to you, but for others, it may feel vigorous. It all depends on you – the shape you’re in, what you feel comfortable doing, and your health condition. What’s important is that you do physical activities that are right for you and your abilities.

Discovery Could Help Slow Down Progression Of Parkinson’s Disease

Rutgers collaborates with Scripps Research hoping to develop new drug treatment

Peer-Reviewed Publication

Rutgers University

A collaboration between scientists at Rutgers University and Scripps Research led to the discovery of a small molecule that may slow down or stop the progression of Parkinson’s disease.

Parkinson’s, which affects 1 million people in the United States and over 10 million worldwide according to the Parkinson’s Foundation, is a neurodegenerative disorder with no cure. Symptoms develop slowly over time and can be debilitating to patients, who most recognizably develop tremor, slow movements and a shuffling gait.

A key feature of Parkinson’s disease is a protein named ?-synuclein, which accumulates in an abnormal form in brain cells causing them to degenerate and die. However, it has been difficult to target ?-synuclein because it does not have a fixed structure and keeps changing its shape, making it very difficult for drugs to target. Because higher levels of the protein in the brain speed the degeneration of brain cells, scientists have been looking for ways to decrease the protein production as a form of treatment.

“We found the molecule to be very selective at both the RNA level and the protein level,” Disney says.

“The reach of our study could go beyond people with Parkinson’s disease to many other neurodegenerative diseases. It is a classic example of how interdisciplinary research leads to significant change,” she shares.

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Journal

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Exercise Can Stop Accumulation Of A Harmful Protein In The Brain

Parkinson

Date:
University of Colorado Anschutz Medical Campus
Summary:
While vigorous exercise on a treadmill has been shown to slow the progression of Parkinson’s disease in patients, the molecular reasons behind it have remained a mystery.

While vigorous exercise on a treadmill has been shown to slow the progression of Parkinson’s disease in patients, the molecular reasons behind it have remained a mystery.

But now scientists at the University of Colorado Anschutz Medical Campus may have an answer.

For the first time in a progressive, age-related mouse model of Parkinson’s, researchers have shown that exercise on a running wheel can stop the accumulation of the neuronal protein alpha-synuclein in brain cells.

The work, published Friday in the journal PLOS ONE, was done by Wenbo Zhou, PhD, research associate professor of medicine and Curt Freed, MD, professor of medicine and division head of the Division of Clinical Pharmacology and Toxicology at the CU School of Medicine.

The researchers said clumps of alpha-synuclein are believed to play a central role in the brain cell death associated with Parkinson’s disease. The mice in the study, like humans, started to get Parkinson’s symptoms in mid-life. At 12 months of age, running wheels were put in their cages.

“After three months,” Zhou said, “the running animals showed much better movement and cognitive function compared to control transgenic animals which had locked running wheels.”

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Why Exercise Can Help Delay The Onset Of Parkinsons Disease

Parkinson’s disease affects more than a million people in the United States alone, and it is the second most common neurodegenerative disorder in the country. It is also the most common of movement disorders, which also include neurological disorders like Dystonia, Huntington’s disease, Tourette’s syndrome, and others. In fact, there are 60,000 new patients diagnosed with PD each year, and men are one and a half times more likely to develop the disease than women.

PD affects both motor and non-motor related faculties and could include symptoms such as tremors, limb rigidity, gait and balance difficulties, slowness of movement, depression, constipation, sleep issues, and cognitive impairment. Though these symptoms may not be readily apparent, they develop and progress as the disease spreads.

Experts remain unsure exactly what causes Parkinson’s — a combination of environmental and genetic factors seems to be at play — but the good news is that there are ways to slow its onset and protect against its development. One helpful method is to maintain good health through a balanced diet high in fiber and antioxidant-rich foods . Other preventative measures include getting proper sleep, minimizing stress, limiting exposure to toxins, and avoiding head injuries.

Research shows that something else is also promising in preventing and delaying the onset of PD: regular exercise.

Parkinsons Disease Natural Treatment & Remedies In 5 Steps

April 17, 2018

Parkinson’s disease is a degenerative illness of the nervous system that results in loss of intentional movement and impaired motor functioning. Parkinson’s disease symptoms affects smooth, natural movements of the body, and can make it hard to perform everyday tasks like speaking properly, walking, swallowing and sleeping.

With Parkinson’s, the area of the brain that controls muscular movements receives less dopamine than usual. Dopamine is an important chemical necessary for not only coordinating proper body movements, but also things like learning, increasing motivation and regulating moods.  This is one reason why depression and other mood changes often affect those with Parkinson’s.

What causes Parkinson’s, and is it curable? There is no specific known cause, but some aggravating factors include exposure to certain chemicals and toxic water, plus inflammation of the brain. While there is no cure for Parkinson’s , there are medications available to boost dopamine in the brain and help manage symptoms.

A 2016 study by researchers at the University of Saskatchewan also found a possible way to stop the progression of Parkinson’s. Researchers created caffeine-based chemical compounds — which also contained nicotine, metformin and aminoindan — that prevented the misfolding of alpha-synuclein, a protein necessary for dopamine regulation.

Foods Containing Nutrients That People May Be Deficient In

Some research suggests that people with Parkinson’s often have certain nutrient deficiencies, including deficiencies in iron, vitamin B1, vitamin C, zinc, and vitamin D.

The above study points out that some of these deficiencies may be associated with neuroinflammation and neurodegeneration, which are key factors in Parkinson’s.

Therefore, people with Parkinson’s may wish to consume more of the following foods.

Foods containing iron

The following foods are good sources of iron:

  • liver
  • certain fortified foods

Eat Plenty Of Protein But Not With Levodopa Medications

Parkinsons disease: Symptoms could be slowed down by doing ...

If you’re taking a levodopa medication, your doctor may tell you to avoid protein when taking your meds. Both animal and plant protein can interfere with the absorption of levodopa medications.

But you should still eat plenty of protein. Just be strategic with the timing. “Don’t take levodopa medications with meals,” Dr. Gostkowski says. “It’s best to take it on an empty stomach — either 30 minutes before your meal or an hour after eating.”

If you get nauseous from the medication, eat a small amount of starchy food with it, such as crackers. Make sure whatever you eat with your medicine doesn’t have protein. “It’s a misunderstanding that people with Parkinson’s should avoid protein,” Dr. Gostkowski says. “You definitely need protein in your diet. Just don’t eat it when you’re taking your levodopa medication.”

Scientifically Backed Ways To Prevent Parkinsons Disease

Dopamine plays a major role in a variety of mental and physical functions, including:

  • Voluntary movement
  • Memory
  • General behavior

Parkinson’s now afflicts roughly 1.5 million people in the United States alone, with primary symptoms being body tremors, slow movement, rigid limbs, reduced memory, a shuffling gait and speech impairment. So we have to ask:

1.) What causes it?

2.) How do we prevent it?

Currently there isn’t a known cure, and it’s not fully understood what causes the dip in dopamine; however, we know that aging is the single most important risk factor for PD, with inflammation and stress contributing to cell damage. And we now know enough about the disease to understand the preventative measures that counter the aging and death of the neurons under attack.

Because there is no known cure, it’s critical that we prevent the disease before symptoms arise. Granted, thanks to recent advancements in modern surgical procedures, there are some safe surgeries that can mitigate some of the more severe symptoms associated with PD. The most common one now is deep brain stimulation, in which they implant an electrode into the brain that can stop some of the more severe symptoms of Parkinson’s.

But this article will try to keep it from getting to that point. The less drugs and surgery we can have in our lives, the better.

What Makes Exercise So Helpful In Preventing Parkinsons

Parkinson’s is characterized by a loss of dopamine neurons in the brain. A majority of PD research thus far has placed a focus on creating neuroprotective drugs to help combat this loss — yet exercise hasshown to be neuroprotective and enhances a participant’s neuroplasticity with few negative side effects.

Exercise offers numerous physical and psychological benefits for all people; but for PD patients, exercise helps maintain balance, improve mobility, enhance mood, and protect the brain. Exercise also remains a powerful long-term solution when compared to PD medications, which are considered short-term because they become less effective over time.

Exercise also functions as a type of targeted PD therapy to improve a patient’s gait, balance, flexibility, grip strength, and motor coordination. Walking exercises target gait issues, while dancing lessons improve balance and coordination. Participating in resistance training improves strength and helps maintain muscle mass, which decreases with age.

For many seniors, physical activity also offers opportunities to have fun and socialize, which may alleviate symptoms of depression caused by PD. Fitness programs are an easy way to meet new people and connect with a wider community.

Other studies have shown that exercise is similarly beneficial for Alzheimer’s and dementia, two other progressive neurodegenerative disorders.

How Patients Are Using Cycling To Slow Down Parkinson’s

Parkinson’s symptoms include tremor, rigid muscles and problems with movement. While early treatment can delay the worst symptoms, people almost always get worse. About 60,000 Americans are diagnosed with Parkinson’s disease each year and about a million Americans have Parkinson’s now.

No medical therapy can cure Parkinson’s and while exercise was always shown to help people feel better, it was not generally accepted as a true therapy until recently.

Now teams are trying to find out how much exercise helps and just which symptoms it affects. Doctors say they’d be thrilled just to slow the inevitable worsening of the disease and if they can freeze progression or reverse symptoms, that would be a home run.

Corcos and colleagues say the most intense exercise appears to have at least temporarily frozen symptoms in many of their volunteers.

“The earlier in the disease you intervene, the more likely it is you can prevent the progression of the disease,” Corcos said in a statement.

“We delayed worsening of symptoms for six months,” he added. “Whether we can prevent progression any longer than six months will require further study.”

Related: Walking Helps Parkinson’s

They worked with 128 patients with early stage Parkinson’s. They randomly assigned them to either moderate exercise four days a week, intense exercise four days a week, or no additional exercise.

“This is not mild stretching. This is high intensity,” Corcos said.

Related: Gut germs affect Parkinson’s

Slowing Down The Progression Of Parkinsons Disease

Exercising 2.5 Hours a Week May Slow Parkinson’s ...

We have all heard that keeping active is good for you and has immediate benefits for your health both short-term and long-term. Regular activity reduces the risk of developing some cancers, cardiovascular disease, as well as obesity and the health issues associated with this. What you may not have heard is regular exercise has also shown to slow the progression of Parkinson’s disease.

Parkinson’s disease is a neurodegenerative disease which targets and progressively damages nerve cells in a particular area of the brain over a long period of time. These nerve cells are very important for their role in producing a chemical called Dopamine. Without this chemical, the brain is not able to control normal bodily movement and the typical presentation of Parkinson’s beings to show in the individual. This can range from balance issues, difficulty with memory and smell, as well as the well-known involuntary shaking. The cause of Parkinson’s is still unclear, however, there is thought to be a combination of both genetic and environmental factors.

The link between exercise and reducing Parkinson’s progression is believed to be focused on a particular protein known as the DJ-1 gene. As we all become more and more sedentary in our day-to-day lives, scientists have noticed an increase of a normal neural protein alpha-synuclein, which is important for relaying messages and normal brain function. However, in excessive “clumps” this could potentially be an issue.

How Often Do Patients Need To Exercise To Benefit

Patients need to engage in at least 150 minutes of exercise each week to see an impact. In a paper published in JAMA Neurology, researchers were able to delay the progression of PD for six months through exercise alone, splitting exercise into three sessions per week, with each session increasing the participant’s heart rate to a maximum of 80-85%.

How Cycling Helps To Slow Down Parkinsons Disease

In the summer of 2003, Dr Jay Alberts, a neuroscientist at the Cleveland Clinic Lerner Research Institute, took a bike

In the summer of 2003, Dr Jay Alberts, a neuroscientist at the Cleveland Clinic Lerner Research Institute, took a bike ride that would change medical history. He rode a tandem bike in the week-long Des Moines Register’s Annual Great Bike Race . His partner on the bike was a woman affected with Parkinson’s Disease, a long-term degenerative illness afflicting the central nervous system.

Symptoms of the disorder include shaking, rigidity, difficulty in walking as well as cerebral and behavioural problems and eventually dementia, and total incapacitation after perhaps 15 years. There is no cure. Treatment is generally carried out with medication that attempts to alleviate the symptoms and slow the progress of physical degeneration.

After riding a few days, Alberts noticed that his biking partner was showing signs of physical improvement, especially in her handwriting, which had become more legible and controlled.

https://www.youtube.com/watch?v=VM-DBsdajTM

In 2006, Alberts rode a tandem bike with another patient, also a doctor, who used a deep brain stimulation implant to control his Parkinson’s symptoms. As an experiment, the patient turned the device off for the ride.

Not surprisingly, the researchers also found that it improves “overall wellness.” In other words, cycling is good for everyone.

Slowing The Spread Of Alpha Synuclein Pathology

There is a mantra that disease modifying treatments must be initiated early if they are to be of any use in preventing disease progression. This is because post mortem specimens suggest that>50% of SNc dopaminergic neurons are already lost by the time that patients present with the classical motor features of the disease . Given that there are many effective symptomatic treatments to help the motor, dopaminergic deficits in PD, it can be argued that the important unmet needs in PD relate to cognitive, speech, gait and balance difficulties and autonomic failure. In this case any treatment that prevented onset/worsening of these symptoms, would be highly relevant even in patients with established motor PD, and would be addressing the major challenges that patients face in its long-term management. From another perspective, since many of these “non-motor” features of PD may precede the onset of motor symptoms, we may have an even earlier window to start therapy, and have an opportunity to slow or stop the development of even the first motor symptoms of PD.

Beyond this, the companies will have to look carefully at the emerging data to decide whether a strategy of enrichment might be advantageous, and/or whether to risk extending trial eligibility to patients with more established disease than those currently being recruited.

Can Progression Of Parkinson Disease Be Slowed

Ambroxol – The New Hope for Slowing Down the Progression ...

Matthew Gavidia

Deep brain stimulation implanted in early-stage Parkinson disease was found to decrease the risk of disease progression. If findings are replicated in a larger trial recently approved by the FDA, DBS would be the first therapy proven to slow the progression of any element in PD.

Deep brain stimulation implanted in early stage Parkinson disease was found to decrease the risk of disease progression and lessen the need for multiple, simultaneous prescription drugs, according to study findings published in Neurology.

PD serves as the fastest growing neurological disorder worldwide, with as many as 60,000 US cases diagnosed each year. Innovations within the treatment of PD have led to better, noninvasive outcomes for common symptoms such as tremor and OFF periods. However, as the disease progresses, these therapies may not prove as effective and can contribute to significant economic burden for both patients and caregivers.

When it comes to managing PD, senior author David Charles, MD, professor and vice chair of neurology at Vanderbilt University Medical Center , noted the “relentless” nature of the disease, which currently has no therapies approved to slow its progression.

After the 5-year follow-up, the study found that those with early-stage PD who received early DBS with ODT had a more than 5 times lesser odds of of experiencing worsening of their rest tremor compared with those given only ODT .

Reference

Why Does Parkinsons Disease Cause Bradykinesia

PD damages many areas of the brain. Scientists believe that PD’s effects on the basal ganglia and the cortex of the brain cause bradykinesia. The basal ganglia are a group of neurons located deep in the brain that process information on movement and play an important role in planning actions to achieve specific goals, such as using hands to catch a ball. The basal ganglia work in cooperation with the cortex to signal and activate muscles. As PD progresses, the impulses from the basal ganglia are insufficient to prepare and execute the commands to move. Several additional factors that contribute to bradykinesia in people with PD include muscle weakness, rigidity, tremor, movement variability , and slowing of thought.3,4

 

 

Foods Containing Saturated Fat And Cholesterol

Some studies suggest that dietary fat intake may increase the risk of Parkinson’s.

Although having a higher intake of cholesterol can elevate a person’s Parkinson’s risk, having a higher intake of polyunsaturated fatty acids may reduce the risk.

Therefore, a person with Parkinson’s may wish to reduce their intake of cholesterol to help control the symptoms of the condition. They may also wish to reduce the amount of saturated fat in their diet.

However, further studies are required to explore the link between dietary fat and Parkinson’s.

Preventing Or Slowing Parkinsons Progression

Exercise

Thus far, physical activity throughout life is the one lifestyle factor with the strongest research support for reducing the risk of Parkinson’s disease.

Aerobic exercise benefits brain health at a cellular level. It gets the heart beating faster, so that more oxygen is supplied to the brain – this reduces inflammation and also improves cognitive function.

Studies which follow large groups of people over many years have found that there is a lower incidence of Parkinson’s in those who reported moderate to high levels of physical activity in midlife. Persons who exercised regularly and did develop the condition experienced slower progression of symptoms.

Furthermore, studies of people with Parkinson’s disease have shown that regular exercise could slow down progression and improve quality of life. It is self-evident that building up endurance, muscle strength, and balance in the early stages of Parkinson’s will provide a reserve of physical function as the disease progresses.

Diet

The following are dietary guidelines, backed by some research, which may help to prevent Parkinson’s or slow down disease progression:

Stress Reduction

Experts are currently theorizing that prolonged emotional stress might trigger Parkinson’s disease. It is known that continuous high levels of adrenalin and cortisol, and the inflammation it causes, damages brain cells.

How Does Parkinsons Disease Affect The Brain

The search for the holy grail: Promising strategies for ...

The part of the brain that is affected is called the basal ganglia, which functions like the autopilot of your brain, facilitating subconscious movements. Because PD causes the brain cells in this deep circuitry to deteriorate, patients’ natural movements become slow and stiff. Many patients describe feeling as if they had aged overnight.

Treating Bradykinesia In Parkinsons Disease

Currently, no cure exists for PD, and there are no known treatments to stop or slow the progression of the disease. Treatments are available that help manage the symptoms and may include medications, surgery , and complementary or alternative medicine.

Most patients with PD are started on medication to help manage their symptoms. Initial therapy is usually levodopa , dopamine agonists, and/or monoamine oxidase-B inhibitors. The combination of levodopa and carbidopa is the most effective treatment available for the management of motor symptoms of PD. However, it can cause a side effect known as dyskinesia, which are abnormal involuntary movements. Dopamine agonists are less effective on the motor symptoms of PD but have a lower rate of causing dyskinesia, although they have other side effects. MAO-B inhibitors are less effective than levodopa or dopamine agonists, however they have fewer side effects. Choice of therapy should be customized to the individual patient with an understanding of the risks and benefits of each class of medication.5

In addition to medication, physical therapy can help with muscle cramps, and regular exercise and stretching are beneficial to strengthen muscles and maintain flexibility. Assistive devices such as walkers or canes can be helpful.


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