Episode Transcript
Speaker 0 00:00:00 Kpi.dot.
Speaker 2 00:00:31 Good evening. Thank you for joining Disability and Progress, where we bring you insights into ideas about, and discussions on disability topics. I'm Mylan Sam. Jasmine produces this show, and Charlene Dolls a research woman and makes great banana bread.
Speaker 3 00:00:48 Thank you very much for joining us. Thank you, Mylan. Tonight the topic is Parkinson's and, um, we'll be talking about that and all that's happening currently with the disease. Meanwhile, Dr. Gerald Vtech is, um, with us, and he is MD PhD, professor and chair of the Department of Neurology at the University of Medic, Minnesota Medical School and neurologist with, um, university of Minnesota Health, getting Dr. Vtech.
Speaker 4 00:01:22 Good evening.
Speaker 3 00:01:23 I hope I got all that right, <laugh>.
Speaker 4 00:01:26 Oh, you did. Right on.
Speaker 3 00:01:28 So thank you very much for agreeing to be on, and this is a always been a pretty interesting topic to me because, um, we'll get into it later, but I think there's, there is some real famous faces with this disease, but I want you to start out talking to me about like, what made you choose your medical path?
Speaker 4 00:01:49 Well, that's an interesting question actually. I, uh, I grew up in a small town in northern Minnesota. Uh, it's called Meadowlands, Minnesota. I think they had 23 kids in my high school class and early on for some reason, I can't explain exactly why. I just, I got interested in medicine, uh, came down here to Minneapolis, uh, went to graduate school and then, and also then went to medical school and enjoyed the classes I've dealt with the brain and brain disorders, and that's kind of how I ended up moving into this field.
Speaker 3 00:02:25 Excellent. Well, let's start out by, if you would, um, I think people have seen it, but they don't really know a definition. So can you give us kind of a layperson's definition of what Parkinson's is and how it works?
Speaker 4 00:02:41 Well, it's a, what we call a progressive merited generative disease, which just means that, uh, there are cells in the brain that de generator die over time, and then based on the type of cells that die, that's the kind of disorder or disability you'd get. In Parkinson's disease, there are cells that make dopamine deep in the brain, and those cells tend to die out a little quicker than they do in the normal population. And when those cells die out, they, you lose dopamine and then you develop a lot of the pronouns of Parkinson's patients develop. It's that lack of that chemical that causes it.
Speaker 3 00:03:19 And I think, Hmm, go ahead. Mm-hmm. <affirmative>, go ahead. I think people hear about dopamine a lot, but can you tell people what it, what dopamine does and what it is?
Speaker 4 00:03:30 Well, it does a lot of things actually. It's not just involved in Parkinson's disease. It can be involved in mood, mood disorders, people, uh, you know, if, uh, depression or other problems, even psychiatric problems. Uh, there's a wide variety of things that dopamine does it when you lose dopamine in a certain part of the brain. Mm-hmm. <affirmative> called the basal ganglia. And we each have two sets, one on each side of the brain, deep in the brain. When you lose that dopamine, those structures, which responsible for a variety of things, including movement, uh, it leads to disorder of movement. And Parkinson's patients manifest primarily as about, probably about half to 70% of the patients get tremor, which is in involuntary shaking. Could be in the hands to be, it can involve the legs of the head, but usually just in the, in the arms, her hands, you get stiff so the limbs can feel stiff, uh, and they're slow. So they have a lot of trouble with movements. Movements are all slowed quite a bit. And there's a ity of, of typical movement that you and I do of spontaneously. Mm-hmm. <affirmative> eye blinking, uh, facial expressions, people for example, rolling bed at night, uh, blinking people blink less and gait and balance disorders. Those are some of the classic things you see in patients with Parkinson's disease.
Speaker 3 00:04:53 And what causes Parkinson's?
Speaker 4 00:04:56 Well, you know, we don't know. Um, it's what we call most, 85% of the cases are what we call sporadic. We don't have a known cause for it. Uh, 15% are generally linked somehow genetically, uh, you know, there are a variety of different genetic changes that people have found. Mm-hmm. <affirmative>. And about 15% of people will have that, but the vast majority really don't. And the arguments that people have made and what FU can come down to, it's a combination of genetic and environmental factors that probably contribute to this.
Speaker 3 00:05:30 Are there different types of Parkinson's? And if so, talk a little bit about them.
Speaker 4 00:05:36 Well, when we look at Parkinson's patients, we, we do kind of categorize them. I, I would say there's a thing that we all have, and that's Parkinson's. Patients are like snowflakes. There's no two that are alike.
Speaker 3 00:05:47 Oh, geez. But
Speaker 4 00:05:48 You can, you can kind of group them, I mean mm-hmm. <affirmative>. So we see some patients that have mainly the tremor, the shaking, and we call those tremor predominant. And we see patients that are mainly just slower and stiff. And we call those akinetic rigid. And we say akinetic because kinetic means movement and a means lack of movement, ah, for this posture of movement, slowness of movement and the stiffness. That's another category. Mm-hmm. <affirmative>. And then there's a group that oftentimes can present mainly with gait and balance problems. That's the third type. And then really the fourth type is any combination of the above three. Some have all the symptoms, some have tremor really has the worst symptom and gait can be very mild or they never have a gate problem. So it can be a combination of all those. That's why we really, that's why we have the phrases right. Snowflakes is really, they aren't, uh, there's no two that are exactly alike.
Speaker 3 00:06:48 I think sometimes people think of Parkinson's as an older person's disease, but that's not true. Is it? I mean, certainly people get it when they're younger too. What's a, um, no,
Speaker 4 00:06:58 That's
Speaker 3 00:06:59 Right. Um, give me like the youngest you've seen, um, is there a general age it hits, I guess, first of all, and then how young can it hit?
Speaker 4 00:07:08 Well, usually people are probably in their sixties or older, but 4% of people will get it, um, uh, below the age of 50. And I've seen people in their teens that can get it. So that, that's really unusual. Most people don't think about that. Uh, cuz we do think it as an older person's disease. Uh, but there are a fair number of people that can get it in their thirties and forties.
Speaker 3 00:07:32 That's, that's, it's not unusual. Very devastating. Charlene, my research person had a question. Charlene, what was your,
Speaker 5 00:07:39 Hi doctor, I'm curious it can an accident, a brain injury, uh, bring the Parkinson's, uh, how to make it happen or be a part of why someone gets it?
Speaker 4 00:07:55 Well, you know, if you have a bad accident that affects that part of the brain, you can get the symptoms that look like Parkinson's disease. But we don't believe that there is a trauma that's going to induce, for example, the same phenomenon of the dopamine cells dying that you see in idiopathic Parkinson's disease. And there are a lot of, actually, the one thing we don't talk about is that there are other disorders that look like Parkinson's disease but aren't. And the difference is that patients with Parkinson's disease will typically respond to medication, a certain type of medication. We can talk about that a little bit if you like. Uh, and we use that almost as a diagnostic tool to diagnose patients with diagnosed patient with pathy Parkinson's disease. There are others that have a more widespread pathology in the brain. It can involve the same circuits as Parkinson's patients, but also it's more extensive. It involves other brain areas. So the medication we typically use for Parkinson's disease can typically affect one particular circuit in the brain, predominantly. Whereas of these other patients, because there are so many other areas of brain involved, the patients who have symptoms that look like Parkinson's but don't have Parkinson's, don't typically respond to the medication.
Speaker 3 00:09:21 Hmm. Interesting. Well, how common is Parkinson's? And does it, does it differentiate in depending on like what part of the world you live in to how, what the rates might be?
Speaker 4 00:09:35 Yeah, it can, um, you know, if you look at, if you look at race for example, it's more common as the greatest occurrence in the Hispanic population really. And then that's followed by Caucasians and then Asians and then African Americans. It's not hugely different. You have the numbers, but, but they are different. And you know, why is that? Well, there are a lot of theories that no one really has a good explanation for that. There's probably a million people in the United States, more than likely even more than that. But that's the number we all go with, uh, that are diagnosed that, that are in the United States. And 60,000 new cases are diagnosed every year in bs.
Speaker 3 00:10:22 Is there a gender preference? Well,
Speaker 4 00:10:24 Yeah. You know, one, it's about 1.5 men to women. There's been some discussion about whether estrogen could be protective somehow. Um, but obviously it's not completely protective cuz women still get Parkinson's
Speaker 3 00:10:38 Disease. Right, right. Interesting. Um, so it's interesting, you know, I, I think we've had, or at least in my lifetime growing up, we've had some real famous faces to Parkinson's. Sometimes I, you know, when doing these, this program, I talk to people and I say, well, why isn't there more research in this particular disease or something? And the guests, you know, I've had people say, well, there's no face to the disease and it makes a big difference if there's a face to the disease. You feel that that's true. And can you talk about some, like, kind of jog peoples memory of what famous people have had Parkinson's?
Speaker 4 00:11:19 Oh, I sure would like to do that. I best example is you lived, says you all recall right? With Muhammad Ali and the, and the torch Oh yes. For the Olympics. I don't remember. Remember how his hand was shaking? Yeah.
Speaker 4 00:11:30 And, and I think the thing that really can drive home, the point about, uh, Parkinson's with Muhammad Ali is, you know, obviously he's standing in front of the whole world and even a man like Muhammad Ali could be a little anxious in those circumstances. Right. And anxiety will make these movement disorders a lot worse. So if you noticed his hand shaking, it was pretty, pretty significant. And I think the anxiety likely exacerbated that. But he's, he's one person, and a, and a good example of it with, uh, with the tremor that he had. A lot of people thought that perhaps the boxing was the underlying cause for his Parkinson's disease. And I don't doubt that it contributed to it, but he, he very likely had idiopathic pd. Uh, but I, I suspect a lot of that was also exacerbated by the injury to his brain through head trauma. Other people. Oh, yeah. Uh, Michael J. Fox is another good example,
Speaker 3 00:12:26 Right? Yes. I do remember that one. And he,
Speaker 4 00:12:29 Do you ever remember that? What, remember the TV interviews? He he did. Yeah. And he was really moving all over the place. You remember that?
Speaker 3 00:12:36 Yeah. And I, I do remember him talking about how, you know, he would work through this and he would have to tell them, okay, I can, I'm good now, I can go for a little while. But when it started to get too much, he had to break and wait until he got things under control.
Speaker 4 00:12:51 Yep. That's right. The the funny thing about that as a physician watching that, who does Parkinson's disease is some of the people on TV said, well, he hasn't got enough medication, but the extra movement that he had was caused by the medication. Wow. Because, again, Parkinson's disease is a, is a ity of movement. Alac of movement, inability to make movements or to be slow on your movement. Again, you don't blink your eyes as much, you don't swallow as much. Some people will look like they're drooling, but that's because they aren't swallowing their saliva. Oh, <laugh>. So it's again, this posse of movement. If Michael J. Fox, when he's not taking his medication, will be much more immobile and wouldn't have all those extra movements. Oh, I see. I get the extra movements are offer the medication.
Speaker 3 00:13:36 And
Speaker 4 00:13:36 That's not typical. I mean, people don't usually get that right away, but it is the side effect of medication over the years. You can start to develop that as a result of the medication.
Speaker 3 00:13:49 If I remember right, he was diagnosed incredibly young, like teen, late teens, early twenties. Right.
Speaker 4 00:13:56 That's right. He's a good example of young o Parkinson's.
Speaker 3 00:14:02 So
Speaker 4 00:14:02 There other people, I mean, you know, one that struck me, uh, was Neil Diamond.
Speaker 3 00:14:08 I had no idea that he had
Speaker 4 00:14:09 For people, for people my age. <laugh>, maybe the sixties. You remember Neil Diamond very
Speaker 3 00:14:14 Well. I'm with you. Yeah,
Speaker 4 00:14:16 There you go. Go. You and I are the same. We're in that gender and that, that age range. Uh, he was diagnosed in 2018.
Speaker 3 00:14:24 Oh, you're kidding. Like recent.
Speaker 4 00:14:27 Wow. Yeah. Very recent. Uh, it, another one is, uh, Jesse Jackson was diagnosed in 2015. And if any of you like to watch mash, uh, aan, all that was was diagnosed in 2015.
Speaker 3 00:14:39 Oh wow. So,
Speaker 4 00:14:41 And then remember Janet Reno?
Speaker 3 00:14:43 Yes.
Speaker 4 00:14:45 So she was diagnosed in 1995.
Speaker 3 00:14:47 Oh is, um, and obviously having a face or having famous people, um, brings not only more money possibly, but education to the disease.
Speaker 4 00:15:03 Yeah. And I think one of the best examples is to show how people live with the disease and they can live with a high quality of life. Um, a lot of times people will take a diagnosis and feel, oh my goodness, you know, like what now what am I gonna do? But people can live very well for decades with Parkinson's disease. You know, we can manage the symptoms with medications. There are surgical therapies that are out there now, um, form of things like deep brain stimulation, we call it brain pacemaker. Uh, and all of those things have been very helpful in treating design motorize, uh, Parkinson's. And you really have improved their quality of life dramatically.
Speaker 3 00:15:43 So can you talk about how can, can someone test for Parkinson's? Let, let's say they wonder if they're going to get it, or let's say they've had people in their family have it. Can they like pretest so to speak, so that they can check to see if they're likely to have it?
Speaker 4 00:16:01 Well, you know, for that small percent that have a genetic link, then you could test for it. Um, but really the vast majority of people, uh, do not have a genetic link. And in that case, there really isn't a test that you can do to diagnose it. It's really a clinical diagnosis. Uh, and so we would, you'd see a physician and that physician would look for these motor signs I talked to you about mm-hmm. <affirmative>, you know, hear stories from patients saying, my handwriting is smaller. Uh, I had trouble going over in bed at night. I feel like I have more trouble with my motor skills, cutting my food, buttoning buttons, things like that. And then you go see a neurologist who specializes in movement disorders. And we can also sort that out. Um, there is a test that people can use to look at the integrity of, uh, the dopamine system. Okay. Um, that's called a D scan. Uh, but it's expensive and it doesn't really change how we treat patients. So many of us will only use that if we really think the diagnosis is questionable. It's not very clear.
Speaker 3 00:17:07 And could that
Speaker 4 00:17:07 Otherwise No, it's really clinical.
Speaker 3 00:17:09 Could that scan though? Could it, it could mean more than one thing is wrong. Like it,
Speaker 4 00:17:15 Yes.
Speaker 3 00:17:16 So very good. It feels like it's not even really a different, uh, a definitive answer that that's Parkinson's. Correct.
Speaker 4 00:17:24 It you're absolutely right. And that, that is the hip on on those kinds of scans. Now that kind of scan will tell you about dopamine and, and this, this pathway. Mm-hmm. <affirmative>. But remember I mentioned those other, those other, um, disorders that look like Parkinson's. Right. But aren't Parkinson's. They have the damage that Parkinson's patients have, but in addition to that, they have more extensive damage. They would look the same way in a D scan that an idiopathic Parkinson's patient would. The time it's useful is if you have somebody who has a tremor that's inherited tremor called essential tremor.
Speaker 3 00:17:59 Okay.
Speaker 4 00:17:59 And this is a tremor that people can get and they can have when they're younger. Uh, you can progress as they get older. Uh, and, and sometimes patients with Parkinson's only have tremor to start with a small percent like that. And if you look at those two types of tremors, sometimes they're pretty close. And it's hard to tell the difference. It doesn't really change how we treat people. But there are people who just want to know, is this essential tremor or is this more like Parkinson's disease? And that, that scan does help in those cases.
Speaker 3 00:18:32 Presumably the people that really wanna know are looking towards, uh, what kind of treatment I can have if I've got Parkinson's. Yes.
Speaker 4 00:18:43 Yes. That's correct.
Speaker 3 00:18:45 So let's dive into that. Talk about the treatments.
Speaker 4 00:18:52 Well, the, the gold standard, I mean there's different, I I breaking into three different things. Okay. I mean, early on we would talk about medical therapy and there are multiple medications out there, but the gold standard is really dopamine replacement cuz that's what you're missing. And that's usually given in the form of something called sin. And that's a combination of, uh, dopa in a form of what they call levodopa with another chemical called carbidopa that allows levodopa to begin as a brain. And so that really is the gold standard. But there are other things out there, uh, that mimic dopamine and they're called dopamine agonist. And we can use those. There are other drugs, uh, whole list of them that work in a similar fashion. And, and some of that worked a little bit differently to treat the symptoms. So, so medical therapy is a variety of them. And, and there are more drugs coming out all the time. The bottom line is the gold standard is still, is still gonna be sentiment.
Speaker 3 00:19:53 And when
Speaker 4 00:19:54 You get to a point that medical therapy is not working as well, so, uh, if I, if I were Parkinson's patient and someone gave me sentiment, I took one tablet, let's say three times a day, I might do very, very well for years over time. However, the medication may outlast quite as long. So then I have to either get more medication or I have to move the doses closer together. So instead of someone taking it, let's say eight o'clock, uh, one o'clock and six o'clock, now I start taking it at eight o'clock, 12 o'clock and four o'clock, and then I may need a dose at eight o'clock at night. And, and that's kinda the way it goes. And over time, as the doses become less effective, you end up moving closer together. So, or you can just increase the dose and keep the spacing the same all kinds of ways to, to, to approach this. But it's the combination of medications
Speaker 3 00:20:49 With the dopamine.
Speaker 4 00:20:50 What medications?
Speaker 3 00:20:51 Oh, I'm sorry. I'm sorry. Go ahead. With the dopamine replacements, is that where you get the extra movements then? Is that what you were talking about?
Speaker 4 00:20:58 Yeah, that's right. Usually doesn't happen right away though. It'll, it'll, it's about 10% per year. Patients will develop some extra movements. By the time you're being treated for five years, a certain percent of patients are gonna start developing these extra movements and they can be quite mild at first. Uh, but as you go on, uh, there's less of a buffering system in our brain. Distort the don't mean that we take orally and the dose you get kind of goes up, the blood level goes up, and then you get the extra movements when the blood level drops down, the movements will tend to go away. But they definitely come, they come strictly from the medication.
Speaker 4 00:21:38 Go ahead. The other therapy uhhuh is well you as you progress to the disease, the medical therapy again, can be unpredictable. You might take a dose that doesn't work anymore and the next dose will work, or let's say take a dose and you think I should be good for three hours. But what happens is I get one hour into my dose and all of a sudden all my symptoms come back and I'm not under control anymore. So the unpredictability becomes a real problem for people. If you can imagine going to the grocery store and saying, I'm gonna go out and I'm gonna shop. I've got three hours for medication's gonna work. And then you get to the grocery store and you're down the walking down the aisle picking up your groceries, and all of a sudden your medication doesn't work anymore. Oh geez. And you're unable to move. Your slow, your stiff, your tremor comes back and all of a sudden people start looking at you and you get embarrassed and you get anxious and the symptoms get worse. You can, you can understand how that's gotta be difficult for
Speaker 3 00:22:33 People. Right.
Speaker 4 00:22:35 So there are surgical therapies now where we can implant like a pacemaker lead, deepen the brain structures that are affected in Parkinson's, and we can produce some pretty significant improvement in their symptoms, turn the clock back at least five years in most patients. Really?
Speaker 3 00:22:50 That's
Speaker 4 00:22:51 Interesting. Yeah. And you can reduce the medication as
Speaker 3 00:22:54 Well. So how does that work?
Speaker 4 00:22:56 Well, that's a good question. I've been doing that since 2003 actually working on that question. Um, well, it changes the pattern of neuroactivity in the brain. So when you lose dopamine, the brain patterns go awry is, is probably the best way I could explain this. Mm-hmm. <affirmative>, they're not under control anymore and the stimulation tends to bring them back into a pattern that the rest of the brain circuitry can adapt to. And so we see pretty marked improvements in these patients.
Speaker 3 00:23:28 So what
Speaker 4 00:23:28 I, you go into a lot more detail, but I don't think you'd want to hear all the details
Speaker 3 00:23:31 <laugh> give what So is
Speaker 4 00:23:32 There, uh, but no, it does, it works well.
Speaker 3 00:23:34 Is is there a progression, like do they generally start out with drug therapy and move to something like this? Or is there a reason why they wouldn't start out with this at the beginning? Because it sounds like it'd be a whole lot less troublesome than the drug therapy.
Speaker 4 00:23:50 Well, you know, the, the labeling for doing the brain pacemaker has changed. Oh. It used to be from the fda. Uh, you had to have a really advanced pd, intractable problems and then you'd be a candidate. They've moved that back now to having been diagnosed for four years. And at that point, if you have trouble, then the FDA is approved, uh, deeper brain stimulation. The difference is, and the reason people don't do it right away, is, is you really don't need to, to start right away. Um, we think that could there be a protective effect of the stimulation? You would be able to prevent people from getting dyskinesia because you're decreasing the medication and they don't have to take as much to start with. Mm-hmm. <affirmative>, the difference is though, is that medical therapy, you can take a dose and, and, uh, you do really well. The side effects really are gonna develop for years. Um, with brain stimulation, there's a one to 2% risk that you'll have a stroke. Oh. When the lead put in, geez.
Speaker 3 00:24:47 Oh, that's not kind. So
Speaker 4 00:24:49 Percent chance. Well, you know, you've got a pretty good chance that's not gonna happen. But Right. If you don't need to take that risk.
Speaker 3 00:24:55 I see. I
Speaker 4 00:24:56 Think most people, if they feel medication works for them, they're, they're not inclined to do so.
Speaker 3 00:25:01 So is, I mean, there's always more. Right. But the, the downside of the dopamine replacement, are you saying is generally that eventually it just doesn't work as it did at the beginning after
Speaker 4 00:25:17 A while? Well, I mean, in many, in certain ways it doesn't work. So typically it becomes unpredictable. Mm-hmm. <affirmative>. So one dose may work, another dose may not mm-hmm. <affirmative>, um, you may have what we call a neurotherapeutic window over time. Whereas early on, I can give you the drug, you're gonna, medication's gonna work your symptoms of bait. You may stay like that for three, four hours and then the symptom will come back. Whereas after five, after a number of years of taking dopamine, um, the symptoms are unpredictable. So they may, they may go away and then they may come back right away. So what we call motor fluctuations. So they appear, then they disappear, but you can't predict when. And so that becomes very cumbersome and difficult for people's quality of life. And remember, it's a progressive disease. So it's not just that you've lost 70% of your cells, which is the case of diagnosis. Over time, you continue to lose more of those cells.
Speaker 3 00:26:18 And what about the
Speaker 4 00:26:18 Deep becomes more difficult?
Speaker 3 00:26:20 The deep brain stimulation is there, besides the stroke, I mean, which is significant if you do have it, have one. Um, is there a downside with doing that?
Speaker 4 00:26:32 You know, the only problem that you would see, I, I think the biggest issue here is I, I I, the analogy I'd draw a deeper in stimulation effectiveness is like selling real estate. It's location, location, location. Huh. So the lead has to be very precisely placed. So when patients look at places that they think would be a good place to go, they need to know that that place is a lot of experience. They do a lot of cases. And then you need to find out how well the cases do and talk to people that had it done there. Uh, because I think that's the biggest factor in, uh, in the effective brain stimulation. But it can be extremely effective. And again, if you're, if you're at a point where you're fluctuating a lot, the medication sometimes works, sometimes it doesn't. Um, you're having dyskinesias, you can't control those. Um, you don't know when you're gonna turn off or you're gonna freeze in place. You can't move. That's a pretty lousy quality of life. Mm. Yes. And if you look at the risk is really relatively small, you're talking one to 2%. That's pretty low for brain surgery.
Speaker 3 00:27:36 And if you're talking about the deep brain stimulation, what, how often do you have to do that?
Speaker 4 00:27:43 Once. So you, you put the lead in once, but now for most patients, you end up gonna put a lead on each side of the brain. Mm-hmm. <affirmative>, uh, if they put a lead on the right side of the brain, it's gonna improve symptoms on the left side of the body. So you're gonna need to put the other side in to control the right side of the body. But once you put those in, provided your, you have good placements, you don't replace them again unless there's a malfunction. And typically the devices are so good now that they will last, uh, virtually for quite, quite a long time. The only change you have to make is like a cardiac pacemaker. Ah. You've got a little pulse generator that generates the current place under the clavicle, under the skin. Mm-hmm. <affirmative>, everything is under the skin. And you know, some of those devices, if you don't have a rechargeable device, <laugh>, you replace it every maybe four to five years. Right. In other cases you have rechargeables that can last 15 years. You wouldn't have to replace it for 15 years.
Speaker 5 00:28:43 You plug in at night, huh? <laugh>? Geez.
Speaker 4 00:28:46 Pretty much. Yeah. Watch TV and hook yourself up.
Speaker 5 00:28:49 Oh boy. <laugh> me in the iPhone. Okay.
Speaker 3 00:28:52 <laugh>. <laugh>. So is there, did you say there's a third treatment?
Speaker 4 00:28:59 Well, the other thing I would like to tell people who are listening is that there are some very basic things that are extremely good for helping you when you have disability of Parkinson's. Mm-hmm. <affirmative>. And, and one of the biggest things is exercise.
Speaker 3 00:29:12 Ah, we hear this all the time. <laugh>,
Speaker 4 00:29:15 Oh, well, you know, <laugh>, we should all do it.
Speaker 3 00:29:19 Yes.
Speaker 4 00:29:20 But the exercise for Parkinson's, there have been some studies that have suggested that it actually can help with releasing more dopamine. Ah. Um, and things like spinning, uh, cycling. People have talked about tight chi and you've heard about the boxing, right? Mm-hmm. <affirmative> mm-hmm.
Speaker 3 00:29:38 <affirmative>,
Speaker 4 00:29:40 I think all these things, anything you do like that is gonna be good for you. But there are some, some studies that were done when I was working, uh, in, at the Cleveland Clinic where we did some studies, uh, a guy named Jay Alberts and we did cycling. And there was an nav body trainer on a tan of Parkinson's, patient on the back of the bike. Mm-hmm. <affirmative>. And he generated this study where naval body trainer would go very fast and the person behind the Parkinson's patient would try to follow, but because it's a tandem bike Right. Their legs were moving just as fast as naval body trainer was. Right. And those patients after exercising, oh, it was a certain period of time for five days. You know, it was like around for like an hour or something in the bike mm-hmm. <affirmative>. And then they did it for five days in a row and we saw marked improvement in their motor signs, you know, and their stiffness to rigidity the tremor that lasted several days, almost out for a week or two in some cases. And so if you do spinning three, four times a week, I tell my patients that they're able to do it, that they should do something like that. What do you, if you just go to the gym and you, or if you walk at a fast pace mm-hmm. <affirmative>, all of those things are, are gonna be helpful and diet nutrition.
Speaker 3 00:30:51 Yes.
Speaker 4 00:30:52 Uh, all those things, uh, that you and I, all of us really used to do can be extremely helpful for patients with Parkinson's.
Speaker 3 00:31:00 The thing is, what do you follow? There's so many stuff, so much different diets now. Meat, meatless, you know, vegan, whatever. The other thing is that now vegans decided they should add meat. No, dairy, dairy, <laugh>, soy. So how do you know what you should follow
Speaker 4 00:31:19 It? It's tough. If you go on and look at the Apda A or Parkinson's Foundation websites, they do talk about, um, diets not gonna eat diet, not we're trying to lose weight. It's the things you're eating. Right. You know, there's been a lot of talked about antioxidant and, and their role in Parkinson's disease, Uhhuh. Uh, so foods that are high in these, in these types of things or what people think are good. Look, it's not gonna stop Parkinson's disease. Mm-hmm. <affirmative>, we don't know if it'll even slow it down. But there have been enough scientific data suggesting that these types of foods might be good for you. So it's not gonna hurt you. It's probably good for all of us. And if you think there's something, a chance that it could help, then I think you should take it. And it's, it's not that hard to do. Again, those websites will tell you what those types of foods are. The biggest thing still, I think goes back to exercise.
Speaker 3 00:32:11 Is there a difference in
Speaker 4 00:32:12 How you, and I think again, we should all do.
Speaker 3 00:32:14 Yeah. Is there a difference in how you treat a patient if they come in, um, diagnosed at the age of 20 as opposed to 60?
Speaker 4 00:32:25 You know, not, not really. Uh, again, what I tell everybody who comes in, I mean, what I would tell someone who's 20 clearly is, is exercise vigorously someone at 60, I'm gonna make sure that their family practitioner, internal medicine doc has assessed them, that they're able to do that kind of exercise.
Speaker 3 00:32:43 Okay.
Speaker 4 00:32:43 Cause it appears like the exercise that you have to do as vigorous exercise for a small amount of time is better than moderate exercise for a long period of time. So you wanna make sure you have a good shape of that. But again, for younger patients or an older patient, I think what we tell them is very much the same thing. And we treat them the same way.
Speaker 3 00:33:04 Dr. Vtech, what are, what are some myths that you have heard people say or think about Parkinson's?
Speaker 4 00:33:14 Well, you know, one thing is that people always feel that if to have parks, since you have to have tremor and you don't, as I mentioned, there are many, many, many Parkinson's patients that don't have tremor, for example. The other thing, it it's not, it's not just a movement problem. So people with Parkinson's often have, uh, mood disorder when they're first diagnosed, about 30% of Parkinson's patients have depression. And by the time they're more advanced it's closer to 50%.
Speaker 3 00:33:48 Wow.
Speaker 4 00:33:49 And dopamine again, affects more than just movement. It also affects mood. And if you think about, um, anybody, if you guys golf, I don't much, I have friends who like to, so they take me up the course every now and then. And, uh, I think just for grins to watch me, you
Speaker 3 00:34:07 Know, <laugh> knock
Speaker 4 00:34:09 Balls all over the place,
Speaker 3 00:34:10 I can't
Speaker 4 00:34:11 Hear. Um, but every now and then, you know, I get lucky and I hit something. Right. And when that happens, you feel pretty good uhhuh. And what happens when in your brain is that there are parts you brainly are being bathed in dopamine. Mm-hmm. <affirmative>. So it can be a feel good drug. Uh, and when you lose that drug, not in addition to the movement problems, your mood can be depressed.
Speaker 3 00:34:36 Yeah.
Speaker 4 00:34:37 And again, 30% at diagnosis. So you know, you need to treat that because that's a major factor of quality of life. The other, the other things that Parkinson's patients have pretty commonly are sleep disorders.
Speaker 3 00:34:51 Ah, sleep
Speaker 4 00:34:53 Disorders. And you can think about if,
Speaker 3 00:34:54 Well go ahead. What was your question? Like not enough sleep too much. What what type?
Speaker 4 00:34:59 No, they, their, their sleep cycles get screwed up. Um, so, you know, usually you go through different phases of sleep and we have people in my department, uh, that focus strictly on this. Uh, but they may not go through their sleep cycles the way you and I might go through our sleep cycles. Um, the other thing they can have is what they call excessive daytime sleepiness. And that's oftentimes due to the medication we give them. So the cinema, and these do agonists I talk about they can make people sleepy. So we have to adjust things for that
Speaker 3 00:35:32 Even though they're making them feel good.
Speaker 4 00:35:36 Well, yeah, I, you know, it, it, it's true. Not everybody responds the same wave. And I know there are some patients with Parkinson's who just hate, you know, being off. And when I say off, that means when the symptoms are at their worst mm-hmm. <affirmative>. So they're, they're slow, they're stiff and they really, they have trouble making movements. Some people can freeze where they get stuck in one spot and can't move again. And people just hate that. You can understand why. Yes. So what those people often do is they'll overdose on the dopamine because they don't want to be in that state. And it can be an addictive drug.
Speaker 3 00:36:09 I was just gonna heroin
Speaker 4 00:36:11 Cocaine or something like that. But it does make you feel better. And uh, I know there's one patient of mine years ago when I was at Emory, I would see her in the hallway cuz she was working with us with our patient population. She had had a surgery done and she would help us with patients who were thinking of surgery. I saw her in the hallway and she looked just fine. But she says, she said we were on a first name basis. She said, Jerry, I really need my medication. I remember saying, well Terry, oh you look fine. She goes, no, you don't understand. I really need my medication. I just feel anxious. I'm nervous. I don't, I just don't feel good. And yet, movement wise she was fine. But she took her medication that all went away. So, you know, there's anxiety, discomfort, um, and a lot of that can be related to the lack of dopamine.
Speaker 3 00:37:01 So because her dopamine levels were still low then even after the, after the surgery, it doesn't necessarily raise dopamine levels, but it will,
Speaker 4 00:37:11 Well the surgery we did, the surgery we did then actually was something called AAL is a lesion surgery that's since been replaced by the deeper stimulation because ah, okay. Side effects of deeper stimulation due to the stimulation are reversible. You can adjust the amount of current that we get people and so we can, you know, increase it or decrease it. Okay. But the lesion surgery, you really can't take it away. It's done.
Speaker 3 00:37:34 Ah.
Speaker 4 00:37:35 And lesion surgery didn't allow us to reduce the medication so she had atomy cuz there was no DBS available then. But now with dbs we can reduce the medication. So it's a very different surgical approach than what we used to do back in the nineties, early nineties.
Speaker 3 00:37:54 So the people who are famous that we talked about Michael Day Fox, he, he's still with us, right? Yeah. I think he's still, what do they, what do they generally opt to do? Do they, do they tough it out with the dopamine first to see if they can level things out? Or do they go for the deep brain surgeries? Well,
Speaker 4 00:38:14 I've been surprised that I haven't seen that Michael G. Fox has had this done and I've always wondered why not. Um, cuz it can improve the quality of life so much for so many people. That's always surprised me. He hasn't had it done. And the extra movements he has the dyskinesias respond extremely well to the surgical therapy. Uh, but you know, everybody has a different perspective on this. Uh, and some people will, will want to do it very early in the course of their disease and others will hold out until they feel they just can't hold on anymore.
Speaker 3 00:38:45 Presumably because the risk, once you have the stroke, you know, there's no going back from there. Right.
Speaker 4 00:38:52 Well, and I, you know, when someone tells you that, so if I were to tell you, if you came to me and, and say I was an oncologist and I said, well, you know, you have this cancer and you have a 50 50 chance and what do you think about, you think, I don't think about a 50% chance I'm gonna live, I think as a 50% chance I'm gonna die. Right. I think that's what most people tend to see it as. Another are some that are very optimistic. You know, I'm one of those class half empty kind of guys unfortunately. So I would see it as, well I have a 2% chance or two 1% chance I could have a stroke. Whereas others see it as I have a 99% or 98% chance I'm gonna come through this and I'm gonna do a whole lot better and my quality of life's gonna be a lot better. It's a very personal decision for people.
Speaker 3 00:39:38 Right. And you talked about progression in the disease and it's clear that what you've said is the progression doesn't necessarily happen the same for everyone. Correct?
Speaker 4 00:39:52 That's correct. It's pretty different. Um, I have a friend of mine who I take care of and we talk not infrequently and the question oftentimes comes up, what am I gonna be like next year? Mm. When I tell people, although I don't know that it's perfectly accurate, is take a look at what you're like last year. Look at what you're like now. When you can project ahead to next year. That's not always the case. Cause I do think people in the early stages, the vast majority will do well for quite some time. Um, mood and, you know, attitude has a lot to do with that. But on the other hand, it's gonna progress. Mm-hmm. <affirmative>, but it just progresses so differently in different people
Speaker 5 00:40:34 Is some of that. But
Speaker 4 00:40:35 When people ask you, you can't, you can't, you really can't tell
Speaker 3 00:40:38 Them. Right.
Speaker 5 00:40:39 Is some of that difference maybe because people have other underlying medical conditions that don't play nice with the Parkinson's?
Speaker 4 00:40:47 Well, that's a great question. I, you know, I think it certainly can be. I don't, we can't rule out that other things can, can play a role in that. It could be, it has in the progression disease. If you think about if you have other illnesses and you're already having trouble with your walking, um, say you have another disorder that compromises your Parkinson's. Yeah, it's true. It can make it worse. Whether it makes it progress faster, that's another question. I mean, I don't know. We don't know what the factors are that makes those cells die out over time. We know that there are some molecular changes in those cells that there are some little protein deposits called Altium that we think could be an underlying cause that might kill those cells. On the other hand, it could just be a result of some other process. And it's in what we call an epiphenomena. It doesn't cause it, but it's a byproduct of something else that's going on. And this is what people really don't understand. And that's where a lot of the science and the research has gone is to understanding those molecular mechanisms that underlie that cell depth. If you can understand that, then you could develop perhaps ways to stop that or at least pull it down.
Speaker 3 00:41:56 Can you talk about, um, what people should look for? Like how do they know if they should even be looking at this type of thing and how do they pick a good neurologist?
Speaker 4 00:42:10 Well, if you, if you, if you're talking about Parkinson's patients, period, and then, and then whether you should have deeper stimulation done. Uh, what what you'd wanna do really is to find a good movement disorder neurologist, someone that's been trained and and knows movement disorders and takes care of Parkinson's patients. Cause a lot of times, uh, most people can handle Parkinson's early in the course, but as things are more complicated, it gets harder. And when you're just, when you're a physician that focuses strictly on taking care of Parkinson's patients, you've learned a few more tricks for the trade, I think, and the ways that you can improve their therapies. And so I really think the first step is to find a good movement disorder neurologist and get an assessment and follow with that person. But remember, if you don't, this is a relationship that you develop and if that relationship doesn't feel right to you, then you can find another person who does movement disorders and work with that person.
Speaker 4 00:43:05 That, that position should help you to understand when do you think you're at a point that you should think about brain paste makers or deep brain stimulation? And again, that's a personal decision. So some people will go early and, and not want to put up with some of these fluctuations or the extra movements at all. Others will put up with it for quite some long time because they're concerned about the surgery. I, I would say, if you're even thinking about it, you should go to a center that has a center that does deep brain stimulation mm-hmm. <affirmative>, um, and talk to the neurologist there just about, you know, what is deep brain stimulation? Am I a candidate? Why would I be a candidate or the things that would make me higher risk than somebody else? What's your, uh, what, what are your results? Like, can I talk to some patients who had it done here? All you're doing when you do that is inquiring mm-hmm. <affirmative> just to get information. You don't have to have the surgery done by making a visits here, disorder, neurologist. You just get information. I, that's what I recommend everybody do. And if you're not sure about it with that person, then go talk to another one who also does it and get a sense this has to be right for you and you've gotta feel good about the people you're working with.
Speaker 3 00:44:21 Second opinions I can't stress enough on, uh, I, but I have a real hard realization of how insurances sometimes work for people. Oh yeah. And sometimes they penalize you for not kind of making up your mind, if that's what you wanna call it.
Speaker 4 00:44:40 Well, I, I agree. You know, when there were some changes in our healthcare system some years ago, um, one of my ex mentees from another institution told me that had a patient been following for quite some time, it was his patient. They had a relationship established. And when the insurance changed, that patient who was going to have surgery with my colleague was not allowed to anymore. That's not a good, that's not a good outcome in my opinion.
Speaker 3 00:45:08 No.
Speaker 4 00:45:09 I don't know how you changed, uh, you know, the network of insurance companies, et cetera to, to avoid that. But that, that is a problem. Usually though you can find within a network, you know, a couple of people that know about this field and and, and get a second opinion from them.
Speaker 3 00:45:27 So do you feel that the general physician is up on things enough to recognize Parkinson's?
Speaker 4 00:45:37 Well, you know, if you look at numbers, what people say is that people in internal medicine or family practice miss a diagnosis about 25% of the time.
Speaker 3 00:45:47 Ugh.
Speaker 4 00:45:48 And even people with specialty areas in movement disorders, people that see Parkinson's patients mm-hmm. <affirmative> can be wrong 10% of the time. So there's nothing that's a hundred percent Right.
Speaker 3 00:46:00 Right.
Speaker 4 00:46:01 But I would say that if you have a question of whether you have, uh, Parkinson's disease, you should see a specialist in movement disorders who, again, works primarily with Parkinson's patients.
Speaker 3 00:46:14 Can you talk about any studies or research that's going on and where can people find out about them?
Speaker 4 00:46:21 So we have website at the University of Minnesota and the Department of Neurology, and it's actually being updated. So if you get on and look at it today, you're not gonna see what we want you to see mm-hmm. <affirmative>. But you will see a list of things that are being done, uh, at the University of Minnesota as well as within our department. So it's not just our neurology department that does work in Parkinson's disease. The basic neuroscience departments do some of the imaging centers, do people in biomedical engineering do. And we have a large cadre of people, uh, at this institution that have formed teams. And we have a large team of people here that work on understanding, you know, what causes those cells to die, what changes in the brain when you have Parkinson's disease. And, um, there are a lot of work being done at this institution looking at the changes in your brain when you get Parkinson's disease.
Speaker 4 00:47:11 We have a, what's called a OL center of Excellence for Parkinson's disease here. Mm-hmm. <affirmative>, um, I think there are nine in the country. And we are fortunate to get one a couple years ago. And that deals a lot with understanding the circuits in Parkinson's disease and how deep brain stimulation can improve that, and how to improve deeper brain stimulation in general. And that's, that's all over our websites. And we have a lot of clinical trials looking at deep brain stimulation. We also have a lot of clinical trials looking at medical therapy for Parkinson's and other movement disorders. There are a number of imaging studies that are being looked at here, there are studies looking at people's gate and their balance studies looking at, uh, different sites to stimulate in. And there are people, again, looking at the molecular base underlying the development of Parkinson. So there's all kinds of work, uh, that's being done at this institution. This is, you know, I I came back to Minnesota about nine years ago. I've been done 26 years across the country. And I came back for two reasons. One, we wanted to come home. Uh, but that wasn't the, the biggest reason, the biggest reason was the quality of the science at this institution and the neuroscience in particular. So this, this is a, this is a very strong site for, uh, circuits and neuroscience and imaging, et cetera, that deals particularly with things like Parkinson's and Alzheimer's and muscle diseases.
Speaker 3 00:48:37 So one of the good places to go if you've gotta go there.
Speaker 4 00:48:42 Well, I would tend to be a little biased, probably <laugh>,
Speaker 3 00:48:45 But,
Speaker 4 00:48:46 But I do think it is, I mean, I, you know, again, I I've been all over the country, uh, spent time in upstate New York, spent time at Johns Hopkins in Baltimore, down to Amory, uh, university in Atlanta for 14 years, Cleveland Clinic for six. And, you know, we came back to Minnesota, we were very happy back in the state last couple days. Didn't completely change my mind, but,
Speaker 3 00:49:07 Uh, I was gonna say
Speaker 4 00:49:09 <laugh>, but you know, it's a hardy it's a, it's a hardy group up
Speaker 3 00:49:13 Here. That's true. That's right.
Speaker 4 00:49:15 And so I, I, yeah, I, I think this is a very good, very good place for the science, but also for the clinical care. We have very good people to take care of patients here.
Speaker 3 00:49:24 I know this is, this may be way off, so if it is to say so, but in a lot of different areas, they're experimenting slash trying things with stem cell. Is there anything that stem cells can do in this area?
Speaker 4 00:49:39 Sure. And you know, they have very good stem cell group. In fact, our, our in that area and stem cells, Jacob Toler, um, and there's a lot of work that people are developing. A STEM cells, when we, when we first started talking about stem cells, we thought we'd, we'd find it here for Parkinson's disease. Mm-hmm. <affirmative>, uh, it's been a lot slower than that. Mm. Uh, but there is still a lot of work being done on stem cells. So that's just another area, uh, that people are looking at. It's really a multifaceted approach. You know, can you replace the dopamine by putting cells in the brain that will make dopamine or replace the cells that we're making domine before? Uh, and that was the whole concept behind stem cells and transplant tissue that would, would replace opening. Uh, it, it didn't go as quickly as we thought it would, but there's still advances that are being made using the thought using stem cells. Um, there are other things. There's gene therapy that people are looking at. Ah, yes. Um, so there's a variety of, of different things that are going on here as well as other places.
Speaker 3 00:50:39 But presumably
Speaker 4 00:50:40 Recently I saw something on a couple of new drugs that were being developed mm-hmm. <affirmative> that people thought not only could be more effective at treating the symptoms, but potentially could be protective of those cells that, that are remaining ah, that make dopamine. So, you know, there's things, I guess what you need to, we need to tell people is that there's an awful lot of work in, um, in this field and, you know, you could find something could occur tomorrow. New discovery, if you go back to levodopa, I mean, levodopa was discovered. Uh, people had nothing therefore levodopa. And when levodopa came into play, it was a huge change for people that had nothing before that. Right. And everybody thought, well, now we've got a treatment for Parkinson's. But then after five, 10 years, they realized there's some problems in medical therapy, may issues down the road, and then surgical therapies came back and that was the brain stimulation world. And that's a big change for people. So, you know, the next discovery, uh, could be tomorrow morning when you wake up and see the paper new drug. Right. So I think people should keep hope because there's a lot of smart people working at a lot of different ways to, uh, to beat this disease.
Speaker 3 00:51:55 When do you think the university website will be, um, working well again for people to be able to access studies and whatnot?
Speaker 4 00:52:04 Well, I was hoping it would've been yesterday, but unfortunately that's not how it works here. <laugh>. So we, I would hope within a few weeks, maybe, maybe no later than a month, uh, I think we're in the queue. We've modified everything at our department. And so we're in the queue at the university to get our website up with new additions. So I would, but in the meantime, if people wanna give a call to our department, they can find us. There's a website with an address and a number for contacts. Um, they're more than welcome to call and we would direct them.
Speaker 3 00:52:34 Do you wanna give a number or website out that people can, you
Speaker 4 00:52:38 Know, if you, if you just get on University Minnesota website Okay. And look in a neurology, we still have something there. Okay. It's not updated like it should be. Mm-hmm. <affirmative>. But you'll see somethings there. But I can actually just give you, I'll give you my, my, my admin assistant above this, but I'm gonna give out a number here. Go for it with the direct people. Okay. And that's, uh, it's 6 1 2 6 2 5 5 9 9 3.
Speaker 3 00:53:02 Can you give that one more?
Speaker 4 00:53:04 Yeah, 6 1 2 6 2 5 5 9 9 3. And we can try to direct those folks to the right place.
Speaker 3 00:53:16 Dr. Vtech, it's been awesome. Um, is there anything you'd like to share with us that we've missed or anything you'd like to say before we leave?
Speaker 4 00:53:24 No, you must have been really thorough. Um, <laugh>
Speaker 3 00:53:26 Try the last
Speaker 4 00:53:27 Thing, the last thing I would leave you with, uh, would be just a little story. And that was when I was a medical student, we were always being told that you should not get too connected with your patients. Mm. Right. That was the old story. Right? Ah, yeah. I would tell you now that that has changed. And that's not how we practice in this department. We believe you have to have a relationship with your patient that they have to know that we care about them as people. We care about how they, how their families are dealing with these disorders as well as with the patient. Uh, and so I would leave that thought that there's been a big change in the mantra for how physicians take care of patients, particularly at this institution. And, uh, it's, it's more, it's very personal and patient specific,
Speaker 3 00:54:09 Kind of like treating the person as a whole.
Speaker 4 00:54:13 It's, yeah. It's not just the disease. That disease affects the family, affects the kids. Yes. It affects the extended family. It affects them socially, it affects them financially. Um, you need to treat everything. Um, it's, it's, you're right. It's de treat the patient as a whole.
Speaker 3 00:54:31 Dr. Vtech, thank you so, so much for coming on. We greatly appreciate your time and uh,
Speaker 4 00:54:36 Oh, my pleasure.
Speaker 3 00:54:37 We will look forward to having you back on when we get another awesome cure come in or treatment. I guess cure is the wrong thing, but treatment maybe is a better word to use. Huh.
Speaker 4 00:54:49 Well, let's hope that's food later.
Speaker 3 00:54:50 Right. Let's hope so. Thank you very much, sir.
Speaker 4 00:54:53 You're very welcome.
