Metabolically, there are two types of exercise, aerobic and anaerobic. Aerobic exercise uses oxygen as energy substrate to metabolize food to adenosine triphosphate (ATP) (see box below, METABOLIC CHANGES DURING AEROBIC AND ANAEROBIC EXERCISE). When the supply of oxygen is no longer sufficient to meet the needs of exercising muscles, anaerobic metabolism begins. In anaerobic metabolism, glucose is converted to ATP without oxygen, and lactic acid is generated as a by-product. A healthy person can perform aerobic exercise for several hours; in contrast, pure anaerobic exercise can only be sustained for a few minutes before severe dyspnea and fatigue set in.
During short bursts of activity, such as sprinting, energy may be obtained only anaerobically. Otherwise, anaerobic metabolism occurs in addition to ongoing aerobic metabolism. Typically, anaerobic metabolism begins approximately midway between resting and maximal oxygen consumption. The point at which anaerobic metabolism begins is called the anaerobic threshold (AT). AT can be identified by a typical pattern of changes in the blood and in expired gases (see the next section).
METABOLIC CHANGES DURING AEROBIC AND ANAEROBIC EXERCISE
During aerobic exercise, both glucose and fatty acids are metabolized. One molecule of glucose utilizes 6 molecules of oxygen and produces 6 molecules of carbon dioxide, for a metabolic respiratory quotient (RQ) of I.O. For fatty acids, 23 molecules of oxygen are used for every 16 molecules of carbon dioxide produced, giving an RQ of 0.71. The average RQ during mild to moderate exercise (before anaerobic threshold) is approximately 0.85.
By contrast, anaerobic metabolism produces only 2 molecules of ATP per molecule of glucose; at the same time 2 molecules of lactic acid are produced, which, when buffered, generate carbon dioxide in excess of that from aerobic metabolism.
AEROBIC METABOLISM
C6H12O6 + 6 02 ----> 6 CO2 + 6 H2O + 36 ATP (RQ = 1.0)
(Glucose)
C16H32O2 + 23 02 ----> 16 CO2 + 16 H2O + 130 ATP (RQ = 0.71)
(Fatty acid)
Parkinson's disease is a disorder of the brain that leads to shaking (tremors) and difficulty with walking, movement, and coordination.
Causes
Parkinson's disease was first described in England in 1817 by Dr. James Parkinson. The disease most often develops after age 50. It is one of the most common nervous system disorders of the elderly. Sometimes Parkinson's disease occurs in younger adults, but is rarely seen in children. It affects both men and women.
In some cases, Parkinson's disease occurs in families. When a young person is affected, it is usually because of a form of the disease that runs in families.
Nerve cells use a brain chemical called dopamine to help control muscle movement. Parkinson's disease occurs when the nerve cells in the brain that make dopamine are slowly destroyed. Without dopamine, the nerve cells in that part of the brain cannot properly send messages. This leads to the loss of muscle function. The damage gets worse with time. Exactly why the brain cells waste away is unknown. Parkinson's in children may occur because the nerves are not as sensitive to dopamine. Parkinson's is rare in children.
The term "parkinsonism" refers to any condition that involves the types of movement changes seen in Parkinson's disease. Parkinsonism may be caused by other disorders (such as secondary parkinsonism) or certain medications.
Symptoms
The disorder may affect one or both sides of the body. How much function is lost can vary.
Symptoms may be mild at first. For instance, the patient may have a mild tremor or a slight feeling that one leg or foot is stiff and dragging.
Symptoms include:
Automatic movements (such as blinking) slow or stop
The health care provider may be able to diagnose Parkinson's disease based on your symptoms and a physical examination. However, the symptoms can be difficult to assess, particularly in the elderly. The signs (tremor, change in muscle tone, problems walking, unsteady posture) become more clear as the illness progresses.
An examination may show:
Difficulty starting or finishing voluntary movements
Tests may be needed to rule out other disorders that cause similar symptoms.
Treatment
There is no known cure for Parkinson's disease. The goal of treatment is to control symptoms.
Medications control symptoms, mostly by increasing the levels of dopamine in the brain. At certain points during the day, the helpful effects of the medication often wears off, and symptoms can return. Your doctor need to be change the:
Type of medication
Dose
Amount of time between doses
How the medications are taken
Work closely with your doctors and therapists to adjust the treatment program. Never change or stop taking any medications without talking with your doctor.
Many medications can cause severe side effects, including hallucinations, nausea, vomiting, diarrhea, and delirium. Monitoring and follow-up by the health care provider is important.
Eventually, symptoms such as stooped posture, frozen movements, and speech difficulties may not respond very well to drug treatment.
Medications used to treat symptoms of Parkinson's disease are:
Levodopa (L-dopa), Sinemet, levodopa and carbidopa (Atamet)
Amantadine or anticholinergic medications -- to reduce early or mild tremors
Entacapone -- to prevent the breakdown of levodopa
Lifestyle changes that may be helpful for Parkinson's disease:
Good general nutrition and health
Exercising, but adjusting the activity level to meet changing energy levels
Regular rest periods and avoiding stress
Physical therapy, speech therapy, and occupational therapy
Railings or banisters placed in commonly used areas of the house
Special eating utensils
Social workers or other counseling services to help you cope with the disorder and get assistance (such as Meals-on-Wheels)
Less commonly, surgery may be an option for patients with very severe Parkinson's disease who no longer respond to many medications. These surgeries do not cure Parkinson's, but may help some patients:
In deep brain stimulation (DBS), the surgeon implants electrical stimulators in specific areas of the brain to help with movement.
Another type of surgery destroys brain tissues that cause Parkinson's symptoms.
Support Groups
Support groups may help you cope with the changes caused by the disease.
Untreated, the disorder will get worse until a person is totally disabled. Parkinson's may lead to a deterioration of all brain functions, and an early death.
Most people respond to medications. How much the medications relieve symptoms, and for how long can be very different in each person. The side effects of medications may be severe.
Also tell the health care provider about medication side effects, which may include:
Changes in alertness, behavior or mood
Delusional behavior
Dizziness
Hallucinations
Involuntary movements
Loss of mental functions
Nausea and vomiting
Severe confusion or disorientation
Also call your health care provider if the condition gets worse and home care is no longer possible.
Alternative Names
Paralysis agitans; Shaking palsy
References
Lang AE. When and how should treatment be started in Parkinson disease? Neurology. 2009;72(7 Suppl):S39-43.
Miyasaki JM, Shannon K, Voon V, Ravina B, Kleiner-Fisman G, Anderson K, et al. Practice Parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson's disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;66:996-1002.
Pahwa R, Factor SA, Lyons KE, Ondo WG, Gronseth G, Bronte-Stewart H, et al. Practice Parameter: treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;66:983-995.
Suchowersky O, Reich S, Perlmutter J, Zesiewicz T, Gronseth G, Weiner WJ. Quality Standards Subcommittee of the American Academy of Neurology. Practice Parameter: diagnosis and prognosis of new onset Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006.66:968-975.
Weaver FM, Follett K, Stern M, et al. Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial. JAMA. 2009;301(1):63-73.
Update Date: 7/4/2009
Updated by: Daniel B. Hoch, PhD, MD, Assistant Professor of Neurology, Harvard Medical School, Department of Neurology, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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