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YOGA THERAPY FOR EARLY ONSET PARKINSON'S DISEASE


My aim was to examine the impact of a diagnosis of Parkinson's Disease upon those diagnosed at a younger age. Although the requirements for this dissertation were very specific it was apparent from the research studied that there are many practices and tools to help alleviate the symptoms and improve quality of life. As Michael J Fox ( diagnosed with EOPD at 29 years old) said,

"Acceptance doesn't mean resignation; it means understanding that something is what it is and that there's got to be a way through it"


PART ONE


Introduction


Parkinson’s disease (PD) is a complex chronic and progressive neurodegenerative disorder associated with a broad spectrum of motor symptoms, most commonly tremor, rigidity, akinesis and postural instability (often referred to using the acronym TRAP), non-motor symptoms and mental health conditions.


Currently PD has no cure, the etiology is not completely understood, and it is the fastest growing neurological condition in the world (Parkinson’s UK). In June 2022 the World Health Organisation (WHO) reported that global estimates in 2019 revealed over 8.5 million individuals with Parkinson’s, an increase of 81% since 2000 and an increase in Parkinson’s related deaths of over 100% since 2000. Parkinson’s UK estimates that in 2020 around 145,000 lived with a Parkinson’s diagnosis in the UK and this is likely to increase by a fifth to around 172,000 people in the UK by 2030.


This paper aims to explore how Yoga therapy, “the professional application of the principles and practices of yoga to promote health and wellbeing within a therapeutic relationship” (ICTY) underpinned by evidence-based research and its individualized, multifactorial whole person focused approach, can be a useful intervention in the treatment of Early Onset Parkinson’s disease (EOPD) symptoms and wellbeing management.

Incidents of Parkinson’s increase with age but the focus of this study is on EOPD which occurs between 21 - 50 years (Mehanna et al 2022).


Whilst the symptoms of Parkinson’s are similar at whatever age it develops, there are differences in aetiology, presentation and progression and younger people’s experiences of EOPD due to their unique life circumstances. Managing a progressive motor neurological condition with no cure and for a longer period can be challenging for a younger person and family from a medical, psychological, and social standpoint. Yoga therapy is in a unique position to work alongside other treatment modalities to provide support from a physical, physiological, and psychological perspective for this multi symptomatic condition which is aetiologically heterogeneous and has multiple risk and protective factors.



History and Definition


Parkinson’s disease is the most common form of Parkinsonism (Armstrong et al 2020).

The National Institute of Neurological Disorders and Strokes (NINDS) defines Parkinson’s as a “movement disorder of the nervous system that gets worse over time. As nerve cells “neurons” in parts of the brain weaken, are damaged, or die, people may begin to notice problems with movement, tremor, stiffness in the limbs or the trunk of the body, or impaired balance.”. According to the UK Parkinson’s Disease Brain Bank the clinical criteria includes the existence of bradykinesia plus either rigidity, rest tremor or postural instability in addition to three supportive features based on a 1992 clinico-pathological study of 100 cases by Consultant Neurologists (Hughes et al 1992)

The understanding of Parkinson’s has evolved significantly over the past two centuries.

James Parkinson’s identified a single disorder in his “Essay on the shaking Palsy” in 1817 (Parkinson 2002). French neurologist Jean-Martin Charot defined bradykinesia as a defining feature and used the term “Maladie de Parkinsons” to describe a disorder characterized by rest tremor, rigidity, facial immobility, and a disturbed gait. The disorder was recognised in the medical community as a single progressive condition distinct from other tremorous conditions (Donaldson 2015).


In 1893 Blocq and Marinesco identified the Substantia Nigra as a major pathological site of Parkinson’s (Parent and Parent 2010).

From the late 1950s research by Arvid Carlsson and later Oleh Horneykiewicz led to an understanding of the essential relationship between dopamine deficiency and Parkinson’s.


Carlsson discovered that Dopamine itself was a neurotransmitter and on examining the distribution of dopamine in animal brains, found that it was highly localized in the basal ganglia, important for motor function. This led to the hypothesis that the motor deficits associated with Parkinson’s disease result from loss of dopaminergic function and the discovery that DOPA (precursor to dopamine) dramatically alleviated Parkinson’s symptoms (McDonald et al 2018) (Goetz 2011).

In the 1960’s Oleh Hornykiewicz went on to develop what still is the first-line treatment today, the restoration of deficient dopamine levels by administering its precursor, L-DOPA. By 1967, L-DOPA was used to treat Parkinson’s disease (Hornykiewicz 2017).


Other notable developments in the aetiopathogenesis are the discovery of the presence of alpha-synoclein, the protein present in Lewy bodies and genetic risk factors.


There are no treatments which slow the neurodegenerative process and there is no cure for Parkinson’s.


Prevalence and Clinical Features


Globally the prevalence of Parkinsons has doubled in the past 25 years (WHO 2022). The fastest growing neurological disorder in the world according to the Global Burden of Disease study 1990-2015 (Dorsey and Bloem 2018) the rising nature of Parkinson’s worldwide has been described as resembling the many characteristics observed during a pandemic except for an infectious cause (Bloem, Okun and Klein 2021) and estimates indicate an increasing trend in numbers due to population ageing.


Usually thought of as a late life condition with most diagnosed aged 60 or older, studies are also revealing an increasing prevalence in EOPD with up to 10% in the western hemisphere (National Institute on Aging 2022). Exact figures are hard to come by due to EOPD being misdiagnosed or undiagnosed, but 10% of all Parkinson’s cases in the UK would suggest 14,500 are living with EOPD. A diagnosis of EOPD is likely to come at a time when individuals are leading active lives, raising families, developing careers, caring for older relatives in addition to the prospect of living with the condition for many years at considerable economic cost (Boland & Stacey 2021).


A diagnosis of EOPD has a longer disease duration, possibly muscular stiffness and walking difficulty, an increase in levodopa induced dyskinesia, a reduced risk of cognitive issues which tend to arise with older onset Parkinson’s but increased risk of mental health issues such as anxiety and depression (Mehanna et al 2014) all of which are relevant when consider quality of life.


During the pre-clinical stage early signs could include; constipation, salivation, sweating, bladder or sexual dysfunction, loss of smell (anosmia), insomnia/difficulty sleeping, depression and anxiety. These may continue for years and evolve, along with cognitive impairment and dysautonomia as the disease progresses (NINDS). The non-motor symptoms of EOPD can be significantly debilitating, interrupt work, socialising and impact mental health.


The presentation of motor symptoms often when a diagnosis is made marks the clinical phase of Parkinson’s. The classical clinical presentation usually consists of:


1.Tremor (3-6Hz) most obvious at rest or when stressed.

2. Rigidity – resistance to passive movement.

3. Bradykinesia or Akinesia- slowness of spontaneous and automatic movement

4. Postural instability – impaired balance and possible shuffling gait. (NINDS).


There is reduced likelihood of tremor at presentation but increased likelihood of dystonia as a presenting feature or of early developing dystonia muscle spasms, repetitive movements, and contractions (Mehanna et al 2014) (Wickremaratchi et al 2011).


A study of 46 patients below the age of 45 with 52 patients over the age of 70 revealed increased muscle stiffness in the younger group (Gibb and Lees 1988 cited in Klepac et al 2013).


In addition to dystonia, levodopa- induced dyskinesia is more common in EOPD impacting treatment decisions and use of alternatives to pharmacology.


Non-motor symptoms affecting quality of life including, depression, anxiety, apathy, and impulse control behaviours (ICB) have increased likelihood of presenting in EOPD (Vela et al 2016). A Meta analysis revealed young males with EOPD were more likely to exhibit ICB. Other risk factors included depression and levodopa and dopamine receptor agonists (Cao et al 2021).


(more to follow)

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