Wednesday, September 26, 2007

Chronic stress can steal years from caregivers' love

Post subject: News: Chronic stress can steal years from caregivers' lives Reply with quote
Dear Friends,
The role of caregivers is sometimes overlooked, yet their health and well-being are important -- to themselves, as well as to those they care for. I hope you'll take a moment to read the following. Best, Kathrynne


Public release date: 18-Sep-2007

Contact: Ron Glaser
Ohio State University

Chronic stress can steal years from caregivers' lifetimes

COLUMBUS , Ohio – The chronic stress that spouses and children develop while caring for Alzheimer's disease patients may shorten the caregivers' lives by as much as four to eight years, a new study suggests.

The research also provides concrete evidence that the effects of chronic stress can be seen both at the genetic and molecular level in chronic caregivers' bodies.

The findings, reported this month by researchers from Ohio State University and the federal National Institute of Aging, were published in the Journal of Immunology.

These are the latest results from a nearly three-decade-long program at Ohio State investigating the links between psychological stress and a weakened immune status. Previous studies have examined medical students, newlyweds, divorced spouses, widows, widowers and long-married couples, in each case, looking for physiological effects caused by psychological stress.

In their recent study, Ronald Glaser, a professor of molecular virology, immunology and medical genetics, and Jan Kiecolt-Glaser, a professor of psychology and psychiatry, teamed with Nan-ping Weng and his research group from the National Institute of Aging.

Earlier work by other researchers had shown that mothers caring for chronically ill children developed changes in their chromosomes that effectively amounted to several years of additional aging among those caregivers.

That work, remarkable as it was, looked only at a broad community of immune cells without identifying the specific immune components responsible for the changes. The Ohio State-NIA team wanted to identify the exact cells involved in the changes, as well as the mechanisms that caused them.

They focused on telomeres, areas of genetic material on the ends of a cell's chromosomes. Over time, as a cell divides, those telomeres shorten, losing genetic instructions. An enzyme – telomerase – normally works to repair that damage to the chromosome, Glaser said.

“Telomeres are like caps on the chromosome,” said Glaser, head of Ohio State 's Institute for Behavioral Medicine Research. “Think of it as a frayed rope – if the caps weren't there, the rope would unravel. The telomeres insulate and protect the ends of the chromosomes.

“As we get older, the telomeres shorten and the activity of the telomerase enzyme lessens,” he said. “It's part of the aging process.”

For the study, the researchers turned to a population of Alzheimer's disease caregivers they had worked with before, and compared them with an equal number of non-caregivers matched for age, gender and other aspects. They analyzed blood samples from each group, looking for differences in both the telomeres and the enzyme, as well as populations of immune cells.

“Caregivers showed the same kind of patterns present in the study of mothers of chronically ill kids,” Glaser said, adding that the changes the Ohio State/NIA team saw amounted to a shortened lifespan of four to eight years.

“We believe that the changes in these immune cells represent the whole cell population in the body, suggesting that all the body's cells have aged that same amount.”

The caregivers also differed dramatically with the control group on psychological surveys intended to measure depression, a clear cause of stress.

“Those symptoms of depression in caregivers were twice as severe as those apparent among the control group,” Kiecolt-Glaser said.

“Caregivers also had fewer lymphocytes,” Glaser said, “a very important component of the immune system. They also showed a higher level of cytokines, molecules key to the inflammation response, than did the control group.”

Other experiments showed that the actual telomeres in blood cells of caregivers were shorter than those of the controls, and that the level of the telomerase repair enzyme among caregivers was also lower.

Kiecolt-Glaser said that there is ample epidemiological data showing that stressed caregivers die sooner than people not in that role.

“Now we have a good biological reason for why this is the case,” she said. “We now have a mechanistic progression that shows why, in fact, stress is bad for you, how it gets into the body and how it gets translated into a bad biological outcome.”

Much of the Ohio State work is now shifting to studies on how to intervene with that stress in hopes of slowing the weakening of the immune system in highly stressed people.


This research was supported in part by both the National Institute of Aging and the National Institutes of Health. David Beversdorf and Bryon Laskowski, both at Ohio State, and Amanda Damjanovic, Yinhua Yang, Huy Nguyen and Yixiao Zou, all with the National Institute of Aging, worked on this study.
Best regards,
Kathrynne Holden, MS, RD
For a Parkinson Tip of the Day visit:

Walking and balance

bject: walking and balance Reply with quote
Dear Drs,

This message was mistakenly sent to the dietician, which she kindly answered. However I would appreciate your input.

I have been a parkinsons patient for 18 years.

My medications are as follows:
2 sinemet 25/100 3x daily
3 mirapex .75 3xdaily
1 amantadine daily
I cannot tolerate comtan

My walking has become consideeeerably worse, and I am unable to exercise as I have spinal stenosis and too much exercise leaves me with considerable pain.

Can you suggest any changes in medication or additions to medication that might help me in this situation so that I can continue to walk unassisted. (I do use a cane)

I want to thank you for your assistance and for your caring.

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Dr. Okun

Joined: 19 Jan 2007
Posts: 251
Location: University of Florida

PostPosted: Mon Sep 24, 2007 12:21 pm Post subject: Reply with quote
My best advice is to see a movement disorders specialist and see if increasing levodopa helps the gait. If not, then physical therapy and assistive devices are the way to go.

Finally you may need a speciality decision as to whether back surgery will be of any assistance.
Michael S. Okun, M.D.

Parkinson's and Age

ubject: Parkinson's and Age Reply with quote
What is the difference between getting old and having Parkinson’s? My 87 yr. old Mother-in-Law has much poorer balance, moves much more slowly, and is much less flexible than 65 yr. old me. Yet she’s said to be OLD and I’m said to be a PWP. The only classical symptom where she comes off looking better than me is tremors, but I’m clearly trouncing her in three of the four most prevalent symptoms.

Do the tremors make the difference? Is the speed of growing old faster for PWP’s than for others? If that’s the case, if I’m alive, should I expect to be worse off at 87 than she was at 87? Then there’s the theory that if all humans lived to be 120, they would all be PWP because of the eventual loss of Dopamine.

My tentative conclusion is that, as concerns Parkinson’s, the basic difference between her and me is that I’m probably losing Dopamine at a faster rate than she did. And that I should have at least some trepidation about the prospect of reaching 87 (or relief in knowing that I won’t).

Then again, maybe we should just say that she’s old and I’m getting older. Speaking metaphorically and with some exaggeration, that way we wouldn’t have to have a scarlet PWP stitched to our clothing and embedded in our minds.

I digress. The question remains: could you help explain the difference between getting old and having Pakinson’s?
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Dr. Fernandez

Joined: 20 Jan 2007
Posts: 90

PostPosted: Sun Sep 23, 2007 8:16 am Post subject: Reply with quote
Very good question.

You are mostly correct in your thinking and observation.

The major difference in PD and physiologic aging is the rate of deterioration of dopaminergic (and other yet unknown) cells. In PD, they deteriorate faster than in normal aging.

The reason why we can't simply state that PD is faster aging is because not every part of the body in PD ages faster...only those responsible for smooth movement. PD patients do not have a faster deterioration of their muscle strength (in general), or their vision, or their sensation, or their bone health (at least not as fast as osteoporosis), or their heart function. Thus, we cannot simply call neuropathy, macular degeneration, osteoporosis, coronary heart disease, and other disorders that occur or worsen with aging as "faster aging". They have their own label depending on the system than they affect.

If someone has 2 out of the three cardinal motor features of resting tremor, slowness and stiffness, that is not explained by other factors such as arthiritis, osteoporosis, malnutrition, other concomitant illness, then yes, that patient is classified as having parkinsonism (perhaps PD, if they respond to medications crisply, and follow other operational criteria) instead of normal aging.

I hope this helps clarify definitions for you.

Hubert H. Fernandez
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Saturday, September 22, 2007

Dis. Requip (Ropinirole) medication: sideeffect

Posted: Fri Sep 07, 2007 4:53 pm Post subject: Q: Requip

I was diagnosed as Parkinson disease patient in 2005. I was prescribed by doctor with Sinemet 25/100 one each three times and Jumex 5 gm one each two times per day for the past of two years. As my physical agility is not too much improving and I changed to Dr, Chew Nee Kong, Consultant Neurologist Pantai Cheras Medical Centre for treatment on the month of July 07 he optimises my medication to 4 gm Requip (ropinirole) each three times and one Sinemet 25/100 two times a day. I am surprised my agility is 90% improving as told by my two trainers. I am glad I am able to do stretching exercises and gym mclasses i.e. body combat, pump, yoga, spinning and box and kick exercises for three hours from Monday to Friday. I do massage on every Saturday to loss en my body tiredness. I rest on bed for an hour after my exercises. I find my Physical mobility and agility is normal and PD is very mild from now as told by Dr. Chew. I wish to take this forum to express my thanks to Dr. Chew Nee Kong my his excellent work and his contribution for the Parkinson's patients. TEOKIMHOE
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Kathrynne Holden, MS, RDJoined: 22 Jan 2007Posts: 94Location:
Posted: Sat Sep 08, 2007 4:47 pm Post subject:

Dear Teo,

Congratulations, both to you and to your excellent physician, Dr. Chew. He has chosen the best treatment regime for you, and you are working hard to maintain strength and agility to combat PD. You are a fine example for us all._________________Best regards, Kathrynne Holden, MS, RD -- For a Parkinson Tip of the Day visit:

Posted: Thu Sep 20, 2007 9:53 am Post subject: Requip

Dear Dr.Kathrynne Holden, I have side effect on taking the 12 gm Requip per day besides Sinemet 25/100 as follows: !. Bloating caused by overdose of Requip. 2. Sleepless at night as my whole body is warm. I feel better now by taking away 4 gm Requip for evening replace with one dose of Sinemet as it is a wonder drug for Parkinson's treatment. I sleep well at night and minimize bloating caused by overdose of Requip. Kindly advise Best regards TEOKIMHOE

Posted: Fri Sep 21, 2007 3:34 am Post subject: Dopamine Agonist: Requip (Ropinirole)

Dear Dr. Kathrynne Holden, I understand that medication of Fluimucil A 600 (Mucolytic) and Motilium 10mg have different purpose for treatment of Parkinson's I refer the website Google :- Mucus may narrow or block the airways, making it difficult to breath. Mucolytic drugs are designed to help loosen and clear the mucus from the airways by breaking up the sputum. The most common type of mucolytic is a medication called N-acetylcysteine. This medication is available in tablet or inhaled form. The inhaled form is given by a nebulizer. N-acetylcysteine is more commonly used by patients in European countries than in patients in the USA Motiulium is for treatment of sideeffects of Dopamine Agonists i.e Requip as it causes the Parkinson's problem i.e Bloating, Nausea and etc. Since Parkinson's have the problem of breathing the best medication is Fluimucil A 600 . Therefore, I am taking both together, one dose of Fluimucil and 3 doses of Motiulium daily. Is it overdose? Kindly advise TEOKIMHOE

Posted: Fri Sep 21, 2007 4:04 am Post subject: Dopamine Agonist: Requip (Ropinirole)

Dear Dr. Kathrynne Holden, As it is common for Parkinson's have problem with breathing that caused patient with drooling from the mouth therefore I am taking one dose Fluimucil A 600 (Mucolytic) to stops from drooling from the mouth daily. It is a wonder drug. Besides that Parkinson's have the problems with Bloating, Nausea caused by side effect by taking medication of Requip therefore I also taking the three doses Motilium 10 mg daily. Is it overdoses? Is it effective drug? Kindly advise TEOKIMHOE

Kathrynne Holden, MS, RDJoined: 22 Jan 2007Posts: 94Location:
Posted: Fri Sep 21, 2007 8:23 am Post subject:

Dear Teo, Regarding replacing Requip with Sinemet, I cannot advise you -- I am a registered dietitian and prescribing or adjusting medications is outside my scope of practice. Here, I advise you speak with your excellent physician, Dr. Kong._________________Best regards, Kathrynne Holden, MS, RD --

Kathrynne Holden, MS, RDJoined: 22 Jan 2007Posts: 94Location:
Posted: Fri Sep 21, 2007 8:25 am Post subject:

Dear Teo, Again, I must point out that as a dietitian, it is outside my scope of practice to recommend changes or adjustments in medication. Your physician is the proper health professional with whom to discuss this matter._________________Best regards, Kathrynne Holden, MS, RD --

Kathrynne Holden, MS, RDJoined: 22 Jan 2007Posts: 94Location:
Posted: Fri Sep 21, 2007 8:28 am Post subject:

Dear Teo, Motilium is a good medication for those with PD, as it can help with slowed stomach emptying, and does not aggravate PD symptoms. I cannot advise you as to the correct dose for your particular needs, however -- this is the domain of your physician._________________Best regards, Kathrynne Holden, MS, RD --

Friday, September 21, 2007

Pedaling benefits Parkinson's by Alex Chin

Posted: Thu Sep 20, 2007 5:04 am Post subject: Pedalling benefit Parkinson"s Patient

Dear Doctor, I refer to the above article. I am a cycling instructor in Malaysia . I am teaching Spinning program from USA . I hve been teaching for about 8 years now. For your information , I have a Parkinson's student besides taking medication , he join my cycling class 3 times a week and i guide him to do the training. He improves tremendously since last year. From walking slowly to now he doesn't look like a parkinson patience anymore. He can drive and can walk and do things on his own. Beside this I also recommend him to do Pilates and strengh training during the week. He is very happy now and his brain is very active. I would like to know more about the pedaling system that you mention and what is tandem bike. It would be great if you can give me the photo or link of the bilkes. Thank you for any information y ou may give and look forward to hear from you soon. Yours sincerely. Alex Chin
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Kathrynne Holden, MS, RDJoined: 22 Jan 2007Posts: 94Location:
Posted: Fri Sep 21, 2007 7:29 am Post subject:

Dear Mr. Chin, What an excellent program you are providing, and how wonderful that your student with Parkinson's has improved so greatly. I do not have any more information, myself; I post items that I think might be of interest, but this is outside my area of training. However, I note the article provides contact information: "If you would like more information, please contact: Erica Foreman Cleveland Clinic I believe if you will email Ms. Foreman, she may be able to provide the answers to your questions._________________Best regards, Kathrynne Holden, MS, RD -- For a Parkinson Tip of the

Pedaling benefits Parkinson's?

Hi Mr. TEo,

Please find the following reply from the Doctor about pedaling
benefit parkinson.
Hi Alex:

Thank you for your interest in our study examining the effects of exercise on Parkinson’s disease. We are currently in the initial phases of this exciting work. The preliminary data are encouraging, however, due to the preliminary nature of this study we are unable to make specific exercise recommendations at this time. Furthermore, you should consult your physician and movement disorders neurologist before beginning any exercise program.

If you are living within the Cleveland metro area and are interested in participating in this research project, please contact the study coordinator, Dr. Angela Ridgel at: Currently, we do not have research sites outside Cleveland metro area.

We will keep your information on file and will contact you when we are able to make specific recommendations on exercise for people with Parkinson’s disease.

Again, thank-you for your interest and we look forward to making more conclusive statements upon completion of this project.

Best regards,

Jay Alberts, Ph.D.
Angela Ridgel, Ph.D.

From: Alex Chin [] Sent: Wednesday, September 19, 2007 4:28 AMTo: Foreman, EricaSubject: pedaling benefits Parkinson's

Hi Ms. Erica ,

I am a cycling instructor in Malaysia . I am teaching Spinning
program from USA . I hve been teaching for about 8 years now.
I was refer to this topic abouthow pedallingbenefit Parkinson's
by a member who diagnosis Parkinson himself.

For your information , beside taking medication , he join my
cycling class 3 times a week and i guide him to do the training.
He improves tremendously since last year. From walking slowly
to now he doesn't look like a parkinson patience anymore. He
can drive and can walk and do things on his own. Beside this
I also recommend him to do Pilates and strengh training during
the week. He is very happy now and his brain is very active.

After I read through your article about Parkinson. I would like
to know more about the pedaling system that you mention and
what is tandem bike. It would be great if you can give me the
photo or link of the bilkes.

Thank you for any information y ou may give and look forward
to hear from you soon.

Yours sincerely.

Alex Chin

Thursday, September 20, 2007

Regular exercises improving Parkinson's

NEW YORK (Reuters Health) - Regular exercise may work as well as medication in improving symptoms of major depression, researchers have found.

In a study of 202 depressed adults, investigators found that those who went through group-based exercise therapy did as well as those treated with an antidepressant drug. A third group that performed home-based exercise also improved, though to a lesser degree.

Importantly, the researchers found, all three groups did better than a fourth group given a placebo -- an inactive pill identical to the antidepressant.

While past studies have suggested that exercise can ease depression symptoms, a criticism has been that the research failed to compare exercise with a placebo. This leaves a question as to whether the therapy, per se, was responsible for the benefit.

The new findings bolster evidence that exercise does have a real effect on depression, according to the researchers.

Doctors may not start widely prescribing exercise as a depression treatment just yet. But for patients who are motivated to try exercise, it could be a reasonable option, the study authors say.

"If exercise were a drug, I'm not sure that it would receive FDA approval at this time," noted study author Dr. James A. Blumenthal, a professor of medical psychology at Duke University Medical Center in Durham, North Carolina.

"But," he told Reuters Health, "there is certainly growing evidence that exercise may be a viable alternative to medication, at least among those patients who are receptive to exercise as a potential treatment for their depression."

The study, published in the journal Psychosomatic Medicine, included 202 men and women age 40 and older who were diagnosed with major depression. They were randomly assigned to one of four groups: one that worked out in a supervised, group setting three times per week; one that exercised at home; one that took the antidepressant sertraline (Zoloft); and one that took placebo pills.

After 16 weeks, the patients completed standard measures of depression symptoms.

By the end of the study, Blumenthal's team found, 47 percent of patients on the antidepressant no longer met the criteria for major depression. The same was true of 45 percent of those in the supervised exercise group.

In the home-based exercise group, 40 percent had their symptoms go into remission. That compared with 31 percent of the placebo group.

There are several theories on why exercise might improve depression. For example, physical activity seems to affect some key nervous system chemicals -- norepinephrine and serotonin -- that are targets of antidepressant drugs, as well as brain neurotrophins, which help protect nerve cells from injury and transmit signals in brain regions related to mood.

Exercise may also boost people's feelings of self-efficacy and promote positive thinking. Some experts speculate that group exercise, with its social aspect, may have added benefits.

Though the home exercise group in this study did better than the placebo group, it's not clear whether it's as good as supervised classes, according to Blumenthal. "Home exercise may be more convenient," he noted, "but patients don't push themselves as hard on their own."

He added that supervised exercise may also be safer for some people, such as those with heart disease.

SOURCE: Psychosomatic Medicine, September

Tuesday, September 18, 2007

DBS Surgeries by Dr.Chew Nee Kong

Posted: Sun Sep 16, 2007 1:30 am Post subject: Deep Brain stimpulation Surgeries in Malaysia

This is a very important post. Dr. Fernandez launched a program called SUPPORT-PD this year and Dr. Rodriguez, Foote, and myself were part of the team. We worked with a 3rd world country (Philippines) for one year setting up a referral network and interdisciplinary surgical team. We then came and lectured for a week in the country, increased awareness and enthusiasm, and then helped do two DBS surgeries with devices donated.... Anyone interested in this tyoe of program should contact Dr. Hubert Fernandez (University of Florida) who has been the visionary and planner for such programs. There is as you pointed out a great need for awareness and access to care. Also we can teach lesion procedures which are cheaper and also effective._________________Michael S. Okun, M.D.S

Stimpulation Surgeries in Malaysia

DBS was first carried out in Malaysia back in 2003, at Sunway Medical Centre, Kuala Lumpur (Dr Lee Moon Keen, Dr Chee Chee Pin, Dr Lee Foo Chiang). One year later, DBS was also started at University Malaya Medical Centre, Kuala Lumpur (Dr Vickneswaran, Dr Chew Nee Kong). So far, about a total of 20 Parkinson's patients in Malaysia have undergone DBS in these two local hospitals. Overall, the response to DBS has been encouraging. There has been significant improvement in symptoms (tremor and slowness of movement), reduction in dyskinesia and total daily dose of medications. Complication rate has been low. I saw with my own eyes how a few of my Parkinson's patients improved drastically after the DBS. Just imagine, prior to the arrival of DBS in Malaysia, I saw so many of my Parkinson's patients dying as a result of lung infection. The recent report on a successful DBS performed on another Parkinson's patient at University Sains Malaysia, Kubang Kerian, Kelantan, is really a giant leap forward in the history of Parkinson's care in Malaysia. Thus, the arrival of DBS in Malaysia is a good news to the Parkinson's community. The prevalence of PD in Malaysia is certainly not as high as that in North America and Europe, but we certainly have a sizeable Parkinson's population - estimated to be 15 000 Parkinson's patients. Of this, perhaps about 2000 patients (who are in the advanced stage of PD) would have benefited from DBS. But, it is sad that only about 20 Malaysian Parkinson's patients have been able to undergo this surgery locally. There are many reasons for this; a) lack of awareness on DBS as it is a new surgical procedure in Malaysia b) lack of funding - as DBS costs about RM80 000 for the first surgery and RM60 000 for each battery replacement, it is easily understood why most Parkinson's patients are reluctant to undergo DBS (most Parkinson's patients are retirees who have no permanent income). Furthermore, the Malaysian government has not set up any special funds for DBS. In contrast, in other countries such as United States and Europe, thousands of Parkinson's patients have successfully undergone DBS. When I was attached to the the Institute of Neurology, Queen Square, London, I saw the surgeons operating on about 2-3 Parkinson's patients per week. Therefore, there is much left to be done for the Parkinson's community in Malaysia - ignorance, misconceptions on PD, lack of neurologists / neurosurgeons and finally the financial difficulty (costs of medications and DBS are expensive). In Malaysia, there is a saying, "PD is a disease of rich people". I'd like to welcome comments from you and the colleagues from other countries (Kathrynn Holden, Dr Okun). Dr Chew Nee Kong, Neurologist, Kuala Lumpur, Malaysia.
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Kathrynne Holden, MS, RDJoined: 22 Jan 2007Posts: 94Location:
Posted: Sun Sep 16, 2007 6:54 am Post subject:

Dear Dr. Kong, I am not a physician, and thus unable to contribute significantly to your very valid concerns re deep brain stimulation surgeries in Malaysia. However, might it be in part due to lack of a strong PD organization in the area? I cite the National Parkinson Foundation as an example; the NPF actively seeds support and donations in order to spread awareness of PD, education regarding special needs, and funding for research. I have noted that PD societies and associations in other countries, such as the UK, Canada, and Australia, have done similar work. If there is sufficient interest among families of those with PD, it would be worthwhile to form such an association. The NPF has materials to help start PD support groups, and from these often grow larger and more influential groups. Perhaps this might be a place to start._________________Best regards, Kathrynne Holden, MS, RD -- For a Parkinson Tip of the Day

Posted: Mon Sep 17, 2007 12:18 am Post subject: Deep Brain Surgery in Malaysia

Dear Dr. Kathrynne, Yes, I agree with you. It is a good idea to seek the help of a PD support group to raise funds for Parkinson's patients opting for DBS. Unfortunately, the awareness of PD in Malaysia is lacking, and thus it is still not considered an important illness. Consequently, the PD patients do not receive much support from the public. Dr Chew
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Posted: Mon Sep 17, 2007 3:21 am Post subject: Public awareness of Parkinson's Disease in Malaysia

In reply to your email there are problems on the public awareness of PD in Malaysia. There are reasons PD sufferers either under-diagnosis or late diagnosis of PD. 1. the lack of public awareness Public are not well aware or informed about the early PD symptoms. This illness is widely under-recognized by our society and even among the medical personnel.Many sufferers of PD regard the early symptoms of PD as a natural ageing process and not a disease. When an elderly person starts to have slowness of movement and tremor, many people will have this to say- " I know you are slowing down. 2.the lack of Movement Disorders Specialists PD sufferers have no choice but to see the general practitioners who may not familiar with the diagnosis of PD. As the result we have late or under diagnosis of PD suffereres. Besides PD suffereres themselves do not understand the onset of illness. Some notice the slowdown of physical movement without knowing the exact cause. In view of the above there are poor response and support i.e manpower, financial aid, public media for the setting up a PD organisation or caregroups . TEOKIMHOE
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Kathrynne Holden, MS, RDJoined: 22 Jan 2007Posts: 94Location:
Posted: Mon Sep 17, 2007 9:04 am Post subject:

Dr. Kong, if you will click on "NPF Home" at the top of your screen, you will find the home page of the National Parkinson Foundation. From there, you can click on "Find Resources" for help starting a support group locally. You can also click "Contacting us" and send a message that will be directed to the person best able to answer. It may be that there is someone who can give you help in this regard. My very best wishes, Kathrynne_________________Best regards, Kathrynne Holden, MS, RD

Monday, September 17, 2007


10 reasons why Singaporean singles are not dating
Face it. You are a big part of the reason why your marital status still reads 'single'. Lydia Gan, who is the principal director of Wow-Her.Com, an online value creation magazine that provides dating tips and relationship advice for singles in Singapore, gives her reasons for what she feels is a lack of oomph in Singapore's dating scene.
She lists 10 of them here.
1. Lack of ConfidenceHave you ever woken up early in the morning, looked at yourself in the mirror and wonder: "Who will ever love me?"
Low self-esteem and fear of rejection can cause such episodes to cripple anyone's love life! As long as such thoughts are foremost in the mind, singles will be unable to take the all-important step to initiate a date or accept one.
2. Clueless In LoveGone out with a date who looks like he just woke up, has npt brushed his teeth, does not open the door for you and picks his nose at the table? You're probably not alone.
Lack of grooming and communication skills, social and dating etiquette can spell disaster for any potential social opportunities. If you want to network, impress someone on a date or connect with anyone in a relationship, better pick up a copy of Grooming and Etiquette for Dummies.
3. Denying the Coming of AgeMummy's boy and Daddy's princess. These big kids can't admit that they are adults and of marriageable age. They are comfortable in their roles as mummy's pets and daddy's little girls. Either too spoilt or too sheltered to take the next big step, the day they actually decide to settle down would be the day you strike lottery.
4. Wa Bo-Chap! a.k.a I Can't Be Bothered
Some singles think it is cool to 'act cool' about their singlehood. When their motto is "Singles have more fun!", there really isn't any impetus to get out of this comfort zone. And even if they do want to get attached, they expect their other half to accept them as they are, warts and all. Don't expect these singles to change for the better or settle for compromises.
5. Consistently "Not Ready for a Relationship"This is the most commonly heard 'default' reason for 'un-dating' singles. They are simply "Not Ready for a Relationship", and are extremely reluctant to do anything constructive to get themselves ready. But as long as you are not ready to prepare yourself for a relationship, you will never find yourself in one.
6. Kia Pai-Seh, or Afraid of being EmbarrassedAfraid of taking the first step, kia paiseh is known as the fear of 'losing face'. Sufferers of such a syndrome will not be caught dead asking someone out for a date or attending any singles events to try and know more people, even self-improvement courses such as dating etiquette.
These activities are akin to announcing to the whole world that they are desperate to get out of singledom. Grow up! There is nothing wrong with wanting to get hitched. Human beings are born to procreate. Be proactive about your dating lives! Truth is, it is much more practical to attend social events and get to know more single friends then to sit around and wait for a life-partner to drop onto your lap!
7. The Fear of CommitmentThis phobia is the inability or unwillingness to share their life with someone else or resolve their past hurts. While it can be a valid and emotionally debilitating phobia, a lot depends on whether the single in question recognises the phobia for what it is. Once they do face up to it, there are life coaches, counsellors, self-help books, forums and informative websites that singles can turn to for help. The trick, as always, is to first recognise that you do have that problem.
8. No Money to DateThe financially insecure among us will lament: "No money to buy expensive dinners, how to date?" or "No money to doll up, how to impress anyone on a date?" Well, the good news is dating is about having fun. There are many ways to have fun without spending a lot of money. Sometimes, fun is all about looking into each other's eyes, sharing a laugh or a moment together.
9. Too BusyAll drained after a hard day's work and too caught up with other commitments to find time for romance? Find the well-spring of strength and stamina that is inside everyone. Busy-ness not just a Singaporean affliction. The youth in Hong Kong work as hard as Singaporeans, and their lifestyles are as stressful as ours. But they adopt a work hard, play harder mentality which makes them such a vibrant population. Their singles still make the time and effort to date. The question is: How much is companionship worth to you?
10. Haven't met someone suitable yetThere are 600,000 singles out there in Singapore. If I had a dollar for each single out there, I would be very rich. I am sure you can find one among the 600,000 whom you can relate well with. But are you making the effort to meet them?
Given the above 10 reasons why singles are not dating, I would like to salute everyone who is attached or married for their courage to change, to give love and to receive love, especially those who have attended singles events and coaching sessions. I feel very proud that you have the wisdom to be open and are proactive enough to try and enriching your lives. These are very attractive qualities. Keep it up!

Stomach and Parkinson Disease

Posted: Sun Sep 16, 2007 5:05 am Post subject: stomach problems

Dear Kathhrynne, I seem to have problems with slow stomach emptying and defecation. My gastroenterologist has not been too helpful. Being so helpful with those of us with pd, I believe you might better to be of assistance to me in this matter. Thank you for being there for all of us. Lois B.

Kathrynne Holden, MS, RDJoined: 22 Jan 2007Posts: 94Location:
Posted: Sun Sep 16, 2007 7:07 am Post subject:

Dear Lois, Both of these concerns occur, and quite commonly, among people with PD. For slowed stomach emptying, your neurologist can prescribe medications to speed movement; if s/he is willing, domperidone can be obtained from Canada via prescription. It is safe with PD and PD medications, but I don't think it's yet available in the U.S. Regarding defecation, if you refer to chronic constipation, I recommend you check with your local PD support group or public library for a lending copy of my books "Eat Well, Stay Well with Parkinson's Disease" and "Cook Well, Stay Well with Parkinson's Disease;" and audiocassette or audioCD with guidebook "Parkinson's Disease and Constipation." These give detailed information regarding constipation and why it occurs; and the cookbook provides numerous high-fiber recipes as well. There is another concern, less common, however, called "pelvic floor dysfunction." In order to expel the stool, the anal sphincter must relax, while the pelvic floor tightens/contracts. In PD, sometimes the opposite occurs, making it very difficult to move the stool. If this is the case, you must discuss it with your neurologist; in some cases botox injections can help._________________Best regards, Kathrynne Holden, MS, RD -- For a Parkinson Tip of the Day visit: http://www.nutritionucanlivewith/

Sunday, September 16, 2007

Complication of parkinson's disease? Dr.NK Chew

I refer to Dr.Chew Nee Kong "understanding Parkinson's disease" most sufferers of parkinson's eventually develop numberous complications especially during the last stage of the illness as follows:

a) motor complications These complications are attributed to both progression of PD and long term sides effect of levodopa. Motor complications have been reported to occur in 50% of patients after three to five years of levodopa treatment.

These complications are as follows: 1,"wearing off ' effect

At early stage of the illness,patients generally feel good(the" on "period}gradually shorten with times and the patients have "wearing off" and need to take lavodopa more frequently than before.

2. Mental complications More often mental complications are attributed to the PD drugs hypoglycemia (low blood glucose) and electrolyte disturbances. The mental complications are as follows:

1.Depression 2,psychosis
3.confusion 4.dementia 5.dysautonomia
a.constipation b. reflux oesophagitis and dysphagia 4. falls 5. sleep disorders

Sufferers of Parkinson's develop numerous complications in addition to the problem with movement. The doctor alone is not enough to deal with the long list of complications of PD

Kathrynne Holden, MS, RDJoined: 22 Jan 2007Posts: 94Location:
Posted: Tue Aug 28, 2007 7:00 am Post subject:

Thank you for an excellent summary of PD complications._________________Best regards, Kathrynne Holden, MS, RD -- For a Parkinson Tip of the Day visit:
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Posted: Sat Sep 15, 2007 9:02 am Post subject: Complications of Parkinson's disease

Dear Kathryn, Can you explain more about the hypoglycemia and electrolyte disturbances? I get very weak, particularly in my chest, at times during the day and I've correlated it with taking Sinemet and significant blood pressure drops. But could it also be blood sugar drops? I often get this feeling about an hour after breakfast, and also at times after taking more Sinemet. If it is hypoglycemia, what is the remedy? It's extremely uncomfortable and hard to explain. My stress test is normal. Thanks very much.
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Kathrynne Holden, MS, RDJoined: 22 Jan 2007Posts: 94Location:
Posted: Sun Sep 16, 2007 6:42 am Post subject:

Dear Friend, If this weakness occurs regularly after use of Sinemet, it is most apt to be drop in blood pressure, as you surmise; true hypoglycemia is not very common. However, hypoglycemia should not be ruled out. You must see an endocrinologist, who can diagnose whether your blood sugar drops somewhat, or whether hypoglycemia is present. Another possibility, if it often occurs post-meal, is that when a bolus of food enters the stomach, the body diverts blood and energy to digesting and metabolizing the food. Some people feel weak, some feel sleepy, due to this diversion of the body’s resources. For this, I would speak with your neurologist, as it also occurs upon taking more Sinemet._________________Best regards, Kathrynne Holden, MS, RD --

Saturday, September 15, 2007

5 Major Deceptions & Myths about ABS & Belly Fat

5 Major Deceptions & Myths about 6-Pack Abs & Your Belly Fat
by Mike Geary - Certified Nutrition Specialist, Certified Personal Trainer (CPT)
1. Did You Know That There are Hidden Foods That are Promoted as "Health Foods" but Actually Stimulate Your Body to Hold Onto Excess Belly Fat & Cover Up Your Six Pack Abs Like a Thick Blanket?
It's True! Scientists have even discovered that some of these particular foods can even produce a hormonal imbalance in your body that triggers belly fat to resist burning and signals it to be stored excessively. These compounds are rampant in our food supply and hard to avoid unless you know what to look for... this goes WAY beyond trans fats... there are some more sinister villians in our food too (more about that later).
2. Did You Also Know That "Abs Exercises" Such as Crunches, Leg Raises, & Sit-Ups are Actually the LEAST EFFECTIVE Method of Getting Rid of Stubborn Stomach Fat & Love Handles to Uncover Your Abs? And No, the Answer to Belly Fat Loss is NOT Cardio Either!
Yep, you heard me right! Abdominal exercises should only be a VERY small portion of your workouts. In addition, If you don't perform the right ab exercises in the most effective fashion, you could actually be making your stomach worse!
Ok, here's the deal... If you want your workouts to stimulate abdominal fat loss for those flat sexy abs, you need a properly designed full body resistance training workout that takes into account certain key factors for stimulating your metabolic rate and increasing your production of fat-burning hormones.
If you ignore these key factors, you're DOOMED to a flabby stomach forever! I'll discuss more details about these key factors in a bit.
3. Another Thing... You've Been Told That Doing Lots and Lots of Cardio is the Best Way to Lose Body Fat... Correct?
WRONG! Once again, the myths that have perpetuated the fitness industry for decades are starting to become more clear.
Did you know that recent properly controlled scientific studies have revealed that people using cardio-based workout routines lost significantly less body fat compared to people who did mostly resistance training based routines? Some subjects even GAINED BODY FAT on the cardio-based workouts, while the resistance trainers got stronger & simultaneously reduced their abdominal fat.
However, you can't just do any old worthless bodybuilder workout routine that you saw in some magazine. Most people inadvertently focus on all the wrong types of exercises in the wrong combinations. That will most likely just set you up for failure and years more of a fat belly with no abs!
There are certain tricks you need to learn to put together a workout routine with combinations that will actually trigger your body to release belly fat. I'll show you those techniques in a minute.4. Do You Really Need "Fat Loss Pills" and Other Hyped-Up Supplements to Get Rid of Your Stubborn Belly Fat for Good?No, you don't need any supplements! The amount of deception in the supplement industry really pisses me off. Some supplements are ok (only a very limited few), but I estimate that at least 95% of supplements are a total waste of your money. I'll talk about the only worthwhile ones you can trust, so you can stop wasting your money and being deceived by the clever marketing tactics they use.5. Ab Belts, Ab-Gadgets, Ab-Rockers/Rollers... all Useless!Come on now... I know the infomercial showed a ripped sexy fitness model using the Fat-Blaster 6000 Ab Gizmo, but do you really think he or she got that sexy flat stomach by sitting on the couch and using that piece of crap while watching TV?Hell no! They are ripped and sexy because they are a fitness model and they work hard using REAL WORKOUTS. I'll even show you some insider secrets as to how some of these fitness models get such lean and sexy bodies with rock hard abs. Some of the techniques are pretty clever!
So, let's set the record straight once and for all...

You Will NEVER Lose Your Excess Stomach Fat and Carve Out Those Rock-Hard Six-Pack Abs that You Desire by Wasting Your Time with 100's of Crunches and Other "Abs-Pumping" Exercises...
Nor with Those Bogus Ab-Gadgets, Gimmick Diets, "Fat-Burner" Pills, and "Miracle" Supplement Powders that are Scamming You Out of Your Hard-Earned Money!
Instead, Discover the Tried-and-True Training & Nutrition Secrets That the Super-Lean Use to Strip Away Stubborn Stomach Fat and Develop Sexy Flat Abs That Turn Heads!
But NOT by following any ridiculous fad diets
NOT by performing long, boring cardio routines
NOT by taking over-priced, over-hyped supplements
NOT by using some piece-of-crap ab belt or gizmo from an infomercial
And NOT by doing hundreds of useless crunches & situps
Enough With the Gimmicks...It's Time for the TRUTH!

To stay Healthy is to be Happy

To stay healthy, the message is: Be happy
Smoke less, exercise more, eat more fruits and vegetables... and now, be happy.
This year's National Healthy Lifestyle campaign, after years of pitching physical well-being, focuses on mental wellness.
The Health Promotion Board (HPB) wants people to learn to love themselves, make friends and be happy.
This is in line with the trend in developing countries to stress mental well-being.
The World Health Organisation, as far back as 1948, had defined health as 'a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity'.
Briefing the media on this year's campaign, HPB's chief executive officer Lam Pin Woon said people here are now smoking less, exercising more and eating more fruits and vegetables.
Now, he hopes to see more happy people.
Five pavilions built around five themes - love yourself, be active, make friends, just relax, and be happy - will be set up at the Singapore Botanic Gardens on Sept 22 and will feature activities like face painting, calligraphy and line dancing.
There is now no way of knowing how mentally well people here are, although Scotland, New Zealand and Hong Kong already have their own ways of measuring this.
What makes people happy varies according to cultural background, said Dr Koh Yang Huang, HPB's senior deputy director for mental health education. In the West, for example, individuality is highly valued, but Asians prefer to be linked to the community. So, Singapore plans to develop its own measurement of well-being, which should be ready in a year or two.
Dr Lynette Tay, a National University of Singapore assistant professor in psychology, said people here are likely to be as stressed as their counterparts in other developed countries. She added that a study in the United States found that poorer people tended to be less happy.
People who are happy are also less likely to become physically ill, she said.
Dr Koh said that many studies have shown that poor mental health can result in poor physical health. She added that companies with a happy workforce have fewer people taking sick leave and have lower health-care costs.
This is why one of the campaign messages is: No health without mental health.
The other is: Everyone can learn to look after their mental well-being.
Prime Minister Lee Hsien Loong will launch this year's campaign, called Healthy Mind, Happy Life, at the Botanic Gardens on Sept 22. There will be activities throughout the day, from 7.30am onwards. Free shuttle buses will ferry visitors from the Orchard and Newton MRT stations

Friday, September 14, 2007

Pedaling benefits Parkinson's

Kathrynne Holden, MS, RDJoined: 22 Jan 2007Posts: 94Location:
Posted: Thu Sep 13, 2007 8:33 am Post subject: News: Pedaling Benefits Parkinson's

Dear Friends, the following may be of interest. Best, Kathrynne ======================================================== Pedaling for Parkinson's By Margot Kim 09/12/2007 - CLEVELAND (Ivanhoe Broadcast News) -- Parkinson's, a disease that causes tremors and other neurological problems, usually strikes people who are near 60 years old. Now, researchers say a special type of exercise could grant some Parkinson's patients relief from their symptoms. For most people, turning 50 years old signifies middle age. For Steve Derman, it meant a shocking health diagnosis. "Not having been sick a day in my life, it came as a complete shock, and we didn't accept the first diagnosis, or the second diagnosis, or the third diagnosis," Derman says. "[Now] I can't button shirts, can't tie a tie." Derman takes medication, but the side effects can be worse than the symptoms. Now, a drug-free therapy is helping. It's forced exercise on a tandem bike. Jay Alberts, Ph.D., a neuroscientist at the Cleveland Clinic in Ohio, says in the past, exercise hasn't really helped patients. But by pushing them out of their comfort zone and forcing them to pedal much faster than they would normally, symptoms can improve more than they do from drugs. "After eight weeks of exercise, symptoms have improved 30 to 35 percent for patients, which is a pretty dramatic improvement," Alberts says. Researchers aren't positive how this method works, but they think driving the central nervous system beyond its normal capacity can lead to biochemical changes. Further proof? Patients only work the lower half of their bodies, but motor symptoms in their upper half improve. "We may be actually treating the disease rather than just treating the symptoms," Alberts says. "It's tremendous," says Derman. "It not only relieves the symptoms, but it really gives you a purpose in life." This article was reported by, which offers Medical Alerts by e-mail every day of the week. To subscribe, click on: If you would like more information, please contact: Erica Foreman Cleveland Clinic foremae

Monday, September 10, 2007

Parkinson's and Mental Health

Posted: Sun Sep 09, 2007 3:36 am Post subject: Q: Parkinson's and Mental Health


Dear Doctor,

Parkinson Disease is not only considered a neurological disease as what many year clinical claim. It is not only disease for body, mind and soul but disease of mind, mood and memory.

With the advancement of research and clinical observations, it has recently been classified as a neuropsychiatric disorder.
It means mental health changes are important as motor symptoms.

Many Parkinson's patient have been neglected as part of the mental sickness and continue struggle wth the complexities of these symptoms. It leads PD patient experience mood disturbance at some point during the illness as treatment are on motor symptoms rather than the mental health.

The mood changes are depression and anxiety and with other unrelated chronic diseases. It is estimated up to 50% of patients with PD experience. The anxiety and depression are due to changes in motor symptoms i.e. wearing off and on periods and other mental disturbances.


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Kathrynne Holden, MS, RD

Joined: 22 Jan 2007
Posts: 94
Posted: Sun Sep 09, 2007 7:28 am Post subject:


Dear Teo,
These are excellent points; and while some symptoms and concerns are medication-related, others may be due to nutrient deficiencies. Certain types of depression can be caused by a lack of omega-3 fatty acids, important for the brain and nervous system, and found in fatty fish, such as salmon. Vitamin B12 can deplete very slowly, over a period of months or years; and one sign can be depression, even an Alzheimer-type dementia.

I recommend that people with PD have blood tests regularly for the B vitamins; and have several servings of fish each week, for best health.
Best regards,
Kathrynne Holden, MS, RD

Sunday, September 9, 2007

Deep Brain Surgery

Posted: Thu Aug 09, 2007 12:54 pm Post subject: DBS


IN perfiorming DBS which is the better target ?


What is the determing factor for the selection


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Dr. Okun

Joined: 19 Jan 2007
Posts: 251
Location: University of Florida
Posted: Fri Aug 10, 2007 1:19 pm Post subject:


This was a version of an editorial that appeared in Archives recently that Dr. Foote and I wrote. BOTH TARGETS work and so if you have either target that is good. We will learn with ongoing studies which is better for what reason. We do need studies which will be available in the next year or two.


The field of Parkinson’s disease (PD) surgery has again re-emerged as an important area of research and clinical advancement. The notion of the possibility of a surgical treatment for PD and tremors probably started in 1937 with Bucy who favored sectioning procedures. Later surgery was refined by the introduction in the 1950’s of Speigel and Wycis’ stereotactic head frame. Lesions of many basal ganglia structures over the next several years were refined, until surgery halted in the late 1960’s with the introduction of levodopa. After complications of levodopa therapy were realized, PD surgery reemerged as an effective therapy. In the past decade lesions in many centers throughout the world have been replaced by deep brain stimulation (DBS). In addition, the rapid and important advances in our understanding of basal ganglia physiology and neuroanatomy1, 2 have led to a long running debate concerning the best target for Parkinson’s disease (PD) surgery and more specifically for DBS. Since the thalamic target has proven effective for only tremor, this has led to an important showdown between GPi and STN DBS. Historically, GPi has been the preferred target, especially since the resurgence of pallidotomy in the early 1990’s3, and later pallidal DBS4, 5. However, following important physiology and lesioning experiments many investigators quickly embraced the STN6, 7. Thus, by the turn of the millennia the field seemed to be moving toward a singular and unified direction, mainly that STN was a better target. The battle between GPi and STN was so quick and so convincing, that the shock and awe left few doubters of STN’s superiority. The literature was flooded with reports about the successes of STN DBS, while the number of reports on GPi DBS dwindled and almost disappeared. However, many of us, experienced with lesion therapy and DBS were not convinced, and some, as our center, are involved in setting up important rematches between targets. A major goal of clinical science is validation, but there is no validity without reliability. In this issue of Archives of Neurology, Anderson and co-workers detail the rematch between PD surgical targets, GPi and STN. The results were sobering. In this editorial we aim to review these findings, and to summarize as well as evaluate current knowledge about the two surgical targets. Finally, we will discuss the need for future studies that compare GPi and STN DBS.

Results of the Most Recent Trial

Anderson and colleagues who studied patients receiving either GPi or STN DBS report several interesting findings, the most important being that there are no significant differences in the overall benefits of DBS at these two sites. Although bradykinesia tended to improve more in the STN group, it was also worse at baseline in STN (18 versus 15) with the overall improvement resulting in the same UPDRS score (both groups improved to scores of 10). The levodopa dose was reduced more in the STN group, and dyskinesia was improved in both groups, perhaps to a greater degree with GPi DBS. Cognitive and behavioral symptoms however, occurred only in the STN group.

In This Corner… The Challenger and Former Champion- GPi DBS and in
in this Corner… The Reigning Champion- STN DBS

In order to properly set the stage for this rematch of GPi and STN DBS we will directly compare the strengths and weaknesses of each surgical target.

Size of the Target

Size is perhaps the most obvious difference between GPi and STN. The GPi is a much larger (500mm3) target than the STN (200mm3)8-10. The size of the lead and contacts is usually (but not always) identical, despite the large discrepancy in target size. Thus, a smaller target, such as the STN, might be associated with a greater probability of success. Each target is separated into three regions that are roughly equally sized (sensori-motor, limbic, and associative). The goal of the surgery is to implant the lead in the sensori-motor region and to limit current spread into the other 2 areas within the nucleus, because spread into these areas might cause unacceptable side effects. Thus, because the STN is smaller, it may be harder to keep the current sent to this nucleus from spreading into associative, limbic, and adjacent neuroanatomical structures and fiber bundles. Further studies of these nontherapeutic effects are ongoing. Because of these size differences there is an increase in the average charge density required in the GPi target when compared to the STN. Taken together these observations support the potential need for a larger or better suited lead for the GPi target.

Improvement in Dyskinesia and Dystonia

Dyskinesia improves dramatically with both GPi and STN DBS. As suggested by the authors of this study and by others, the mechanism underlying this improvement may be for each target be different11. Although the majority of the anti-dyskinetic benefit of GPi DBS may be due to active stimulation, while the benefits in STN may be as a result of medication reduction. The reasons for these differences remain to be determined. However the anti-dyskinetic effects of GPi DBS seem to be greater than STN DBS.
It is unknown which target is better for PD dystonia, but preliminary experience suggests both may be effective. The recent successes of GPi DBS for primary generalized dystonia have raised the question as to whether GPi is superior to STN for PD dystonia relief, although there is a lack of data at this time to make this determination.

Improvement in Other Parkinsonian Features

DBS in both GPi and STN has been shown effective in improving the cardinal manifestations of PD (tremor, rigidity, bradykinesia, gait disorder)4, 6, 12. DBS in both targets has also been effective in decreasing off time, and in improving motor fluctuations. The majority of published papers suggest STN DBS may be superior particularly in improving motor scores13. There remains however, a lack of comparative trials. The recent report by the DBS for PD study group in 2001 highlights the existing bias to implant the STN target over GPi. Investigators in this study chose target site based on experience and preference only. The bias was reflected when STN DBS was chosen 96 times and GPi only 3813.
Several authors including Anderson have suggested that STN DBS may be superior in improving bradykinesia. In the current study the baseline bradykinesia score was worse in the STN group (score 18), compared to the GPi group (score 15), and both groups improved to a total score of 10. The difference in the baseline scores in this study could have accounted for this small difference. Thus, more investigation will be needed to answer this question, as well as the question of possible superiority in axial rigidity and gait.
Another difference in GPi and STN DBS may be in the efficacy of tremor improvement. It has been our experience and the experience of others that tremor improves more completely and more consistently with STN DBS. The reasons for this remain unclear. A better understanding of this phenomenon may be gained from exploring the lesion literature where posterior GPi lesions resulted in more tremor benefit. Similarly lesions in different areas of GPi showed differential improvement in specific PD symptoms14. Thus, a lead placed in STN may, based on the size and area it will affect, provide more consistent improvement in tremor, whereas a lead placed in GPi may provide an insufficient area of stimulation, particularly posteriorly. This potential difference will need to be explored.

Medication Reduction

It is now widely accepted that initial medication reduction following surgery is much larger in the STN target5, 6, 13. It will be important in future studies to employ standardized protocols for decreasing doses and medication intervals. Medication reduction should not be the goal of surgery, i.e. if reducing or discontinuing medications makes the patient worse in any PD symptom, reductions should be discontinued. A medication reduction is often required to improve dyskinesia with STN DBS but not GPi DBS. Practitioners should be aware that the initial reports of large-scale medication reductions in STN should be monitored with longer follow-up periods. All of the patients we have treated with STN DBS, who completely discontinued medications, eventually had to restart them. Additionally, many of our patients have required slow increases of dose and interval of medication therapy with disease progression. However, the medication reductions in the STN target constitute an important potential benefit for patients opting for surgery. The long-term differences in medication reduction will require future study.

Cognitive, Behavioral, and Mood Symptoms

Anderson and colleagues point out in their study a potentially important difference between the GPi and STN DBS in the area of cognitive, mood, and behavioral features. Problems in these domains occurred primarily in their STN group. There has been a recent alarm sounded amongst groups implanting DBS with the increasing numbers of reports documenting cognitive, mood and behavioral side effects15-20. Although the initial concern has been with the STN target, as more GPi cases are published, and comparative trials performed, we will get a better idea of these effects with GPi DBS. We have been concerned with leads placed in the STN having the propensity to spread current into associative and limbic regions of the nucleus, as well as into the medial forebrain bundle, zona incerta, lateral hypothalamus, and other regions that have extensive limbic connections. The most concerning side effect reported has been suicide. Currently, our center is randomizing and comparing these targets for mood and cognitive outcomes.

Caution Regarding Interpretation of Comparative Trials of STN and GPi DBS

Comparative studies of GPi and STN DBS will have to be designed to avoid type 2 statistical errors (inadequate power). There are often significant technical difficulties when implanting electrodes in either target and many centers currently have less experience implanting GPi than STN DBS. There also seems to be less of a consensus as to where to place the lead within the GPi. Therefore, large multi-center surgical trials involving several centers that might use different techniques, equipment, patient selection criteria, and have different experience will need to be interpreted with caution.
The issue of microelectrode recording also remains unresolved. An unavoidable weakness of Anderson et. al.’s paper was a delay in the use of microelectrodes on all cases and the failure to use microelectrodes in a systematized fashion. Some groups believe that microelectrodes are unnecessary and increase the surgical hemorrhage risk. We believe however, that given the size of the targets, microelectrodes are necessary to refine implantation and improve outcomes. Further confusing the issue is how they are utilized by different groups. Some use a single or double pass for target verification. We prefer multiple passes in several planes to map borders and construct a three dimensional representation. Still another approach is using many microelectrodes at once, sometimes in a “Ben gun” configuration. The impact of these variables on the therapeutic index is unknown. The impact on the presence or absence of individual team members (particularly a trained neurologist and/or physiologist) in the operating theater is also unknown.

Risk-Benefit Ratio of GPi versus STN

One important deciding factor between GPi and STN DBS will be the incidence of surgical and post-operative complications. Assuming that the rates of the procedure related and device complications are equal, then long-term cognitive, mood, and behavioral problems may become an important consideration.

Depending on what the long-term data reveal about these side effects in GPi and STN DBS, several scenarios are possible. If the motor benefits are equal, but there are many more mood, cognitive, and behavioral side effects with one site versus the other, then the site with less side effects may be a more desirable target. Alternatively, if the motor benefit is greater for one e.g. STN DBS, but the cognitive, mood, and behavioral symptoms are worse, this will constitute a more difficult decision. One factor in this decision that practitioners should consider is that a 10% improvement in UPDRS motor scores (based on a UPDRS score of 50, and looking at the difference between 60% improvement and 50% improvement) of one target over another, may constitute as little as 5 UPDRS points. Will those 5 UPDRS points be worth the risk of a higher complication rate? Further complicating the decision will be other factors including medication reduction, dyskinesia, age, and ease with which side effects can be successfully treated or managed.

The unanswered questions regarding target selection will require several more head to head rematches between GPi and STN. Future improvements in implantation technique and in lead design, may also enhance the benefit in each target. Studies may prove that STN is a better target than GPi, and/or that STN is superior for certain features of disease such as tremor, bradykinesia and medication reduction. Alternatively, studies may also prove that GPi is equal to STN with regard to motor improvements, is a better anti-dyskinesia treatment, but has less cognitive, mood, and behavior side effects. Whatever the outcome, we will need to be open to changes in our current practices, and open to the possibility that individual patient needs will need to be matched to the strengths and weaknesses of individual targets.


1. Albin RL, Young AB, Penney JB. The functional anatomy of basal ganglia disorders. Trends Neurosci. Oct 1989;12(10):366-375.
2. Alexander GE, DeLong MR, Strick PL. Parallel organization of functionally segregated circuits linking basal ganglia and cortex. Annu Rev Neurosci. 1986;9:357-381.
3. Laitinen LV, Bergenheim AT, Hariz MI. Leksell's posteroventral pallidotomy in the treatment of Parkinson's disease. J Neurosurg. Jan 1992;76(1):53-61.
4. Ghika J, Villemure JG, Fankhauser H, Favre J, Assal G, Ghika-Schmid F. Efficiency and safety of bilateral contemporaneous pallidal stimulation (deep brain stimulation) in levodopa-responsive patients with Parkinson's disease with severe motor fluctuations: a 2-year follow-up review. J Neurosurg. Nov 1998;89(5):713-718.
5. Kumar R, Lozano AM, Montgomery E, Lang AE. Pallidotomy and deep brain stimulation of the pallidum and subthalamic nucleus in advanced Parkinson's disease. Mov Disord. 1998;13 Suppl 1:73-82.
6. Benabid AL, Pollak P, Gross C, et al. Acute and long-term effects of subthalamic nucleus stimulation in Parkinson's disease. Stereotact Funct Neurosurg. 1994;62(1-4):76-84.
7. Limousin P, Pollak P, Benazzouz A, et al. Effect of parkinsonian signs and symptoms of bilateral subthalamic nucleus stimulation. Lancet. Jan 14 1995;345(8942):91-95.
8. Richter EO, Hoque T, Halliday W, Lozano AM, Saint-Cyr JA. Determining the position and size of the subthalamic nucleus based on magnetic resonance imaging results in patients with advanced Parkinson disease. J Neurosurg. Mar 2004;100(3):541-546.
9. Bejjani BP, Dormont D, Pidoux B, et al. Bilateral subthalamic stimulation for Parkinson's disease by using three-dimensional stereotactic magnetic resonance imaging and electrophysiological guidance. J Neurosurg. Apr 2000;92(4):615-625.
10. Guridi J, Rodriguez-Oroz MC, Lozano AM, et al. Targeting the basal ganglia for deep brain stimulation in Parkinson's disease. Neurology. 2000;55(12 Suppl 6):S21-28.
11. Wu YR, Levy R, Ashby P, Tasker RR, Dostrovsky JO. Does stimulation of the GPi control dyskinesia by activating inhibitory axons? Mov Disord. Mar 2001;16(2):208-216.
12. Burchiel KJ, Anderson VC, Favre J, Hammerstad JP. Comparison of pallidal and subthalamic nucleus deep brain stimulation for advanced Parkinson's disease: results of a randomized, blinded pilot study. Neurosurgery. Dec 1999;45(6):1375-1382; discussion 1382-1374.
13. Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson's disease. N Engl J Med. Sep 27 2001;345(13):956-963.
14. Gross RE, Lombardi WJ, Lang AE, et al. Relationship of lesion location to clinical outcome following microelectrode-guided pallidotomy for Parkinson's disease. Brain. Mar 1999;122 ( Pt 3):405-416.
15. Saint-Cyr JA, Trepanier LL, Kumar R, Lozano AM, Lang AE. Neuropsychological consequences of chronic bilateral stimulation of the subthalamic nucleus in Parkinson's disease. Brain. Oct 2000;123 ( Pt 10):2091-2108.
16. Vitek JL. Deep brain stimulation for Parkinson's disease. A critical re-evaluation of STN versus GPi DBS. Stereotact Funct Neurosurg. 2002;78(3-4):119-131.
17. Herzog J, Reiff J, Krack P, et al. Manic episode with psychotic symptoms induced by subthalamic nucleus stimulation in a patient with Parkinson's disease. Mov Disord. Nov 2003;18(11):1382-1384.
18. Anderson KE, Mullins J. Behavioral changes associated with deep brain stimulation surgery for Parkinson's disease. Curr Neurol Neurosci Rep. Jul 2003;3(4):306-313.
19. Kulisevsky J, Berthier ML, Gironell A, Pascual-Sedano B, Molet J, Pares P. Mania following deep brain stimulation for Parkinson's disease. Neurology. Nov 12 2002;59(9):1421-1424.
20. Miyawaki E, Perlmutter JS, Troster AI, Videen TO, Koller WC. The behavioral complications of pallidal stimulation: a case report. Brain Cogn. Apr 2000;42(3):417-434.
Michael S. Okun, M.D.

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USM creates history with Parkinson's Surgery

KOTA BARU (April 24, 2007): Universiti Sains Malaysia Hospital (HUSM) in Kubang Kerian here has achieved a landmark when it successfully treated a long-suffering Parkinson's disease (PD) patient.

The feat was achieved last March 21 when an electrode implant was placed in the brain of a 54 year-old patient, HUSM consultant neurologist Prof Madya Dr John Tharakan K.J. told a media conference here today.

Retired Telekom Malaysia Berhad employee Che Idris Che Yusoff had been suffering from Parkinson's for 17 years, Bernama reported today.

Tharakan said other than the electrode implant, the surgery which took about three hours also involved placing a battery in the patient's chest.

He added that the patient gave positive reaction during treatment, signalling that HUSM had successfully treated other PD symptoms like essential tremor (ET) and dystonia which caused tremors and stiffness that lead to movement disabilities.

Seven specialists were involved in the surgery where the patient was not injected with anaesthetic except when the battery was placed that took 30 minutes. They included neurosurgeon and neuroscience senior consultant Prof Dr Jafri Malin Abdullah and neurosurgery specialist surgeon Dr Abdul Rahman Izaini Ghani who is also a USM lecturer.

Tharakan said the treatment involved placing a 0.8mm or 10mm wire (electrode) to a sensitive part of the brain and is connected with an electrical wire to a battery placed in the patient's chest.
The 1.2mm wire can last a lifetime while the battery has to be changed once every five years at a cost of RM5,000."As soon as the electrode wire was in place and the switch at the battery was activated, the patient started to respond and the hand tremors then stopped," he added.

Tharakan said the Parkinson's surgery at HUSM cost about RM90,000 compared with between RM200,000 and RM250,000 charged by private hospitals.

Updated: 01:55AM Wed, 25 Apr 2007
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When to have Surgery?

Posted: Wed Aug 29, 2007 5:57 pm Post subject: when to have surgery


I have been researching DBS and reading whatever i can. It seems that there are different thoughts on when to "go for it", In Europe they are doing it much earlier than here. When is it optimum and can there be a time when it is too late to do it?

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Dr. Okun

Joined: 19 Jan 2007
Posts: 251
Location: University of Florida
Posted: Sat Sep 01, 2007 9:06 am Post subject:


All great questions. There are ingoing early intervention studies at Vanderbilt and also in Paris/Kiel. I would advise not going early until there is data to support it---or alternatively doing a clinical trial.

The surgery STN or GPi, works best for medication responsive symptoms. As long as symptoms stay med responsive you are ok. If you want a non-medication (levodopa responsive symptom) then STN or GPi may not be useful (except for dyskinesia and tremor).

The risk is less under the age of 70 and that should factor into your decision.

If you are well controlled on meds I would not rush into surgery.

If you are seeing a specialist and getting to 3 hour or 2 hour intervals then surgery may be reasonable to start talking about.
Michael S. Okun, M.D.

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Medication for symptomatic thereapies

Posted: Sun Sep 09, 2007 3:09 pm Post subject: Medication for Symptomatic Therapies

I understand there are now two groups of medications at replacing the dopamine deficiency in the brain of treatment.

There are dopamine agonists and levodopa. As a doctor which are you prefer ? What's effective in treating the symptoms of the disease? Which one are more applicable for younger patient and the older patient or both?

I understand Levodopa is the "wonder-drug" and has been associated with "wearing off" and dyskinesias. The dopamine agonists started at a low dose and increased gradually to avoid side effects that include nausea, vomiting and giddiness on standing.Is it true? What's the reason why some patient start either one agonise and later with both?

I am taking Levodopa i,e. Sinemet 25/100 one dose three times per day and one Jumex 5gm one dose two times per day for 2 years.

Dr. Chew Nee Kong my doctor recently starting me with Requip at low dose and increased gradually to 12 gm with two dose of Sinemet 25/100 to optimize the medication.

My two personnel trainers are surprised that my agility improving by 90% and pleased with my mobility and flexibility. I can do standing tree posture in Yoga. I do not feel tired whilst spending 3 hours gym
classes in the gym centre from Mon to Friday. I do two body massages on every Wed and Saturday to loosen my muscles.


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Kathrynne Holden, MS, RD

Joined: 22 Jan 2007
Posts: 94
Posted: Sat Sep 08, 2007 4:59 pm Post subject:


Dear Teo,
I am not a doctor, but a registered dietitian; advice regarding medication is outside my scope of practice. I can comment that in general, the agonists are preferred for younger patients, and that some older patients do not do well on them.

I will move your question to "Ask the Doctor." Drs. Okun, Rodriguez, and Fernandez are excellent PD specialists and highly qualified to respond to your concerns.
Best regards,
Kathrynne Holden, MS, RD
For a Parkinson Tip of the Day visit:

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Dr. Fernandez

Joined: 20 Jan 2007
Posts: 90

Posted: Tue Sep 11, 2007 8:21 pm Post subject:


Deciding which drug to use first in a PD patient is not a one-size-fits-all thing.

In patients who are older or who have more significant symptoms we tend to use sinemet. This is because older patients are less likely to develop motor fluctuations (especially dyskinesias) from sinemet. As for why we use sinemet for more significant symptoms, this is because sinemet is the most efficacious drug there is to date.

In patients who are younger or those who have milder disease, we can start with dopamine agonists such as ropinirole or pramipexole or MAO-inhibitors such as rasagiline. Some may even start with amantadine.

It really all depends on the situation.

Hubert H. Fernandez

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The effect of Requip (Ropinirole) medication on me

Posted: Fri Sep 07, 2007 4:53 pm Post subject: Q: Requip


I was diagnosed as Parkinson's disease patient in 2005.

I was prescribed by doctor with Sinemet 25/100 one each three times and Jumex 5 gm one each two times per day for the past of two years.

As my physical agility is not too much improving and I decide to change Dr. NK Chew, Neurologist of Pantai Cheras Medical Centre for treatment on the month of July 07 . He optimises my medication to 4 gm Requip (ropinirole) each three times and one Sinemet 25/100 two times a day. I am surprised my agility is 90% improving as told by my two trainers. I am glad I am able to do stretching exercises and gmx classes ie. body combat, pump, yoga, spinning and box and kick exercises for three hours from Monday to Friday. I do massage on every Saturday to loosen my body tiredness. I rest on bed for an hour after my exercises. I find my Physical mobility and agility is normal and PD is very mild from now as told by Dr. Chew.

I wish to take this forum to express my thanks to Dr. Chew Nee Kong for his excellent work and his contribution for the Parkinson's patients.


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Kathrynne Holden, MS, RD

Joined: 22 Jan 2007
Posts: 94
Posted: Sat Sep 08, 2007 4:47 pm Post subject:


Dear Teo,
Congratulations, both to you and to your excellent physician, Dr. Chew. He has chosen the best treatment regime for you, and you are working hard to maintain strength and agility to combat PD. You are a fine example for us all.
Best regards,
Kathrynne Holden, MS, RD
For a Parkinson Tip of the Day visit:

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