May 2025

Remember: Levodopa’s best friends are: Entacapone & Amantadine. The medications discussed here (the MAO-B inhibitors) are also supposedly “friends of levodopa/dopamine”. Except, two of them,  like the older brothers Karamazov, these medications are somewhat useful but full of flaws. These medications probably belong to an older generation. I use them very sparingly, if at all. The newest amongst them, Safinamide, is a promising baby. Considering the reputation of its brothers, it’s difficult not to be slightly wary about it. The flawed elder brothers: Rasagiline & Selegiline Rasagiline & Selegiline are the bad brothers that you should probably avoid. How do Rasagiline / Selegeline work? Their mechanism of action is similar to Safinamide: They prevent the destruction of dopamine and therefore preserve it in the body, prolonging it’s action. Uses/Advantages: Two studies indicate that these medications may slightly slow the progression of Parkinson’s disease. However researchers and doctors have ferociously debated the results of these studies. Most doctors believe that there is either no effect, or a very minor effect that should not affect the choice of medication. The effects of Rasagiline & Selegiline in slowing progression of Parkinson’s disease are very minimal. Many researchers believe there is no such effect. Most doctors start by using levodopa (or rarely, the dopamine agonists) for a patient with newly diagnosed Parkinson’s disease. The thought process is as follows – Levodopa is the most potent medication for Parkinson’s disease. If I delay using levodopa, this patient will continue to have symptoms of Parkinson’s disease. Therefore, let me give him levodopa which I am sure will control most if not all of his symptoms, right now. These side-kicks are probably of no use in protecting the brain and produce too many side-effects. It may be worthwhile, for the astute reader, to know about the details of these two studies: The ADIAGO study published in 2009 – Rasagiline at 1 mg per day seemed to slow Parkinson’s disease progression. But 2 mg per day had no beneficial effect! Many doctors believe that the positive result is just due to statistical chance, and is not real. The DATATOP study published in 1993 – Selegiline was useful in relieving the early symptoms of Parkinson’s disease, and therefore using the boss medication – levodopa – could be delayed by a few years.However, there was no direct comparison to the usual strategy of starting levodopa as the first medication. Although often cited as one of the studies that shows possible neuroprotection with these medications, it does not look at this question directly. Disadvantages: These medications have all of the same shortcomings as safinamide, except to a much greater degree. Sometimes they can cause or worsen high blood pressure They may occasionally cause liver problems. Some antidepressants including SSRIs (e.g. fluoxetine) and TCAs (e.g. amitriptyline, nortriptyline, amoxapine) Stimulants such as Amphetamine & Methlyphenidate Painkillers that contain opioids Some muscle relaxants such as cyclobenzaprine A few other medications such as the antibiotic linezolid. Fermented and pickled food e.g. fermented cheeses and Red Wine – these can cause a very uncomfortable, and occasionally serious condition called “Cheese reaction” due to accumulation of a chemical called tyramine in the body.The affected person has severe flushing of the skin, his/her heart starts beating faster, and he/she has a marked increase in BP. This can last hours – certainly not a good thing to go through! These medications can interact with fermented foods & cause a terrifying, very uncomfortable reaction. More importantly, they can interact with a large number of medications. You should avoid the following medications if you are taking rasagiline/selegiline: The new kid on the block: Safinamide. How does Safinamide act? Safinamide acts just like Rasagiline and Selegiline. It inhibits an enzyme called MAO, which prevents the destruction of dopamine and keeps it in the body for a longer period of time. It seems to be the less harmful brother of the older brothers Karamazov (Rasagiline & Selegiline), but only time will tell. This is 2019: Safinamide was released only 4 years ago. No one is perfectly sure how useful it will be. Uses/Advantages: Since it is a very new medication, its uses are still being worked out. However, it seems to be effective in late-stage Parkinson’s disease. Addition of Safinamide again seems to smoothen-out the effect of levodopa, so that patients experience fewer fluctuations in their functioning throughout the day. Safinamide is very unlikely to cause liver injury. Safnamide is less likely to interact with other medications. But you should probably avoid the medications mentioned above, if you can. Safinamide is less likely to interact with fermented foods. But perhaps it would be wise to avoid the foods mentioned above until we have more experience with the medications. Disadvantages: The side-effects of Safinamide seem to be the same as Rasagiline/Selegiline, but they occur less commonly. Just like its brothers, Safinamide can cause or worsen high blood pressure. Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

(Brand names in India: Amantrel, Parkitidin) How does Amantadine act? Amantadine is a another friend of levodopa (remember: its other friend is entacapone). While it can decrease the symptoms of Parkinson’s disease, it works best when it is given to support the action of levodopa. While Entacapone can sometimes increase the side-effects of levodopa, Amantadine is the friend who smoothens out your rough edges, makes you a better person. Amantadine decreases some side-effects of levodopa and makes it more wonderful. Levodopa’s two friends: Entacapone & Amantadine. No one quite understands how Amantadine works for Parkinson’s disease. It was originally designed to kill the influenza virus. However, doctors accidentally discovered that it makes Parkinson’s disease better as well. It has one, fantastic and unique effect in Parkinson’s disease that is described below. Use/Advantages: Treatment of “Dyskinesias”: Some patients with Parkinson’s disease start getting bothersome movements of the hands, legs and neck after a few years of treatment. I want you to understand these movements. So with all respect: please allow me to describe these movements in the simplest way possible. These movements are dance-like movements, somewhat similar to the way Michael Jackson dances on stage. The Latin word for dance is chorea, and therefore these movements are called chorei-form (dance-like) movements. Since that word is very complicated, they are also called “Dyskinesias”. These movements are often time-linked to levodopa. They are maximum in intensity 30 min – 1 hour after taking levodopa. Dyskinesias are dance-like movements. Amantadine has one fantastic effect – it decreases these movements tremendously. For patients who have not been able to take enough levodopa because of these movements, it enables intake of an adequate quantity of levodopa, so that they can have a much better quality of life. It may smoothen-out the effect of levodopa, and can help in relieving “Predictable wearing OFF” to some degree. But, other stratergies such as entacapone, long-acting medications etc are much more useful for this purpose. Rarely, it can be given as the only medication for Parkinson’s disease. But when used by itself, its effectiveness is limited. Disadvantages: Most people don’t have any side-effects from Amantadine. Some people can have mild swelling or slight purplish discolouration of the feet. Since it is an anti-viral, it can decrease the effectiveness of some viral vaccines. If a live viral vaccine (e.g. Hepatitis B vaccine) needs to be given, Amantaide should be stopped 2 weeks prior and 2 days after the vaccine is administered. Amantadine can decrease the effectiveness of some vaccines. Bottom-line: It is used to control troublesome dance-like movements caused by high doses of levodopa. Although it is only modestly effective by itself, it is extremely good at smoothing out the rough edges of our superstar (levodopa), hence the sorbiquet – The lawyer of levodopa. Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

Click here for the Complete Parkinson’s Patient Guide (Brand names in India: Pramipex, Pramipex ER, Ropark, Ropark XL) How do dopamine agonists work? These chemicals are imitators. They look just like Dopamine itself. They attach themselves to the same sites that Dopamine usually attaches itself. Therefore, they produce similar effects in the brain as Dopamine and relieve the symptoms of Parkinson’s disease. Pramipexole (and Ropinirole) looks like Dopamine. Use/Advantages: “Extended-release” / 24-hour preparations: The effect of a single tablet of “Extended Release” Pramipexole (or Ropinirole) can last for 24 hours. The main advantage is that these medications have “extended-release preparations” that gradually dissolve in the stomach so that they keep gradually entering the blood and then the brain for the entire day. Therefore the effects of a single tablet taken in the morning can last for 24 hours. This infrequent dosing is very convenient! But even more importantly in patients who have Predictable-wearing-OFF or other motor fluctuations with levodopa, these long-acting medications can maintain good movement throughout the day, to “smoothen out the day”. They may produce less dyskinesias than levodopa. They may therefore be used to start treatment in younger patients (e.g. below 45) or may be added to the treatment of a person who cannot tolerate high doses of levodopa due to dyskinesias. Disadvantages: These medications are not as strong as levodopa. When given in smaller doses, they may not relieve all the symptoms of Parkinson’s disease. When given in higher doses, they can produce troublesome side-effects including excessive daytime sleepiness, impulse control problems such as gambling and rarely, sleep disturbances & hallucinations. In particular, the excessive sleepiness during the day often limits their use – restricting their use to smaller doses. Rarely, dopamine Imitators can cause Impulse Control Disorders including gambling, excessive spending or excessive eating. But the most common side-effect is sleepiness. Bottom-line: While good in theory, it is difficult to use these medications in practice. They are sometimes used for the treatment of very young patients with Parkinson’s disease. Also, the fact that 24 hour preparations are available make these medications useful in certain niche situations such as predictable-wearing OFF. Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

(Brand names: Sinemet, Syndopa, Syndopa plus, Syndopa CR, Tidomet etc) Levodopa is the MOST POWERFUL, POSSIBLY BEST medication for Parkinson’s disease. If Parkinson’s was a jungle, Levodopa would be an Elephant. It is the Optimus Prime of Transformers, the Mount Everest of mountains… I could go on… Levodopa is the best medication for Parkinson’s disease, for most people How does levodopa work? In a very simple fashion! Levodopa travels inside the brain, and is converted into Dopamine! As described here, low levels of dopamine in the brain is the main problem in Parkinson’s disease. So, levodopa directly addresses the basic problem. Once it enters the brain, Levdoopa is converted into Dopamine. Use/Advantages: It is one of the strongest medications for Parkinson’s disease. It has a very marked effect on relieving the movement and many of the non-movement problems associated with Parkinson’s disease. Disadvantages / Side-effects of levodopa: Absorption: The absorption of levodopa is decreased if you have food in your stomach at the same time. Ideally, levodopa should be taken on an empty stomach. You should not eat at least 30 minutes (and if possible one hour) before and after taking levodopa. It is mainly protein in the food that hampers the absorption of levodopa. But, you should drink a glass of water with each dose to help the tablet dissolve. Logistics: Levodopa needs to be taken multiple times in a day. In the initial stages, it has to be taken 3 times a day, but in the later stages, it may need to be taken 5 or more times per day. It is sometimes difficult to remember to take each dose on time! It is somewhat inconvenient to take Levodopa. Nasuea: Some patients complain of nausea after taking levodopa. Carbidopa, which is always given with levodopa, does decrease nausea somewhat. High doses of levodopa can cause some people to become nauseous. Usually, levodopa should be taken on an empty stomach because food decreases its absorption. But If the nausea is so very severe, then taking levodopa with a small piece of bread can be permitted. It is mainly protein that hampers the absorption of levodopa, and bread does not contain a lot of protein. Sometimes, your doctor may prescribe medications such as domperidone for this problem. Lightheadedness: Some people may complain that when they take levodopa, they feel lightheaded. This feeling usually goes away. Sometimes, it is caused by a drop in blood pressure when standing up. In this case, drinking enough water (7-8 glasses/day if okay with your cardiologist/nephrologist), and getting up gradually helps a lot.This often is worst in the morning or night. When you get up from bed in the morning, first sit by the side of the bed for some time. Then stand up gradually and stand by the side of the bed for some time. And only after you spend some time standing and feel stable, start walking (after 30 seconds – 1 minute). Some people may feel a bit lightheaded after taking levodopa. Rarely, medications (e.g. fludrocortisone or Pyridostigmine) may need to be given for this problem. Fludrocortisone increases the amount of fluid in the body. No one completely understands how Pyridostigmine works in this scenario. But it is a safe and very effective medication to prevent this kind of drop in blood pressure. “Dyskinesias”: Earlier, some doctors used to believe that levodopa should be avoided in very early Parkinson’s disease. They were concerned that the early use of levodopa leads to the early development of abnormal movements called dyskinesias. However, most recent research shows that this is not a very valid concern. These movements are now believed to be due to the disease itself, rather than any particular medication. In very young patients, below 45 years of age, it may be reasonable to consider using drugs other than levodopa because of this concern. Dyskinesias are extra dance-like movements. Earlier, it was feared that levodopa worsens dyskinesias. However, this does not seem to be the case. Other side-effects: Since this book cannot be comprehensive, it is impossible to cover all side effects here. However, some patients report disturbed sleep etc. with levodopa – if you have any of these relatively rare side-effects you should make sure to talk about them with your doctor. Bottom-line: Since it is a potent, safe medication with minimal side-effects, levodopa is the most frequently prescribed medication for Parkinson’s disease. Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

(Brand names in India: Syncapone, Entacom plus) How do Entacapone & Tolcapone act? Entcapone is a friend of levodopa. It prevents the breakdown of levodopa by inhibiting an enzyme called COMT. The name of the enzyme is not important, what is important is that entacapone protects levodopa. Therefore, it makes the levodopa stay longer in the blood. As a a result the effect of levodopa is increased, and more importantly – the effect of levodopa lasts for a longer time. Entacapone is a friend of Levodopa. It enables levodopa to work better and longer. Use/Advantages: It directly increases the effect of levodopa. In some patients, when Parkinson’s disease progresses, the effect of levodopa lasts for a shorter and shorter time. These patients may often say something like the following: Well, I agree that levodopa helps me. It perks me up, makes me want to walk, in fact, I can walk very, very well for the first 2 hours after taking levodopa. But, 2 hours later the effect goes away! And I am back to the stage where I was before taking levodopa. This roller-coaster ride continues throughout the day. – This is called “Predictable wearing OFF”. Entacapone is extremely helpful in this situation. Entacapone prevents levodopa from wearing-off early. Disadvantages: Rarely, it may cause mild liver side effects. This is not very common. The stronger brother – Tolcapone – is not available in India. Tolcapone is more effective than entacapone. But Tolcapone can result in serious liver injury, and therefore it’s use needs to be very closely monitored. Bottom-line: Who doesn’t need friends? Entacapone helps its buddy levodopa to keep acting longer. Doctors don’t use Entacapone much, because of the risk of liver injury. Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

Slowing progression (Click) Part 1: Exercise & Preventing Injuries Part 2: Medications Part 3: Traditional meds & Coffee Part 4: Stem Cell Therapy Important! Please note that the effect of these interventions is still under research. Do NOT take any medication without a prescription of a registered doctor. The medications we have for Parkinson’s disease are very effective in controlling the symptoms of Parkinson’s disease. But wouldn’t it be great to have some intervention that would slow the progression of Parkinson’s disease? Let me preface by saying that at the present time (as of November 2019), Stem Cells should NOT be used for the treatment of Parkinson’s disease, outside of carefully controlled research trials. They are not approved for this purpose yet, and the long term effects of such treatment are not known. Stem cells have fantastic potential. Neurodegenerative diseases like Parkinson’s disease, which are caused by loss of cells, may benefit the most with Parkinson’s Slow Progression – Stem Cell Therapy for Parkinson’s Disease. It is something that each patient with Parkinson’s disease can look at with hope. What are stem cells? Stem cells are special cells that can develop into many different cell types. Also, a single stem cell has the potential to divide many times and produce thousands and even millions of cells. A stem cell has the ability to produce many different kinds of cells. There lies the potential! Parkinson’s disease is caused by the gradual destruction of Dopamine-producing cells in the brain. If you had a cell that could form many millions of Dopamine-producing cells, perhaps you could use it to replace these dying cells! There are many technical difficulties involved, however: How do you get the Stem cells? How do you transport the stem cells to the substantia nigra (the part of the brain where they should be)? If you are using Pluripotent cells, how do you tell these cells to start producing dopamine? How do you make sure there are no undesirable cells mixed with the Dopamine cells? How do you make sure the Stem cells survive for a long, long time inside the brain? The networks in the brain are very complex. Scientists are still deciding where in the brain the stem cells should be implanted, and how to deliver them there. These technical difficulties and the possible risks associated with this therapy (see below) are the main hurdles in offering Parkinson’s Slow Progression – Stem Cell Therapy for Parkinson’s Disease and many other diseases such as Alzheimer’s in which there is a loss of cells. Where are stem cells obtained from? Let us talk about two types of Stem Cells, most relevant to Parkinson’s disease research:1. From Embryos or Aborted Fetus(es): These are called embryonic (or fetal) stem cells. These are the powerful kind of stem cells and are capable of tremendous division and differentiation. These cells are also very difficult to handle.2. From Adults: These have been removed mostly from 3 places: Bone marrow, Fat & Blood (including umbilical cord blood). Stem cells are even present in blood, especially in umbilical cord blood. Image from – National Institutes of Health, USA. These cells have obvious advantages: The ethical concerns are minimal, the supply is plentiful, and they are much easier to handle than Embryonic/Fetal stem cells. Also, when the stem cells are obtained from the patient himself, the risk of the body rejecting these cells is virtually zero.A problem with these (adult stem) cells is that are only multipotent: that is they can only produce particular kinds of other cells similar to themselves. For example, a stem cell from the bone marrow can usually produce only bone.But gradually scientists are learning how to manipulate these cells & make these cells Pluripotent: i.e. capable of differentiating into many different kinds of cells. For example, in the future, we might be able to manipulate a blood cell into having hair (see figure)! OR we could make a stem cell obtained from the bone marrow start producing Dopamine! Scientists are learning how to manipulate Stem cells with limited abilities to produce all-powerful “pluripotent” stem cells. Undoubtedly, this is the future – in the future, all stem cells will probably be derived from the patient’s own body and manipulated to produce Dopamine. But this is a very, very difficult science. At present, this manipulation has not been perfected, and so far, only Embryonic/Fetal stem cells have been researched for Parkinson’s disease. Why do scientists feel stem cells may be useful for Parkinson’s disease treatment? The thinking is straightforward: – Parkinson’s disease is caused by the death of Dopamine-Producing cells in the Substatia Nigra. – This produces a deficiency of Dopamine in the brain. – If you implant Stem cells here, and they start producing Dopamine… – The problem would be solved! But there are many hurdles. The most significant difficulties have been pointed out above. Because of these hurdles, experiments in human beings with stem cells have had mixed results. Have stem cells been tried for Parkinson’s disease treatment in Humans? Surprisingly, YES! Many times!! And the first such time was 30 years ago (in 1987)!!! A group of Swedish researchers at Lund University were the first to implant stem cells in patients with Parkinson’s disease. Fetal stem cells were surgically placed into the brain (more precisely, the putamen) of two patients with Parkinson’s disease, by doing open brain surgery. Both patients had very mild, barely detectable, improvement in their movements after the procedure. Lund University Hospital in Sweden Although this first study was not a roaring success, it demonstrated that such a procedure was possible and relatively free of short-term side-effects. The same researchers improved their surgical procedure and tried using the new method on two other patients with Parkinson’s disease… Success! Both these patients showed significant improvement in movement, and one of the patients was even able to stop taking levodopa! This spectacularly improved patient showed minimal signs of Parkinson’s disease even 10 years after the procedure! Many researchers after this time reported seeing modest improvements in their patients

Slowing progression (Click) Part 1: Exercise & Preventing Injuries Part 2: Medications Part 3: Traditional meds & Coffee Part 4: Stem Cell Therapy Important! Please note that the effect of these interventions is still under research. Do NOT take any medication without a prescription of a registered doctor. The Best Pain Medication for Parkinson’s Disease we have are very effective in controlling the symptoms of Parkinson’s disease. But wouldn’t it be great to have some intervention that would slow the progression of Parkinson’s disease? 1. Rasagiline/Selegiline: These work by suppressing an enzyme called “MAO-B” in the brain. There are two studies that suggest that these Best Pain Medication for Parkinson’s Disease may be neuroprotective, at least in the very early stages of Parkinson’s disease. However, many neurologists think these studies are not conclusive. Many neurologists feel this effect is minimal. Also, these medications have many possible side-effects, some of which are bothersome. I call these medications “The brothers Karamazov” – Just like them, these have significant flaws and probably belong to another era. Therefore, at this time, they are not used very commonly. Sometimes they are used in patients with very early Parkinson’s disease. Relevant studies: The DATATOP study (1989) The ADAGIO study (2008) 2. Vitamin D: It is critical to make sure your vitamin D levels are normal in Parkinson’s disease. Our skin produces Vitamin D when it is exposed to sunlight. At a fundamental level, this is because normal Vitamin D levels are required for strong bones. Parkinson’s disease patients are likely to fall, and a fracture of the hip or the spine can be extremely disabling. Therefore, make sure your Vitamin D levels are normal. If you tend to fall often, you should also do a test to check the density of your bones, called DEXA. If the density of your bones is low, you may require Best Pain Medication for Parkinson’s Disease (in addition to Vitamin D) to make them dense again. But, guess what, Vitamin D may actually help relieve Parkinson’s disease as well! People with low levels of Vitamin D may be at a higher risk for Parkinson’s disease (Knekt 2010). It may decrease inflammation and may be neuroprotective in Parkinson’s disease (Calvello 2017) In patients with Parkinson’s disease, Vitamin D may prevent falls, especially in younger patients (Hiller 2018). It does this by improving the postural corrections that prevent falls. Vitamin D may help to prevent falls. In patients with Parkinson’s, Vitamin D may prevent thinking and memory problems (Peterson 2013). Although the evidence for this part is weak: Some studies indicate that low levels of vitamin D can be associated with worse motor function/movements as well (Soliman 2019) Most tantalizingly, preliminary research indicates that Vitamin D supplements may slow the progression of Parkinson’s disease!=This effect may be more prominent for some patients than others, based on genetics (Suzuki 2013). Unfortunately, Vitamin D does not seem to have received the attention it deserves when it comes to the treatment of Parkinson’s disease. Thankfully, as demonstrated by the studies mentioned above, this is rapidly changing. This requires thorough research. But will the money to conduct research on a low-cost treatment be made available? Time will tell. At this point, it is not possible to recommend Vitamin D supplementation if your levels are normal. What is very easy to recommend is that most patients with Parkinson’s disease should have their Vitamin D levels measured. If low, you should certainly try to bring them back to normal. This can be done by taking Vitamin D supplements, by eating foods rich in vitamin D or by increasing exposure to sunlight. Check your Vitamin D level. If it is low, you may need to take Vitamin D supplements. If you start taking Vitamin D supplements, you should recheck your Vitamin D levels after a few weeks to make sure they are normal/increasing. Relevant studies: Low vitamin D levels may place you at higher risk of Parkinson’s disease (Knekt 2010) Vitamin D may reduce inflammation and protect Dopamine-producing cells (Calvello 2017) Vitamin D may reduce falls (Hiller 2018) Vitamin D may help with balance – Study no.2 (Peterson 2013) Vitamin D may protect against thinking & memory problems associated with PD (Peterson 2013). Vitamin D may help both thinking and movement in Parkinsons disease (Soliman 2019) Vitamin D supplementation may slow progression of Parkinson’s disease (Suzuki 2013) 3. Vitamin E: Vitamin E is a strong antioxidant. Just like CoQ-10, the hope is that it will decrease damage to Dopamine-cells by harmful oxygen radicals. Almonds are a rich source of Vitamin E, an antioxidant. But the data seems to indicate otherwise. In fact, Vitamin E has been studied more thoroughly than CoQ-10. A large study published in the most respected journal in medicine (NEJM) strongly indicates that Vitamin E does not slow the progression of Parkinson’s disease (Shoulson 1993). However, in medical research, just one study, however significant and well designed is not considered to be the final word. Recently, there have been studies that indicate that Vitamin E may be slightly beneficial (Schirinzi 2019). However, these are smaller and less thorough than the NEJM study. Since the large NEJM study clearly concluded that Vitamin E is not beneficial, it is hardly prescribed by any doctor for Parkinson’s disease. Of note, Vitamin E is found in nuts including Almonds & Walnuts. Including a few nuts in your diet may not be a bad idea. If you have trouble swallowing, there is a risk of choking if you try to eat whole nuts. Instead, crush them into a powder or incorporate them in your smoothie. Relevant studies: Large multicentric study: Vitamin E is not helpful in Parkinson’s disease. Smaller questionnaire study published in a good journal (Zhang 2002) A very recent Italian study (Schirinzi 2019) 4. Statins (e.g. Atorvastatin): Statins are medications that are given to decrease “bad” cholesterol. Some examples of statins are Atorva-statin, Rosuva-statin, Simva-statin, Fluva-statin etc. Cholesterol lowering medications called Statins may affect the progression of Parkinson’s disease. Patients with Parkinson’s disease can

Slowing progression (Click)

Slowing progression (Click) Part 1: Exercise & Preventing Injuries Part 2: Medications Part 3: Traditional meds & Coffee Part 4: Stem Cell Therapy Important! Please note that the effect of these interventions is still under research. Do NOT take any medication without a prescription of a registered doctor. The medications we have for Parkinson’s disease are very effective in controlling the symptoms of Parkinson’s disease. But wouldn’t it be great to have some intervention that would slow the progression of Parkinson’s disease? The process of slowing down Parkinson’s disease by preventing further death of Dopamine-producing cells is called “Neuroprotection”. There are no approved medications for neuroprotection. However, there are many candidate drugs and many things you can try to slow down Parkinson’s disease. 1. Stay Active: Multiple studies have demonstrated that moderate levels of physical activity reduce the risk of Parkinson’s disease. The largest such study is a Swedish study that studied more than 43,000 patients over 12 years! (Yang 2015). Physical activity can improve many of the movement problems caused by Parkinson’s disease, especially balance (Dibble 2009). Also, physical activity can improve many other non-movement symptoms related to Parkinson’s disease, such as Thinking & Memory! (Tanaka 2008). Exercise slows down the progression of Parkinson’s disease. Although only a few studies have been listed here for reference, the evidence in support of exercise having a beneficial effect is extremely robust. Many prominent publications have highlighted physical activity as being an essential component of treatment in early Parkinson’s disease (Ahlskog 2011). Consider reading this article by Dr. Ahlskog in detail: Click here: Vigorous physical exercise may be neuroprotective (Alshkog 2011) Now that, hopefully, I have convinced you that physical exercise can benefit you tremendously, the next question is – what kind of exercise? I recommend that you exercise in two ways: Aerobic exercise – Walk for 30 minutes everyday. If possible, walk for 30-40 minutes every day and make it brisk. Vigorous exercise – or aerobic physical activity for 20-30 minutes that increases the heart rate and the need for oxygen – is thought to be more protective than light exercise.Therefore, brisk walking or a jog might be better than leisurely walking – Although both are infinitely more beneficial than doing nothing. Balance training – This is best learnt from a Physical therapist. Patients with Parkinson’s disease are at high risk for falls. They can fall because their feet get “stuck” to the ground. Also, Parkinson’s disease patients can fall because the normal postural reflexes that prevent falling are impaired. Balance training is a set of exercises that can help you maintain a better balance. Yoga can improve your balance & prevent falls. I will post a small video on balance training soon, but until that time you can meet your neighborhood physiotherapist to learn these exercises or follow the exercises posted on Mayo clinic’s website (click here) You may want to explore Yoga or Tai-Chi, many of the Yoga exercises emphasize balance. Remember: Only do the exercises you feel safe doing. Relevant studies: Physical exercise reduces risk of Parkinson’s disease (Yang 2015) Exercise improves balance in Parkinson’s disease patients (Dibble 2009). Exercise improves thinking in Parkinson’s disease patients (Tanaka 2008). Vigorous physical exercise may be neuroprotective (Alshkog 2011) Balance exercises : Mayo Clinic website. 2. Prevent Injuries: This one should be obvious. All measures should be taken to prevent Parkinson’s disease patients from falling down and breaking bones. Using a cane can prevent falls. When it is hot outside, you wear a cap. When the ground is rough, you wear shoes. So if you are unsteady, you should use a cane, preferably one with multiple legs (picture below). There is no shame in using a cane, it should be as natural as wearing a cap in the hot sun. Physical exercise & balance training (see above) can help a lot in preventing falls. Patients with Parkinson’s disease should have their Vitamin D levels monitored. If they are at high risk for falls, the doctor will do a Bone density or DEXA test – these topics are covered in another article. Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

Parkinson’s disease may cause difficulty swallowing (Dysphagia). Food may go into the lungs – this is called Aspiration. The decrease in swallowing saliva may also cause drooling. These problems are particularly severe in a disease called Progressive Supranuclear Palsy (PSP). Although PSP is slightly different than Parkinson’s disease, all the information given here is helpful if you have PSP. Parkinson’s Problems discussed in this article 1. Swallowing difficulty (Dysphagia)2. Aspiration3. Drooling It is absolutely critical to recognize these problems. Aspiration in particular can cause a life-threatening bad lung infection (Aspiration Pneumonia). Although drooling is not life thereatening, some Parkinson’s patients report that drooling is one of their most inconvenient problems. Is difficulty swallowing (Dysphagia) common in Parkinson’s disease? Yes. Many patients with Parkinson’s disease may complain of difficulty swallowing. The medical term for swallowing difficulty is “Dysphagia”. In milder cases, you may just have the feeling that food gets “stuck” in your throat. Some patients may report that they have a feeling of their “throat closing” when they try to swallow. In more severe cases, you may tend to choke on your food if you try to swallow it too quickly. How does Parkinson’s cause Aspiration? Our mouth connects to two pipes: The food-pipe (oesophagus) and the windpipe (trachea). When we are swallowing, the muscles in our throat move rapidly. They close the wind-pipe and make the food-pipe bigger, so that food goes into the food pipe. Swallowing food requires many muscles to move in a coordinated manner. These movements become slow in Parkinson’s disease – as a result, food may go into the wind-pipe instead and end up in the Lungs. Food going into the lungs is called “Aspiration”. The paths taken by air and food are different. Ideally, absolutely no food should go into the windpipe (trachea).Why do Parkinson’s patients cough while swallowing food? When a small particle of food goes into the wind-pipe, we gag & start coughing vigorously to throw the particles out. These are called the “Gag” and “Cough” reflexes. Food can go into the wrong pipe often in Parkinson’s patients (see above). Therefore they frequently cough while swallowing food. Gagging and coughing are protective responses to prevent food from going into the wind-pipe. These are “good” reflexes, which protect our lungs. But the condition becomes even more problematic in advanced Parkinson’s disease. In advanced Parkinson’s disease, there may be no coughing even when particles are entering the windpipe. This is dangerous! Thus, particles of food may repeatedly go into the lungs of Parkinson’s patients without them noticing it. This is called “Silent Aspiration”. Why does Parkinson’s disease cause Drooling? Saliva is produced by small glands around our mouth, called “Salivary glands”. Our salivary glands continuously produce saliva, even when we are not eating. It is a common misconception that Parkinson’s patients have drooling because they are producing too much saliva. In fact, multiple studies have shown that most Parkinson’s patients produce less saliva.  Our salivary glands continuously produce saliva, even when we are not eating. Normally, we automatically swallow this saliva, through small gulps that we don’t even notice. But in Parkinson’s disease, there is a marked decrease in all automatic movements, including automatic swallowing. Therefore, saliva accumulates in the mouth. When the mouth is full, it drips out. We call this “Drooling”. Let’s talk about treatment… In Parkinson’s disease, how is swallowing difficulty (Dysphagia) & Aspiration treated? If your Parkinson’s is causing dysphagia, the following things are helpful in preventing aspiration. A. Exercises to improve swallowing difficulty (dysphagia): A speech-swallow therapist evaluates how your muscles move while swallowing. They can teach you important exercises to improve swallowing difficulty (dysphagia) and prevent Aspiration. Click here for an excellent video by a speech & swallow therapist: https://www.youtube.com/watch?v=YBTIUE1oMEA Speech therapists specially trained in Parkinson’s can teach you exercises such as Expiratory Muscle Strength Training (EMST) or Lee Silverman Speech Therapy (LSVT) or LOUD therapy. These specialized training sessions are tremendously helpful in improving voice. But these exercises also make swallowing easier. Lee Silverman Speech Therapy – also called LSVT or LOUD therapy – can help you speak much more loudly and also decrease the risk of aspiration.B. Adequate treatment with levodopa: As described earlier, swallowing is a series of movements. These movements are slow if you have Parkinson’s disease. In many (but not all) patients Levodopa can make these movements rapid again. If your movement problems are adequately treated, then the movements of your swallowing muscles may also improve dramatically. The same medications that help your body move faster also help your speech and swallowing muscles to move faster. It is not just levodopa – any medication that improves your movements may improve dysphagia caused by Parkinson’s disease Proper movements of the lips, jaw, tongue and throat reduce difficulty swallowing & reduce the risk of aspiration. C. Follow these tips to decrease swallowing difficulty (dysphagia) & Aspiration risk: Although these tips are not a substitute for evaluation and training by a speech-swallow therapist, I think following these instructions will be very helpful for you. Try to avoid very hard foods: These are difficult to chew and grind. If you try to swallow larger chunks of food, you may find it difficult. For example, try to avoid hard fruits like green apples. How do you get your fibre then? Well, you can still eat these foods by putting them through an electric mixer first to make a smoothie! (Click here). Avoid hard to chew food items, like hard fruits. Put small portions of food in your mouth: This makes it easier for you to chew and grind them up adequately. Chew food adequately: If needed, you can count the number of times that you chew your food – Chew each piece of food that you put in your mouth at least 20 times before trying to swallow it. Don’t put too much food into your mouth at one time. Sit upright while eating: Make gravity do your work! Sitting upright while eating helps your food pipe to dump the food into your stomach. Never have food while lying down in bed. Sitting upright while eating