Understanding Parkinson's Disease

BY JAMES S. BURKHARDT, D.O.

Many people have heard of Parkinson’s disease, but most know very little about the condition and how it affects a person and their friends and family. While there are no official statistics, Parkinson’s disease is thought to affect over one million people in the United States.

Parkinson’s disease is a neurodegenerative condition and after Alzheimer’s is the second most common disease in the United States. Neurodegenerative is a term which refers to a progressive loss of nerve cells (neurons) and/or their function. Neurodegeneration from Parkinson’s disease can give rise to a wide spectrum of symptoms which can vary widely between people in terms of type and severity.

Parkinson’s disease is a movement disorder that progresses slowly. Some people will first notice a sense of weakness, difficulty walking, and stiff muscles. Others may notice a tremor of the head or hands. Parkinson’s is a progressive disorder and the symptoms gradually worsen. The general symptoms of Parkinson’s disease include:

· Slowness of voluntary movements, especially in the initiation of such movements as walking or rolling over in bed.

· Decreased facial expression, monotonous speech, and decreased eye blinking.

· A shuffling gait with poor arm swing and stooped posture.

· Unsteady balance: difficulty rising from a sitting position.

· Continuous “pill-rolling” motion of the thumb and forefinger.

· Abnormal tone or stiffness in the trunk and extremities.

· Swallowing problems in later stages.

Early symptoms of Parkinson’s disease are usually mild and generally occur gradually. You may have fatigue or a general sense of uneasiness. You may feel a slight tremor or have difficulty standing. Some may notice that their speech has become softer or that their handwriting has changed. You may forget a word or thought and have feelings of depression or anxiety. Generally, friends and family begin to notice the changes before you do. They often notice the stiffening or lack of movement, or the absence of facial expression (“masked face”) seen in Parkinson’s disease.

As the disease progresses, it begins to interrupt daily activities. It is important to note that not all people with Parkinson’s disease experience the full range of symptoms; in fact, most people with Parkinson’s have mild, non-intrusive symptoms.

The cause of Parkinson’s disease is not known, but there is progressive deterioration of nerve cells called neurons. When functioning normally these cells produce a brain chemical or neurotransmitter called dopamine. Dopamine is a chemical messenger to communicate with different areas of the brain. This communication coordinates smooth and balanced muscle movement. In Parkinson’s disease, there is damage to these nerves, resulting in abnormal levels of dopamine, and this in turn causes a decrease in the ability of the body to control movements.

Do You Take Your Medication as Directed?

BY JAMES S. BURKHARDT, D.O.

Taking medication as directed is very important.  Sometimes it really is a matter of life or death.  Even so, people forget to take their medications all the time.  Here are some frightening statistics:

  • One in three patients fail to fill their prescriptions.
  • 32 million American take more than 3 medicines daily.
  • Approximately 75% of adults report that they do not consistently take their medications as directed.
  • It is estimated that about 50% of medication-related hospital admissions in the U.S. are due to poor compliance.
  • Approximately one-fourth of all nursing home admissions are related to improper self-administration of medications.
  • In chronic conditions such as diabetes and high blood pressure adherence rates average between 50-65 percent.
  • The economic impact of non-adherence is estimated to be $100 billion annually.
  • Patients who take a medication once per day and are able to do so correctly per prescription instructions is 80 percent.  But it drops to 50 percent if you take a medication 4 times daily. 
  • A Canadian study followed patients who had been hospitalized for a heart attack. After a year, medication compliance declined.   A Swedish study in patients who had suffered a stroke demonstrated the same thing after 2 years. 

There are many reasons why patients do not take their medication as prescribed.  Some are related to the patient themselves, such as poor understanding or lack of involvement in the decision-making process.  Some reasons are related to physicians, such as prescribing a complex medication regimen or poor communication about the risk and nature of potential side effects.  Other reasons fall into a category called “system problems” such as time limitations in the office, or poor access to care or lack of healthy information technology. And let’s not forget about the cost of medication may be prohibitive. 

It is also common for patients to see more than one doctor.  A typical Medicare patient may see 7 physicians in one year: 2 primary care doctors and 5 on more specialists.            

Thus, with so many reasons for non-adherence, it is almost impossible to come up with a strategy that is simple and effective.  Therefore, it is extremely important for you to talk with your doctor or doctors about your medications.  Make sure you are clear on why you are taking medicines and confirm the dosages.  Also, if you are seeing more than one doctor, make sure that they all know that you are receiving medications from different physicians.  

As the former Surgeon General C. Everett Koop reminded us, “Drugs don’t work in patients who don’t take them.”

Watch the Fat Through the Holidays

BY JAMES S. BURKHARDT, D.O.

            Recently the Food and Drug Administration announced that trans-fats are no longer “generally recognized as safe.”  I applaud this announcement.  But just what are trans fats and why is there concern?  

            Trans fats are partially hydrogenated oils.  Partially hydrogenated oil is formed when hydrogen is added to liquid oils to make solid fats like shortening and margarine.  It increases the shelf life and the flavor of foods.  Partially hydrogenated vegetable oil, or shortening, was used in American kitchens as early as 1911.  Small amounts of trans fats occur naturally in beef, lamb, and full-fat dairy products. But most come from processing liquid vegetable oil to become a solid fat.

            Trans fat can be found in processed foods including desserts, microwave popcorn products, frozen pizza, margarine and coffee creamer, and has been linked to an increased risk of heart disease.  However, in recent years many food manufacturers have taken steps to limit or eliminate trans fat from their products. 

            McDonald’s, for instance, stopped cooking french fries in trans fat more than a decade ago.  The company’s website says all fried menu items are free of trans fat. 

            The American Heart Association recommends limiting total trans fat intake to less than 1 percent of total daily calories.  Translated, if consuming 2,000 calories a day, 20 calories or fewer should come from trans fats, equating to less than 2 grams daily.  Keep in mind this amount includes naturally occurring trans fats. 

            The bottom line is to stick to healthy fats whenever possible.  Research has shown the omega-3 fats in fish oil may decrease muscle protein break-down.  This may be through improvements in insulin sensitivity and insulin resistance associated with muscle break-down.  A study in the American Journal of Clinical Nutrition showed fish oil helps to enhance the effect of strength training in elderly women.  Omega 3 fatty acids in particular have been associated with lowered risk of coronary artery disease, helping to reduce inflammation. 

            So while it may be impossible to resist chocolate from Winan’s (because it is delicious) remember to try and make some better choices through the holidays.  Again, a diet containing a variety of fruits, vegetables, and whole grain products is preferable.  Moving to fat free and low fat dairy products is better.  Changing to eat leaner meats and poultry as well as fish such as salmon can promote a healthier lifestyle.

NEW YEAR, NEW GUIDELINES

BY JAMES S. BURKHARDT, D.O.

Recently, new guidelines have emerged for both cholesterol reduction and blood pressure control.  The Eighth Joint National Committee (JNC8) has released guidelines on the management of high blood pressure.  In November, the American Heart Association (AHA) and the American College of Cardiology announced new guidelines for treating cholesterol.

            Both hypertension (elevated blood pressure) and high levels of cholesterol are associated with increased risk of heart attack and stroke.  The other major risk factors are family history, diabetes mellitus, and smoking.  And by family history, I am specifically referring to a first-degree relative; mother, father, sister or brother.  If one of them had a heart attack or stroke, then you are at increased risk.

            Let’s take blood pressure first.  The 14-page, JNC 8 guidelines formed nine recommendations which are discussed in detail.  The authors also published over 300 pages of supplemental evidence in outlining their review process. 

            There are nine recommendations, some of which are new and some are modifications.  Among the recommendations:

            -In patients 60 years or over, start treatment in blood pressure over 150 mm Hg     systolic or over 90 mm Hg diastolic and treat to under those thresholds.

-In patients under 60 years, treatment initiation and goals should be 140/90 mm Hg, the same threshold used in patients over 18 years with either chronic kidney disease (CKD) or diabetes. 

            -In nonblack patients with hypertension, initial treatment can be a thiazide-type diuretic, Calcium Channel Blocker ( CCB), angiotensin converting enzyme (ACE) inhibitor, or angiotensin receptor blocker (ARB), while in the general black population, initial therapy should be a thiazide-type diuretic or calcium channel blocker.

            -In patients over 18 years with chronic kidney disease (CKD), initial or add-on therapy should be an ACE inhibitor or ARB, regardless of race or diabetes status.

            The medication recommendations for black patients and for diabetic patients is not exactly new.  The loosening of blood pressure goal for those over 60 is new, however.  This is also not to say that if your blood pressure is well controlled at 130/80, that you can stop your medicine. 

            While the blood pressure recommendations are new, we are still treating to a target number.  The new cholesterol guidelines are somewhat muddier.

            The guidelines include new weight and lifestyle measures to lower the risk of having a heart attack and stroke.  The guidelines also recommend that doctors focus on overall risks to the heart and less on cholesterol numbers. 

            To determine that risk, doctors use a calculator that figures out the chances of having heart problems in the next 10 years.  It is also available online. (You must know your cholesterol numbers and blood pressure to use it.) 

            The calculator takes into account cholesterol numbers, age, blood pressure, smoking habits, and use of blood pressure medicines.  All of these things affect your chance of having heart problems.

            Initially it appears that more people will be taking cholesterol lowering drugs, usually in the form a family of medicines called statins. 

            Just as in the past, people diagnosed with heart disease will start taking a statin.

New to the guidelines: People with extremely high LDL, or “bad” cholesterol, and all middle-aged people with type 2 diabetes will be advised to take a statin.  

Also, men and women 40-75 who have an estimated 10-year risk of heart or blood vessel problems of 7.5% or higher will be recommended a statin. 

            Living a healthy lifestyle is still most important.  These things include diet, exercise and not smoking.  Many people make resolutions at this time of year.  While these New Year resolutions often involve healthy lifestyle changes, I encourage you to continue with healthy living. 

            As always, consult your family doctor regarding blood pressure or cholesterol questions.

We Can Create a Healthier Community

BY JAMES S. BURKHARDT, D.O

           When we say the word health, what do we mean?  What are we really talking about?  There are many ways to define good and I do not believe that it is merely the absence of disease or illness.  Good health is more than that.  It really reflects a state of physical, mental, psychological and social well-being.

            One of the central issues has to do with balancing the role of the individual with the role of government in promoting health.  This issue came to light in New York City under Mayor Michael Bloomberg.  The Bloomberg administration touched off huge controversy with its “portion cap rule” limiting the size of sugary drinks.  This was opposed by many stating that “New Yorkers need a Mayor not a nanny.”

            So, on one hand, government policy approaches – taxes, bans and other regulations – are viewed as “nanny state” intrusion by “big government”.  On the other hand, changes in regulation can help with a “savvy state” to fight conditions that lead to epidemic of chronic diseases such as diabetes. 

            Chronic diseases, such as heart disease, cancer and diabetes, are responsible for seven out of every 10 deaths among Americans each year and account for 75 percent of the nation’s health spending.  Many of the risk factors that contribute to the development of these diseases are preventable. 

            No one would deny that in the United States in general and in Miami County in particular that we eat too much, smoke too much, drink too much and exercise too little.  Health status and related healthy behaviors are determined by influences at many levels including personal choice, (Do I supersize my meal?) environment (How do I get to the bike path?) and policy (taxes on cigarettes).  So community based programs are most likely to succeed when they address all of these issues. 

            Increased awareness and education are the place to start.  Areas where personal choice and policy meet occur at some restaurants.  For example, fast food places have been under the gun for promoting unhealthy lifestyles.  While some of this may be warranted, kudos are in order for McDonald’s restaurants which have begun posting calorie content on their menu boards.  While it may not make much difference, their increased awareness of what you are eating may give some people pause and change to a healthier choice. 

            There are areas that may be easy to identify and change.  Here are some ideas that would create healthier choices.  I have seen food at concession stands and not much would be considered “good for you.”  One simple change would be to price water cheaper than soda pop. 

            Another simple change would be to provide nutritional information on vending machine food.  Again, not much in vending machines would be considered “healthy.”  At Ohio Northern University, pharmacy students developed a labeling system for foods in vending machines based on sugar, salt, fat and fiber content.  To view this in detail go to onu.edu/trafficlightplus.   This would be a great project for any number of high school groups or even for leaders club at the YMCA.

            Providing nutrition information or a financial incentive to drink more water are only 2 easy ways to increase awareness and improve the health of our community.

 

High Blood Cholesterol: What You Need to Know

BY JAMES S. BURKHARDT, D.O.

Your blood cholesterol level has a lot to do with your chances of getting heart disease.  High blood cholesterol is one of the major risk factors for heart disease.  A risk factor is a condition that increases your chance of getting a disease. In fact, the higher your blood cholesterol level, the greater your risk for developing heart disease or having a heart attack.  Heart disease is the number one killer of women and men in the United States.  Each year, more than a million Americans have heart attacks and about a half million people die from heart disease.

When there is too much cholesterol (a fat-like substance) in your blood, it builds up in the walls of your arteries.  Over time, this buildup causes “hardening of the arteries” so that arteries become narrowed and blood flow to the heart is slowed down or blocked.  The blood and oxygen cannot reach your heart, you may suffer chest pain.  If the blood supply to a portion of the heart is completely cut off by a blockage, the result is a heart attack. 

High Blood cholesterol itself does not cause symptoms so many people are unaware that their cholesterol level is too high.  It is important to find out what your cholesterol numbers are because lowering cholesterol levels that are too high lessens the risk for developing heart disease and reduces the chance of a heart attack or dying of heart disease, even if you already have it.  Cholesterol lowering is important for everyone-younger, middle age, and older adults, women and men, and people with or without heart disease. 

Finding out what your cholesterol numbers are is an easy process. It is a simple blood test performed after 10-12 hours of fasting.  It will give information about

-Total cholesterol

-LDL (Bad) Cholesterol – the main source of cholesterol buildup and blockage

-HDL (Good) Cholesterol – works as a scavenger to prevent cholesterol buildup in the blood vessels

-TRIGLYCERIDE – another form of fat in your blood

Total Cholesterol Level                                                    Category

Less than 200 mg/dL                                                           Desirable

200-239 mg/dL                                                                     Borderline high

240 mg/dL and above                                                         High

LDL Cholesterol Level                                                      LDL Cholesterol Category

Less than 100 mg/dL                                                           Optimal

100-129 mg/dL                                                                     Near optimal/above optimal

130-159 mg/dL                                                                     Borderline high

160-189 mg/dL                                                                     High

190 mg/dL and above                                                         Very high

Note: Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (d) of blood

HDL (good) cholesterol protects against heart disease, so for HDL, higher numbers are better.  A level less than 40 mg/dL is low and is considered a major risk factor because it increases your risk for developing heart disease.  HDL levels of 60 mg/dL or more help to lower your risk for heart disease.

Triglycerides can also raise heart disease risk.  Levels that are borderline high (150-199 mg/dL) or high (200 mg/dL or more) may need treatment in some people. 

In general, the higher your cholesterol levels and the more risk factors you have, the greater your chances of developing heart disease.  To find out your risk for having a heart attack, you can access a scoring tool @ hp2010.nhlbihim.net/latpiii/calculator or search Frammingham Risk Score. 

For more information risk of heart disease and cholesterol contact your family doctor.

 

Beware of Medical Info on the Web

BY JAMES S. BURKHARDT, D.O.

When I was a medical student and learning about diseases and disorders, every time I read about medical conditions I was convinced that I had contracted that malady.  No matter that Leishmaniasis occurs due to the bite of sandflies native to Africa and the Middle East.  I was certain I had it. This type of self diagnosis is very common when I was a student, but much less common as I grew more knowledgeable about medicine.  This is a form of hypochondriasis.  Hypochondria is an “abnormal concern about one’s health, with the false belief of suffering from some disease, despite medical reassurance to the contrary,” according to Taber’s Medical Dictionary. 

I see concerns like this from folks quite regularly in my office.  These people are what I like to call “the worried well” and often suffer with good health.

The availability of information from sources on the internet has made finding out about almost any topic very easy.  And most of the time the information is accurate.  But what is needed is context, and being discerning about what is likely and not likely.  If, for example, I hear hoof beats outside my window, I would expect to see horses and not zebras.  In medical parlance, zebras are rare and unusual disorders. So those muscle twitches you might have areprobably nota sign that you have ALS (Amyotrophic Lateral Sclerosis, aka “Lou Gehrig’s Disease”).  But if you’re using search engines to diagnose what ails you, there’s a chance you’ll come to that conclusion. 

In a new paper, Microsoft investigates cyberchondria:  “. . . the unfounded escalation of concerns about common symptomatology, based on the review of search results and literature on the Web.” 

Microsoft researchers Ryen White and Eric Horvitz studied a 40-million page sample of search results (from Live Search) and surveyed 500 Microsoft employees about how they search for health information.  They found that health search on the web sometimes makes our problems worse, in the form of heightened anxiety that can disrupt other aspects of normal, daily life.  In other words, the information we learn from search engines often adds stress to whatever our current health problem might be. 

“. . .the unreliability of Web sources and the content of Web search engine result pages contributed to the heightened anxiety of around three in ten survey respondents.

The responses show that search engine result pages, the contents of the pages visited directly from the result pages, and pages visited thereafter, may all contribute to health-related anxiety to different extents.”

One problem, according to the paper, is that web searches for common symptoms sometimes lead to information about serious, rare illnesses. A search for ”headache” might lead to information about tension, but could also lead to information about brain tumors, which are extremely rare.  A search for “chest pain” can lead to information about heartburn or heart attacks. 

So if you have a complaint or concern, you can certainly find good information on the Web. But be advised that you want to make sure that you react appropriately to avoid “cyberchondria.”

If you have any concerns about health matters, your family doctor should be your first resource.

Elbow and Shoulder Injuries

BY JAMES S. BURKHARDT, D.O.
 

This baseball season promises to be very exciting and for Red’s fans expectations are high. Injuries are certainly a part of sports. Every manager, coach and player is well aware of how injuries can derail a season for a team and a career for a player.

This month’s article will review 2 common injuries often associated with baseball players: elbow and shoulder injuries. These commonly involve tendons and ligaments around those joints. Ligaments connect bone to bone and tendons connect muscle to bone.

Anyone can sustain a ligament injury to the elbow from repetitive activities or from trauma. But athletes that throw have the highest risk. That’s because the overhand throwing motion puts extreme stress on the joints. In the elbow, the ligament which is at most risk is the ulnar collateral ligament. This ligament connects the upper arm bone, the humerus, to a bone in the forearm. It is located on the inside of the elbow.

Over time and with the excessive activity such as throwing in general, and pitching in particular, the ligament can develop small tears and begin to fray. The ligament stretches and lengthens until it does not hold the bones tightly enough during throwing activities.

Tommy John surgery repairs a damaged elbow ligament. It is most commonly performed on college and pro athletes, especially baseball pitchers. The surgery is named after former Los Angeles Dodgers pitcher Tommy John. In 1974, he underwent the first surgery of this type. During Tommy John surgery, the surgeon replaces the ligament with a tendon that is taken from someplace in the patient’s body, usually from the forearm or hamstring.

When Dr. Frank Jobe performed this operation, he thought the pitcher only had a 1 in 100 chance of resuming his professional baseball career. But Tommy John returned to pitch for 14 more years in the major leagues and win 164 more games.

Now this procedure is commonly performed. In fact, often pitchers return throwing harder than they did prior to the surgery. This phenomenon of increased velocity has prompted some to consider undergoing surgery to “get it over with” to start recovery and have greater velocity on the fastball even without a ligament tear.

A rotator cuff injury is a strain or a tear of a tendon in the shoulder. The rotator cuff is a group of four muscles and tendons that hold the arm onto the body and allow movement in the shoulder. They run from the shoulder blade out to the top part of the arm. There are 4 muscles that make up the rotator cuff. They are the supraspinatus, infraspinatus, teres minor and subscapularis. These tendons connect the muscles to the arm bone, the humerus.

Sometime these tendons can become damaged, especially with overhead movements. Certain sports such as baseball (mainly pitchers), swimming, tennis, football and volleyball place heavy use on these tendons and can gradually strain the tendon. Visualize rubbing a rope over a rock and understanding how that rope can fray and weaken. That is how the muscle and tendon unit in the shoulder can get damaged.

ymptoms of rotator cuff problems include shoulder pain and muscular weakness. Range of motion is usually limited especially overhead motion and internal rotation. You can reproduce external rotation by the movement you use to put on a coat by sliding your arm in your sleeve.

tendon in your shoulder can be inflamed, partially torn, or completely torn. What is done about it depends on how much damage has occurred and how much it hurts.

f your tear is a minor one, it can be left to heal by itself if it does not interfere with your everyday activities.

f you have a bad tear, you may need to have it repaired by arthroscopy. Arthroscopy can be used to perform surgery on a joint as well as to see inside the joint. The rough edges of a torn tendon can be trimmed and left to heal. Larger tears can stitched back together. After surgery, your treatment plan will include physical therapy to strengthen your shoulder as it heals.

s always for more information about elbow or shoulder injuries, your family doctor should be your first source for help.

Gene Testing Moves Mainstream

BY JAMES S. BURKHARDT, D.O.
 

A recent article in The Wall Street Journal discussed some future trends in medicine.  One of those areas was in the realm of genetic and DNA testing. 

Genetic tests are tests on blood or other tissue to find genetic disorders.  About 900 such tests are available.  Some of these can detect such diseases and disorders as cystic fibrosis, inherited types of breast cancer, Huntington’s disease and hemophilia, and many more. 

For most of us, the knowledge of gene testing is limited to police television shows where DNA testing is used to determine who the father of the baby is or to convict a criminal of a murder or sex crime. 

The other area that gene testing is familiar to us is with newborn screening.  Newborn screening is the practice of testing every baby for certain harmful or potentially fatal disorders that aren’t apparent at birth. 

For years, genetic testing was limited to hospital or research settings.  Now, new advances have made it possible and practical to perform testing in the office setting.  This enables doctors to specifically and individually treat patients from many conditions.  My practice, Upper Valley Family Care, is the first practice in Miami County to offer such gene testing.  Surely others will soon follow due to its utility and practicability.  

One specific example of practical application is with the medication clopidogrel (brand name Plavix).  There is a gene that controls the conversion from the pill you take to its active metabolite.  Some people have variations in the gene, ZCYP19, that do not convert clopidogrel to an active form.  This may occur in as many as 4% of the population.  By identifying these variations, or mutations, doctors can individualize treatment of their “blood thinner” medication that may not be effective. 

There are genetic pathways that influence or alter how some of us process medications.  Some of the medications include many commonly used drugs such as statin medicines to treat cholesterol, seratonin specific re-uptake inhibitors (SSRIs) to treat depression, and beta blockers to treat blood pressure.

By identifying alterations in enzyme function this gene testing has the potential to truly individualize the approach to treatment for certain medical conditions.  This is an exciting new area of interest as gene testing moves away from the theoretical and into practical application.