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Treatment for Pain in Parkinson’s patients: by Dr. De Leon

 

According to my research, laughter is the best medicine, giggling is good for mild infections, chuckling works for minor cuts and bruises, and snickering only makes things worse.

 

Recently I wrote about how 85% of PD patients suffer from pain in my last blog titled “Revisiting Pain in PD: the 50 Shades of Pain Experienced by Parkinson’s Patients” in which I explained that PD patients may experience 5 types of pain syndromes:

All can occur in one person at any given time and sometimes may have more than one type of pain concomitantly!

  1. Central pain (rare; CAN be INITIAL PD symptom presentation)-dull ache all over!!
  2. Musculoskeletal pain- throbbing
  3. Nerve root pain- electrical
  4. Dystonia- cramping
  5. Akathisia- urge to keep moving.

For this reason it is extremely important to be able to properly recognize the various different syndromes of pain in Parkinson’s patients and the best way to do this is getting a detail history- that’s where YOU COME IN!!!

As I mentioned previously untreated pain can lead to devastating consequences in all aspects of life. Know that all types can exist in the same patient throughout the disease course. Thus, identifying quality, location, triggering mechanisms can be extremely useful for your physician to provide the best treatment possible. Keeping a diary helps both you and your physician(s) to get started in the right direction. Once the source of pain is identified proper treatment can be initiated. Many times the pain can be managed successfully by your MDS/ neurologist. However, there may be times that other specialist might need to get involved. Subsequently, treating pain in Parkinson’s patients takes a multidisciplinary team or approach in which you must partner with your

1) MDS/neurologists- he or she MUST always be the quarterback or gate keeper to ensure best outcome!!! They not only know you best but first can determine if pain is related to PD either central (primary pain –i.e. Symptom of PD like tremors or stiffness etc.); or pain due to medication “Too Much” causing akathisias- or severe inner restlessness or “too little” causing dystonias or musculoskeletal pain at large joint due to rigidity, contractures and lack of flexibility and mobility.

2) PT/ OT- they will help you do stretching exercises, Range of motion exercises to prevent contracture and increase flexibility and mobility.

3) Pain specialists- this I would defer as last resort once exhausted all other venues of treatment to obtain narcotics or opiods because even a small dose CAN & WILL make PD symptoms worse in terms of cognition, constipation, sedation, depression, memory, prone to cause hallucinations, increase risk of falls, and may also directly interact with the PD medications negatively. However, they have a place if for instance you have nerve root pain and tried medications and not sure if want to do surgery or not a surgical candidate, nerve block may just do the trick and since its effect is localized will not interfere with other PD medications.

4) PCP/primary care doctor- some times because Parkinson’s is usually not the only disease most of us have, other medical illnesses like diabetes, arthritis, and gout could be the cause of your pain. Hence, it will be up to your primary doctor to do the appropriate laboratory to check for these underlying causes. In the case of cramps, these can be due to electrolyte abnormalities, medication withdrawal (dopamine agonists), or be a harbinger that you are developing neuropathies. So both neurologists and PCP have to be aware of these!!!

5) Psychiatrist/psychologists- because depression colors our perception and pain can makes depressed starting a vicious cycle sometimes we need a little help breaking this cycle to be able to rid the pain and the depression! There for psychotherapy may be beneficial.

6) Neurosurgeon – if there is a herniated disc- with clear dermatome distribution with WEAKNESS and pain unresponsive to other treatment modalities! ( MUST HAVE WEAKNESS otherwise having surgery for pain is a 50/50 shot of getting better and if you don’t get better you might get worst!! If no WEAKNESS involved suggest Botox injections or/and DBS electrical stimulation for pain –have been shown to have great response in my personal experience in my years of practice. A baclofen pump also works well for those that have a lot of pain due to spasticity. (ALL of these procedures MUST be done by someone with LOTS of experience for OPTIMAL results!!!) All of these latter procedures can be done by various specialists depending where you live so trust your neurologists, ask lots of questions always and go with someone with lots of experience!

According to 2 recent studies, there seems to be a consensus that PD patients should delay or avoid back surgery or fusion because of higher risk for “failed back syndrome.” The reason for this is believed to be natural PD symptomatology like poor posture and brittle bones ( although these studies were very small less than 30 patients each, I think that the message is valid but requires further study).

As someone who has undergone two similar back surgeries performed by the same physician one few years prior to my PD diagnosis and one as recent as last year as well as having treated countless patients with back pain including many of whom had PD; I tell you that the recovery is much different and harder with PD. It took me several months to recuperate and get strength back the second time around. My patients and I required increased dosages of dopa in order to overcome weakness!

While the procedure had been exactly same and actually much longer surgery the first time I was back to work within a week! Not a lot of data is available on the subject, but the rare article does allude to the fact that there is an increase in likelihood of compression of nerve roots as well as bulging and herniated discs simply by way of mechanical extrusion from asymmetrical stiffness, bad posturing and abnormal ambulation. I believe this is true for me and most of us with PD that suddenly end up with herniated discs without history of trauma, injury nor hard labor.  (I had a pristine back and neck and  literally had a spontaneous herniated disc doing routine activities without trauma as was the case for my first disc injury – lifting a patient)!!!

Thus, before you submit to surgery make sure it is ABSOLUTELY necessary and have exhausted all other resources!

7) Orthopedist – if there are fractures causing pain, or joint dislocations, or carpal tunnel.

First thing to rule out is pain due to Parkinson’s disease central pain. Or due to wearing off either one requires PD medication adjustment. The main stay of treatment of all syndromes after identifying cause is medication. The types of medications we use for pain include muscle relaxants (have to watch for a couple of them which may interfere with the PD meds and vice versa). Antiinflamatories, also work well. The ones I like best in this class are topical e.g. ketorolac -Toradol ( Flector patch, or your pharmacist can make a compound of topical toradol and topical anesthetics e.g. patches (lidoderm 5% patches, or lidocaine topical lidocaine intment).

Other treatments include antidepressants, anti anxiety, anticonvulsants, while opioids should be taken as last resort. What I have found is that especially with acute pain that is radicular in nature or due to fracture it is best to treat with strong medications as soon as pain comes on to prevent from becoming chronic and/or central then can go back to other treatments above. Usually something like a hydocodone will do if you treat as soon as pain starts. Worse disservice you can do to yourself is waiting until the pain is unbearable before you seek medical attention. This will make your pain much more difficult to control. YOU DON’T have to be STOIC!

Besides medications along with a team approach, other alternative therapeutic modalities reported to be effective anecdotally are:

Massage therapy & Acupuncture – again first discuss with your MDS make sure this is appropriate and find someone that is reputable in the community. Down side is that these services are usually not covered by insurance and thus are an out of pocket expense!

Next time you have pain, you will know exactly what to do and rather than suffering or enduring you can take charge and confront head on.

 

References:

http://www.pdf.org  topics on pain

Surgical outcome of lumbar fusion surgery in patients with Parkinson disease. J spinal Disord Tech. 2012-PubMed-NCBI

Spinal Surgery inpatients with Parkinson’s disease: experience with the challenges posed by sagittal imbalance and the Parkinson’s spine. Eur Spine J. Oct. 2010; 19(10);1785-1794.

Parkinson’s Disease Sufferers-  spinal -foundation.org

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at defeatparkinsons101@yahoo.com contributor http://www.assisted-living-directory.com Contributor http://www.lavozbrazoriacounty.com

pain%20scale

Revisiting Pain in PD ….the 50 shades of Pain Experienced by Parkinson’s patients: By Dr. De Leon

Whenever you get Pain in your life, think about the full form of PAIN! -Positive Attitude In Negative Situations!”-unknown

Lately, I have been reading a lot about the frustration experienced by so many of us that have Parkinson’s disease due to the fact that pain syndromes in Parkinson’s is still very poorly understood by most of us even those of us who are ” experts” in the field.  The reason is not only because pain is such a complex syndrome produced by different sources even in the same patient which is susceptible to change as the disease progresses but because it is such a subjective thing –difficult to describe. Unless you hit the right description words, unfortunately, your doctor may not clue in to where the problem lies;

Hence, I am writing this to help you focus your physician’s attention in the right direction to accurately diagnose your pain syndromes. Ironically, as much pain as we seem to be in most of the etiologies have treatable solutions.

The most difficult to treat is ‘central pain’ but even this if caught early can be treated successfully without having to resort to use of narcotics. It is extremely important to address pain whatever the cause at the earliest sign of it because this can be a huge source of disability interfering with an individual’s day-to-day activities and overall quality of life. Pain can permeate and affect all areas of one’s social, emotional, and physical life. This can lead to not only overall healthcare costs but undue stress from multiple testing and general malaise that can lead to severe depression and hopelessness which turns into a catch 22 since scientists have shown depression itself can make the pain syndromes worst. This involves 30- 40% of PD patients. How a person view pain and reacts to it is extremely important and will color the behavior around it. For instance if you tend to focus on the pain it will worsen rather than if you try to minimize or think positively that it can and will go away!

About a decade ago if someone had asked me if pain was part of the  initial Parkinson’s presentation, I would have answered with a resounding NO! Dopamine cells are not involved in pain modulation, yet here I am as many of you! Years of seeing and treating patients had taught me this but in an instant my own illness taught me otherwise!

However,  there are several different pain sources in Parkinson’s, in fact about 85% of PD patients complain of pain usually as the disease advances.

But, in rare instances some people like myself (probably less than 10% although not found an exact number) have pain as an initial complaint or PD symptom!! This can be the FIRST symptom of disease. In my personal experience, this appears to be more common in YOPD. This type of pain associated intrinsically with PD ( like tremors, loss of smell, bradykenesia, etc.) is known as a “central pain” originating in the brain. This particular pain is typically described as a generalized -all over the body dull aching deep pain.

Other Common pain types in Parkinson’s disease patients are:

Musculoskeletal pain- usually due to poor posture (stooped forward), areas affected usually are large joint areas -hips, neck, back, shoulders, wrists. (throbbing, aching, sharp). Tender to touch, hurts to move but usually gets better after it starts moving.

Nerve root pain- usually related to neck and back pain, carpal tunnel. There appears to be an increase rate of back and neck herniated discs due to PD (presumably due to rigidity of axial muscles causing discs to bulge out) just like the same stiffness and rigidity can result in a dislocated shoulder. This is usually a sharp shooting, electrical –shock- like, burning, tingling, touch sensitivity (feels different to touch can be very painful or numb) and numbness. Usually triggered by particular position and relieved when resting most of the time).

Dystonia- one of which is “wearing off” dystonia. –twisting, cramping, or posturing of affected body part.

Restleness (akathisia)- extreme inner restlessness, unable to sit still, have to keep moving or pacing

In order to help your doctor determine cause of pain keep a diary.

Tell him/ her where the pain is?

What does pain feel like?

Does it go anywhere (radiate)?

When does it start?

Is it in the am or pm?

Is it related to medication intake? Or time they wear off?

Any activity brings on the pain?

How long it lasts? Is it continuous?

What makes it better? (Specifically if Parkinson’s medications make it better).

Remember the key to a good outcome in treating your pain before you go bonkers is being able to communicate your problem with your physician with as much detail as possible and keeping good notes. Pain in Parkinson’s like in any other disease sometimes is caused by the disease itself, at other times the medications and sometimes by completely unrelated factors just because we have Parkinson’s it does not exclude us from other illnesses which can cause pain (e.g. Diabetes, thyroid disease, fractures, arthritis, gout). With this in mind, you will be on your way to not only identifying correct source of pain but also getting appropriate treatment (which I will discuss in my next blog).

References: Wertheimer, Jeffrey. Understanding Pain In Parkinson’s. http://www.pdf.org newsletter winter 2012

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at defeatparkinsons101@yahoo.com contributor http://www.assisted-living-directory.com Contributor http://www.lavozbrazoriacounty.com

Pee Rex.

Treatment for over active bladder in Parkinson’s (revisited) : by Dr. De Leon

 

 

Whenever somebody tells me, you go girl! I generally have to!” -unknown

As I mentioned before in a previous blog Parkinson’s patients as do patients that have various parkinsonian syndromes like MSA ( multi system atrophy) can have varying degrees of bladder issues ranging from increase urgency,frequency to outright incontinence!  Having bladder function problems can lead to severe psychosocial problems like depression and anxiety particularly among patients over 65 years of age, they can also lead to significant medical and economic burden.  This is by no means an easy task to solve since independent of neurological disease, over active bladder ( OAB ) affects up to 27% of men and 43 % of women of the global population. Now add a neurological condition atop of this and the problem becomes even more challenging for physicians.

Fist,we should review a few medications which make this problem worst, if possible should try to avoid:

  • Diuretics
  • antipsychotics
  • cold medicines
  • narcotics
  • sedatives
  • hypnotics
  • antidepressants
  • antihypertensives
  • analgesics
  • Over the counter sleep aids
  • herbal remedies

Proper management of patients with urinary problems like any other problem begins with a thorough and comprehensive evaluation, including a void diary, urine test to look for infections, diabetes and the such. Of note those of us who have chronic illnesses by definition are on multiple medications which tend to complicate evaluation and treatment but worsen by age. Physical exam is also extremely important since it can tell physicians for instance if there is enlarged prostate in men or enlarged uterus in women causing pressure on bladder or blocking sphincter. Your doctor may choose to do urodynamic studies which includes measuring pressures of pelvic muscles and urethra and voiding flow-this sometimes requires insertion of needles into bladder and abdomen to evaluate…can be uncomfortable and moderately painful at times especially if you are in mid to late stages of disease. Other tests may include cystoscopy which involves looking into bladder with a camera inserted through a long narrow tube via the urethra …similar to a colonoscopy except different organ! Other times, they may simply choose to do volumetrics…fill your bladder with fluids via an IV ( intravenous Cath) until they can reproduce symptoms.

Once all these studies are done, which usually are done either by a urologists or a gynecologists, and a cause of the urinary malfunction is ascertained then treatment can be instituted.

Aside from evaluating all medications which MUST always be done at the onset of any visit to make sure current medications are not the ones causing or aggravating the problem, an adjustment of dopamine medications is often necessary and should be done early on as well. This is because Parkinson’s and other parkinsonian syndromes commonly have bladder dysfunction as part of the disease spectrum. If however you are still having problems after going through above steps then the recommendations are as follow:

1) Behavioral modification:

This entails a strict commitment on the part of the patient in order to improve voiding…if done properly..it can be very effective. Insurance will pay for this however, must go to a trained professional experience in this type of therapy to have greater success rate.

I like this because this is treatment modality epitomizes “individualized medical care

This includes voiding diaries, timed voiding, pelvic floor muscle strengthening exercises, and urge suppression techniques (e.g distraction, self-assertions), biofeedback, electrical stimulation into sacral nerves or pelvic muscles, fluid management, caffeine, reduction, dietary changes ( I.e avoiding bladder irritants like caffeine, chocolate, spicy foods etc.), weight loss and other life style changes.

The beauty of this is that it can be combined with other treatment modalities.

2) Pharmacotherapy:

this includes a number of oral and transdermal( across skin) medications. These can be very effective and used after behavioral therapy failed or in combination. However, their efficacy is limited due to side effects although usually non life threatening. All medications come in extended release.

The medications in this class are primarily antimuscarinic- they include oxybutin (Ditropan, Oxytrol), tolterodine (Detrol), solifenacin (Vesicare), darifenacin (Enablex), **trospium (Sanctura- does not cross blood brain barrier), fesoterodine (Toviaz). **This latter may be best suited for treatment of elderly patients due to less side effects. Typical side effects of this class include dry mouth, constipation,dyspepsia, urinary retention, urine infections, impaired mental status, and dry and itchy eyes. Since a lot of these symptoms can already occur with PD or as side effect of other PD medications have to be extra vigilant when starting these meds and discuss any sudden changes with your physician ASAP!

The new comer is mirabegron ( Myrbetriq) for those that can’t tolerate antimuscarinic. Although may act as one it is a beta 3adrenoreceptor. I find this medicine to work very well especially for those patients that have mixed type urinary problems where they have over activity and increase sphincter control.

3) Botulinum toxin A:

Once patient had failed above treatments, your physician may suggest this treatment modality. However, not everyone is qualified to do this procedure…it requires operating room time and frequent visits…effects can last up to 9 months (on average 6 months). You Must always have an experienced physician doing this procedure. It is expensive and not all insurances cover costs.

4) Sacral neuromodulation:

This has become the leading treatment of choice for those that do not respond to normal treatments. This treatment was approved since 1997 by FDA . Reports have shown great efficacy and safety with gradual implant of electrodes into third sacral nerve foramen (aperture) initially during a test phase of 1-2 weeks followed then by implantation of pulse generator. The electrical impulses delivered to the root of the third sacral nerve has been shown to reduce urgency, frequency, and incontinence. Most common side effects include pain at stimulator site, pain at lead site, lead migration, electric shock, and revisions. However, as these procedures are done more frequently, they are becoming less invasive along with smaller devices which will lead to fewer adverse effects. Just like having DBS, you will need periodic adjustments and will not be able to do MRI’s and will require replacement of pulse generator.

5) Surgical Intervention:

This still remains as the last possible alternative for severe cases that are unresponsive to any of the above treatment modalities.

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References-Kim, Ja-Hong. Management of Overactive Bladder and Urge incontinence. Practical Neurology. Vol. 13, No.7, September 2014. 27-32.

 

Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at defeatparkinsons101@yahoo.com contributor http://www.assisted-living-directory.com Contributor http://www.lavozbrazoriacounty.com

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Surviving a Stroke at 33 (and Blogging About It)

defeatparkinsons:

There is definitely an increase in strokes in young people over the last decade….

Originally posted on WordPress.com News:

Christine Hyung-Oak Lee suffered a stroke when she was 33, and she has written about her experience in an inspiring personal essay for BuzzFeed.

Before that, she was using a pseudonym on WordPress.com to blog about her experiences, share details about her life, and practice her writing. In 2007, shortly after New Year’s Day, Lee wrote the following in a blog post:

something in my brain burped. most of what i want to do is just out of my grasp. i feel like i know how to do them, but then when i go to do them, i just…CAN’T. day by day, i’m regaining my abilities, so i hope this is just temporary.

Lee’s commenters urged her to see a doctor, and the next day, she responded to them from a hospital bed: “I had a stroke! Will be better.”

I spoke with Lee about her experience, and…

View original 837 more words

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The Golden Team Necessary for the Best Parkinson’s Care: By Dr. De Leon

The other day, I read something someone wrote about which ideal team members should engage when considering long term care of PD. I was a bit disappointed to find that whoever wrote that piece was missing a large part of what goes on with Parkinson’s patients behind the scenes and what their needs really are. Especially when we realize that this chronic illness not only affects dopamine but other neurotransmitters like serotonin in the brain; but more importantly their function or lack off has great implications for our entire body from our guts to our skin and everything in between.

Therefore, when choosing your fantasy team or ideal “golden” players to be in charge of your PD care is best to keep in mind that just as you would not take an expensive car like a Ferrari to just any local mechanic if there was a problem with it you should not trust the care of your complex Parkinson’s disease just to anyone!

An all-star team that you should pick to stand on your corner to help fight for your interests. Ideally, this should include the following members:

1.  Neurologist (at minimum if MDS are not readily available in your area/ preferably an MDS- no need to have both if MDS readily accessible). MDS/Neurologist needs to act like the quarter- back. He or she understand your disease intricately and know you the best therefore, should be the ones coordinating all the care when it comes to PD issues to ensure the BEST possible outcome with the most prolonged quality of life!!!

2.   GI (gastroenterologists) – because of decrease motility, increase constipation, increase reflux,    trouble swallowing and nausea both due to medications and subsequently due to poor gastric motility; therefore, it is imperative you have a good GI specialist you follow on a routine basis. They can provide alternative treatments that neurologists may not be aware of like new meds for constipation etc. (Linzess is the latest and it won’t interfere with PD meds or aggravate PD symptoms).

3.   Urologist- because of increased bladder problems with PD, erectile dysfunction in men due to medications and sometimes due to disease if have other Parkinsonian syndromes like MSA, also because there is a documented increase in prostate cancer in those men taking Stalevo. Therefore, they serve to screen for pathology as well as offer various treatments and surgical procedures like Botox injections into the bladder that the neurologists or MDS may not be able to do themselves.

4.   Gynecologist – for women with PD because medications can cause menstrual irregularities, sexual dysfunction can occur both as part of disease and due to medicines, bladder issues, and an increase in breast cancer in certain subtypes of Parkinson’s population like LLRK2. They can treat these diseases and screen as well as offer procedures to help. Newest medication for treatment of bladder dysfunction which I have found to work well in PD patients with over active bladder issues is Myrbetriq.

5.   Dermatologist-due to an increase incidence of melanoma in PD patients especially if you have a history of this disease already present in your family. They can screen and provide treatment and early cure should melanomas develop and safe your life!

All these specialists should be able to work well as part of a group of multiple specialists where the neurologist or MDS is in charge of the ultimate game plan (this is crucial for a good working relationship with everyone involved). They should also have good working knowledge of the entire body system as it relates to Parkinson’s disease not just their own specific area. (This is equally important if things are going to progress in the right direction to maintain and prevent issues down the road). It is important to bring these specialists on board as early on as possible and maintaining them on as a regular part of the team for the duration of the illness not just on as needed basis. ( you may not need to see them as often as the MDS/neurologists but at least once a year just to maintain contact and make sure that all preventive measures are being done and keeping up with new treatments; more often if you have risk factors in some of the cancer areas)

Finally, you MUST engage the services of ancillary staff: PT, ST,OT, perhaps even a dietician and social worker – the service of these professional will become more invaluable as time progresses and disease advances. They will be the backbone to guaranteeing you have the right tools for a successful journey with PD.  At very least they will offer valuable information and tools to help improve your quality of life and those around you for every stage of your illness. Find those that have training and expertise in dealing with Parkinson’s disease and preferably those that are certified in Lee Silverstein voice training (LSVT) and the equivalent of the voice program LOUD, the BIG program which activates the gross motor system!

I guarantee a brighter Parkinson’s journey with this “golden” all-star team guiding your disease forward.

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at defeatparkinsons101@yahoo.com contributor http://www.assisted-living-directory.com Contributor http://www.lavozbrazoriacounty.com