Could Parkinson’s Disease Cause or At Least Increase the Risk of Asthma? By Dr. De Leon

“Breathing is the greatest pleasure in life.” ~ Giovanni Papini

They say doctors make the worst patients- I am no exception. In my entire medical experience, I have found that those of us who work in the medical field when confronted by illness typically have the worst most complicated and rarest disorders.  I am any primary doctor’s and sometimes specialist’s worst night mare. If I were my own patient, I would be pulling my hair at times because trying to maintain a balance in such delicate system where the slightest shift throws everything (me) into total chaos is hard to manage to say the least. As predicted by Murphy’s Law, I am not an easy patient to manage. To complicate matters, out of the clear blue I have develop asthma of all things…

I thought for sure I had one organ system intact that I did not have to check a box in the review of systems form. C’est la vie! I suppose. Yet, I often feel it might be easier for my doctors to ask me what I don’t have than the reverse. So, while I waited for my appointment to see my pulmonologist (one more specialist to see and coordinate care with!), I wondered why it was that I am becoming asthmatic; of course my first thought was to blame the radiation therapy I received for my thyroid cancer …but then again…it seems like Parkinson’s, at least the type I have LRRK2 gene, appears to be associated with inflammatory disease all of which are immunological in nature. What is asthma after all? But another autoimmune disease problem. I thought could there be a relation between my PD and asthma? Then, today I see an article talking about an increased risk of PD in those with asthma.

I began to think some more about the matter, a dangerous thing I tell you; But a sign that my dopamine is working JUST fine!

We know that asthma is widespread (~235 million worldwide) because of prevalence is easily identified and diagnosed as opposed to Parkinson’s despite the nearly 7 million plus worldwide. Because PD can have a very prolonged prodrome (pre-motor period) making diagnosis more challenging in the earlier stages. Playing devil’s advocate here- perhaps biasing results towards asthma leading to PD.

This led me to launch my own search of the literature for association between PD and asthma and unfortunately not unlike a lot of things in medicine in which we don’t have an answer the results are all over the place. Yes! PD can causes asthma. No! Rather asthma causes PD. Asthma prevalence is higher among those with inflammatory bowel disease such as ulcerative colitis which we know is more common in those with LRRK2 gene. One thing is for certain there is a clear relation and association between the two. The question remains to find out which came first the chicken or the egg?

In meantime, although most commonly patients experience shortness of breath particularly in advance stages due to wearing ‘off’ periods and stiffness of respiratory muscles; it may perhaps be worthwhile to keep in mind other possibilities and not assume it’s related to Parkinson’s medications directly because an asthmatic attack can be life threatening. There are more than 3,600 deaths per year due to asthma. While all the details are sorted out especially if you are like me (female gender higher risk) are LRRK2 carrier and have had or have other inflammatory immunological diseases such as ulcerative colitis / Crohn’s disease and have shortness of breath – at least consider the possibility of Asthma.

Things to look out for that are common in asthma:

  • frequently Coughing especially at night
  • Wheezing or coughing after exercise Shortness of breath or losing your breath easily, short winded
  • Chest tightness, pressure, pain
  • Feeling tired, fatigued, easily upset, grouchy, irritable, or moody
  • Trouble sleeping

Sometimes may be hard to differentiate since most of them can be seen with PD when in doubt consult your physician. Of course if shortness of breath gets worst with exercise or during cold weather or during viral infections like a cold, all of these are indicators of possible asthma Follow up with your physician immediately!

Now, I have one more medicine to carry in my already overflowing medicine bag…. but breathing freely once more. You, too, may be in need of some extra evaluation if experiencing any of these symptoms and not improved with increasing dopamine. Don’t Delay & BREATH HAPPY!

Sources:

http://www.webmd.com/asthma/guide/asthma-symptoms

https://www.ecco-ibd.eu/index.php/publications/congress-abstract-s/abstracts-2013/item/p664-asthma-prevalence-in-patients-with-inflammatory-bowel-disease.html

http://www.neurologyadvisor.com/movement-disorders/parkinsons-disease-asthma-severity/article/436675/

https://en.m.wikipedia.org/wiki/Epidemiology_of_asthma

#1 Cause of Cramping Toes & Legs In PD- By Dr. De Leon

“These cramps are crazy! But look on the bright side- at least is not a baby!” -unknown

 

In the past, I have written about the different causes of leg and toe cramping in Parkinson’s disease. However, the number one cause of cramping in those of us who have had Parkinson’s disease for many years is actually a metabolic cause indirectly related to PD Symptoms. What I mean is that we all have one singular symptom in common which is extremely trouble some for all of us despite our PD presentation. This horrible symptom which makes all of our lives particularly troublesome and even causes us to become moody, forgetful, and lethargic is no other than my friend and your friend-CONSTIPATION! Unfortunately, this is one of those symptoms that just wont go away! It often precedes the motor symptoms by up to 20 years and as the PD progresses not only does Gi motility slow down to a near halt due to PD but the medicines themselves are against us from the start.

So, how do we combat this pesky problem? throwing everything but the sink into our bodies sometimes just to be able to have a bowel movement. The thing we all forget is that with time the constant sloughing off the lining of the intestines by laxatives – especially those over the counter can cause severe Hypokalemia (low potassium) because it alters the function of the kidneys permanently!

To make matters worst, as we age many of us become hypertensive (high blood pressure) for which many receive treatment in the form of diuretics. This only compounds the problem and increases risk for cramps. Also, many of the medicines cause increase fluid retention again necessitating a type of diuretic.

 Therefore, I suggest that :

Featured image

1) Do not take laxatives on a daily basis – this only causes the body to become dependent and work even less unless higher amount (dosages) of laxatives are  consumed. I will suggest a cocktail solution for this which includes high water intake, increase natural juices, increase daily fiber in food and as supplement through over the counter fiber tablets, powder etc. increase exercise, increase vegetable and fruit intake along with stool softener. Then few times a week take prescription meds like lactulose, Miralax, Amitiza, or Linzess.

2) However, if above still not producing the desired effect – use over the counter laxatives –SPARINGLY! always alternate types such as enemas, mag citrate or other oral laxative brands-e.g. Ex-lax, Dulcolax… 

3) Have your doctor write you a prescription for potassium supplement 20mEq. EVERY TIME you take a laxative make it a point of taking a Potassium supplement pill along with it. Also increase consumption of potassium rich foods like white beans, lentil, raisins, pistachios, soy bean, avocados, and cocoa bean (my favorite)..

4) Have your doctor monitor your potassium routinely if staying low may need to be on a daily potassium supplement!

5) If possible avoid diuretics – try using naturally occurring diuretics like cucumbers, watermelon, tomatoes, green tea, asparagus, cranberries, and oats. This will also help to maintain regularity.

6) If you Must be on a diuretic if possible try potassium sparing medications -NOT LASIX.

7) Finally, if you do experience cramps quick remedy is a spoonful of mustard (keep packets handy especially when traveling) & drinking pickle juice- best when cold! If you are experiencing cramps multiple times a week and the other causes of pain and cramp have been ruled out then need to take daily potassium supplement and take extra dose when use laxatives!

References: (see prior blogs)

How to Deal with the 6 Common Causes of Leg pain in PD?

Tips to dealing with cramping toes

@copyright 2015 all rights reserved Maria De Leon

How to Deal with the 6 Common Causes of Leg pain in PD? : By Dr. De Leon

One of the biggest complaints I hear from people in PD support groups is a continuous relentless severe leg pain. Prior to a decade ago, I as all my fellow movement disorder specialist would have not thought leg pain to be a direct precursor of PD or an initial non-motor symptom. My grandmother often complained of pain and deep aches in her calves and in her legs which started before her tremors and shuffling were noticeable. But, I was unaware of the connection at the time and erroneously assumed her pain was neuropathic in nature due to her diabetes but was always somewhat surprised that she continue to complain of this pain on and off throughout her illness despite neuropathic medication. With hind sight what she was experiencing was central pain of PD. I too had severe pain first in one leg then the other which would come on suddenly without warning stopping me in my tracks throughout the day. I was constantly asking my husband to massage my legs just as my grandmother had asked of us time and time again.

So why do we have leg pain in PD and what can we do to relieve the discomfort?

First, some believe that lower limb pain is a specific non-motor phenotype variant of central pain in Parkinson’s disease. I, too, believe this; more importantly it can be one of the very first signs of PD as it was for me. This pain is usually bilateral.

Second, leg pain can also occur secondary to dystonia as an initial symptom or as a consequence of long term levodopa use (most common). When related to levodopa it usually occurs as a wearing off but can also occur at peak dose. In most cases this leg pain is unilateral and has direct correlation to medication intake.  When is due to dystonia pain is more common in early morning. This type of leg pain is usually accompanied by toes curling and foot abnormally posturing. dystonia in feet

Third, musculoskeletal pain due to rigidity, abnormal posturing and lack of mobility affects legs commonly causing pain in the legs, however this pain is usually more pronounced on the more affected side.

Fourth, pain in legs can also be caused by radiculopathy; nerves can become trapped or temporarily pinged in the spine or as they exit the spinal canal due to stiffness/rigidity of the muscles which exert an abnormal lordotic (curvature) of spine. Once again, this type of pain is usually confined to only on one side of the body and is positional meaning it is worst with standing and sitting and relieved by laying down. Pain usually radiates from back or hip down to leg and can also get worst with coughing or straining.

Fifth, pain in legs can also be due to medication effects or withdrawal from certain types of medicines like NEUPRO. In the latter, the pain which can be in both legs is more cramping.

Sixth, Let’s us not forget that we do not live in a vacuum and that just because we have PD does not make us immune to other common diseases such as peripheral vascular disease (PAD). Men are more likely to have this but women are not exempt. Risk factors include diabetes (remember PD may increase this risk), high blood pressure (again some PD meds may increase this risk), heart disease, high cholesterol, smoking, stroke, kidney disease.

The symptoms of this are:

– walking fast or uphill or for long periods to point of hurting immediately when walking

-Feet and legs feel numb at rest and skin is pale and cool to touch

Symptoms are worse with elevating legs and better with dangling over the bed.

Sometimes pain in legs can be a combination of all of the above.

Pain can be the most disability of all PD features interfering with all activities of living. Despite this fact it is often under treated and frequently overlooked. Any pain in PD should be promptly and effectively treated especially that of leg pain before the pain becomes chronic and your brain reorganizes itself completely to be able to handle the pain. I feel terrible because I did not fully understand the phenomena of central pain in PD at the time of caring for my grandmother. Fortunately, with adjustment of her levodopa meds her pain subsided for the most part. As I said before we have come a long way in understanding pain in PD, so there should be no reason why anyone should be subjected to dealing with pain on a daily basis when we have so many treatment options.

TREATMENTS:

Treatments therefore depend on properly identifying the source of pain.

  • If bilateral always assume it is central pain- pain due to PD and treat accordingly. As I mentioned many times before, Azilect works great for this type of pain.
  • Massage therapy works for all types of leg pain-my favorite.
  • If having pain due to dystonia first find out if occurring at end of dose or at peak dose so meds can be adjusted. If medication adjustment don’t work consider DBS. Pain due to dystonia also responds well to Botox, Myobloc, or Dysport injections, baclofen, Dantrolene, and Klonopin work well alone or in combination with other treatment modalities. Physical therapy (PT) can go a long way to alleviating pain of this type.
  •   If having radicular pain try trigger point injections, epidurals, nerve block, surgery, DBS (deep brain stimulator) for pain in the spine, Botox, Lidoderm patches, muscle relaxants, anti-inflammatories and steroids and PT.
  • To avoid and alleviate pain caused by stiff muscles the best treatment is activity in the form of stretching exercises- any number of activities will do such as walking, tai-chi, water aerobics, swimming, dancing, bicycling, yoga; of course if needed can use a Tylenol plus a Motrin or Advil as needed. Sometimes may need to up levodopa if stiffness is persisting or add a centrally acting muscle relaxant like baclofen or Neurontin.
  • To avoid cramps stay well hydrated. Make sure your patches don’t fall off! Eat food high in potassium like avocados, bananas, and strawberries. When cramp hits quick remedy spoonful of mustard with warm water or take some pickle juice.
  • If you have symptoms of PAD or suspect consult your physician immediately this can be a life threatening problem!!