We recently diagnosed a newly retired teacher with Parkinson’s disease or PD, and referred him to the neurologist (brain and nervous system specialist) in our group.
He presented with tremors of his hand and fingers, which is more prominent at rest or when he’s not doing anything with his hands. His handwriting has also changed drastically so the bank does not accept the checks he has issued. His muscles are somewhat rigid and he has slowed movement (bradykinesia), with the typical PD gait—small, shuffling steps as if he has difficulty raising his feet.
The disease is essentially caused by a loss of nerve cells in the part of the brain called the substantia nigra. These cells are responsible for producing a hormone called dopamine, which helps fine-tune our muscle movements.
The loss of nerve cells in the substancia nigra may be caused by hereditary factors, various environmental and metabolic toxins; and chronic repetitive head trauma as in the case of boxers.
When told that he likely has PD, our patient asked us how come he developed the disease when he’s not a boxer, obviously referring to the late Muhammad Ali, who was disabled by the disease for many years before he died.
Unsolicited advice
The ordinary man on the street does not know much of PD. Ali had somehow become the face of PD. He was known for his agility and nimbleness in his youth as a heavyweight boxing champion, so it was pitiful seeing him in news features and documentaries before he died with full-blown features of PD—resting hand tremors as if he’s rolling a pill or marble with his fingers, stiffness of the limbs, decrease in facial expression, shuffling or “small steps” when walking. The exuberance in his movements at his prime was replaced by an extreme poverty of movement when he developed the disease.
A related concern was raised for Manny Pacquiao after his knockout loss to Juan Marquez in 2012, and recently, with news that he plans to return to boxing. Manny should take the unsolicited advice that he hung up his gloves for good before it’s too late. He’s pushing his luck too far, which might deprive him of an enjoyable quality of life in his senior years.
Although PD and Parkinsonism are sometimes interchanged, they’re not exactly the same and some brain experts explain that it’s Parkinsonism that is linked more to boxing-related trauma. Parkinsonism is the general condition and PD is just a type of it.
Permanent injury to the brain cells may result from single severe injury to the brain or repetitive head trauma. The brain cells or neurons in an area of the brain called substantia nigra deteriorate; hence unable to produce enough dopamine. Dopamine serves as a chemical messenger responsible for coordinating smooth and balanced muscle movement. When there’s dopamine deficiency, one loses the ability to control body movements.
In boxing, the head is hit at a high speed and with great force, causing shear movement between different brain tissues, resulting in small bleeding areas called microhemorrhages. This could not be detected with the old CT scans but with modern brain imaging techniques, they’re able to identify these.
Some correlate the risk of developing Parkinsonism in a boxer with the number of boxing matches and the duration of his boxing career. It’s the additive effect of all the fights that he’s been through, and all the head punches that he has endured through the years.
Long-term outcome
So if Manny were to ask us if he should quit boxing at this point, we’d probably tell him he should have done it long ago. But it’s still better to quit ASAP than lining up boxing matches indefinitely until he’s still able to throw a punch. That’d certainly be be unwise and foolhardy. Even exhibition matches can add insult to the chronic brain injury he already has.
Although linked to boxing, PD or Parkinsonism could develop as a degenerative disease in anyone. Being a degenerative disease, it’s more common in the elderly. Aside from repetitive head trauma, it can also be caused by prolonged intake of some drugs like major tranquilizers, antipsychotic drugs and some medicines for nausea and vomiting.
Street drugs like heroin derivatives, blood-vessel disorders leading to repeated strokes and infections like HIV-AIDS and encephalitis have also been reported to cause PD-like signs and symptoms.
Despite currently available treatment, the outlook for PD or Parkinsonism doesn’t look good. One experiences a progressive decline in physical function and mobility, such that even activities of daily living become a challenge. However, several studies have recently come out showing that regular physical therapy (PT) exercises may alleviate such progressive deterioration.
In a pooled analysis of 39 well-designed clinical trials (trial-length range 4-52 weeks), involving more than 1,800 patients, PT was associated with significantly faster walking speed and longer distance walked in two or six minutes, significant improvements in functional tests, ability to maintain balance and gait. The researchers also noted fewer falls or accidents in the PT group.
The results of these studies show significant positive results such that some treatment guidelines now consider PT as an important alternative or supportive treatment for PD particularly for those who could not tolerate the side effects of drugs given to reduce its signs and symptoms.
Although researchers are not sure on the long-term outcome with PT for PD patients, the short-term benefits are encouraging and should offer a ray of hope for many of our patients with PD or Parkinsonism. INQ