The Latest Thinking on Parkinson’s Disease Treatment

There may be no cure yet, but the right treatment plan for Parkinson's disease will help to improve symptoms and everyday function. "Medication is the starting point once a diagnosis is confirmed," says Adam Mednick, M.D., Ph.D., a board-certified neurologist in North Haven, CT.

Parkinson's disease involves a shortage of the brain chemical dopamine, which is produced in a region of the upper brainstem called the substantia nigra. While you may have heard of dopamine as a "feel-good" chemical in the body, it serves multiple other functions as well, including being essential for smooth, coordinated movement. When dopamine levels drop sharply, the brain can't send proper signals to muscles, resulting in movement problems. "Medication to replace the deficient dopamine can improve slowness (known as bradykinesia), stiffness, drooling, and tremor," says Dr. Mednick.

However, medication therapy alone is rarely enough to treat Parkinson's disease—in part because people with the disease become less active and deconditioned. The latest thinking on Parkinson's disease treatment? "Combining medication with rehabilitation and regular exercise gives someone the best chance of regaining an active and independent lifestyle," says Dr. Mednick.

How Is Parkinson's Disease Treated Today?

While every case is different, treatment of Parkinson's disease typically involves the following:

• Medication to manage movement and non-movement symptoms
• Regular exercise
• Physical, occupational, and speech therapy
• Mobility aids and home adaptations
• If necessary, advanced treatments for symptoms that become difficult to control

Medications for Parkinson's Treatment

The main players on any Parkinson's medication list are the combination drug carbidopa-levodopa, dopamine agonists, MAO-B inhibitors, COMT inhibitors, and amantadine. Let's take a closer look at each medication.

How Does Carbidopa-Levodopa Work?

Of all Parkinson's disease treatments, carbidopa-levodopa is the mainstay and most effective medication. "Dopamine itself cannot cross the protective barrier around the brain, so levodopa is used because it can cross that barrier and is then converted into dopamine inside the brain," explains Dr. Mednick. "Meanwhile, the carbidopa component stays outside the brain and blocks levodopa from being converted into dopamine too early in the body, delivering more levodopa to the brain and reducing side effects like nausea."

Carbidopa-levodopa is used in the early stages of Parkinson's disease. Dr. Mednick notes that when taken over many years, the benefit from each dose tends to wear off sooner and extra involuntary movements can appear. This reflects disease progression, not harmful side effects from starting the medication early. "There is no reason to delay it once symptoms affect daily life," he says.

It's important to take carbidopa-levodopa exactly as your doctor prescribes. "It works best on an empty stomach, usually about one hour before or two hours after meals, because a high-protein meal competes with the drug and can reduce how much reaches the brain," Dr. Mednick explains. "When taken separately from protein-heavy meals, the medication is absorbed more reliably and works more consistently. People who feel nauseated when taking it on an empty stomach can use a small, low-protein snack such as crackers or applesauce."

Dopamine Agonists for Parkinson's

A milder alternative to carbidopa-levodopa is a dopamine agonist such as pramipexole, ropinirole, or the rotigotine patch. "Dopamine agonists mimic the effects of dopamine in the brain. Rather than being converted into dopamine, they directly stimulate dopamine receptors, essentially making the brain respond as though more dopamine were available," explains neurologist Daniel Truong, M.D., medical director of the Truong Neuroscience Institute at MemorialCare Orange Coast Medical Center in Fountain Valley, CA, and editor in chief of the Journal of Clinical Parkinsonism and Related Disorders.

Dopamine agonists can improve slowness, stiffness, and tremor. They may be used alone or in combination with levodopa to help reduce "off" periods, the time when levodopa wears off and Parkinson's symptoms can return. But Dr. Truong notes that these drugs can cause more behavioral and neuropsychiatric side effects than levodopa. "These may include excessive sleepiness or sudden sleep attacks, hallucinations, leg swelling, and impulse-control problems such as compulsive gambling, shopping, eating, or sexual behavior," he says. "These potential side effects are particularly important to discuss when deciding whether a dopamine agonist is appropriate."

Taking MAO-B Inhibitors

Another Parkinson's disease medication, MAO-B inhibitors, help reduce symptoms by allowing dopamine to remain active in the brain longer. "MAO-B, or monoamine oxidase B, is an enzyme that helps break down dopamine," says Dr. Truong. "Medications such as rasagiline, selegiline, and safinamide inhibit this enzyme, prolonging dopamine's effects." They generally provide a modest improvement in motor symptoms, he adds.

MAO-B inhibitors may be used alone in some people with early Parkinson's disease or added to levodopa when its effects begin to wear off between doses.

What Are COMT Inhibitors?

COMT inhibitors, such as entacapone and opicapone, may also be prescribed to people with Parkinson's disease alongside levodopa. "COMT, or catechol-O-methyltransferase, is an enzyme involved in breaking down levodopa," says Dr. Truong. "COMT inhibitors make each dose of levodopa last longer and are primarily used in people taking carbidopa-levodopa whose symptoms return before the next dose is due. They help keep levodopa available for longer, providing more sustained symptom control and reducing 'off' time."

Amantadine for Parkinson's

Amantadine is a drug that can be particularly useful for treating levodopa-induced dyskinesia, the involuntary, excessive movements that can develop after prolonged levodopa treatment. The exact mechanism of amantadine isn't completely understood, says Dr. Truong. "In simple terms, it helps rebalance some of the brain signals involved in movement and can modestly improve Parkinson's symptoms. However, attention should be paid to its potential side effects, such as confusion, hallucinations, dizziness, ankle swelling, and livedo reticularis, a mottled or net-like discoloration of the skin, which can be particularly important in older adults."

The Role of Exercise Rehabilitation in Parkinson's Treatment

The Parkinson's Foundation recommends early referral to physical therapy as part of every Parkinson's treatment plan. Research has found that physical therapy and regular exercise can significantly improve motor symptoms, balance, gait, and overall quality of life for people with Parkinson's disease.

Physical therapy can be beneficial at all stages of Parkinson's disease to help you keep moving. The Parkinson's Foundation recommends asking your doctor to refer you for a baseline physical therapy evaluation as soon as possible and continuing with routine re-evaluations throughout the course of the disease.

According to the Parkinson's Outcomes Project, a clinical study of more than 13,000 Parkinson's patients in five countries, increasing physical activity to at least 2.5 hours a week helped slow the progression of Parkinson's symptoms in study participants.

How Occupational Therapy Helps Preserve Independence

Parkinson's disease treatment often involves a multi-disciplinary approach, and occupational therapy typically plays a prominent role. "An occupational therapist focuses on how Parkinson's disease symptoms may be impacting participation in meaningful daily tasks," says Melissa Werz, OTD, OTR/L, an occupational therapy doctorate program instructor at Duke University School of Medicine in Durham, NC.

This may include activities such as dressing, grooming, showering, cooking, cleaning, handwriting, typing, driving and hobbies or leisure, explains Werz. "They will work with you to identify where there are concerns and provide strategies to modify tasks or use adaptive equipment so you can keep participating in the tasks that are most important to you."

An occupational therapist helps to preserve independence by observing a person's greatest challenges with Parkinson's, then creating tailored treatment plans through exercise and equipment modifications while educating people on how to modify daily tasks, Werz adds.

How Mobility Aids Support Parkinson's Treatment

Every person living with Parkinson's disease may require mobility aids at some stage, but there's no set timeline for when to introduce a cane, walker or rollator, or other type of support. What's right for you depends on your particular mobility challenges, such as balance, freezing, or difficulty transferring. A physical or occupational therapist can carry out an assessment to help you decide when it's the right time for mobility support and what that might look like for you.

Advanced Medical Treatments for Movement Symptoms

When oral medications no longer provide steady control over Parkinson's movement symptoms, advanced medical treatments include:

• Continuous pump infusion therapies. A wearable pump can deliver carbidopa-levodopa gel directly into the small intestine via a small tube placed in the stomach.
• Deep brain stimulation (DBS). This therapy helps to normalize electrical rhythms in deep brain regions via tiny electrodes.
• Focused ultrasound. By targeting specific areas of the brain, focused ultrasound can reduce tremors and movement issues using acoustic energy to form tiny thermal lesions.

How Parkinson's Treatment Changes Over Time

Treatment for Parkinson's disease will evolve as the disease changes. "Physicians look at when symptoms occur in relation to medication doses, how long each dose lasts, whether there are 'off' periods or dyskinesias, and whether problems such as freezing, falls, hallucinations, or excessive sleepiness are developing," says Dr. Truong.

Medications for Parkinson's continue to improve. As the disease progresses, most people end up taking more than one class of drug, adding agents such as MAO-B inhibitors, COMT inhibitors, or amantadine to smooth out fluctuations and control dyskinesias while keeping the levodopa dose manageable, adds Dr. Mednick.

The important thing to remember is that although there is no cure for the condition, there are an increasing number of effective treatments to help you keep symptoms at bay. If one stops working, don't be discouraged. Talk with your doctor about alternative approaches. Together, you will come up with a treatment plan that works.

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