Counseling Sheet

Agatha M. Thrash, M.D.
Preventive Medicine

Also called the shaking palsy or paralysis agitans, Parkinson's disease is a degenerative disease of the aging central nervous system. The cause is not certain. Dr. James Parkinson, a London physician, first described Parkinson's disease in 1817. It was relatively uncommon until the 1930s, when it erupted to epidemic proportions. Then, inexplicably, new cases of Parkinsonism appeared less frequently. Parkinson's disease is a slowly progressive deterioration of certain parts of the brain called the basal ganglia. Among the white races the prevalence of Parkinson's disease ranges from 66 to 188 per 100,000 in the general population. There is no specific geographical pattern. Parkinson's usually begins after age 50.‍

SYMPTOMS‍

In Parkinson's disease, the brain is deprived of dopamine, a catecholamine neurotransmitter. It is estimated that at least 85% of neurons requiring dopamine must be lost before symptoms of Parkinson's disease are apparent.

The changes in the brain are expressed in the person by a disturbance of motor function and by a slowing down of the emotional responses. The three diagnostic signs of Parkinson's disease are muscular rigidity, tremor, and a slowing of voluntary movements. There is also weakness, shuffling gait, slight flexion attitude of the trunk and a movement of the hands called "pill-roller's" movement. There is a tendency to drool and a disturbance of speech, respiratory changes, nutritional changes because of difficulties in chewing and swallowing, osteoporosis, contracture and deformity, pressure ulcers of the skin, and problems with the autonomic nervous system. There is little rotary movement of the cervical spine or free swinging of the arms. The gait is that of hurrying with small steps in a bent attitude as if trying to catch up with the center of gravity to avoid falling forward. The symptoms may come on over a period of a few months to many years. The person begins to have a mask-like face without expression, and staring eyes.

Two principal symptoms of Parkinson's disease are resting tremor and stiffness of muscles. The disease more frequently starts with a tremor of the hands while at rest, or in a single extremity. The tremor is an involuntary rhythmic movement and the rigidity causes difficulty in relaxing a muscle, even during sleep. Eventually, difficulty in swallowing both foods and liquids ensues. Besides muscular rigidity and tremors, the person may also drool, stoop, have a shuffling gait, burning of the skin, and loss of appetite. The speech may be impaired and there may be a fixed facial expression.

‍CAUSES

‍Parkinson's disease has been related to viral infections, such as flu. There is actual death of cells in brain centers, such as could be expected from toxins or viruses. When these conditions begin to develop, treat the patient vigorously with exercise, diet, herbs, and massage to minimize the damage from the agent. In a study done in Vancouver of 891 Parkinson's disease patients, researchers concluded that individuals with Parkinson's disease had suffered a viral infection, and that it was somehow linked to this illness. Teachers, medical workers, loggers, construction workers, and others who worked together in groups were most likely to be affected (Medical Tribune. 40(17):11;1999). Parkinson's disease frequently follows an attack of encephalitis. The average age of new patients is getting older. For a while, it was going up one year with each passing year.

Metals. Work-related exposure to certain metals over a period of two to three decades appears to increase a person's risk of developing Parkinson's disease. Exposure to manganese, zinc, aluminum, copper, and certain combinations of metals (lead and copper, lead and iron, iron and copper) has been associated with a much higher risk of Parkinson's. Pipe fitters, electrical workers, chemists, and fire fighters are all in jeopardy from exposure to metals.

Herbicides and Pesticides. Industrial exposure to pesticides or herbicides may be a factor in the development of Parkinson's disease. Organophosphate poisoning leads to acute Parkinson's, but it is reversible.

Toxins. Perhaps a ubiquitous toxin which kills the brain cells of people who are genetically predisposed to such damage may be the cause of Parkinson's disease. It was found that Chinese people who live near industrial chemical plants are four times more likely to develop Parkinson's disease than rural villagers who work in undeveloped areas.

Well Water. Drinking well water in a rural environment is a risk factor for Parkinson's disease, and the total life exposure to an environmental toxin may be more important than exposure in early life.

Drugs. Metoclopramide has been definitely linked to Parkinson's disease. Dialysis may be a cause of Parkinson's disease. Possibly this is due to aluminum in the dialysis water.

Iron. Maintenance of brain iron homeostasis is important for the normal functioning of this organ. Certainly, a high iron level acts as an oxidant in the body, and may hasten all other degenerative processes. Low iron seems to cause a subsensitivity of striatal dopamine neurotransmission. By contrast, the selective increase in free iron in the substantia nigra pars compacta of Parkinsonian brains is thought to initiate oxidative stress, from iron induced liberation of cytotoxic oxygen free radicals. This kind of process may be responsible for dopamine neuron degeneration in Parkinson's disease. Perhaps iron chelators could be of help. Iron supplementation may set the stage for some of the known causes to be more operative in causing Parkinson's.

Diet. A low intake of antioxidants such as vitamins C and E, selenium, and fruits and vegetables have all been implicated in the development of Parkinson's. Predisposing factors for Parkinson's are diets high in animal food, high in vitamin D (notably milk), vitamin A supplementation, and diets low in folic acid (plentiful in fruits and vegetables). Replace refined calories with complex carbohydrates. Use 6-10 prunes taken with breakfast. The excessive use of polyunsaturated fats without sufficient antioxidants is suspected as contributing to Parkinson's.

Excess Protein. A low-protein diet improves tremors and reduces slowness in walking. Protein intake in excess of 0.5 gm/kg tended to make patients worse, and to make them deteriorate faster. The full nutrient content of the diet in the investigations made was not reported, and the number of patients was small. Very low levels, 7-10 gm. per day, may be tried for a period of time such as two months to determine improvement. Treatment of Parkinson's with Levodopa, a large neutral amino acid that can pass the blood-brain barrier, and high levels of protein cause Levodopa to be adsorbed poorly, and the blood levels fall of L-dopa. The protein competes with the L-dopa. All patients so far investigated have benefited from the low-protein diet. High levels of L-dopa must be given to gain the therapeutic effect if the patient is on a high protein diet. On a high-protein diet, patients are likely to get dyskinesias from overmedication because of having to overcome the absorption effects of high levels of protein. Patients on a low-protein diet can often reduce their L-dopa levels up to 40% or more.

Do not eat rancid foods or free fats (margarine, mayonnaise, fried foods, cooking fats, or salad oils). Avoid eating any ready-prepared mixes with eggs or mono- or diglycerides, as they are often altered by storage in an unhealthful way for the nervous system.

Overeating. It has been found by researchers that overeating may be related to the development of Parkinson's disease. It is felt that an overabundance of animal fats or carbohydrates might be an intermediate or contributory risk factor for Parkinson's disease because of the potential overload of the antioxidant system. None of the researchers is yet willing to state definitely that overeating causes Parkinson's, but merely suggests that there may be an increased risk from Parkinson's disease caused by excessive intake of calories. Neurology. 49(1):310; July 1997. Avoid heavy foods such as nuts, free fats, and concentrated proteins. Food restriction, even in thin patients, may increase the lifespan and decrease the neurodegenerative diseases such as Parkinson's, Alzheimer's, and Huntington's disease, as it does in animals. Alternating days of feeding helps animals, and may help humans as well.

Islander's Traditional Food. The cause of Parkinson's disease has not been fully delineated, but for West Indians there are several suspects. Environment and consuming a lot of paw paws (another name is papayas), custard apples, and herbal teas made from the leaves, seeds, or bark of these plants are suspect. Similar symptoms have been reported from Guam and Guadalupe. It has been thought that a slow toxin in the islander's traditional food was the culprit in these instances as well as the high incidence of Parkinson's disease in Afro-Caribbean and Indian immigrants in England who continue to eat their own ethnic food. The Lancet. 354: 281, 1999.

Genetics. Other possible causes of Parkinson's disease are genetics (although some think it is unlikely), and zones in the brain producing "noisy interference."

‍TREATMENT‍

The treatment of Parkinson's disease must include the whole person. It should be emphasized that there are stationary periods in the development of this illness lasting from 5, 10, or more years when there is little, if any progression in symptoms. We should play down the progression and incurability and emphasize problems such as stiffness, and fixation of joints in the bent position. Mechanical aids and devices may achieve many normal functions for the patient and should not be denied him in the mistaken belief that dependency on them will be harmful. Exercises for Parkinson's disease are directed mainly toward counteracting the rigidity and postural defects. Breathing exercises, stretching, manual resistive exercises and passive exercises to obtain maxim range of motion of joints constitutes significant portions of the exercise program. Speech therapy may be used and exercises for the face, tongue, neck, chest, and abdomen, rhythmic marching, clapping and singing can be helpful. Exercises should be faithfully performed so as to prevent muscle and joint freezing. A high step gait is practiced to prevent shuffling and to keep the lower extremities limber. It can be achieved while walking on a floor containing irregularly located obstacles such as books. If the patient's feet become frozen to the floor so that he cannot initiate a step forward, he should be instructed to bend his toes upward and this will often unfreeze him for walking. The patient may compound his physical problems by weakness due to disuse. Pain may occur from lack of movement and faulty posture.

The treatment of any chronic disease must extend over long periods of time and is often unsatisfactory when the cause of the disease is unknown, as in Parkinson's disease. Keeping the symptoms under control is primary in the treatment. ‍

Newsweek of August 14, 2000, reported on a woman who underwent experimental brain surgery for her advanced Parkinson's disease. Before the operation, she could hardly take a step. A month or two later, the same woman was filmed striding easily across a room. Her operation, however, had been a sham. In a study on fetal cell transplantation, researchers had put her in the placebo group, anesthetizing her and actually drilling holes in her skull, but they had not placed any new cells in her brain. The placebo response was entirely responsible for her miraculous recovery. It was found that the patients receiving the sham procedure benefited almost as much as those who had live fetal cells implanted. No longer can the placebo response be considered the result of quack doctors with gullible patients who had imaginary illnesses.‍

Herbs

‍For spasm and rigidity of the muscles, use Atropa belladonna. The root of the Atropa plant is recommended in all forms of Parkinson's disease, but the dosage must be reduced for a time if dryness of the throat develops.

Henbane leaves (Hyoscyamus niger) make a good tincture for Parkinson's disease. If the fresh herb can be found, use two to six ounces per pint of alcohol soaked together for three weeks. Start with five drops, three or four times daily, and slowly build up to 30 drops, three or four times daily. Also recommended is the use of Aloe vera capsules.

Formula for PD Tremors: Black cohosh is a muscle relaxant, even for smooth muscles, and can dilate blood vessels in the head to cause headache because of its muscle relaxing qualities. Cut the dosage of black cohosh in the formula to one teaspoon if one tablespoon of it causes headache.

1 T black cohosh
2 T St. John's Wort
2 T skullcap

Bring five cups of water to boiling. Then add one tablespoon black cohosh. Simmer gently for 25 minutes. Remove from heat and add the other two herbs (and 1/4 cup peppermint tea leaves for flavoring the otherwise harsh flavors). Let steep for 30 minutes, strain, and drink in five doses throughout the day. Make fresh daily.

Kava kava is contraindicated in Parkinson's disease. Although no side effects have been reported, kava may interfere with dopamine production and thereby worsen Parkinson's disease. Until this issue is cleared up, kava extract should not be used in Parkinson's disease.

Other herbs that can be used include Corydalis cava to reduce tremors and Harmine (Peganum harmala). A tincture made from the seeds of thorn apple (Datura stramonium) also relieves tremors. Use one to two ounces of the seeds to one pint of alcohol. Soak them together for three weeks, strain, and begin using 15 drops of the tincture per day. Gradually increase to 40 or even 60 drops a day; it is best taken in a single dose only once a day.

It should be noted that the herbs recommended for Parkinson's disease above can be toxic. It is probably best to use the commercial preparations which have been standardized. After becoming familiar with their properties, then you may consider making your own from the herbs and alcohol.

‍SUPPLEMENTS‍

L-dopa, the standard drug treatment for Parkinson's disease, is a toxic drug associated with nausea and loss of appetite, has major side effects in some persons of loss of sanity, a variety of cardiac disturbances, and a fall in blood pressure (6). Fava beans (broad beans) and velvet beans are both excellent natural sources of L-dopa, yielding about 25 grams of L-dopa per kilogram of beans. The average daily dosage is about 3 grams. It seems reasonable that the development of favism may be due to the large amount of L-dopa found in these beans (7). They may be cautiously used to determine if a benefit can be derived.

Taking 750 milligrams daily of any magnesium salt may help to relax the rigidity Vitamin B-6, up to 1,000 milligrams, and vitamin C, up to 3,000 milligrams, may be helpful in the initial stages of Parkinson's. Start with a small amount of the vitamins and build it up slowly. If diarrhea occurs, reduce the magnesium salt to 300-500 milligrams.

As much as 2,000 units a day of vitamin E have been recommended. We recommend less than this as a general rule, perhaps 400-800 IU, as this dose is better for long-term maintenance. Use the natural form of mixed tocopherols rather than synthetic alpha tocopherols. Taking some nuts, olives or avocado daily is also good.

The B vitamins are believed by many to be helpful in nerve disorders. Foods such as bananas, asparagus, whole wheat bread, brewer's yeast, carrots, dried lima beans, frozen lima beans, oatmeal, oranges, peanuts, soybeans, sweet potatoes, winter squash, avocado, walnuts, wheat germ and yams which are high in vitamin B-6 may be used. Thiamine should also be emphasized in various foods such as dried limas and navy beans, rice, cooked oatmeal, potatoes, grapefruit, strawberries and peaches (5).

Other nutrients that are believed to be helpful in Parkinson's disease include niacin, phenylalanine, tryptophan, and essential fatty acids taken as a supplement. Co-enzyme Q-10 (CoQ-10) is believed to be helpful in doses of 250-300 milligrams daily. Natural vitamin B supplement - uncooked brown rice polishings (two tablespoons per day) should prove helpful in most cases. Avoid zinc in any of your supplement preparations, as it may encourage neurodegenerative diseases like Parkinson's and Alzheimer's diseases. Eat foods that are high in zinc naturally, such as pop corn, pumpkin seeds, and nuts. Soy lecithin for two months out of every year can be helpful.‍

Massage

‍Massage is helpful for Parkinson's - especially neck, shoulders, and head massage.

A relaxing foot rub before or after a soak in warm water to assist in reducing muscle pain and inducing sleep.

Massage to the lower limbs to normalize gait, improve sense of balance, and minimize problems encountered when trying to rise from the sitting position.

To relieve general fatigue caused by lack of exercise.

Stretching traction and range of motion to reduce the rate at which weakness and stiffness occur.

An olive oil rub, whole body (or at least the extremities), two times a week is beneficial. A good routine is to start with wet sheet packs and massage every other day for one month, then one per week. The hot bath or sauna should be helpful, as well as the fomentations.‍

Other Measures

SKIN CARE:‍

Drooling may occur because of difficulty swallowing. Skin irritation should be treated with frequent wiping and the use of an emollient such as "Vaseline milk" prepared by emulsifying a small lump of Vaseline by rubbing in the palms with water. Patients should be instructed to lie on their side to prevent saliva from pooling in the back of the mouth.

Parkinson's disease patients often have excessively oily skin, and external eye disease is frequent. Greasy scales should be removed from the eyes daily with a saline-moistened cotton tip. Patients should wash their bands before touching their eyes.‍

MOUTH CARE:

‍Mouth care is important to prevent aspiration of any remaining food particles, as it is often difficult for Parkinson's disease patients to manipulate and swallow food. After each meal the patient should brush the teeth and rinse the month to remove any remaining food particles. Because of the difficulty swallowing many patients suffer from chronic dehydration which increases the likelihood of urinary tract infection. Fluid intake should be adequate to keep the urine almost colorless.‍

BATHING:

‍The use of the continuous bath (a hammock swing in a tub of continuously running or intermittently drained water) can relieve symptoms remarkably. Begin the bath at 92° F in a well-ventilated and cool room. Some patients may want a warmer room than others, and may want the bath water at 99 or even 98° F. The comfort of the patient should be consulted. Maintain the bath for about two hours and follow it with a light general massage or alcohol rub. Give the baths five to six times a week. During the first half hour, a slight fall in blood pressure and increase in pulse and respiration can be expected. Very quickly, the burning and other unpleasant sensations cease. The tremors diminish or stop while in the water. Some patients are enabled by this treatment to stop all medication and make permanent improvement. Others are helped only while they are actually in the bath. For these, it is quite permissible to continue the baths beyond two hours, even 12-15 hours, as availability of personnel permits. The beneficial effect of the bath is the soothing of a barrage of nerve impulses from the skin which reflexively produces a calming influence to reduce the tremors and rigidity. Anything that will quiet nerve impulses from any part of the body will have a beneficial effect on Parkinson's disease - keeping the extremities warm both summer and winter, relieving skin problems, avoiding minor illnesses, and keeping the bowels cleansed and freely functioning. Medical Record. August 26, 1916, p.367-368.

The patient may benefit from a salt glow with each daily shower. The salt tends to draw out acid through the skin from 1/8th inch depth.

‍SAFETY PRECAUTIONS

‍Bars in the bathroom, and a non-slip bathtub surface will help prevent falls. Throw rugs should be tacked to the floor.‍

BED‍

The patient should have a firm bed, without a pillow, to assist in keeping the spine straight. Lying face down may help some patients. If the patient has difficulty rising from bed, elevating the head of the bed on four inch blocks, or attaching a knotted rope to the foot of the bed to allow him to pull himself up, may be helpful. Movement may be initiated by vigorous rolling or rocking movements. The patient should not sleep with anyone, as both will be disturbed.

‍CLEANSING PROGRAM‍

A 2-week cleansing program may be used for patients as follows: Fast three days drinking two quarts of warm water every morning.‍

Continue the fast with the water but add, day by day, the following meals:

• First day, only raw food, fake only this one food in the one meal.
• Second day, two raw foods, one in each of two meals.
• Third day, three raw foods, two of which are at breakfast, and one at lunch.
• Fourth day, four raw foods, two at each meal.
• On the fifth day, gradually begin returning to a regular diet. A vegan cuisine is the most favorable diet for Parkinson's.

The patient should never lie down after a meal, or do any kind of heavy work - either physical or mental. There should be some light work or light exercise immediately after the meal. The person should not eat a large evening meal. A bit of fruit and some bread or cereal would be all right, although it must be taken at least two to four hours before going to bed.

‍Exercises in Parkinson's Disease:

• Bring the toes upward with every step. In Parkinson's disease, "one never makes a move" without lifting the toes.
• Practice 15 minutes daily walking a few yards and turning, walking in the opposite direction and turning, taking long steps (at least 28 inches to a stride). It may be necessary to keep the legs 12 to 15 inches apart when walking or turning, and not crossing one leg over the other when turning. It is best to do the walking exercise out-of-doors.
• During at least 5 minutes of the walking, the eyes should be fixed on a point in a tree directly over the top of the head while walking, compelling him to throw the head and shoulders back, concentrating on talking long steps.
• Practice walking into tight corners of a room to overcome fear of close places.
• To help ensure good body balance practice rapid, small excursions of the body, backward, forward, to the right and left, for 5 minutes several times a day. Do not look for a wall when you think you are falling; just learn to balance yourself.
• When the feet feel frozen or glued to the ground, a lift of the toes will eliminate muscle spasm and the fear of falling and free one to walk again.
• Swing the arms forcefully when walking to help take the body weight off the legs, lessen fatigue, and loosen the arms and shoulders.
• When arising from a chair, get up with "lightening speed" to overcome the pull of gravity and any muscle spasm. Sitting down, however, should be done slowly with the body bent sharply forward until touching the seat. Practice sitting down and getting up at least a dozen times a day.
• Practice with a pair of wooden dumbbells standing erect, raising them from the side, above, and back of the head touching them together. Hold the dumbbells straight in front; carry them back as far as possible in a horizontal line, repeating four times.
• Standing erect open the hands and extend them as far back as possible, then carry them high above the head and back as far as possible after the fashion of flying. This should be repeated 20 times while holding the head back and looking at the ceiling.
• Select a small stone from the woods just large enough to fill the hand comfortably and swing it around, one stone in each hand, with arms at full length about 20 times.
• Squat on the ground and place the hands flat on the ground, palms downward (a picnic table may be used if preferred). Place the stones used in the exercise above on the backs of the fingers and raise the stones up ten times with each hand, keeping the fingers flat, and the heel of the hands on the table.
• To stop tremor, take a rubber ball (which one carries handy with him) and work the hand on the ball. By squeezing it and turning it in the fingers, the tremor can be stopped for considerable periods.
• If rigidity is a major factor (and to prevent rigidity from progressing) a very hot bath may be taken just prior to the exercises, as hot baths tend to relax the rigidity. While treatments may not entirely prevent the spread of rigidity, the crippling effects of rigidity can be entirely prevented by exercising and hot baths.
• The exercises should be performed happily and under cheerful circumstances so that the greatest benefit can be obtained, and the patient will be willing to continue with them.

Routine for Parkinson's disease:

• Be on a regular schedule for all major events, eliminations, exercise, meals, sleep.
• Exercise out-of-doors several hours daily, and stay out-of-doors as much as possible, sleeping on a sleeping porch and doing one's reading or writing out-of-doors. To be near vegetation with its discharge of negative ions has some benefit.
• The extremities must be kept entirely warm at all times as even slight chilling increases rigidity. There must be no tight bands.
• Charcoal by mouth can be used if toxicity appears to be a part of the problem. Use 4 tablets twice daily taken in the mid-morning and mid-afternoon.
• The diet should not contain any free fats as they tend to cause a reduced oxygen supply to the brain. A sugar-free diet is best, as free sugars (honey, syrup, molasses, and cane sugar) tend to make the blood heavier and thicker, and less able to get into small capillaries in the brain.
• L-dopa occurs in the seedlings, pods, and beans of broad beans or fava beans, velvet beans, and certain other beans. In their natural balance, the beans my have sufficient quantities of L-dopa to give the person with Parkinson's disease some relief.

More Suggestions on Exercise:

‍The patient's determination and faithfulness in exercising will go far toward slowing the progression of the disease. They should be as independent as possible. Muscles will not freeze up as long as they are being kept active. When walking, let the heel touch first, and the toes be brought up with every step. They should take large steps and lift the feet as though stepping over objects on the floor. Swing the arms forcefully when walking. This loosens arms and shoulders, decreases fatigue, and shifts body weight off the legs. When walking, clasping the bands behind the back will discourage leaning forward.

Practice rising and sitting at least a dozen times daily. Sit down slowly with the body bent sharply forward until touching the seat. Rise rapidly to overcome the "pull of gravity." Placing the feet well apart is often helpful. Sometimes putting one foot slightly backward beneath the chair is easier. An overhead pulley helps to loosen up the shoulders. Lift the arms at least a dozen times daily. Rotate the arms upward as far as possible 12-15 times a day.

Exercising by marching, clapping and calisthenics, using music will help overcome the slowness of motion typical of Parkinson's. Patients who have difficulty walking will often have great improvement of the speed and the length of stride, with decreased numbers of times in which they are temporarily unable to move, by using an ordinary musical metronome. These can be purchased from music stores for under $30.00. The device will help them to cross streets faster and to get more exercise (Lancet 347:1337, May 11, 1996). Patients quickly learn to put the foot down with each click of the metronome.

At times, the feet of patients afflicted with Parkinson's disease feel frozen or glued to the floor. Lifting the toes eliminates muscle spasm and frees the feet to continue walking. Keeping the feet 12-15 inches apart when walking or turning gives a broader base of balance. To change directions when walking, use short steps with feet widely separated. Do not cross one leg over the other while turning. Practice walking a few yards, turning, walking in the opposite direction, and turning for 15 minutes every day. Also practice climbing stairs.Neck, shoulder, finger, thigh, knee and ankle muscles are particularly likely to form contractures, and special attention should be given to exercising these muscles. It is the contracture of the anterior group of neck muscles which draws the head and shoulders forward in the typical Parkinson stoop. The patient must constantly strive for proper posture with a straight spine, shoulders back, and head up. Stand with the heels, hips, shoulders, and head against a wall, pressing in the lower part of the back to reduce the lumbar curve. Try to hold this posture when walking or standing. Practice looking straight ahead when walking, instead of looking down at the feet. Sitting with pillows pressed against the upper spine and moving the head backward as far as possible will stretch these muscles.To exercise the elbows place the fingers on the shoulder, then straighten the arm. Repeat 12-15 times a day. Stretch the fingers at the same time. Lying face down on a firm surface, lift the head and shoulders five to ten times three times a day. Bracing the hands against door jams while standing in the middle of a doorway, and doing push-away with the arms strengthens pectoral muscles. Keep the head erect and the chin retracted during the exercise. Typing, playing a piano, working with clay or putty, buttoning and unbuttoning a piece of clothing, etc., all serve as good finger exercises.

A stationary bike is an excellent method of preventing hip adduction and ankle contractures. Walking in a "goose-step" with legs stiff is a good form of exercise for the ankles and legs.

Chest expansion may be decreased because of muscular rigidity, decreasing vital capacity. Deep breathing exercises will mobilize the rib cage, and improve lung capacity and volume. Diaphragmatic breathing should be practiced at all times.

Frequent rest periods should be taken. The patient is easily fatigued, and frustrated by his symptoms. Clothes with front fastenings, zippers or Velcro fasteners rather than buttons, elastic waistbands, and slip-on shoes will assist the patient in dressing himself. Tight-fitting garments should be avoided. Constipation should not be allowed, as this condition makes both rigidity and tremors worse. Constipation sends to the brain impulses that signal a disorder, and act as an irritant to cause tremors and rigidity. Check the transit time to see if it is more than 30 hours. If it is more than 30 hours, measures should be taken to increase the physical activity and emptying of the bowel.

Singing lessons, speaking, or reading out loud are helpful to maintain voice control and developing better voice volume. Singing with forced lip movement will mobilize the facial muscles. Holding a voice sound for five seconds helps improve facial control. Expression of vowel sounds will be best. Singing the scales helps improve tone inflection. Extending the tongue to the nose and then to the chin develops tongue control.

Pure and positive thinking, trust in Divine power, and an attitude of forgiveness and trust toward others can have a very positive effect on Parkinson's disease.

References:

‍Hopkins, Helen and Helen Smith. Occupational Therapy. 5th Edition, Philadelphia, Lippincott Co. 1978.

The Lancet May 7, 1977, p. 1005.

Baker, A. B., editor. Clinical Neurology, Volume 3, Hagerstown, Maryland, Harper and Row, 1980.

The New England Journal of Medicine 267:297-299, August 9, 1962.

Let's Live, August, 1989, page 22.

Modern Medicine, October 29, 1973, page 35.

The Lancet, 2:640, Sept. 20, 1969.