Archive for the "Medical Corner" Category

VIDEO – Symptoms and Diagnosis

Continuing to explore the topic of symptoms and diagnosis, watch this short video which was part of our partnership with TPT in 2014.

All through the month of January we will continue to explore symptoms and diagnosis of PD, so keep checking back!

Parkinson’s Disease – Early symptoms and diagnosis

january MOAWith the start of 2015 NPFM is launching a new initiative, addressing issues surrounding Parkinson’s disease. The articles and videos used during the year-long campaign will open a conversation about the disease and its affects on individuals and families living with PD.

Each month will feature a new topic. If you have an issue you would like to see addressed, please contact our office.

For the month of January NPFM will focus on early symptoms and diagnosis.

We have two features this month: a video regarding the topic from our partnership with TPT in 2014 and a written piece from Dr. Martha Nance of the Struther’s Parkinson’s Center in Golden Valley.



By Dr. Martha Nance
The four “cardinal features” of Parkinson’s disease that lead doctors to make the diagnosis are:
Slowness or smallness of movement
Stiffness of the limbs
Changes in posture, gait, and balance

An occasional person might use exactly these words to describe the symptoms that they have noticed, but some may use a variety of other words, or notice more specific or different symptoms.

“Tremor” refers to rhythmic, repetitive movements, often in the finger, hand, or arm, and often just on one side.  Some people may use the word “shaky” or “shakiness”.  Some people can make the tremor go away by clenching the fist or moving the hand to a different position.  The typical tremor of Parkinson’s disease is most noticeable at rest (a “resting tremor”) and improves or goes away with activity. Tremor can involve the chin or mouth or the leg, less often the trunk or neck.

“Slowness” and “smallness” of movements may manifest as slower walking, a shortening of the stride length (“shuffling gait”), or slowness doing usual activities like dressing or preparing meals.  Smallness of movements in the hands may lead to small handwriting, inaccuracy or slowness of keyboarding, sewing, playing the piano, or other hand activities that require a high degree of coordination.  If movements of the tongue and lips and throat are slow or small, the voice may become quiet, raspy, slurred, or stammering in nature.  Family members and friends may notice a lack of facial expression or slowed blink rate.

“Stiffness” may present as cramping, tightness, charley horses, or aching—often in the same limb or limbs that have tremor or smallness of movement.  The hand or arm may be held in a stiff posture when a person is walking.  It can be hard to separate the stiffness due to Parkinson’s disease from stiffness due to arthritis or other causes.  Stiffness occasionally results in pain.

Changes in posture and gait are often more noticeable to the viewer than to the person who has the problem.  Family members may repeatedly urge the person to “stand up straight” or “quit slouching” or “hurry up”.  A stooped or forward-leaning posture, shortened stride length or arm swing, and reduced confidence about a person’s balance are common.

In addition to these core symptoms, people with Parkinson’s disease may experience—or may have experienced—a host of other symptoms in the years leading up to the diagnosis of Parkinson’s disease.  Constipation, loss of sense of smell, changes in mood, and a variety of disturbances of sleep are common and may begin years (possibly decades!) before the motor symptoms start. Of course, there are many other causes of constipation, loss of smell, mood and sleep disturbance that have nothing to do with Parkinson’s disease.  Therefore, doctors do not make a diagnosis of Parkinson’s disease until the motor symptoms are present.

So, how does a doctor diagnose Parkinson’s disease?  Usually just by recognizing those core motor features.  The more of the features a person has, the more confident the doctor is about the diagnosis.  If only one or two features are present, the doctor may be reluctant to call it Parkinson’s disease.  If there are additional or atypical symptoms (prominent changes in thinking or memory right away, hallucinations, falling as an early symptom, and abrupt onset of symptoms are some atypical symptoms), the doctor may suspect a variant of Parkinson’s disease rather than the usual condition we described above.  If the doctor is unsure whether a person has Parkinson’s disease or not, he may ask the patient to return in a few weeks or months for a second neurological exam.

Researchers are working to develop a “test for Parkinson’s disease”, but that hasn’t quite happened yet.  The FDA has approved a kind of brain scan called a DAT Scan (different from a CT scan or MRI scan), which measures the availability of dopamine in the brain, but the test is expensive (and may not be covered by insurance), not necessary in clearcut cases of obvious Parkinson’s disease, and hard to interpret in cases that are unusual or atypical.  If your doctor has ordered a DAT scan, check to make sure your insurance will cover the cost of the test!

Depending on the situation, the doctor may order a regular brain imaging test (CT or MRI), to rule out other things that can cause symptoms similar to Parkinson’s disease, or do blood tests to look for other medical conditions that can cause stiffness, tremor, or pain.

For many years, doctors have said that “the best test for Parkinson’s disease is to see how well the person’s symptoms respond to levodopa.”  In a sense, taking a levodopa pill determines just about the same thing that a DAT scan measures—the need for more dopamine in the brain—but in a way that is often quite obvious to the person with Parkinson’s disease, the family, and the physician.  You should discuss with your doctor whether you should take levodopa, or any other Parkinson medication.

The time of diagnosis is a difficult time for a person with Parkinson’s disease.  If the diagnosis comes as a surprise, it is difficult.  If the diagnosis is slow in coming, or different doctors disagree about the diagnosis, that is equally difficult.  Make sure that your doctor has told you what you need to know about the diagnosis, any medications that you might receive, and any rehabilitation therapy that has been recommended.  Seek out accurate information, as available through the National Parkinson Foundation pamphlets and books.  And don’t be afraid to ask questions!  There is life after a diagnosis of Parkinson’s disease!

For more about Parkinson’s disease, early symptoms and useful information visit the national website:

Struthers Receives HealthPartners Award











The Struthers Parkinson’s Center, a National Parkinson Foundation (NPF) Center of Excellence located in Golden Valley, was recognized with the HealthPartners President’s Team Award Thursday evening in downtown Minneapolis.

The award is presented to teams within the HealthPartners network that go above and beyond to improve the health of members, patients and the community.

Struthers innovative model of care using a team-based approach, has been servicing the area since 1978, and has resided at its current location in Golden Valley since 1995. Struthers serves the needs of Parkinson’s patients and their families through comprehensive assessment, interdisciplinary treatment, support, research and education for both patients and care partners. The ultimate goal is to improve quality of life at every stage and help people live well with Parkinson’s disease.

For more information about Struthers and what it offers visit its website.

NPFM Clinical Advisory Board Statement Regarding Robin Williams

A message from Dr. Martha Nance, chair of the Clinical Advisory Board for the National Parkinson Foundation of Minnesota:

The Minnesota Parkinson’s disease medical community, like the rest if the country, is grieving the recent death of Robin Williams. Even more, we are saddened by the tragic manner if his death. Depression is common in people with Parkinson’s disease, but like many symptoms of the disease, it is often quite treatable.

Many people lead a rewarding and active life for many years after a diagnosis of Parkinson’s disease.  If you think you might have Parkinson’s disease, make an appointment with a Parkinson’s specialist to get an accurate diagnosis and appropriate treatment: Parkinson Disease Specialists.

And if you are depressed, uncertain, lost, or panicky after a diagnosis of Parkinson’s, or if the recent revelation about Robin Williams has sent you into a tailspin, call your primary care physician, your neurologist, or a mental health specialist for help. Let us hope that Mr. Williams’ tragic death will help others to live better.

Dr. Martha Nance, chair of the NPFM Clinical Advisory Board and medical director of the Struthers Parkinson's Center in Golden Valley, a NPF Center of Excellence.

Dr. Martha Nance, chair of the NPFM Clinical Advisory Board and medical director of the Struthers Parkinson’s Center in Golden Valley, a NPF Center of Excellence.

Parkinson’s and DBS: Fargo hosts seminar

Our friends in the Parkinson’s-Friendly Community of Fargo, N.D., recently hosted a seminar for local residents to learn more about the Deep Brain Stimulation procedure and how it may help some people with Parkinson’s. Here’s the seminar in three components:

Presentation Part 1

Presentation Part 2

Presentation Part 3

Reassurance regarding the recall of Medtronic DBS devices

People with Parkinson’s disease should feel free to contact their treating physician or clinic with any concerns. Please do not worry unhelpfully about this issue without contacting someone about your concerns.


By Martha Nance, M.D., Struthers Parkinson’s Center


We learned late last week of a recall on the Medtronic deep brain stimulator devices that are used for Parkinson’s disease. Although the recall has been classified by the FDA as a Level 1 recall, meaning that the device could cause “serious adverse health consequences or death”, the surgeons and neurologists who use the devices are confident that our patients are not at any substantial risk of harm.

The problem that was identified has to do with a temporary cap that is used by some surgeons at the time that the stimulator devices are implanted in the brain. Most neurosurgeons place the leads into the brain (the subthalamic nucleus or the globus pallidus) during one procedure. Then, in a second procedure a couple of weeks later, they place the impulse generator, or battery, under the collarbone and connect the brain leads to the battery by means of some flexible wires tunneled under the skin. At the time of the first procedure, the surgeons often place a temporary cap under the skin over the top of the leads, which is removed when the device is connected to the battery during the second procedure.

The cap is fixed in place by a small set screw. If the set screw is tightened too forcefully, it can damage one of the leads within the device. Neither the surgeon nor the patient would be aware of that at the time, because the device is not connected to a battery yet and is not turned on. When the battery is connected to the leads a couple of weeks later, it would be immediately obvious even in the operating room, and certainly at the time of initial programming, if one of the leads was damaged, because the electrical properties of that lead (the impedance) would not be in the expected range.

The DBS device has four leads, and the one that is most likely to be impacted by an over tightening of the screw is the shallowest lead, which is often not used in programming anyway (think of the subthalamic nucleus as a baseball and the DBS electrode as a bat; ordinarily, the middle two of the four contact points would most likely represent the “sweet spot” for stimulation, just as the batter would prefer to hit the ball in the middle with the middle of the bat rather than either end!) If a particular lead is damaged, one would either make a note not to use that lead for programming, or replace the device. Replacing the device obviously carries with it the risk of an additional surgical procedure.

Some surgeons do not use the cap in the first place; like wearing a hat when you go outside in early May, it is an optional thing, not necessary for the proper placement of the DBS device. Many surgeons have used the caps successfully, without over tightening the screw. The cap itself is not dangerous, and does not remain in the body after the brain leads are connected to the battery. One report that I read indicated that 0.25 percent (1 out of every 400) of the DBS devices implanted are affected by this problem, which means that 99.75 percent of people who have had DBS devices implanted are not having a problem related to this recall.

I am trying to be as reassuring as possible to anyone who has had a DBS device implanted, without making light of a problem viewed by the FDA as serious. At Struthers Parkinson’s Center, we will work closely with Medtronic in the coming days to ensure that patients are notified of the recall, that we review our records for any evidence of DBS leads that were nonfunctional at the time of initial programming, and that any of our patients who have concerns are able to speak with the doctor or nurse, or to be seen, if necessary, in a timely fashion.

People with Parkinson’s disease should feel free to contact their treating physician or clinic with any concerns. Please do not worry unhelpfully about this issue without contacting someone about your concerns. And for those who are anticipating DBS surgery in the future, do not worry about the safety of the procedure; surgeons have been instructed not to over tighten the screw, and Medtronic is working on a more fool-proof solution to this problem.

I do not receive any personal financial compensation of any type from Medtronic; the opinions expressed in the blog are my own and do not represent an official statement from Medtronic, Park Nicollet Health Services, or Struthers Parkinson’s Center.

Diagnosing Parkinson’s disease … by colonoscopy?

by Martha Nance, M.D.,  medical director, Struthers Parkinson’s Center

Diagnosing Parkinson’s disease…by colonoscopy? Just kidding. But this idea may not be as far-fetched as it sounds! For years, people with Parkinson’s disease have been telling their doctors that Parkinson’s disease affects more than just the arms and the legs. Doctors are finally starting to listen. (more…)

Depression and Parkinson’s: A simple test

by Steven Stein, M.D. Minneapolis Clinic of Neurology

Depression is a very common symptom in Parkinson’s disease and may affect nearly half of all patients. The cause of depression may be related to the circumstances that the Parkinson’s disease creates, but also may be related to some of the chemical changes going on in the brain. Depression is an important symptom to recognize because it can have a very significant effect on quality of life and because it is potentially treatable.

Sometimes the diagnosis of depression may not be immediately apparent. Your doctor may often ask you questions about your mood, but sometimes your doctor may also utilize various rating scales to help make that diagnosis. One such scale, included here, is the 15-item Geriatric Depression Scale.

Please feel free to answer the questions on this simple test and then share the results with your treating physician.

Note: The information included on this blog post is for educational purposes only. It is not intended or implied to be a substitute for professional medical advice. The reader should always consult his or her healthcare provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a medical condition or treatment plan. Reading the information on this blog does not create a physician-patient relationship.


Summer sun, your skin and Parkinson’s

By Martha Nance, M.D., medical director, Struthers Parkinson’s Center

The long-awaited long days of summer are here, and I head out to my garden, as do many of you (or to the lake, the jogging path, or even just the back porch), I am reminded to review the special measures that people with Parkinson’s disease need to take to maintain good skin health.

People with Parkinson’s disease have twice the risk of developing melanoma (a serious, potentially fatal form of skin cancer) as people who do not have Parkinson’s disease. In Caucasians, the risk of developing melanoma during a person’s lifetime is about 2 percent. In people with Parkinson’s disease, that risk doubles, up to about 4 percent.  (Interestingly, the correlation also goes the other way: people who have had melanoma are more likely to develop Parkinson’s disease).

The good news for non-Caucasians is that the lifetime risk of developing melanoma is lower than in Caucasians (about 0.3 to 0.4 percent in Hispanics and Native Americans, and 0.1 percent in people of Asian or African descent).  Unfortunately, there is no specific information about the risk of melanoma in people with Parkinson’s disease in those non-Caucasian groups, but we guess that they also have a higher risk than normal.

Scientists aren’t sure what the connection between Parkinson’s disease and melanoma is.  Is it something about the diseases?  Is it the medications that we use to treat Parkinson’s disease?  We don’t have a satisfactory answer to that question, but since the association between the two conditions goes both ways, it seems likely that it has something to do with the diseases themselves.

What can YOU do to lower your risk of developing melanoma?  We can’t make the Parkinson’s disease go away or change how much time you spent in the sun as a teenager, but you can protect your skin from the sun now and in the future.  Some researchers think that intermittent sun exposure (sunburn) increases melanoma risk even more than chronic heavy sun exposure (as in farmers or construction workers).

People with Parkinson’s disease can develop many other skin conditions, some related to Parkinson’s disease, and some just related to age; basal cell carcinomas, actinic keratoses, squamous cell carcinomas, seborrhea, etc.  Reducing sun exposure can also help to protect against some of these conditions, and an annual skin examination can help to detect them early.  All of these skin conditions and lesions can be treated, so there is no reason to postpone seeing the doctor about them.

So, my recommendations for people with Parkinson’s disease are:

  • Use sunscreen; avoid excessive sun exposure in general, and sunburn in particular
  • If you have a worrisome spot—a “mole” that is growing, bleeding or painful—have your doctor or dermatologist (skin specialist) take a biopsy as soon as possible. Don’t wait!
  • Have an annual skin exam, which includes the scalp and other areas that you can’t see
  • Consider scheduling regular visits with a dermatologist; ask your Parkinson’s doctor for a referral
  • Have fun in the sun this summer, but make sure your good health is “skin-deep!”
Note: The information included on this blog post is for educational purposes only. It is not intended or implied to be a substitute for professional medical advice. The reader should always consult his or her healthcare provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a medical condition or treatment plan. Reading the information on this blog does not create a physician-patient relationship.

Did you get the message about exercise? Keep Moving!

by Martha A. Nance, M.D., medical director, Struthers Parkinson’s Center

Run, run, run!

Did you get the message yet about EXERCISE as an important treatment for Parkinson’s disease? I know everyone just wants a pill that will make their Parkinson’s disease go away, but unfortunately, we don’t have that yet.

What we DO have, what has been shown to help both mice and humans with Parkinson’s disease, is exercise.

Just about every week for the last two to three years, there has been an article in a medical research journal describing the benefits of exercise. Some of the studies have looked at mice. Some have looked at bicycling, some at the effects of Tai Chi. The most recent article I saw showed that people who took levodopa had a more dramatic and sustained improvement in the function of the dominant hand, than in the nondominant hand. The researchers felt that this demonstrated that medication and active use of the limb combine together to produce more benefit. The nondominant hand improved some with medication alone, but the improvement was never as great as in the more active dominant hand.

Along those lines, there is a sense that vigorous exercise may help preserve brain cells better than lighter activities. Doctors do not agree yet on what the term “vigorous exercise” means in a person with Parkinson’s disease, or how often a person needs to exercise in order to get any benefit. Half an hour of exercise four days a week is certainly better than nothing! Give it a try!

If you have no idea where to begin, then start with your doctor, and ask for a referral to a physical therapist. The therapist can work with you to customize a home exercise program that fits your abilities, and is safe. Some people, after that, will join exercise classes or groups at the health club, the senior center, or the Parkinson’s Center.

A little peer pressure sometimes helps you to stick with a program! Others use a personal trainer to help keep them motivated. We do not know for sure that one kind of exercise is better than another for people with PD. I often say to people, however, based on common sense, that bicycling, or an elliptical machine, may be particularly useful. Using these pieces of equipment force a person to use the limbs on both sides in a symmetrical fashion. Often Parkinson’s is worse on one side than the other, so you can use your “good” side on the bicycle or elliptical machine to force the “bad” side to move bigger or faster than it would on its own. And then you keep those pathways in the brain activated.

Summer is a great time to start an exercise program, or to get back on track if you were less active over the winter. Join the growing number of people with Parkinson’s disease who walk, run, swim, pedal, Nordic walk, ski, golf, and bowl. Get out there and do SOMETHING!

Note: The information included on this blog is for educational purposes only. It is not intended nor implied to be a substitute for professional medical advice. Readers should always consult their own health care provider to determine the appropriateness of the information for their own situation. Readers should also contact their own providers if they have any questions regarding a medical condition or treatment plan. Reading the information on this blog does not create a physician-patient relationship.
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