When investigating the lifestyle impact of PD, Kuopio et al. found that women scored significantly lower on five of the eight dimensions of the SF-36 outcome measure. This study found depression to be more common among women than men [11]. They concluded that, to improve the quality of life in PD patients, it is necessary to recognize and treat the depression. Parkinsonian symptoms and symptoms of autonomic dysfunction such as constipation and sexual impotence in males predominate early in the course of the disease and certainly have an effect on mood. Constipation may be unrelenting and hard to manage in some patients.

Shy–Drager syndrome may be difficult to diagnose in the early stages; however, within a year of onset most patients develop postural hypotension. For the majority of patients, blood pressure is unstable – often fluctuating up and down and may cause severe headaches. Other symptoms may also develop, such as generalized weakness, double vision and/or other vision disturbances, impairment of speech, sensory changes, difficulties with breathing and swallowing, often causing pronounced snoring; dysphagia is a late symptom and affects both solids and liquids. This difficulty arises either from an inability to force the food down the throat or rigidity of the voluntary muscles of the throat and leads to complaints of food getting stuck in the throat. Ingestion of only small portions of food and careful chewing, one morsel being swallowed before the next is taken, may help. The problem is important because of the risk of aspiration. Other symptoms may include irregularities in heart beat, inability to sweat and diarrhoea.

Parkinson’s disease and physiotherapy

Exercise has long been a popular form of treatment with physiotherapists, although the effects seem to be best in the short term. A recent study by Morris et al. [12] confirms this. For the exercise group, quality of life improved significantly during inpatient hospitalization and this improvement was retained at follow-up. Inpatient rehabilitation produced short-term reductions in disability and improvements in quality of life in people with PD. Exercise training has also been found to decrease significantly the number of falls experienced by these patients [13]. Other techniques, including auditory cues [14] or the use of treadmills, have been tried with some success [15], but all the studies were relatively small and none appear to hold the key. As a novel way of combining both forward and backward walking in a pleasurable environment, tango lessons have been investigated, with some success [16].

The Royal College of Physicians guidelines have recommended the following:

‘Physiotherapy should be available for people with PD.

Particular consideration should be given to:

• Gait re-education, improvement of balance and flexibility

• Enhancement of aerobic capacity

• Improvement of movement initiation

• Improvement of functional independence, including mobility and activities of daily living

• Provision of advice regarding safety in the home environment’ [17].

All of the above will be tackled in a course of physiotherapy treatment at any stage of the disease but the addition of acupuncture may be of considerable benefit. There have been several studies investigating the effect of acupuncture on the symptoms of PD and a recent systematic analysis summed the situation up well, concluding that ‘there is evidence indicating the potential effectiveness of acupuncture for treating idiopathic PD’. The review found that, out of the 10 trials selected, nine claimed a statistically positive effect from the use of acupuncture [18].

The outcome measures most used were the Unified Parkinson’s Disease Rating Scale (UPDRS) and the outdated Webster scales. The Motor Dysfunction Rating Scale for Parkinson’s Disease (MDRSPD) was only used in one of the studies. The results were limited by the methodological flaws, unknowns in concealment of allocation, number of dropouts and blinding methods in the studies, but as acupuncture has been used clinically to treat the symptoms of PD for hundreds of years, the picture is encouraging for further research.

Acupuncture in Parkinson’s disease

Acupuncture remains a popular treatment for PD in far-Eastern countries.

Occidental medicine has a given definition for PD and knowledge of PD pathophysiology has led to development of therapeutic management. PD, even if not named, is likely to have always existed in different parts of the world. Description and management of this neurodegenerative condition are found in ancient medical systems. The following section attempts to introduce the philosophical concepts of traditional Chinese medicine (TCM) and the description, classification and understanding of parkinsonian symptoms in TCM.

There has been a serious attempt to re-evaluate the traditional treatments in the light of modern knowledge, in particular the herbal remedies [19], but a scientific review of all TCM therapies in this context is now needed.

In a non-blinded pilot study, 85% of patients reported subjective improvement of individual symptoms, including tremor, walking, handwriting, slowness, pain, sleep, depression and anxiety [20]. There were no adverse effects; however there were only 20 patients in this study.

Electroacupuncture may be a refinement that will be more effective in treating PD. It is used on body needles and also on those inserted into the scalp (see section on scalp acupuncture, below).

Some interesting work has been done by a Chinese research group, where electroacupuncture was applied at a frequency of 100 Hz at the points GV 20 and GV 14 to MFB transected parkinsonian rats who had rotenone (3 μg) administered bilaterally and stereotaxically into the medial forebrain bundle (MFB) to produce parkinsonian symptoms [21]. An extension of this work to human patients might produce significant results.

Nonetheless, the following sections will offer a selection of acupuncture points and techniques with varying rationales. The reason for point selection may ultimately be less important than the point itself. Table 7.1 gives a summary of expected symptoms.

Table 7.1 Symptom picture for Parkinson’s disease (including multiple-systems atrophy)

Symptom	Characteristic presentation	Parkinson’s disease
Decreased mobility	Rigidity
Fatigue	Lack of energy
Respiratory problems	Snoring	X Shy–Drager syndrome only

Muscle spasm Tremor

Contractures Stiffness and rigidity

Autonomic changes Slowing circulation

Cognition/mood

Communication

Bladder and bowel problems Usually drug-induced

Visual problems Rare X

X, usually absent; , common; , very frequent.

Body acupuncture

Acupuncture points, mainly on Yang meridians, can be used, as in all neurological diseases, to tackle the superficial musculoskeletal symptoms. Both pain and movement problems can be addressed. The points can be selected according to symptoms and Table 7.2 gives some of the alternatives. Many problems are directly caused by the medical interventions and these have also been listed. Electroacupuncture may be used at some of the points; the recommended frequency for body points is 2 Hz, while that for scalp points is 100 Hz.

Table 7.2 Parkinson’s disease – useful points

There is a danger of the list of acupoints becoming endless, so only the most specific points are given. These are selected for completeness from both Western medicine approaches and those more traditionally Chinese. Those that relate directly to the following TCM syndromes are also mixed in.

Scalp acupuncture

Perhaps surprisingly, scalp acupuncture is a technique frequently recommended for PD, in both Western and modern Chinese texts. This is a relatively modern idea and the technique claims to stimulate the surface of the brain, most particularly the sensory and motor cortices (see Chapter 12).

Points are located by identifying the anteroposterior median line as a reference (Figure 7.1).

Figure 7.1 • Location of motor area [29].

In PD both motor and sensory lines should be treated with the addition of the chorea or tremor area (Figure 7.2).

Figure 7.2 • Lateral surface stimulation areas [29].

The treatment can be used on either the unaffected side or bilaterally. The usual frequency should be between 100 and 200 Hz.

Some studies [22] have used scalp and body acupuncture together as an addition to the drug regime and there has been some attempt to analyse what may be happening in the brain during scalp acupuncture in a Parkinson’s patient, particularly as regards dopamine production; however more work needs to be done [23].

Some authorities claim that scalp acupuncture used early enough can alleviate tremor without any additional drug treatment, but if the disease has been present for more than 2 years the improvement will only be temporary [24]. Once the patient has been taking regular drug medication for many years it would be unwise to try to replace this with acupuncture treatment.