Forty-one

The tremor in her right arm has been so intense she has taught herself to write with her left hand. A list of the medications she has tried include three- Sinemet, Stalevo and Comtan, which doctors routinely prescribed to patients with Parkinson’s disease, though the doses have not been sufficient to produce a therapeutic effect.
She’s only forty- one but her medical work- up has been so thorough she could be two decades older. Her recall of events began with a debilitating headache that sent her to bed early, four years ago. She woke in the morning fuzzy, feeling hung- over and with pain in both arms. Tremor came as the pain subsided. After some time, the movement on the left side disappeared and only the right arm was left with tremor. Around this time she experienced sharp shooting pains on the left side of her face and a physician diagnosed her with trigeminal neuralgia. From a plastic Dollar Tree bag, she pulls the medical reports of her past tests, noting the physician who tested her for Lyme’s disease found she tested positive for antibodies, meaning she had been exposed to the illness. The movement disorder specialist leafs through these reports and finds the statement that reads the test was negative. The doctor asks how many times she was tested, and the patient replies the lab analyzed her blood several times.
A well- known physician specializing in movement disorders in New York City told her she the cause of her symptoms was stress. The doctor facing her explains what he thinks when he hears a physician tell a patient those words; symptoms have a psychogenic basis, or stem from the patient’s unconscious. In the older days they called it hysteria; one might suffer from hysterical paralysis, muteness or any other odd manifestation of psychological illness. The patient takes this news stoically, she doesn’t appear insulted. The same New York physician tried to dissuade the patient from undergoing a fluorodopa-signal PET scan, at the Feinstein Institute for Medical Research that performs the highly specialized test, telling her the results would only make her more confused. The results showed the patient had the findings of people with Parkinson’s disease. The specialist has great respect for the testing facility, and feels if the results harmonize with the physical findings of his exam, than they can conclude with some certainty, she has the illness.
Indeed, the doctor finds rigidity in the muscles of the right arm and wrist, while the left side appears unaffected. As he plies open and closed the joint at her elbow, the patient reveals she recently traveled to Germany where she underwent an infusion of her own bone marrow stem cells to alleviate the tremor of her arm. The clinic promised a fifty- percent chance of alleviating her tremor, and cautioned it might take up to six months to see a positive effect. It has been four months and she feels no change in her symptoms. The news peaks the ire of the physician and he feels compelled to tell her of an Argentinean clinic that had purported to find a cure through bone marrow stem cell infusion for patients with Parkinson’s disease. He pulls up the news story on the internet and reads the details to the patient before he inquires about how much money she spent at the German clinic. Adamant about the highly unethical nature of the treatment, which is at best only shoddy research; he comments the clinic should not have charged for a service without definitive and published proof the treatment was effective, and should have been checking on her to determine what sort of outcome she experienced.
Eventually, he sits and begins constructing a diagram that will increase the dose of Sinemet by a half tablet every three days, until the patient is taking approximately 1000 mg. of levodopa per day. While he writes, he speaks about the possibility that she may need to avoid proteins in the diet if she does not respond to the medication. The amino acids that make up protein compete with levodopa for transport across the blood brain barrier with the medication. And avoiding the proteins will assure that she gets the most levodopa into brain. Typically avoidance of protein is not necessary when patients are first started on Sinemet. However, when individuals state they did not improve on Sinemet, the doctor wants to see if the highest dose tolerated while on a protein free diet has any effect at all. If there is no benefit, then he can conclude that the patient does not have a dopamine deficiency (idiopathic Parkinson’s Disease). He passes the sheet to the patient and begins explaining he has made a staircase that she will ascend, with the goal of finding the dosage of medication that she can tolerate well, has a minimum of side effects and sees a reduction in her symptoms. This might occur at any of the higher stairs. Should she find the side effects too cumbersome she may back off a stair, to a lower dose of medication, but she should not throw away the medication and abandon treatment entirely. He suggests returning in three months time, so he can reassess the situation.

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