It’s been several months since his initial diagnosis. The medication- a 25/100 dose, three times per day has little, if any impact on his symptoms. Is it the protein in his diet, blocking the absorption of the drug? His last dose was about noon. Three hours later his left hand has noticeable tremor. The doctor concludes he is under-medicated.
They speak about augmenting the dose of levodopa. Higher doses of the medication increase the possibility of hallucinations. The doctor comments patients usually see small people, though animals are also common. The patient confides he already sees things that aren’t real. In a hanging print in his home, he sees the bicycle wheels spinning. The doctor nods and tells the couple that sort of visual trick is an illusion, where a hallucinations can be tested by reaching out towards the object. If the object is real it won’t dissapear. The doctor explains he likes to give Seroquel along with an increased dose of levodopa. Seroquel diminishes the likelihood a patient will experience hallucinations, and helps to provide more restful sleep. Nodding, the patient decribes a scenario where he has the same dream, over and over throughout the night.
Patients may choose to change their diet, rather than increase the dose of levodopa. In that case, the doctor recommends pooling the day’s protein into the last meal of the day, knowing that after dinner he’s apt to be more slow and rigid. Should he have an evening event scheduled, it would benefit him to avoid proteins in that meal as well.
A separate solution to under-medication is to add an dopamine agonist to the daily regimine. The agonist delays the absorbtion of levodopa, so it is remains available for a longer time. The Neupro patch (which delivers the dopamine agonist Rotigotine), bypasses the digestive system, transfering the medication directly through the skin. With both the patch samples and the larger dose of levodopa, the patient may find he needs less levodopa. The doctor cautions him, should he feel light-headed when he stands, it’s a sign his blood pressure is low. In that case he might cut the levodopa back slightly.
About the neuropsychological testing he underwent after the previous appointment, the doctor scans the note in the computer. No diagnostic determination was made. The physician felt the patient’s depression may have led to the low scores. In sum, the scores gave some indication the patient suffers from compromised executive function, which is in line with those who suffer from Parkinson’s disease. The results give credence to the patient’s complaint that he feels not as sharp as he once was.
Before allowing the couple to exit, the doctor asks about exercise. He reinforces the notion that cardiovascular exercise is a valuable tool to slow progression of the illness and improve the quality of life.
The patient’s phone calls precede his appointment. He has read researchers have found a link between influenza and Parkinson’s disease. Diagnosed with PD not long ago, he found a journal from a year ago in which he describes a transient flu-like illness. The nurse coordinator brings the patient’s phone call notes, as the patient may want to discuss the matter directly with him. She recalls the Spanish influenza outbreak that occurred in 1918, with patients subsequently suffering with encephalitis lethargica and later developing Parkinson-like symptoms. The doctor begins to expound on the relationship between influenza and PD as the patient appears with the nurse.
A small, balding man the patient engages immediately with the doctor. He’s read an article exploring the relationship between inflammation brought on by a virus, and the loss of dopamine-rich cells in the brain. His interest was piqued because he’d discovered he’d had a virus before he was diagnosed with PD. The medical student asks, “How long was the gap in time?” She notes a recent study in Movement Disorders sites the span as being within weeks of diagnosis. The patient nods. His face and gestures enthusiastic, he states this describes his personal scenario. Behind the desk the doctor nods, lifts his eyebrows and shares that the relationship between influenza and later PD might be trickier than they think. For example, some researchers report inverse relationships between childhood infections and later PD. Childhood red measles may offer some protection against later viral infections that may threaten dopaminergic populations by activating the immune system at an early age.
The medical student notes a secondary issue bridging influenza and PD was the medical attention severe illness warrants, bringing an increased scrutiny of the patient, and therefore any symptoms would likely be caught by the healthcare team. The doctor concedes studies of antibodies would reveal what exposures a patient’s had. The student interrupts him, “They found no relationship between examination of influenza antibodies and PD patients, when compared to controls.”
The doctor adds an influenza virus may have been the final insult, precipitating Parkinsonism. Unfortunately, whatever the reason, the patient has symptoms that are worthy of management. Whatever the cause, the pathology; the dwindling population of dopamine neurons requires attention, if one hopes to lead a high quality of life. The doctor slides from his seat and take the patient’s elbow in his hands. He opens and closes the arm feeling the response of the muscles to movement. He notes a fraction of rigidity. The student follows him, mimicking his motions as the doctor asks whether the patient has other concerns. The patient asks about his research and how far into the future will it be before there is something new for the illness. The doctor agrees too many years have passed since the sixties when levodopa first became available. A lot has changed since those days, we think of Parkinson’s disease as a group of related illnesses now. Theories exist on how the illness develops. Drug companies are looking for ways to address other dwindling neurotransmitters. With an aging population such questions will demand more attention.
Two patients in addition to those scheduled have arrived in the last half hour. The department of Neurology allocates thirty minutes for people returning for a follow-up appointment. New patients are granted an entire hour. The scheduling error has the doctor in a mildly irritated state. The nurse coordinator pokes her head in the room indicating two patients are competing for his attention for the next appointment. The double booking was done by the university secretarial staff, who was unaware of the length of time given to the doctor’s patients.
The new patient, who has waited twenty-five minutes arrives with his grand-daughter. The patient is Greek. His language, and his parkinsonism make his speech difficult to understand. The black-haired girl comes along to translate his words. She begins speaking as soon as they enter the small space. Her grandfather has been cared for by his regular doctor. When his problems became more severe the family sought an appointment with the movement disorder faculty. The doctor explains his new patients normally receive an hour, but today’s situation is unusual as two others are waiting to see him as well. The doctor shakes off his aggravation with the wave of a hand and asks, “What brings you to the movement disorder clinic this afternoon?”
The young woman gazes at him, stating, ‘Yes, but this isn’t our problem. We have insurance and pay for our time.’ The doctor nods and sits as the grandfather speaks Greek in a whispery voice. The girl bends in towards him, translating his words.
The main problem is he gets stuck every night. Nodding, the doctor scans the paperwork. Medications are listed, as well as the dose. What does he mean by stuck? The doctor explains patients with Parkinson’s disease suffer from freezing episodes. The daughter translates, he has episodes of freezing but that’s not his current concern. His right leg gets stuck inward and it occurs in the middle of the night while lying in bed. The doctor nods and comes around the desk. He tells the granddaughter he must check the rigidity of the man’s muscles, to see how well the medication is working. As he moves the limbs of the bent man in the chair, he speaks about three common ailments people with PD tend to suffer from.
Tremor is the initial symptom in many patients, and he illustrates moving his hand in a fine jiggle. The girl nods, she’s seen the tremor. The left foot of her grandfather also jiggles. Dyskinesia. He repeats the word when the girl looks at him questioning. The word describes the somewhat writhing-like movements patient’s endure. Occurring after several years of treatment with levodopa, the unusual actions are caused by medication, a side effect. The grandfather shakes his head. What the physician pantomimes is not his problem. He stands carefully, pushing off the arm rests of the chair, then turns his right leg inward so the toes of his foot meet the instep of his left side. Standing, he speaks Greek and makes a face indicating with his hands the pain he experiences. Nodding at the old man, the doctor comments, “A lot of pain.”
“Much pain, too much” and he retakes his seat.
“Dystonia.” Explaining that it’s a muscle cramp that forces the limb into unusual sustained postures. The doctor concedes they can be quite painful, and afterward leave the tissue sore. He thinks if her grandfather switches his evening dose of medication to a sustained release variety, he may find some relief from the episodes. The girl translates this and the man gives a thumb up.
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.
He gets anxious behind the wheel of the car, cursing at people who pull out unexpectedly from their hidden driveways; he grips the steering wheel tighter. When his daughter drives, he clasps the handrail by his temple and doesn’t let go until they have arrived at the grocery store. She needs to take him by the arm, because he walks slowly and will stop if she engages him in conversation. If she lets go of him she’s afraid they’ll never leave, he’ll get caught up in looking at the variety of breads, instead of just choosing the multigrain and moving on. With the three girls, he is less serious. Their energy draws away some of the anxiety he carries with him, all the time. The youngest asks him whether he likes a spread of sun-dried tomatoes. He has to adjust his hearing aid before he asks what she just said. She doesn’t mind repeating herself to her grandfather. Her face is intent and her thick eyebrows high when she’s asked him three times. He makes a face at her; sundried tomatoes are not his thing.
The daughter mentions her father’s driving to the physician, conveying her apprehension over the anxiety it causes him. The doctor asks whether he’s been involved in any accidents. She shakes her head. The father adjusts his hearing aid, and it squeals and he flinches. How often does he drive? The patient answers now that he can hear the questions, he drives several times a week, just around town to get groceries, sometimes to the hardware store, and to the senior center where he meets other chess players. The car gives him freedom. Without the car, he would be dependent on someone to take him places. The daughter sees that time coming; the patient cannot conceive of that life.
Quality of life is important, the doctor notes, as he begins the physical exam, and asks when the patient last had his medication. He takes his pills with 2% milk and coffee, Latin style, though he uses instant instead.
The daughter has urged him to try Cremora instead of milk, but he hasn’t tried it yet. She reminds him the milk protein in the coffee competes with his medication. He might have more energy to walk if he used Cremora, he nods, though she has told him before. The physician comments that he needs to try to exercise every day, if not a walk, then at least some stretching. The doctor takes an emergency call and steps outside the examination room, leaving the medical student briefly with the patient and daughter. It is silent in the room, until the student engages the two demonstrating something he has noticed in the patient. A stooped posture, he demonstrates by rounding his head and shoulders, impairs his breathing. He tells the patient he can hook a broom, or cane between his elbows, to open the chest and practice standing against a wall so that the heels, buttocks, shoulders and head all touch, then move away and stand erect. The doctor re- enters the room, corrects his posture and asks whether the senior center offers yoga. The patient smiles and admits he thinks only women attend the class.
Having seen the patient repeatedly over a span of ten years he expresses his frustration when he learns she only tried the Seroquel twice, and never at a high enough dose to cause her to sleep solidly for several hours. It gave her a nightmare, she claims. At that dose, it could have no effect, counters the physician. You were probably upset about something else in your life. She raises her voice telling him he is not listening to what she has to say. While she speaks, her body contorts with dyskinesias.
The physician wants to know when the dyskinesias begin. The patient answers it depends upon when she takes her medications, and that depends on what she has done the night before. He directs her to tell him about this morning because her dyskinesias suggest she is overmedicating. She needs to stop taking the Sinemet throughout the night, and sleep continuously for several hours. If she were sleep as he recommends, she would have to wear Depends or something comparable, because she would not wake to use the toilet. The friend nods in understanding, but the patient is still upset. This is no quality of life, the physician comments, looking at the patient. You have to cut back on the Sinemet.
She tells him she feels she can’t breathe, and thinks she will die. Adamantly, he tells her patients with Parkinson’s disease do not die that way… he admits though it can be very scary. The friend asks, Is there nothing that can be done, when she feels that way?
The doctor shakes his head and tells her, there is nothing to use on a regular basis. The episodes pass, it’s like childbirth… though your anxiety about the symptoms makes it worse and heightens the feeling. Then he explains respiratory dyskinesias affect the muscles of the diaphragm and intercostal muscles between ribs, inhibiting regular movement of the chest muscles in normal breathing. The real solution is to regulate the Sinemet so dyskinesias don’t occur. And seroquel might be helpful as well.
The physician instructs her to resume making the liquid Sinemet each morning and he writes out the recipe which he tells her to sip every hour and a half, during the day. She must keep it away from light, in a thermos, in the refrigerator and pour out the excess she does not use. She understands the recipe, she has used the method before. When she tells him she has someone visiting every morning for four hours he is pleased, he adds she also needs a pet. She nods and tells the doctor about the cat who lives with her. He nods and inquires, What does the cat think about the dyskinesias?
He goes into another room, he knows when I am not feeling well, she says. Sometimes he curls up with me when I nap.
She’s the only person wearing a hat in the waiting room. Perhaps the dress is taffeta, whatever the fabric, it’s large blocked checks; black and white with a distinct waistline. She draws the stares of other more sedately dressed patients.
In the examination room she takes a seat opposite the doctor, and folds her hands delicately in her lap. She comments she lacks her gloves, then she inspects her manicured fingernails. The physician looks over at the younger woman, who wears a dress as well, and asks what brings them to the Parkinson clinic. The older woman volunteers she has noticed her left hand shakes at times. The doctor asks when she first noticed the symptom. She looks up but her focus seems indiscriminant, she responds it’s been awhile, a year or so, maybe longer…. and she looks over at the younger woman, who nods her head and takes a notebook from a large handbag at her feet. The blond much younger woman verifies the tremor in her left hand appeared three years ago when they were on a cruise.
The physician asks about the movement: does it happen at rest? Does it improve with a glass of wine? The older woman interrupts the questioning; it improves with vodka and tonic, and the physician smiles fleetingly, turns to the younger woman, and asks what relation they are to each other. The younger woman replies she is the granddaughter and lives down the block from her Nanna. She tips her head in the direction of the elder and relates she dreads having to visit a doctor, which is why she is present. She cancelled the appointment three times before a family member agreed to attend with her. Behind the desk, the doctor nods, gazing at the women in front of him.
The patient fixes the physician with her pale blue eyes and comments she heard he was among the most highly rated neurologists in the area. The specialist smiles, commenting she may suffer from an essential tremor. Does she recall her parents or grandparents having tremor? The woman gazes above the doctor’s head and recalls her grandmother’s head and hands shook. The doctor nods and asks her to raise her arms straight out in front of her. The skin visible from the three- quarter length sleeves is pale, almost translucent, but her hands appear curiously unwrinkled, her finger joints slim and her moderately long nails painted a soft pink. The right hand jitters quickly and the left also moves, though not as dramatically. He asks how old she is and the granddaughter answers eighty- five. Asking whether she has noticed any movement of her head, the woman looks to her granddaughter, though she answers herself; sometimes she feels her head jittering like one of the bobble- headed characters. The younger lifts her eyebrows and admits she has only heard her Nanna’s voice wavering on the phone.
The physician asks the patient to sit on the examination table and she turns and stands, leaving her black woven hat on the seat of the chair. Without the brim over her forehead, her face is more visible. She wears her white hair drawn back in a ponytail at the nape of her neck. Her leather shoes have a small rubber platform and a hole where her large toenail peeks through. The doctor explains to the medical student, the muscles at the joint of her arm are supple, without rigidity. Reflexes are normal, as are fine hand movements. He asks the patient to retake her seat, scans her medical history and comments she is a healthy woman.
Essential tremor, the doctor feels secure in the diagnosis and asks how debilitated she is by the movements; do they prevent her from participating in activities? Well, No she replies. Her sphere of social contacts all have their own issues, though sometimes she has trouble applying mascara, and her writing has suffered terribly, though she has taken to communicating via email. The doctor suggests a trial of Inderol, which is effective in reducing tremor, to see whether she appreciates its benefits. She nods once and agrees.
With some reservation, the patient allows the medical student and others to sit in during her first appointment with the movement disorder physician. She is young, petite and blond. Whether it is nerves or something else her right hand jiggles as does her right foot. The foot movement disappears when the physician asks what brings her into the clinic. Her right hand continues to shift in her lap. She glances down at her hand and tells the doctor the tremor in her hand used to appear only from time to time, but lately she has found the movement never diminishes, the way it had. She takes a breath and relates that it is hard for her to write on the blackboard, and that in desperation she has begun using her left hand, though her penmanship is worse.
Initially she attributed the tremor to nerves, and the start of the new school year, and her first year teaching third grade. She fears she has Parkinson’s disease, because her father was diagnosed with the illness when he turned sixty- two. His first symptom was a shaking right hand, and being a golfer the tremor compromised his swing.
The physician asks about other symptoms, and her face seems unsure. Her gaze takes in her torso and stops at her feet. With some hesitation, she confides sometimes her right foot taps, and she cannot control the movement. She used to tap her foot voluntarily while sitting at her desk in the classroom. Now she finds her foot will be tapping and she will suddenly become aware of its movement and will be unable to suppress the action.
As the physician asks her to move to the examination table, he asks her age. She is twenty- nine. He opens and closes her arm, holding her arm at the elbow. Then he asks her to pat her left hand on her thigh while he works the arm open and closed. Hmm. He looks at the people observing, and comments to the young woman he can feel some rigidity in the muscles on right side. He compares sides and narrates that her left side feels normal. The doctor leads her in several dexterity skills and comments the movements of her right hand seem a bit slower than the left. Then he opens the door and asks the patient to walk down the hallway so he can observe her gait. She holds her right elbow in towards her waist while her left arm swing is full.
Returning her to her chair, the physician asks how long ago did she first detect hints that something in her body might be awry, she gazes up at the ceiling and estimates it has been less than a year. He nods and remarks that people receive a diagnosis of PD when they have three of the classical textbook symptoms: tremor, slowness, and rigidity. Though many people have different presenting symptoms; a masked face, cramped small writing and low volume speech are several others. At present, she has some slowness in the movements of her right hand, as well as tremor and some rigidity. She looks into her hands in her lap as tears well in her eyes and run down her cheeks. Behind the desk, the physician comments that she may have what is called young- onset illness. He states that replacement of dopamine with levodopa should be reserved for later, but that relief of symptoms of tremor can be done with anti-cholinergic medications, like trihexyphenidyl. Also he suggests that a dopamine agonist (pramipexole) might also alleviate slowness and rigidity with a lessened likelihood of development of the motor fluctuations that are often seen within a few years when levodopa is started in young patients. She wipes her eyes, nods and states she would like to give it a try.
Every chair and stool in the small room has a person in it and the nurse and social worker stand against one wall. Few patients bring so many family members, but this man has Huntington’s disease, a genetic neurological disease characterized by chorea or spontaneous uncontrollable movements, and such patients tend to have non- typical families. The patient sits in his wheelchair. His face is unshaven; he wears glasses and keeps his hands fixed in his lap between his knees.
The nurse taking his weight and blood pressure notes he has lost fourteen pounds since his last appointment in June. The patient’s sister mentions this to the physician when he enters the room. The doctor asks the patient whether he has had trouble swallowing, and he shakes his head. The ex- wife comments when she comes by with meals he has been sleeping in bed, and she thinks he has been sleeping too much, and not eating enough. The doctor gazes at the patient telling him he sleeps like a teenager, while he informs the family in the room patients with HD have increased metabolic needs. He wheels his seat in front of the wheelchair, asking the stubbly- faced man how much exercise he gets, commenting he could use an exercise routine and to consider riding a stationary bike or walking every day. The sister remarks,
Well that went over well…
The patient rolls his eyes, as the sister concedes she has tried to get him to walk around the apartment complex he lives in, to no avail.
The doctor recommends Boost, Ensure or smoothies; added calories will thwart further weight loss. The patient’s voice is unintelligible, yet the physician knows him and the remark he makes. Heavier patients with HD tend to have an easier course of illness. The physician asks about the time the patient retires to bed at night, and the patient responds when he feels tired, around one, and sometimes later. The physician nods in understanding, commenting under those conditions one might sleep later in the morning, but not until 4:00pm. He examines the list of the patient’s medications on the computer and suggests decreasing the nighttime risperidone dose by half.
On physical examination, the patient feels rigid. The doctor inquires about when he first received his diagnosis, noting he is in the rigid phase of illness, which occurs after in advanced stages of the disease when most chorea has subsided. The ex- wife and sister agree it has been ten to eleven years.
Wearing a black dress and blue glasses, the social worker comments she is beginning a support group for those with HD, and their families. They will meet in the Orlando area. She takes several email addresses so various arms of the family will be informed about future activities revolving about Huntington’s disease.
We are eighty or so people of the three thousand on the Navigator of the Seas bound for the Cayman Islands and Cozumel. Scheduled are two days of lectures, workshops, dinners and gatherings organized by a travel agent and small group of women from the Parkinson Research Foundation, with Doctor Sanchez- Ramos specialist in movement disorders, Mary Spremulli- speech therapist and Eman Nakshabendi- dietician.
Dressed in pirate garb with ornate boots and a tricornered hat, Larry Hoffheimer, founder of the PRF and Brian Curro the director, welcome the group and explain briefly how the conference will proceed. Shorty after, we disband to our staterooms and are soon called by the captain to participate in the safety drill. The raging pirate theme draws heads as two perspiring buccaneer vixens pass passengers waiting shoulder to shoulder in the scorching sun of Broward County and Brian Curro attends the required drill dressed in his brigand costume, appropriately sweating into his eight-inch beard which adorns his naked and quite hairy ample belly. Others less ostentatiously dressed mingle among the ship’s population, though with some knowledge of Parkinson’s disease you may notice them. Some have the Parkinson jiggle of the hand, others the forward bent posture and quick steps. Some use wheel chairs, others use walkers, most have a caregiver at their elbow, or not far away. Many blend in, their disease going unnoticed by the general population.
In the conference rooms on days at sea we are something of a family, all somehow involved in an illness that is progressive, debilitating and has no cure. After twenty minutes or so in the warm meeting room, some heads nod forwards in slumber, while family members remain attentive to the details of the physician’s lecture. Mary Spremulli gives a lecture on Methods to Improve and Strengthen Your Voice on the second day. She shows before and after video clips of several of her patients to illustrate the changes that are possible after regular work with a fifty-minute exercise class that combines voice and physical movement. Eman Nakshabendi gives a lecture on the daily requirements for optimum health and addresses other concerns like the maximum dose of vitamin D. There is a bootcamp workout and yoga for patients and at the end, a session in which all are invited to probe the panel of healthcare professionals with questions.
On the eve of the final day we gather again and under the influence of rum punch, appetizers and gold coins of milk chocolate Larry Hoffheimer thanks all for attending and reiterates the major goal of the PRF is education. He invites us to attend again, and mentions another seminar to be held in Tampa, Florida in March, 2011. Before we break apart to attend the nightly show, peruse the venues of live music or visit the casino, we vote on the most dapper pirate. Three elaborate pirate patients walk the plank strutting their swords, mustaches, patched eyes and striped trousers. The guy with blousy striped pantaloons, an ample white smock with romantically wide sleeves, eye patch and kerchief draws whistles from the crowd. He stands bent at the waist though he was tall once, he face is static as a mask and his long legs take small shuffling steps.