Dr. Michael Smith (Host): Welcome to Meaningful Medicine, a podcast by Novant Health. I'm your host, and joining me today is Dr. Robert Wiggins, a neurologist from Novant Health. In this episode, we're going to be navigating the journey beyond a Parkinson's diagnosis and explore how to build a fulfilling life after someone receives the diagnosis.

So, let's start off, Dr. Wiggins, welcome to the show.

Robert Wiggins, MD: Thanks. Thanks for having me.

Host: Let's start off, you know, for patients who have just received the diagnosis, what are the first steps that you recommend they take?

Robert Wiggins, MD: Yeah. I think the first time that someone hears that they have a diagnosis of Parkinson's disease, I think there's oftentimes a lot of panic and fear for the future and terror of what might be to come. And so honestly, one of the first things that I recommend, and we oftentimes even do this in my exam room, is just to take a deep breath, right,? To really try to take a deep breath, really try to kind of re-engage in the conversation, and think through a few things. Why do you think I have this diagnosis? What are we going to do about it? And what does that really mean for me? I think that's a way that we try to recenter things, to try to kind of move away from that fear and panic that can oftentimes set in. Because just the term Parkinson's disease, we're somewhat familiar with it, but it's so foreign as well. I think that patients really try to take a deep breath. That's the first step that I oftentimes recommend. And the encouraging thing is there are a lot of things that we can actually do to try to help make people who have Parkinson's disease feel a whole lot better.

Host: When you talk about that first step, taking that deep breath, I think that's a great thing. Because it's almost like, you know, "Let's take a pause, let's take a moment. Think about the diagnosis, get your family together." It gives people an opportunity to begin to prepare, right? And I think that's fantastic. But early on, in the course of disease, what does that look like for patients? Like, what can they expect early on? And how does that maybe change, you know, with time?

Robert Wiggins, MD: What we know is that Parkinson's disease is what we call a progressive condition. So, it does change with time. But typically, whenever people first come to me, they typically have kind of one thing that's bothering them, and it's typically a tremor or slowness, trouble using their hand or walking, maybe some shuffling of their gait. Those are typically the first symptoms that people come to me with.

And honestly, for the most part, for the first few years that someone has Parkinson's disease, I think oftentimes they will say that they can live a very, very normal life. We have really good, effective, safe, well-tolerated medications that can really help to optimize their life. And so, oftentimes at first, patients, they're able to keep working, they're able to keep playing sports, keep doing the things that they love doing.

After several years of having the condition, patients can start having or will have more of what we call the non-motor symptoms of Parkinson's disease. Those are things like maybe more depression, anxiety, sometimes even some memory troubles. And those are the things that I think patients are actually more bothered by in the long term. And we have medications that can help those symptoms as well. But I think with time, those are some of the things that patients really start to kind of deal with.

And as you kind of mentioned, I think it's really important at these stages particularly, these steps particularly, to not go it alone. There's oftentimes a great relationship between me and a patient and their loved one, their partner, their children. But we oftentimes say, "Hey, there's a lot of other resources out there in the community, whether that's physical therapists, occupational therapists, speech therapists, yoga instructors, support group members. I mean, here in Charlotte even, there are several organizations that are really here to help people who have Parkinson's disease. So, there is a lot of hope. There's a lot of hope that can get the help that you need.

Host: That's fantastic. I love that support group idea, right? Coming together with other people who have gone through the same things you're going through. That's a great place to be. Moving on to treatment, I mean, this is where I think the conversation is naturally going to go, it's really about treatment. What are some of the most promising developments that you've seen over the past few years with treatment? And do patients have more options now?

Robert Wiggins, MD: Golly, yes, they do. And it's a good thing. So quickly, we got to remember that Parkinson's disease occurs because there's not enough typically dopamine in the brain. A lot of the medications that really try to treat Parkinson's disease are effectively trying to either replace dopamine in the brain or try to serve a similar purpose to dopamine in the brain.

And so, for the longest time, we just had pills, and we would just kind of have patients take more and more and more pills. One of the most exciting, really innovative changes that we've seen in the Parkinson's disease treatment landscape over the past-- gosh, I mean, it has been maybe nine months, right? I mean, this is crazy changes we're seeing, is that there's actually now a what we call subcutaneous or just under the skin delivery mechanism from a pump. So, it's effectively the same active ingredients that we have been using most often via pill form. It's actually delivered continuously just underneath the skin. And the best part about it is this, is rather than having to take pills several times a day, having peaks and valleys throughout the day of feeling good, feeling bad, they can feel more stable throughout the entire day.

And what's the positive of that? Well, rather than having to plan, "Okay, well when am I going to be able to go to my exercise class?" Or "I'm not going to be able to go to my grandchild's graduation because my medicines don't work at that moment." The goal of these therapies is to try to create more of a predictable good on time, so to bring that good life back to people. And here at Novant, we have been using these therapies and we have had great results and we're really excited about what the future holds.

Host: Are those therapies common throughout the country or is Novant kind of leading the way in this?

Robert Wiggins, MD: So, Novant was one of the first in the country to use one of these medications called Vyalev commercially. The other folks in the country are kind of picking up the pace and catching up with us, you could say. But they're really, really great therapies. You know, our goal is to offer the most innovative therapies that are available. Not just to be first, right? Not just to be second, but really to try to offer the best things that we can for our patients.

Parkinson's disease is a tough condition, not only to have for yourself, but also for a loved one to have. And there are really good ways that we can try to make life better. And even if the things don't bring about a cure at this moment, there are ways to have a good life with Parkinson's disease, and that's what we're really all about.

Host: Yeah, that's great. So when you look into the future now, right? Maybe it's 10 years, maybe 20 years, whatever, what do you see? Is there something that looks really promising, still needs a lot of research, but you're really excited about?

Robert Wiggins, MD: I'll be honest, we don't have time to talk about all of the things I'm excited about when it comes to Parkinson's disease, but what I would say is that with more and more understanding of why people even have this disease in the first place, we will have more and more understanding of how to try to prevent it in people and more people.

So, Parkinson's disease is the second most common neurodegenerative disease. It will probably soon be the most common neurodegenerative disease. It's increasing so rapidly. And we think that that we know kind of why, at least partly why, whether that's from toxic exposures to things like pesticides, air pollution, other contaminants, that kind of a thing. We think that has a great risk, really increases risk. Well, as we understand those exposure risks and trying to reduce those, less people will have Parkinson's disease, we hope. But also, people who have Parkinson's disease will hopefully progress slower, right? There are also several drug studies or several trials going on, which are trying to bring about really innovative ways to slow down the progression of Parkinson's disease.

There has been a lot of new things happening, even in the Alzheimer's disease space. And we're hoping that some of the advances that have been seen in the Alzheimer's disease space will be seen very soon in the Parkinson's disease space, even like more simple blood tests that might be able to diagnose Parkinson's disease, looking for that protein that we know is so common in Parkinson's disease.

So, there are a lot of things to be involved with. And I think patients love to be involved in research, and there's so many opportunities in the country to be involved in research. And Novant is really starting our involvement in research in the area, and we couldn't be more excited.

Host: Oh, that's fantastic. I'd like to back up just for a sec. You had mentioned earlier in the podcast that early on in Parkinson's, you see a lot of the motor symptoms. And you mentioned tremor, and I want to talk about that for a moment. Because I think most people, whether they are just diagnosed with Parkinson's or just lay people in general, when you say Parkinson's, that's what they think, tremor, right? Because I know there's different types of tremors. So, can you walk us through a little bit of what the Parkinson's tremor is like and how it's different from others?

Robert Wiggins, MD: Totally. So, tremor does not equal Parkinson's, and Parkinson's doesn't equal tremor. But you're right, there's a specific type of tremor that we'll oftentimes see. It's called a rest tremor or a tremor at rest. I sometimes call it the movie tremor. And what I mean by that is when you're watching a movie or a television and your hands are just completely relaxed in your lap, that's when they may start shaking, particularly if a loved one is the one that notices the shaking. People will oftentimes tell me, "Oh, it is okay because I can stop it." We think that they can probably stop it because their brain unconsciously is sending signals to stop the rest, or kind of put that hand more into action. So, typically a tremor that is most prevalent or most present when you're using your hands, eating, drinking, writing, that's typically called an action tremor, and that's not the most common form of tremor in Parkinson's disease. It's that rest tremor.

But like I was saying, it's not just the tremor, right? Tremor doesn't bring a Parkinson's diagnosis. The Movement Disorder Society says that we have to have something called bradykinesia, which just means slowness or smallness of movement. And that's really the linchpin of the diagnosis. So, not only does someone have slowness in, say, their right hand, but they're also using their left hand more and more, because they're just not using that right hand, it doesn't move as fast. I have a number of patients who tell me that they'll shampoo their hair and one side is stopped and it won't move, or it's much harder to get to move.

And so, that's something that we oftentimes hear. So, it's not just one thing, it's complex symptoms. But the most important thing to do is, if someone has a concern, that they have shaking or a tremor or Parkinson's, talk with somebody, right? The the best place to start is with your primary care doctor. And oftentimes they can take a look at it and say, "Oh, I don't think this is Parkinson's disease." But there are neurologists out there like myself, who focus specifically on Parkinson's disease, who can kind of help out as well. So, I really just want people to be thoughtful about what's going on in their life and what's going on in their hands and in their movements.

And the trick is this, is that if we can diagnose Parkinson's disease earlier, not only can we start really good therapies that can make quality of life much better, but we can really help people find exercise and activity and cardiovascular activity is the one thing that we do know will actually slow down the progression of Parkinson's disease. So, all of my patients are encouraged to exercise.

Host: Very good. Right. Be active, right?

Robert Wiggins, MD: Yeah. Yeah. And that's something I'm working on myself as well.

Host: Right. It is a work in progress and it always will be. And that's fine, right? It's okay. I want to move into Novant Health and how you guys over there-- you're the specialist in Parkinson's. I know you guys follow kind of a comprehensive care plan. What does that mean? What does that look like?

Robert Wiggins, MD: Totally. Yeah. So, we're really trying our best to think of new, creative, innovative ways to try to offer patients what they need and offer caregivers what they need. I think when I think of comprehensive, I think what that means is you're not just having a visit with a doctor, right? It's not just purely about those medications.

My vision would be that we have a larger team of someone who can help with questions like, "Hey, I don't know. Can I drive still? Is it safe for me to drive?" Or even that question of, "I want my husband to stay at home, but I don't know if it's safe anymore. How do I deal with that?" And so, we've been really deliberate and passionate about trying to make this happen. So, we're hiring new providers, a nurse practitioner who's going to come and help us think through some of these questions.

And the other thought is that all of the Novant system, including our therapies, our physical therapies, speech therapies, swallowing therapies, language therapies, and occupational therapies, we have people who are focused specifically on Parkinson's disease. So, sometimes you don't necessarily want a physical therapist who's an expert in knee reconstruction to be the one helping with your Parkinson's disease and vice versa, right? And so, we're really trying to have the right people with the right training, helping out our patients, our people who have Parkinson's disease. And that's a work in progress and it's something that I'm really excited about some of the ways that we're moving forward here at Novant.

Host: That's great. Let's talk about caregivers for a second. So important in this process. And we know caregivers also have to take care of themselves. What advice would you give to the caregivers who are supporting a loved one with Parkinson's centered around preserving physical and emotional health in both of them, the patient and the caregiver?

Robert Wiggins, MD: Yeah. There's that idea of you can't be there for your loved one if you're not there first for yourself. And so, I think the first thing I would say immediately start to ask the question, "Who's in my team? Who's on my side here?" And that's obviously the doctor. But there's also support groups and different organizations who are specifically focused on caregivers, right?

And so, oftentimes caregivers in a support group will just meet up just themselves, and so really knowing, "Okay, here's who I can go to," that's important. That includes children, that includes your brothers and sisters. Those kind of resources are very helpful. And here's the thought. If you are feeling like you are not good enough, if you're feeling like you don't just have enough skill, or you're just absolutely exhausted, those are probably less of an indicator that you are doing not enough, and probably an indicator that you just care a whole lot.

And I think those moments are times when we have to learn that we should consider-- not stepping back forever-- but just taking a step back and taking a break. There are resources in the county and in the community to kind of give, even, we call it like respite, right? Whether that's an hour or two or three hours, that kind of a thing. It's just so important, even for me, I find to make sure that I am not just present today, but that I'm going to be present in 5, 10, 15 years here in the community. So, that's really important. It's always okay for caregivers, for loved ones to ask for help. That is the healthiest thing to do.

Host: Yeah, for sure. That's great advice. When you kind of create this comprehensive care plan that you put together, this larger support group, how important is mental health in that as well?

Robert Wiggins, MD: I mean, it is so important. We like to say sometimes that if a patient has Parkinson's symptoms that just are not responding to medication, think about depression. Because depression and anxiety oftentimes can almost get in the way so much that the medicine may not do the trick. And so, one of our kind of pre-visit questionnaires has questions about sadness, depression, anxiety, hallucinations, delusions, that kind of a thing. It's just so important, because life is good and life is worth living.

And one of the ways that we do that is really try to take care of and promote really good positive mental health. It's okay to mourn. It's okay to weep. It's okay to go through tough times. It's when we get stuck in those ruts, that's when things turn from normal life experience to a disease or a condition that could be treated, and those are the things that we're looking for. And if I may, Mike, those can be present both in a person with Parkinson's disease and those can also be present in someone who's caring for someone who has Parkinson's disease.

Host: Yeah, for sure. That's a fantastic point. When you are dealing with patients, you have many people, many patients living with Parkinson's, right? What do you want them to know about their future?

Robert Wiggins, MD: Yeah, I think that there are really kind of two sides of that coin. I think being honest and upfront about what the future may hold is really important. I don't think I've lied to a patient yet about what the future holds. Parkinson's disease is a progressive condition that does slowly worsen.

I steal a quote or a phrase from a patient of mine or a patient's wife who I think also stole it. But here's the thing though, there is so much innovation and change in this world with Parkinson's disease that the goal of every person who has Parkinson's disease should be to try to stay as healthy as possible, as active as possible, so that one day, if there is a drug trial that's looking for a curative or a disease-modifying therapy, they will be able to qualify for it, right? So, they say, this person says, "Try to stay healthy enough so that you can get that medicine, so that that'll be really helpful for you."

The last thought I would say is this is, don't give up, right? There are so many ways, so many new medications that can make people better. I oftentimes think a lot about this idea of optimization, just thinking if we can make sure that your sleep is good, we can try to make sure that your mental health is good and we can try to make sure that your nutrition and diet is good and your exercises, all of these things, there's a decent chance that you'll feel better. If I'm eating greasy cheeseburgers every day, I'm not optimized. If I'm sitting watching television all day, I'm not optimized. So to all the listeners, I would say is get up and go on a walk, right? Really start your day with activity.

Host: Dr. Wiggins, you're so spot on. There's been studies looking at people with chronic diseases and looking at those that eat well and get their activity and just that group right there without no difference in medicine or anything, they feel better, their quality of daily life is better.

Robert Wiggins, MD: Yeah. And I don't know if I'm able to quote a study exactly, but I have seen studies where even depression improves, right? Maybe sometimes just as much as medicine. Now, I don't think we should neglect medicine. I think there are oftentimes cases when that is really paramount. But it is totally the right move to say, "Hey, while I'm waiting for this medication to work and some medications take six weeks to start working, I'm going to start taking back over life. I'm going to be back in charge of what I'm doing." I know that helps me a whole lot in my own life as well.

Host: Dr. Wiggins, this has been fantastic. You did a great job, great information. Thanks for coming on today.

Robert Wiggins, MD: Yeah. You're welcome. Thanks so much for having me and hope to come back sometime.

Host: To find a physician, you can visit novanthealth.org. And for more health and wellness information from our experts, you can visit healthyheadlines.org. If you like this podcast, please share it and explore the entire podcast library for topics of interest to you. This is meaningful medicine. I'm Dr. Mike. Thanks for listening.