Jon's column

Dr Jon Stamford often tells the story of when he was studying the dopamine systems in Parkinson’s; the first patient he met was himself in the mirror. As former researcher now PwP he has a unique perspective on PD.

Speaking a common language - Winter 2018

Having insight as both patient and scientist, Parkinson’s Movement’s own Dr Jon Stamford celebrates the art of communication and a yen to visit the Far East for the WPC in 2019.

One of my favourite lines in the film Cool Hand Luke is towards the end. Luke, already holed up in a hideaway surrounded by police sharp-shooters, comes to the front door and, in open mockery of the prison camp warden, calls out “what we’ve got here is failure to communicate.” The prison warden immediately closes all further communication by shooting Luke.

Well, things aren’t quite that bad in the Parkinson’s arena, I’m pleased to say. We talk a lot about communication and the need to communicate – specifically the need for patients to be heard and understood by researchers and clinicians. Although this seems essential it has not always been perceived thus. Until recently patients were seen as passive recipients of information rather than active seekers. In large part this was due to the absence of communication channels. There was no way of bridging that gap.

Until perhaps a decade or so ago, scientists spoke to scientists, physicians to physicians and patients to patients. Conferences were constructed on the basis of those communication channels – science conferences for scientists, clinical forums for clinicians and beyond a little ‘tea and biscuits’ socialising, pretty much nothing for patients. 

On the whole, the situation appeared to suit each caucus. Scientists were happy talking to each other, clinicians swapped case-notes and the patients finished off the biscuits, unaware that there was anything better on offer. Up until 2006 there wasn’t.

This  complacent ignorance was shattered when the first World Parkinson Congress took place in Washington. The brainchild of Stanley Fahn, doyen of American neurology, this inaugural WPC allowed patients, scientists and clinicians to meet at the same conference, in the same sessions even.

Patients could observe the gods of neurology and neuroscience in their natural habitat. Scientists could see the pages of their lab books brought to life in front of them. Graduate students who could barely spell festination watched as patients broke into that characteristic stuttering run. Species that had never met before came face-to-face. It was like Jurassic Park. Or perhaps that should be Jurassic Parkinson’s. Sorry.

When the dust settled and the post conference feedback was examined, it was clear that the conference was a triumph. Patients were ecstatic, the scientists were fascinated and even the gods of neurology grudgingly admitted that they could see some merit in the arrangement.
WPC 2006 was an experiment. WPC 2010 in Glasgow took the experiment further, with even greater integration of the groups. These developments have continued with the meetings in Montréal and Portland. WPC has opened up entirely novel channels of communication. It has brokered relationships between groups and individuals. It has forged friendships and built opportunities. Fundamentally, it is no exaggeration to say that WPC has changed the landscape of communication in Parkinson’s. More than anything it has shown what can be achieved when we bridge that communication divide.

Expectations now are very different from those a decade ago. Scientists want to hear what patients think, and patients increasingly expect to be consulted in every decision that relates to them. Even the most recalcitrant of our clinical colleagues are learning the benefits of listening where previously they would be speaking.

The benefits are there for all to see. Treatments are now designed for patients rather than conditions. Patients lead discussions they once would have struggled to follow. And clinicians ask about aspects of the condition they didn’t even know existed a decade ago. All of this is because of improved communications, leading to a better bridging of that knowledge divide.

This coming year sees Eli Pollard, the current force behind the WPC, pushing the boundaries. Until now the host countries have been English-speaking, on one or other side of the pond. In June 2019 the PD community is off to Kyoto, the ancient capital of Japan. It’s an incredible opportunity, with much to be learned as West meets East. Personally, I’m delighted that I’ll be there as part of the  Parkinson’s Movement team, supporting WPC through the Clinical Trials Village. 

The scientific world may use the English language as  default, but advocates would be well advised to make some kind of effort to at least learn a few stock Japanese phrases. In a country which holds such store in etiquette and manners it will be appreciated and will, no doubt, open doors and start conversations.

Ignore the low hanging fruit - Autumn 2018
I often have the feeling, rightly or wrongly, that medicine is happy to investigate those areas where it is more easily successful than those which prove more challenging. These are in essence the low hanging fruit, easy wins for impatient researchers. And in a research culture where early success or failure can build or blight a career, it’s easy to see why some areas of research are more fashionable than

In the context of Parkinson’s for instance, we have known about rigidity, bradykinesia, postural instability and tremor. We have known about them because they are easy to identify, easy to characterise and, in simple clinical terms, easy to treat. Results are visible and readily quantifiable by physicians. They are, for Parkinson’s, the low hanging fruit.

Further up the tree, and less readily accessible, are some of the non-motor symptoms of Parkinson’s. These might include fatigue, affective disorders, bowel and bladder control issues, apathy, sleep disorders, loss of sense of smell and so on. And although often nebulous and, in many respects, non-specific, they nonetheless form key parts of the Parkinson’s experience. Indeed for many patients nonmotor symptoms have a larger role in determining quality of life than the motor symptoms.

Yet even nowadays nonmotor symptoms tend to be thought of as an adjunct to the central motor symptoms of Parkinson’s. Somehow they are not considered still to be central to the condition. Even now in 2018 we persist in calling Parkinson’s a movement disorder rather than the broad-spectrum neuropsychopathological condition that it is. We seem to insist on the preeminence of motor symptoms.

But why should this be? Why should we persist with this archaic terminology and its stultifying implications for our understanding of Parkinson’s?

A number of possible explanations come to mind but I like this one – that by placing undue emphasis on motor symptoms, the condition is medicalised. It is taken out of the ownership of the patients and becomes the province of the treating physician. When it is a motor condition, a movement disorder, it is easy for a treating physician to claim therapeutic success and easy for a researcher to study. A reduction in the amplitude of tremor is something numerical and therefore scientific. For nearly 2 centuries since its original characterisation, Parkinson’s has been a movement disorder that is managed by physicians with scarcely a nod towards the nonmotor symptoms.

There is a tendency to believe that the nonmotor symptoms of Parkinson’s are something new or at least newly identified. The derivation and application of scales with which to quantify the nonmotor symptoms has taken them into the spotlight, the point at which the medical research community has begun to show interest.

But nonmotor symptoms are nothing new. In his original essay on the shaking palsy, Parkinson described nearly all of the currently understood nonmotor symptoms of the condition. Parkinson knew they were part of the condition, because he asked the right questions of the patients. Since then nearly 2 centuries worth of physicians have found it more convenient not to ask the right questions. So although nonmotor symptoms have been part – a central part – of the patient experience of Parkinson’s, they have only more recently become legitimate targets for researchers and physicians. Before they were merely irritating distractors, blemishes on their motorcentric views of the condition.

Nonmotor symptoms are often difficult to define as they are often interlinked and therefore hard to treat. It’s relatively easy to improve mobility or reduce tremor but apathy and fatigue remain less amenable targets. But if you ask any patient, you will find that the nonmotor symptoms impinge every bit as assertively on a patient’s quality of life as their mobility. They may be more tricky to treat. They may be less readily quantifiable. They may even be elusive research targets. But they are vital components in the Parkinson’s jigsaw.

I was a researcher in Parkinson’s for more than 20 years before I was a patient. More importantly, I had to become a patient before I really understood this condition. My dozens of research papers as a scientist were testaments to what we could measure in Parkinson’s, not what we should.

We have gorged for too long on the low hanging fruit. It’s time to set our aspirations higher.

An 'a' for awareness, advocacy and action - Summer 2018
There exists a relationship between patients with any condition and the researchers. For some conditions there is barely an acknowledgement of each other. For others, such as AIDS, the relationship is tighter, with a strong knowledge interchange between the two communities.

In Parkinson’s, as in so many other conditions, we use terms such as awareness, advocacy and activism, often rather broadly; sometimes even synonymously. Yet, to my mind, there are subtle but important distinctions between the terms.

Awareness of the condition is essentially the entry point into the whole spectrum of patient engagement. It is the point at which the person with Parkinson’s begins to develop an understanding, both personal and general, of the condition.

Advocacy is a level up from there. In the context of Parkinson’s, advocacy can be defined perhaps as public endorsement of the importance of research. It is the point at which the person with Parkinson’s changes from being a net recipient of information and/or benefit to a net contributor, in essence sharing their knowledge and experience.

Activism can, on the one hand, be seen as synonymous with advocacy but, to my mind, the term has slightly different connotations. Activism is a more dynamic term, suggesting greater vigour. One might almost think of it as a more forceful, aggressive even, form of advocacy. Activism is also perhaps the form of advocacy most likely to effect action.

Let me explain… The AIDS community is often held up as an icon of the power of patients to exert change. This change was not achieved by gentle advocacy but by forceful activism. A simple Internet search for the term “AIDS advocacy” generates 61,900 hits, while a search for “AIDS activism” finds 186,000 pages, more than three times as many.

This is, of course, a crude measure but nonetheless makes a clear point – people with AIDS are more activists than advocates. And this has translated into tangible results – better access to drugs, improved treatment paradigms and hugely enhanced public understanding of the condition. Indeed, the AIDS community were very much involved in translating AIDS from the death sentence it initially was to a long-term treatable condition.
Similar searches, in the context of Parkinson’s, are illuminating. “Parkinson’s advocacy” yields 5210 pages while “Parkinson’s activism” finds a mere 42. In essence,  although we have a community of advocates, we are not necessarily seen as activists. Although it is a simplistic analysis, one could suggest that this inertia is hampering research. The researchers do not know what we, as people with Parkinson’s, see to be the research priorities. Following the AIDS model through, more activists translates into greater action. We are not making the transition. To my mind we need to take that step from polite advocacy to more forceful activism. Because that’s how we will exert action.

At the start of this year, Bas Bloem and Ray Dorsey co-wrote a paper called ‘The Parkinson’s Pandemic – A Call To Action’. It too cited AIDS as an example of a motivated and determined community demanding universal, affordable and effective treatment. Not for them the quiet belief that someone would solve their problem for them. 
The AIDS community has shown us the way or, at least, a way. We need to learn from their successes and failures how best to exert leverage on Parkinson’s research and researchers. How can we most effectively make our issues their issues?
We need to come up with the answers. We need you to get involved.

Pin It on Pinterest

Share This