Rethinking Parkinson’s Disease: From Icebergs to Seeds and Trees

The “tip of the iceberg” analogy has long been used to explain the symptoms of Parkinson’s disease (PD). This analogy emphasizes that the visible motor symptoms, such as tremors, slowness, and gait changes, are just the tip with a much larger portion of the disease, the non-motor symptoms, lurking unseen beneath the surface.[1] While this analogy effectively highlights the hidden aspects of PD, it may not completely capture the progressive and interconnected nature of the disease. We propose a shift in perspective: PD as a seed growing into a tree. This analogy offers a more dynamic and accurate representation of the evolution of the disease. The seed, planted by a combination of genetic predisposition and environmental factors acting as manure, begins to develop a root system—non-motor symptoms such as loss of smell, constipation, and REM sleep behaviour disorder.[2,3] These roots, hidden beneath the ground, establish a foundation long before the visible aspects of PD appear [Figure 1].Figure 1: The tree, where the trunk represents the core of a neurological condition. The large branches, easily visible from afar, symbolize the prominent symptoms such as tremor, slow movements, and changes in gait. As you approach closer, you notice the smaller details, such as the subtle motor symptoms, including changes in handwriting or facial expressions, akin to the grass and leaves that require a closer look. Below the surface, the roots spread out, representing the complex and often hidden non-motor symptoms, including autonomic dysfunction, behavioral changes, and sleep disturbances. The tree as a whole illustrates that symptoms can emerge from various sides, interconnected and growing in different directionsAs the roots strengthen and grow, the plant eventually breaks through the soil, revealing the motor symptoms often associated with PD. However, unlike the iceberg which remains static or melts away, the tree continues to grow. Both the roots and the visible tree expand over time, with the non-motor and motor symptoms evolving together, each influencing the other. This seed-to-tree analogy captures the complexity and progression of PD in a way that the iceberg analogy may not. It emphasizes that the disease is not a simple matter of hidden symptoms beneath the surface but a living, growing entity where early, unseen changes lay the groundwork for the later, more apparent symptoms. As we continue to understand and treat PD, it may be time to let go of the iceberg and embrace the tree of PD. Acknowledgement None. Author contribution Research project: Conception: Arnav Kukkle Organization: Arnav Kukkle Execution: L. K. Prashanth Statistical analysis: Design: Execution: Review and Critique: Manuscript preparation: Writing of the first draft: Arnav Kukkle Review and Critique: L. K. Prashanth Ethical compliance statement We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. This revealing image did not require Ethical board approval. Declaration of patient consent Informed consent was not necessary for this work. Affirmation by authors We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.