Parkinson's Disease

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  • 1. Parkinson’s disease (PD) is a chronic progressive disease of the nervous system characterized by the cardinal features of rigidity, bradykinesia , tremor and postural instability.
  • 2. EPIDEMIOLOGY  Parkinson's disease, which was first described in "An Essay on the Shaking Palsy" in 1817 by a London physician James Parkinson, has probably existed for thousands of years.  In India, the crude age-adjusted prevalence rate of Parkinson's disease per 100,000 population is 14 in northern India, 27 in the south and 16 in the east, while it is 363 for Parsis in Mumbai.
  • 3. ETIOLOGY  PARKINSONISM: Refers to a group of disorders that produce abnormalities of basal ganglia (BG) function.  PARKINSON’S DISEASE or IDIOPATHIC PARKINSONISM is the most common form.  SECONDARY PARKINSONISM results from number of identifiable causes, including virus, toxins, drugs, tumors.  PARKINSONISM-PLUS SYNDROMES: refer to those conditions that mimic PD in some respects, but the symptoms are caused by some other neurodegenerative disorders.
  • 4. PATHOPHYSIOLOGY BASAL GANGLIA NORMAL PHYSIOLOGY :
  • 5. FUNCTIONS OF BASAL GANGLIA  Plays an important role in planning and programming of movement by selecting and inhibiting specific motor synergies.  Plays an important role in cognitive processes, primarily the caudate nucleus, including the awareness of the body orientation in space, ability to adapt behavior as task requirements change and motivation.
  • 6. Degeneration of dopaminergic neurons that produce dopamine. Loss of the melanin containing neurons produce characteristic changes in depigmentation. Formation of LEWY BODIESLoss of dopamine results in akinesia, rigidity and bradykinesia. What happens in Parkinson’s Disease?
  • 7. CLINICAL PRESENTATION Rigidity  One of the clinical hallmarks of Parkinson's disease.  Defined as increased resistance to passive motion.  Felt uniformly in agonists and antagonist muscles in both directions.  Spinal stretch reflexes are normal.  Two types: Cogwheel and Lead pipe rigidity.  Cogwheel rigidity: jerky, ratchet like resistance to passive movement and muscles alternately tense and relax.  Lead pipe rigidity: no fluctuations, more sustained resistance to passive movements.  Prolonged rigidity results in decreased range of motion and serious secondary complications of contractures and postural deformity.
  • 8. Bradykinesia  Akinesia: absence of movement.  Moments of freezing may occur and are characterized by a sudden break or block in movement.  Hypokinesia: reduced amplitude of the movement.  Bradykinesia: slowness and difficulty maintaining movement. Movements are typically reduced in speed, range, and amplitude. Rigidity and depression can also influence bradykinesia. It is the most disabling symptom of PD.
  • 9. Tremor  It is an involuntary oscillation of body part occurring at a slow frequency of 4 to 6 Hz.  Parkinsonian tremor is described as resting tremor, as it is typically present at rest and disappears with voluntary movement.  Manifests as pill-rolling tremor of hand.  Resting tremors may also be seen in the forearm, jaw, or tongue.  Lower limb tremors are apparent when the patient lies supine.  Postural tremor is seen in head and trunk when patient tries to maintain upright position against gravity.  Completely diminish during sleep. Pill-rolling tremor
  • 10. Postural instability  Narrowing of base of support.  Competing attentional demands increases postural instability.  Increasing difficulty during dynamic destabilizing activities like walking, turning and functional reach.  Contributing factors are rigidity, decreased muscle torque production, loss of available range of motion particularly of trunk motions, and weakness .  Extensor muscles of the trunk demonstrate greater weakness than flexor muscles, contributing to the adoption of a flexed, stooped posture with increased flexion of the neck, trunk, hips, and knees.
  • 11. MOTOR PLANNING AND MOTOR LEARNING  Start hesitation is evident especially when the disease progresses.  PD patients typically demonstrate micrographia, an abnormally small handwriting that is difficult to read.  Freezing episodes occur and can be triggered by confrontation of competing stimuli.  Poverty of movement is demonstrated by patients of PD in the form of hypomimia i.e. the reduction in expressiveness of the face (masked face).  This leads to mental fatigue and loss of motivation.  Procedural learning deficits are common in patients with PD while declarative learning is usually intact. micrographia
  • 12. Gait  An abnormal stooped posture contributes to development of a festinating gait, characterized by a progressive increase in speed with a shortening of stride.  Gait can be anteropulsive (a forward festinating gait) or retropulsive (a backward festinating gait).  Some patients are able to stop only when they come in contact with an object or a wall.  Plantarflexiorn contracture leads to toe walking and adds to postural instability.
  • 13. Sensation  No primary sensory loss.  50% may experience paresthesias and pain, numbness, tingling, coldness, aching pain and burning.  Some of the pain and discomfort can result from postural stress syndrome secondary to lack of movement, muscle rigidity, faulty posture, or ligamentous strain.  Some can experience Akathisia, a sense of inner restlessness and need to move.  Proprioceptive regulation of voluntary movement may also be impaired.
  • 14. Speech, Voice, and Swallowing  Dysphagia : Impaired swallowing as a result of rigidity, reduced mobility and restricted range of movement. This can lead to choking or aspiration pneumonia and impaired nutrition with significant weight loss.  Nutritional inadequacy contributes to fatigue and exhaustion.  Presence of sialorrhea (excessive drooling) as there is increased salivary production and decreased swallowing.  Hypokinetic dysarthria: characterized by decreased voice volume, monotone/ monopitch speech, imprecise or distorted articulation, and uncontrolled speech rate. Speech is hoarse, breathy and harsh.  Reduced mobility, restricted range of movement, and uncontrolled rate of movement of muscles controlling respiration, phonation, resonation and articulation is present.  In advanced cases patients demonstrate mutism.
  • 15. Cognitive function and behavior  Dementia: Occurs in approximately 20-40% of the PD patients. It is characterized by loss of executive functions like planning, reasoning abstract thinking and judgment and changes in visuospatial skills, memory and verbal fluency.  Bradyphrenia: disorders of intellectual function. It is characterized by a slowing of thought and information processing.  Patients demonstrate problems with selective attention and in shifting attention.  Hallucinations and delusions are common complications owing to L-dopa toxicity.  Depression in PD patients is common.
  • 16. Autonomic Nervous System  Dysautonomia: ANS system dysfunction occurs with PD.  Thermoregulatory dysfunction : excessive sweating and abnormal or uncomfortable sensations of warmth and coldness.  Seborrhea and seborrheic dermatitis are common.  PD patients exhibit abnormally slow pupillary responses to light and pain.  Gastrointestinal dysfunction includes poor motility, changes in appetite, sialorrhea, constipation and weight loss.  Urinary bladder dysfunction occurs with common symptoms of urinary frequency, urgency, urge incontinence, and nocturia.  Sexual dysfunction also present.
  • 17. Cardiopulmonary Function  Orthostatic hypotension.  Low resting blood pressure.  Compromised cardio vascular reflexes.  Cardiac arrhythmias.  Airway obstruction.  Restrictive lung dysfunction.  Decreased chest expansion.  Lower forced vital capacity (FVC), forced expiratory volume (FEV1) and higher residual volume.  Cardiopulmonary deconditioning.  Venous pooling in lower extremities in long standing cases as a result of decreased mobility and prolonged sitting.
  • 18. MEDICAL DIAGNOSIS  Accurate diagnosis is possible only with continued observation of evolving clinical signs and symptoms.  The diagnosis is made on the basis of history and clinical examination, handwriting samples, speech analysis, interview questions that focus on developing symptoms, and physical examination are used in the preclinical stage to detect early manifestations of the disease.  A diagnosis of PD can be made if at least two of the four cardinal features are present.
  • 19. FRAMEWORK FOR REHABILITATION  A combined approach of physical therapy and pharmacological intervention plays a key role in management of the patient.  Physical therapist should be fully aware of the medications the patient is taking and its potential adverse effects.  Optimal performance can be expected at peak dosage (on-state) whereas worsening performance is associated with end of dose cycle (off-state).
  • 20. ASSESSMENT Hoehn and Yahr Classification of Disability
  • 21. EXAMINATION AND EVALUATION 1. Patient History. 2. System review: a. Neuromuscular. b. Musculoskeletal. c. Cardiovascular/ pulmonary. d. Integumentary.
  • 22. PHYSICAL THERAPY INTERVENTION Motor learning strategies  Large number of repetitions to develop procedural skills.  Random practice order should be avoided.  Environment should be clutter free to avoid freezing episodes.  Structured instructional sets should be used.  External cues like Visual cues, Rhythmic auditory stimulation, Auditory cues, Pulsed cues and Multisensory cueing facilitate movement by utilizing different brain areas.
  • 23. EXERCISE TRAINING Relaxation exercises  Gentle rocking to produce relaxation.  PNF technique of Rhythmic Initiation.  Relaxation audio tapes.  Gentle yoga and Tai chi exercises.  Lifestyle modifications and time management techniques. Flexibility exercises  Emphasize on active range of motion exercises.  ROM exercises in physiological patterns of movement.  Traditional stretching techniques.  Passive positioning to correct phantom pillow posture.  Mechanical stretching by the use of tilt table.
  • 24. Strength training  Strengthening exercises are indicated for patients with primary muscle weakness and insufficient central activation of the motor unit as well as for disuse weakness associated with prolonged inactivity. Functional training  Mobility in bed.  Exercises in sitting posture to improve pelvic mobility.  Sit-to-Stand transitions.  Standing training.  Teach how to get up after a fall.  Mobilizing facial muscles.  Correcting eating impairments.  Verbal skills practiced with breath control.
  • 25. Balance training  Emphasize practice on dynamic mobility tasks.  Seated activities on a therapy ball.  Challenge the balance by stepping of marching in place, and functional reach.  Standing exercises including heel-rises and toe off, partial wall squats and chair rises, single-limb stance with side-kicks or back-kicks and marching in place.  “Kitchen sink exercises” as important components of HEP for patients with balance deficiencies. Locomotor training  Training programs are designed to lengthen stride, broaden base of support, improve stepping, improve heel-toe gait pattern, increase contralateral trunk movement and arm swing, increase speed, and provide a program of regular walking.  Trick movements or rotational stimulationssuch as dropping a tissue that the patient must step over can be successful in reducing freezing.
  • 26. Cardiopulmonary training  Diaphragmatic breathing exercises, air- shifting techniques, and exercises that recruit neck, shoulder and trunk muscles.  Improving chest wall mobility by PNF techniques.  A supervised aerobic pool program can be administered. Group and Home exercises  Patients benefit from the positive support, camaradie, and communication the group situation offers.  Stretching exercises or calisthenics involving large joints can be used as initial warm-up activities.  A self supervised home exercise program is effective in improving motor symptoms same as therapist- supervised programs do.
  • 27. Therapists need to provide a message of hope tempered with realism. THANK YOU