Rehabilitation of a person with Parkinson's Disease. There is a brief discussion about Parkinsons disease, Etiology, Pathology, Pathogenesis, Clinical Features, Medical Management, Physiatric and Rehabilitative Management as well. Hope a medical personnel especially Physical Medicine Residents will be benefitted from this.

1. Rehabilitation
of a person with
Parkinson’s Disease
Dr. Md. Mamunul Abedin
MBBS, BCS (Health), FCPS Trainee (PMR)
Dept. of Physical Medicine & Rehabilitation
National Institute of Neurosciences and Hospital, Dhaka
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2. Parkinson’s Disease
Parkinson's disease (PD) is a neurodegenerative
disorder that affects predominately
dopaminergic neurons in a specific area of the
brain called substantia nigra.
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3. Epidemiology
-The 2nd commonest neurodegenerative disease.
-Affects men and women of all races, all
occupations, and all countries.
-Mean age of onset is about 60 years. Frequency
increases with aging.
-The prevalence of the disease will be dramatically
increased in the next several decades.
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4. Etiology
-Unknown (85 – 90%)
-Environmental Factors
Exposure to Pesticides
Rural Living
Drinking Well water
MPTP
Reduced risk with Cigarette smoking & Caffeine
-Genetic Factors
Gene mutations
Gene associations
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5. Pathophysiology
The Pathological Hallmarks of PD:
-Depletion of the pigmented dopaminergic neurons in
the substantia nigra
-The presence of α-synuclein and other protein inclusions
in nigral cells (Lewy bodies)
-There are also other neuronal degenerations.
Loss of dopaminergic neurotransmission: Causes motor
symtomps
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6. Pathophysiology (cont.)
Physiologically, Substantial Nigra is the major
output region of the Basal ganglia.
The output of Basal Ganglia provides inhibitory tone
to Thalamus & Brainstem, and in turn, control motor
functions,behavioral, emotional & cognitive functions.
Decreased neuronal activity in SN is associated with
movement facilitation via Dopaminergic projections.
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7. Pathophysiology (cont.)
In PD,
Dopamine denervation/ Loss of Dopamine tone
Excessive inhibition of the Thalamus
Reduced activation of Cortical motor systems
Development of Parkinsonian features
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8. Cardinal Features
Clinically, Parkinson’s Disease is characterized
by:
-Rest Tremor,
-Rigidity,
-Bradykinesia (Slowing), and
-Gait Impairment.
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9. Clinical Features (Motor symptoms)
Positive Phenomena
▪ Tremor
 Resting Tremor
 Postural Tremor
 Re-emergent Tremor
-Suppressed by sleep and activity,
-Increased by fatigue or stress.
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10. Clinical Features (Motor symptoms)
Positive Phenomena
▪ Rigidity
 Cogwheel type
 Lead pipe type
▪ Flexed Posture
Dominance of progravity flexor muscles
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11. Clinical Features (Motor symptoms)
Negative Phenomena
▪ Bradykinesia
-Slowness of movement
▪ Loss of postural reflexes
▪ Postural instability
▪ Freezing phenomenon
-Transient inability to move.
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12. Gait
▪ Slow to start walking
▪ Rapid, Short stride length, Tendency to
shorten (Festination)
▪ Reduction of arm swing
▪ Impaired balance on turning
Clinical Features (Motor symptoms)
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13. Normal Findings
Power, Deep tendon reflexes, Plantar
Eye movements
Sensory & Cerebellar examination
Clinical Features
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14. Clinical Features
(Other Motor features)
▪ Micrographia
▪ Masked facies (Hypomimia)
▪ Reduced eye Blinking
▪ Soft voice (Hypophonia)
▪ Dysphagia
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15. Clinical Features (Non-motor Symptoms)
▪ Cognitive Impairment (Dementia)
▪ Neuropsychiatric Features:
Anxiety,
Depression,
Apathy,
Hallucinations/ Psychosis
▪ Sleep Disturbances & Hypersomnolence
▪ Fatigue, Drooling, Weight loss
▪ Sensory Disturbances (Pain)
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16. Clinical Features (Non-motor Symptoms)
Autonomic Disturbances
▪ Orthostatic Hypotension
▪ Sphincter Disturbance
▪ Constipation
▪ Sexual Problems
Erectile failure,
Loss of Libido,
Hypersexuality
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17. Differential Diagnosis
 Dementia with Lewy Bodies
 Multiple-System Atrophy (MSA)
 Progressive Supranuclear Palsy
 Secondary Parkinsonism
▪ Drugs
▪ Stroke
▪ Toxin
 Wilson’s Disease
 Huntington’s Disease 17

18. Investigation
Diagnosis is Clinical.
Structural imaging is normal.
Functional dopaminergic imaging is
abnormal in early stages (SPECT or PET)
To exclude Huntington’s/ Wilson’s
disease (in younger patients)
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19. Management
Drug Therapy
▪ Levodopa
▪ Dopamine receptor agonists
▪ MAOI-B inhibitors
▪ COMT inhibitors
▪ Amantadine
▪ Anticholinergic drugs
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20. Management (cont.)
Surgery
Deep Brain Stimulation
Rehabilitation
▪ Physiotherapy
▪ Occupational therapy
▪ Speech therapy
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21. Rehabilitative Mx
Medical and Nursing
▪ Use of Firm bed
▪ Regular meals with proper diet (Low Protein)
▪ Measure vital capacity and enforce incentive
spirometry
▪ Gradual changing of positions, elastic stockings,
abdominal binder, sodium tablets, and possibly
pseudoephedrine, midodrine, and/or fludrocortisone
for orthostasis
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22. Rehabilitative Mx
Medical and Nursing(cont.)
Bowel program for gastrointestinal hypomobility (stool
softeners, bulk-forming agents, cisapride, and
suppositories may be required)
Bladder evaluation and urodynamics; anticholinergics
(e.g., oxybutynin chloride [Ditropan]) for hyperreflexic
bladder
Artificial tears for lack of blinking
Sexual dysfunction evaluation
Anticholinergic medications before mealtime to help
facilitate oral and pharyngeal movements
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23. Rehabilitative Mx
Gait Disturbances
▪ Shuffling gait pattern: Decreased step and stride length,
decreased cadence and velocity
▪ Festination
▪ Stooped (flexed) posture
▪ Freezing, “start hesitation”
▪ “Cautious” gait (fear of falling)
▪ Impaired balance and unsteadiness due to lightheadedness
▪ Dystonia, dyskinesia
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24. Rehabilitative Mx
▪ Relaxation techniques
▪ Slow rhythmic rotational movements
▪ Gentle ROM and stretching exercises, quadriceps and hip extensor
isometric exercises
▪ Neck and trunk rotation exercises
▪ Back extension exercises and pelvic tilt
▪ Proper sitting and postural control (static and dynamic); emphasize
whole body movements
▪ Breathing exercises
▪ Functional mobility training, including bed mobility, transfer
training, and learning to rise out of a chair by rocking; may require a
chair lift
Rehabilitation for Gait Dysfunction
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25. Rehabilitative Mx
▪ Functional mobility training:
Bed mobility,
Transfer training,
Learning to rise out of a chair by rocking; chair lift
▪ Stationary bicycle
▪ Training in rhythmic pattern to music or with auditory cues
▪ Standing or balancing in parallel bars (static and dynamic)
with weight shifting, ball throwing
Rehabilitation for Gait Dysfunction (cont.)
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26. Rehabilitative Mx
▪ Slowly progressive ambulation training
Large steps using blocks to have patients lift legs,
Proper heel-to-toe gait patterns,
Feet 12–15 in. apart, arm swing;
Use inverted walking stick, colored squares, or stripes as
visual aids
▪ Use of assistive devices (may need a weighted walker)
▪ Aerobic conditioning (swimming, walking, cycling)
▪ Frequent rest periods
Rehabilitation for Gait Dysfunction (cont.)
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27. Rehabilitative Mx
Movement Initiation
-Slow movement initiation.
-Result from delayed
activation of the motor cortex,
impeding one’s ability to
initiate and execute normal
movement.
-exacerbated with high-
complexity tasks.
-Difficulty in handwriting.
▪ It may be a strategy to
facilitate motor tasks.
▪
Rehabilitation
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28. Rehabilitative Mx
Dyskinesia
-the excessive movement of
muscles in the trunk or
limbs that cannot be
controlled voluntarily.
-complication of levodopa
therapy after 7 or 8 years.
-due to highest conc of
Levodopa, and progressive
loss of dopamine neurons.
▪ If Mild, No measures
▪ If bothersome,
reduction of dose &
dosage of Levodopa
▪ Add Amantadine
Rehabilitation
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29. Rehabilitative Mx
Dystonia
-the involuntary contraction of
a single muscle or multiple
muscles that cause an
abnormal posture,
-most common site is the foot
(contraction with flexion of the
toes and inversion of the entire
foot).
-Occurs when plasma
concentrations of Levodopa are
at their lowest and highest
▪ If at end of dose,
Ingestion of another dose.
▪ In Peak-dose dystonia,
if causes focal problem,
Local injection of
Botulinum toxin
Rehabilitation
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30. Rehabilitative Mx
Orthostatic Hypotension
▪ Lifestyle modification and education
-Avoid warm or hot bath / A heavy meal /Excessive
straining while defecating and other tasks
-Taking high-fiber diets and stool softeners
▪ Gradual changing of positions (may use Tilt table)
▪ Compression leg stockings and abdominal binders.
▪ Omit unnecessary drugs
▪ Fludrocortisone or midodrine, if needed. 30

31. Rehabilitative Mx
Gastrointestinal
Problems
Swallowing Dysfunction
-Dysphagia due to loss of
lingual control
-Esophageal dysmotility
-Hypopharyngeal Stasis
-Aspiration
-Deficient positioning of
oesophagus
▪ Oral-motor exercise
by speech pathologist
▪ Chin-Tuck Maneuver
▪ Thickened liquids
Rehabilitation
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32. Rehabilitative Mx
Gastrointestinal
Problems
Nutrition:
-At risk for weight loss
-Amino acids & Vit B6
hampers absorption of
Levodopa.
▪ Nutritional Consultation
▪ Advise patient to take Levodopa
01 hour before or after a meal
▪ Reduce amount of protein early
in the day, main protein meal in
the evening.
▪ Requirement: 0.7gm/Kg BW
▪ Precise amount of Vitamin
supplementation
Rehabilitation
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33. Rehabilitative Mx
Gastrointestinal
Problems
Constipation:
-Altered sympathetic
innervation of the GIT,
-Concomitant
medications,
-overall limited mobility,
-impaired hydration.
▪ Adequate hydration,
▪ Increased physical activity,
▪ High-fiber diets.
▪ use of a daily osmotic agent
(lactulose)
Rehabilitation
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34. Rehabilitative Mx
Bladder Problems
Detrusor Hyperreflexia
-Nocturia
-Urgency
-Frequency
▪ Timed voiding,
▪ Peripherally acting
anticholinergics (Oxybutynin),
▪ Redistribution of fluid intake:
bulk of fluid ingestion earlier in
the day
Detrusor Hyporeflexia
-Retention of urine
▪ Intermittent
catheterization,
Rehabilitation
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35. Rehabilitative Mx
Occupational Therapy
-ROM activities of upper extremity with stretching
-Fine motor coordination and training, hand dexterity
training using colored pegs or beads
-Hand cycling to help train reciprocal movements
-Rocking chair to help with mobilization
-Transfer training
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36. Rehabilitative Mx
Occupational Therapy (cont.)
-Safety skills
-Adaptive equipment evaluation,
Velcro closures, raised toilet, grab bars, eating
utensils with built-up handles, and key holders
-Family training and home exercise program
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37. Rehabilitative Mx
Speech Problem
▪ Deep breathing and diaphragmatic breathing
exercises
▪ Articulatory speech training for dysarthria
▪ Facial, oral, and lingual muscle exercises
▪ Swallowing evaluation, including a modified
barium swallow as needed
▪ Teaching compensatory strategies for safer
swallowing
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38. Thank You
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39. Q & A
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