Parkinson's pt management

1. PARKINSON’S DISEASE

2. Definition
• Parkinson’s disease (PD) is a progressive
neurodegenerative disease that is characterized by
rigidity, bradykinesia, resting tremor, mask like face
and postural abnormalities.
• The disease was first described by Parkinson in 1807.

3. Prevalence
• The prevalence is approximately 1 percent in the
general population, with the rate rising from 0.6
percent for ages 60-64 to 3.5 percent for ages 85-89.

4. Risk Factors
• PD results from a reduction in the neurotransmitter
dopamine stores of the substantia nigra with a
consequent loss of pigmentation in this structure.
• Though the exact cause is unknown,many risk factors
have been identified:
• Toxic exposure: Several studies have identified a link
between PD and the exposure to pesticides,
insecticides, herbicides and well water.

5. • Genetics: Individuals with family history, particularly first-degree
relatives of patients with PD are at approximately twice the risk for the
disease.
• Aging: Dopamine shows an increase in concentration very early in
life, followed by a rapid decrease from 5 to 20 years of age and a slow
continuous loss from age 20 to 80 years.
• Infections: A high rate of postencephalitic parkinsonism suggests the
important role of infection in the incidence of PD.
• Medications: Medications such as antipsychotic agents, Lithium,
metoclopramide are known to be associated with parkinsonism.

6. Clinical Features
The triad of resting tremor, bradykinesia and rigidity is the
key feature of PD.
1. Tremor: Though resting tremor is often considered the
hallmark of PD, about 20 percent of parkinsonian patients will
lack tremor. The features of tremor with special reference to
PD are described as below:
– Present at rest
– Has a regular rhythm of about 4 to 7 beats/sec

7. – Usually disappears with movement
– Rarely interferes with ADL
– No tremor during sleep
– Some patients may have a postural tremor
– “Pill-rolling”: The patient appears to be rolling a pill
in his fingers as the wrist cycles between pronation
and supination

8. 2. Bradykinesia: Bradykinesia is a term used to describe the
slowness in the execution of movement, whereas akinesia
refers to the paucity of movement and ‘freezing’or an inability
to move.
The features are:
– An impairment in the initiation of movement
– Delay in the reaction time
– Decreased ability to stop the movement once it is started

9. – Lack of spontaneous or associated movements, e.g.
arm swinging during walking
– Abnormally small amplitude movements, e.g. small
steps during walking or micrographia,
i.e. reduction in the size of the written word

10. 3.Rigidity: Rigidity is one of the cardinal features of Parkinsonism.
Clinically, it is defined as an increased resistance to stretch and the
inability to achieve complete muscle relaxation.
• Two types of rigidity are there:
a. Lead Pipe -
b. Cog-Wheel -

11. 4.Postural instability: Postural instability is the
hallmark of stage III disease. Patient becomes more and
more flexed as the condition deteriorates.
• This results into reduced rotation and forward shifting
of center of gravity and makes the patient more prone
to falls.
• There are balance difficulties, even when the patient
is seated.

12. 5.Gait: The characteristic features of the gait of parkinsonian patient
are shortened stride,festination, loss of arm swing and increased
cadence.
• Patients take increasingly fast but short steps in order to position
their lower limbs under their flexed trunk.
• Instead of a heel-toe progression there may be a flatfooted or, with
disease progression, a toe-heel sequence.
• This results into the decreased ability to step over obstacles or to
walk on carpeted surfaces.

13. Other symptoms
Several other symptoms are also associated with PD. For example:
– Mask like face(Hypomimia)
– Reduced blinking of the eyes
– Slowing of speech with a decrease in volume
– Cognitive changes such as depression or dementia
– With the progression of the disease other symptoms may get
involved. For example, pulmonary infection or gastrointestinal
dysfunction such as dysphagia and constipation or autonomic
dysfunction such as postural hypotension

15. Evaluation and Assessment
• PD is revealed by itself over the time
• The diagnosis is based on history and physical examination
• No laboratory or imaging studies are available to diagnose PD
• Physical examination should focus on the degree of tremor,
bradykinesia, rigidity, balance
and gait impairments
• The overall disability can be evaluated by using Parkinson’s disease
evaluation form

16. Management
• Pharmacotherapy:
• – The aim of pharmacotherapy is to provide the symptomatic
relief by replacing or compensating for lost dopaminergic
neuron activity.
• – Levodopa is the most commonly used drug in the
treatment of PD
• – Dopamine agonists are most commonly used as an adjunct
to levodopa.

17. • – Nutrition:
i. A high-fibre diet and sufficient fluid intake to reduce the severity of
constipation, which is a common complaint in PD.
ii. Calcium and vitamin D supplementation to improve bone health.
iii. Protein restriction, especially in later stages of the disease, to reduce
amino acid
competition with levodopa for absorption.
– Speech therapy to assist tongue dysfunctions and improve voice
volume

18. Physical therapy
1. Relaxation techniques: This is a vital component of treatment
program with an aim to reduce rigidity. Physical therapist should
remember that unless and until the rigidity is reduced, it is difficult to
initiate the movements. In addition to it, relaxation techniques may
help in reducing the tremor. The techniques used may be:
i. Gentle, slow rocking movements (Fig. 9.23)
ii. Rotation of extremities and trunk (Fig. 9.24)
iii. Savasana
iv. Biofeedback
v. PNF techniques

19. 2.Active ROM and stretching exercises: These are especially important
in the earlier stages of PD, to prevent shortening of muscle because in
PD, the contractile elements of flexor muscles become shortened,
whereas those of the extensor muscles become lengthened.
• Scapular and pelvic mobility should be given special emphasis.
i. Sitting is the better starting position then supine lying because rigidity
may be increased in the later position.

20. ii. Movements should be started first in distal joints and then progression can be
made for
more proximal joints. This is because trunk and other proximal muscles are more
involved
than the distal muscles.
iii. Movements performed should be large, simple and through the full range.
iv. Rhythm or music may facilitate the movement.
v. It is easier to perform the movements in bilateral symmetrical patterns rather
than
reciprocal patterns. For example, arm swinging.
vi. Progression may be made by performing movements in diagonal pattern.

21. • Breathing exercises: As the patients of PD adopt a more flexed
posture, the chest expansion is reduced. Moreover, the most
common cause of death in these patients is pneumonia.
• The exercise may range from simple chest expansion exercise to
specific breathing exercise.

22. • Strengthening exercises: Muscular weakness is not the main
feature of PD. However, strength may be decreased due to
disuse.
• In addition to it, strengthening exercises may help to prevent
falling.
• Physical therapist should remember that functional strength
training is more effective than weightlifting in improving
muscular strength in the patients of PD.