Parkinson's disease is a progressive brain disorder that causes a gradual loss of muscle control. Its symptoms include tremors, stiffness, slowed movements, and poor balance. Early signs may include slight shaking, difficulty walking or writing, and stooped posture. Treatments include medications like dopamine agonists and surgeries like deep brain stimulation. Physical therapy focuses on exercises to improve mobility, balance, posture, and prevent contractures. Symptoms fluctuate between "on" and "off" periods depending on dopamine levels, affecting the appropriate exercises.

1. o PARKINSON’S DISEASE (PD)
Presented by:Trcoski Boge

2. What Is Parkinson's Disease?
 Parkinson's disease is a brain disorder that
causes a gradual loss of muscle control. The
symptoms of Parkinson's tend to be mild at
first and can sometimes be overlooked.
 Distinctive signs of the disease
include:tremors, stiffness, slowed body
movements, and poor balance.

3. Early Signs of Parkinson's
 The early signs of Parkinson's may be subtle and
can be confused with other conditions. They
include:
• Slight shaking of a finger, hand, leg, or lip
• Stiffness or difficulty walking
• Difficulty getting out of a chair
• Small, crowded handwriting
• Stooped posture
• A 'masked' face, frozen in a serious expression

4. SYMPTOMS
 Tremor
 Tremor is an early symptom for about 70% of
people with Parkinson's. It usually occurs in a finger
or hand when the hand is at rest but not when the
hand is in use. It will shake rhythmically, usually four
to six beats per second, or in a "pill-rolling" manner,
as if rolling a pill between the thumb and index
finger. Tremor also can be a symptom of other
conditions, so by itself it does not indicate Parkinson
disease.
 Bradykinesia (slowness of movements)

5. POSTURAL INSTABILITY
 People with Parkinson's
tend to develop a stooped
posture, with drooping
shoulders and their head
jutted forward. Along with
their other movement
issues, they may have a
problem with balance. This
increases the risk of falling.

6.  RIGIDITY
 Stiffness or rigidity of the muscles, resulting in
decreased ability to move. When a joint of a
Parkinson's patient is moved, there is
resistance to the movement. "Lead
pipe" rigidity is a form of increased tone that is
particularly prominent in Parkinson's and can
result in muscle stiffness, fatigue, and
weakness. "Cogwheel" rigidity occurs when
there is also a tremor and is characterized by a
"stop and go" effect during a range of motion
maneuver.

7.  OTHER SYMTOMS :
 Weakness of face and throat muscles
It may get harder to talk and swallow. Speech
becomes softer and monotonous. Loss of
movement in the muscles in the face can
cause a fixed, vacant facial expression, often
called the "Parkinson's mask.“
 Constipation
 Sleep problems
 Depression

8.  Who Gets PD?
 The average age of
onset is 62, but people
over 60 still have only a
2% to 4% likelihood of
developing the disease.
Having a family
member with PD
slightly increases the
risk. Men are one-and-
a-half times more likely
to have Parkinson's
than women.

9.  Surgeries used:
 Deep Brain Stimulation
 Electrodes can be implanted
into one of three areas of the
brain(VIN of the talamus)A
pulse generator(pacemaker)
goes in the chest near the
collarbone. Electric pulses
stimulate the brain to help
reduce a patient's rigidity,
tremors, and bradykinesia. It
doesn’t stop the progression of
PD or affect other symptoms.
Not everyone is a good
candidate for this surgery.
 Phlebotomy and
Thalamotomy
• These surgical procedures use
radio-frequency to destroy a
pea –sized area in the globus
pallidus of the tallamus

10.  Treatment (drugs)
Dopamine Agonists
 Drugs that mimic dopamine,
called dopamine agonists,
may be used to delay the
movement-related
symptoms of Parkinson's.
They include Levadopa,
Apokyn, Mirapex, Parlodel.
Side effects may include
nausea and vomiting,
drowsiness, fluid retention,
and psychosis.

11. Parkinson's and Exercise
 Exercise may actually have a protective effect by
enabling the brain to use dopamine more effectively.
It also helps improve motor coordination, balance,
gait, and tremor. For the best effect exercises
should be done consistently and as
intensely.Preferably three to four times a week.
Working out on a treadmill or biking have been
shown to have a benefit.

12.  Most PD patients face mobility deficits
 Difficulties with transfers
 Posture
 Balance
 Walking
 Fear of falls
 Loss of independence
 Inactivity

13. ASSESMENT OF THE PATIENT

14.  Şükriye Arslan is a 68-years-old
woman,1,57 hight and 68kg weight.She
was a cook for the last 12 years and she
finished just primiry school.She came to
the PAU hospital for consult and she
obteined schedule for deep brain
stimulation surgery and she was
operated on 13.03.2014

15.  Pre-operation PT assesment wasn’t made.
 Post-operation PT assesment was porformed
with couple of tests and meassurments.

16. RESPIRATORY ASSESMENT
Breath type: Abdominal
Breath frequency: 28/min
Breathing : Superficial

17. CHEST MEASUREMENT
NORMAL DEEP
INSPIRATION
DEEP
EXPIRATION
DIFFERENCE
AXILAR 92 94 92 2
EPIGASTRIC 95 96,5 94 2,5
SUBCOSTAL 94,5 96,5 94,5 2

18. DTR RIGHT LEFT
ACHILLES REFLEX ++ ++
PATELLA REFLEX + +++
BICEPS REFLEXES + +++
TRICEPS REFLEXIS ++ ++
BRACHIORADIALIS
REFLEX
+ ++
0=LOSS OR RECIVED; +=DECREASE; ++=NORMAL; +++=INCREASE

19. PATHOLOGICAL REFLEXES
 Glabellar = -
 Snout = -
 Hoffman = -
 Palmomental = -

20.  DRUGS USED :
 Modapin
 Azidect
 Pramipex
 Medsil

21. SENSATION :
 Is intanct for light touch,pain,temperature,
deep pressure ,and kinesthesia.

22. BED MOBILITY AND TRANSFER
 Independent rolling on bed with low axial
rotation,difficult independent sitting from
supine position.
 Sit transfer :
 sit – stand = independent
 bed –chair =independent

23. GAIT AND POSTURE
 At this time patient is walking without any
assistive device ,without freezing,with
minimal forward flexed posture.While walking
there is swinging of her arms with no
cerebellar signs.
 Balance test is positiv in static and dinamic
position,without retropulsion or propulsion.

24.  Time up & go test (3m) = 13,81 sec.
 12 metere walking = 17,45 sec.
 sit – stand /14 times = 30 sec.

25.  Posture analysis:
 kifosis(toracal)
 head anterior
 chest inside
 shoulder contraction

26.  PRESENT SYMPTOMS :
 Disarthrya
 Bradikinesy
 Rigidity (more in left arm)
 Incontinence
 Tiredness
 Cognition
 Concentration : difficult
 Memory : intact

27.  Schwab & England Activities of Daily Living
scale
• She is estimate on 90 % - completely
independent. Able to do all chores with some
slowness, difficulty, and impairment. Might
take twice as long. Beginning to be aware of
difficulty.
 Hoehn – Yahr scale (stages of PD)
• Stage 1.5 -Unilateral and axial involvement

28. MUSCLE AND ROM EXAMINATION
 Moderate dicrease of muscles power on neck
and trunk muscles.
 PROM without dicrease .
 Moderate dicrease in AROM on neck and
trunk muscles.

29. Physical Therapy

30. Physical Therapy Pogram
of the patient
 Relaxation tehniques to dicrease rigidity
 Slow lhytmic rotational movements
 Gentle ROM and streching exercises to
prevent contractures,quadriceps and hip
isometric exercises.
 Neck and trunk rotation exercises
 Back extension exercises and pelvic tilt
 Breathing exercises

31.  Functional mobility training including bed
mobility,transfer training
 Training in rhytmic pattern to music such as
clapping may help in alternating
movements,standing and balancing in
parallel bars(static and dynamic)with weight
shifting,ball throwing
 Stationary bicycle to help train reciprocal
movements.

32.  Large steps progresssive training using
blocks to lift legs,teaching proper heel –
floor strike.
 Arm swing exercises

33. Motor Fluctuations
 The on – off respons:
 On and Off periods
occur wuthout warning
as a result of fluctuating
dopamine levels in the
brain.

34.  During ON times, patients report they feel
relatively fluid, clear, and in control of their
movements. Often, symptoms of PD may be
invisible to all but professionals.
 During OFF periods, patients experience
stiffness, lack of muscular coordination, pain,
difficult handwriting — the full range of classic
PD symptoms. Most patients have visible
symptoms. Typically, patients will cycle
between ON and OFF periods three to four
times every day, although everyone’s
experience is unique.

35.  In the “off” period , we need to prefer
approaches that does not require the
patiant to actively participate that much,such
as respiratory therapy ,inhibation for pain
and rigidity
 In the “on” period , balance,
coordonation,posture,walking exercises and
gait training should be preferred.

36. THANK YOU 