Parkinson's disease is a progressive nervous system disorder that affects movement. It is characterized by motor symptoms like rigidity, bradykinesia, tremor, and postural instability. Non-motor symptoms can also occur and include loss of smell, sleep disturbances, mood changes, and others. While the cause is largely unknown, both genetic and environmental factors are involved. Treatment focuses on managing symptoms through medication and other therapies. As the disease progresses, symptoms worsen and disability increases.

1. Parkinson’s Disease

3. OUTLINE
• DEFINTION
• INCIDENCE
• ETIOLOGY
• PATHOPHYSIOLOGY
• STAGES
• CLINICAL FEATURES
• MEDICAL MANAGEMENT
• FRAMEWORK

4. DEFINTION
• Parkinson’s disease (PD) is a progressive disorder of
the central nervous system (CNS) with both motor
and nonmotor symptoms.
• Motor symptoms include the cardinal features of
rigidity, bradykinesia, tremor, and, in later stages,
postural instability.
• Nonmotor symptoms may precede the onset of
motor symptoms by years.

5. Early symptoms can include loss of
sense of smell, constipation, rapid eye
movement (REM)
sleep behavior disorder, mood
disorders, and orthostatic
hypotension.

6. INCIDENCE
• Parkinson’s disease is a common disease that
affects an estimated 1 million Americans and an
estimated 7 to 10 million people worldwide.
• More than 2% of people older than 65 years of age
have PD, second only to Alzheimer’s disease among
neurodegenerative disorders.
• The prevalence of the disease is expected to
increase substantially in the coming years due to
the aging of the population.
• The average age of onset is 50 to 60 years.

7. • Only 4% to 10 of patients are diagnosed
with early-onset PD (less than 40 years of
age).
• Young-onset PD is classified as beginning
between 21 and 40 years of age, and
juvenile-onset PD affects individuals less
than 21 years of age.
• Men are affected 1.2 to 1.5 times more
frequently than women.

8. ETIOLOGY
• The term parkinsonism is a generic term used to
describe a group of disorders with primary
disturbances in the dopamine systems of basal
ganglia (BG).
• Both genetic and environmental influences have
been identified.
• Parkinson’s disease, or idiopathic parkinsonism, is
the most common form, affecting approximately
78% of patients.

9. • Secondary parkinsonism results from a
number of different identifiable causes,
including virus, toxins, drugs and
tumors.
• The term parkinsonism-plus syndromes
refers to those conditions that mimic PD
in some respects, but the symptoms are
caused by other neurodegenerative
disorders.

10. Parkinson’s Disease
• Parkinson’s disease was first described as
“the shaking palsy” by James Parkinson
in 1817 and refers to those cases where
the etiology is idiopathic (unknown) or
genetically determined.
• Two distinct clinical subgroups have
been identified.

11. • One group includes individuals whose
dominant symptoms include postural
instability and gait disturbances (postural
instability gait disturbed)
• Another group includes individuals with
tremor as the main feature (tremor
predominant).
• Patients who are tremor predominant
typically demonstrate few problems with
bradykinesia or postural instability.

12. Secondary Parkinsonism
Postencephalitic Parkinsonism
• The onset of parkinsonian symptoms
typically occurred after many years,
giving rise to the theory that a slow
virus infected the brain.
• In the absence of a recent outbreak,
this type of parkinsonism is no longer
seen.

13. Toxic Parkinsonism
• Parkinsonian symptoms occur in individuals
exposed to certain environmental toxins,
including pesticides and industrial chemicals.
• The most common of these toxins is
manganese, which represents a serious
occupational hazard to many miners from
prolonged exposure.
• Severe and permanent parkinsonism has
been inadvertently produced in individuals
who injected a synthetic heroin containing the
chemical MPTP (1-methyl-4-phenyl-1,2,3,6-
tetra/ hydropyridine)

14. Drug-Induced Parkinsonism (DIP)
• A variety of drugs can produce extrapyramidal
dysfunction that mimics the signs of Parkinsons
disease.
• These drugs are thought to interfere with
dopaminergic mechanisms either presynaptically or
postsynaptically
• They include
(1) neuroleptic drugs such as chlorpromazine ,
haloperidol, thioridazine and thiothixene

15. (2) antidepressant drugs such as amitriptyline
(Triavil), amoxapine (Asendin), and trazodone
(Desyrel); and
(3) antihypertensive drugs such as methyldopa
(Aldomet) and reserpine.
• High doses of these medications are particularly
problematic in the elderly.
• Parkinsonism can be caused in rare cases by
metabolic conditions, including disorders of calcium
metabolism that result in basal ganglia calcification.
• These include hypothyroidism,hyperparathyroidism,
hypoparathyroidism, and Wilson’s disease

16. Parkinson-Plus Syndromes
• A group of neurodegenerative diseases can
affect the substantia nigra and produce
parkinsonian symptoms along with other
neurological signs.
• These diseases include striatonigral
degeneration (SND), Shy-Drager syndrome,
progressive supranuclear palsy (PSPO),
olivopontocerebellar atrophy (OPCA), and
corticalbasal ganglionic degeneration.

17. • In addition, parkinsonian symptoms can
be exhibited in patients with multi-infarct
vascular disease, Alzheimer’s disease,
diffuse Lewy body disease (DLBD),
normal pressure hydrocephalus (NPH),
Creutzfeldt-Jakob disease (CJD), Wilson’s
disease (WD), and juvenile Huntington’s
disease.
• Many of these conditions are rare and
affect relatively small numbers of
individuals.

18. PATHOPHYSIOLOGY

19. PATHOPHYSIOLOGY

25. STAGES OF PARKINSON’S DISEASE
• Postmortem studies by Braak and colleagues have
yielded evidence supporting the view that PD is a
widely dispersed neurodegenerative disease that
demonstrates a progression through different
stages.
• In stage 1 lesions are found in the medulla
oblongata dorsal IX/X nucleus or intermediate
reticular zone.

26. • In stage 2, pathology is expanded to involve lesions
of the caudal raphe nuclei, the gigantocellular
reticular nucleus, and coeruleus-subcoeruleus
complex.
• In stage 3, involvement of the nigrostriatal system
is apparent.
• In stage 4, lesions are also found in the cortex
• In stage 5, pathology is extended to involve the
sensory association areas of the neocortex and
prefrontal neocortex.

27. In stage 6,
pathology is extended to
involve the sensory
association areas of the
neocortex
and
premotor areas

33. Clinical features
(or)
Clinical presentation
Primary Motor Symptoms
• Rigidity
• It is felt uniformly in both agonist and antagonist
muscles.
• Spinal stretch reflexes are normal.
• Rigidity is fairly constant regardless of the task,
amplitude, or speed of movement.

34. • Two types are identified: cogwheel or lead pipe
• Cogwheel rigidity is a jerky, ratchet-like resistance
to passive movement as muscles alternately tense
and relax.
• It occurs when tremor coexists with rigidity.
• Lead pipe rigidity is a sustained resistance to
passive movement, with no fluctuations.
• Rigidity is often asymmetrical, especially in the
early stages of Parkinson’s Disease.
• affects shoulders & neck first and later involves
muscles of face & extremities

35. Prolonged rigidity results in decreased
range of motion (ROM) and serious
secondary complications of contracture
and postural deformity.
Rigidity also has a direct impact on
increasing resting energy expenditure
and fatigue levels.

37. Bradykinesia
• Bradykinesia refers to slowness of movement
and is one of the cardinal features of
Parkinsons disease
• Weakness, tremor, and rigidity may
contribute to bradykinesia but do not fully
explain it.
• The principle deficit is the result of insufficient
recruitment of muscle force during initiation
of movement.

38. • Akinesia refers to a poverty of spontaneous
movement.
• For example, the patient with PD
demonstrates hypomimia or masked facial
expression, with significant social
consequences.
• The absence of associated movements (e.g.,
arm swing during walking) or freezing (e.g.,
sudden stops in movement as in freezing of
gait [FOG] ) are other examples.
• Freezing episodes can be triggered by
confrontation of competing stimuli.

39. • Akinesia can be influenced by the degree of rigidity,
as well as stage of disease, fluctuations in drug
action, and disturbances in attention and
depression.
• Hypokinesia refers to slowed and reduced
movements and can also be seen in PD. For
example, patients with moderate or severe PD
typically present with handwriting that may start
out strong but becomes smaller and smaller as
writing proceeds (micrographia).
• During walking, rotational movements of the trunk
with arm swing may also start out strong and
decrease over time.

41. Tremor
• Tremor, a third cardinal feature of PD, involves
involuntary shaking or oscillating movement
of a part or parts of the body resulting from
contractions of opposing muscles.
• In the early stages of the disease, about 70%
of patients experience a slight tremor of the
hand or foot on one side of the body, or less
commonly in the jaw or tongue.
• It tends to be mild and occurs for only short
periods.

42. • The tremor is known as a resting tremor
because it is present at rest, suppressed
briefly by voluntary movement, and
disappears with sleep.
• Tremor in the lower limbs is most apparent
while the patient is supine.
• Tremor of the head and trunk, postural
tremor, can be seen when muscles are used to
maintain an upright posture against gravity.

44. Postural Instability
• Individuals with PD demonstrate abnormalities of
posture and balance, resulting in postural
instability.
• Postural instability is rare in early years until 5 years
of diagnosis.
• As the disease progresses, a number of problems
become evident across a broad spectrum of
movement control.
• Patients demonstrate abnormal and inflexible
postural responses controlling their center of mass
(COM) within their base of support (BOS).

45. • Narrowing Base of support , or competing
attentional demands increases postural
instability.
• The response to instability is an abnormal
pattern of coactivation, resulting in a rigid
body and an inability to utilize normal
postural synergies to recover balance.
• Contributing factors to postural instability
include rigidity, decreased muscle torque
production and weakness, loss of available
ROM particularly of trunk motions, and axial
rigidity.

46. • Progressive development of postural
deformity occurs.
• Weakness of antigravity muscles contributes
to the adoption of a flexed, stooped posture
with increased flexion of the neck, trunk, hips,
and knees.
• This results in a significant change in the
center-of-alignment position, positioning the
individual at the forward limits of stability.
• Frequent falls and fall injury are the result of
progressive disease.

48. Secondary Motor Symptoms
MUSCLE PERFORMANCE
AND
MOTOR FUNCTION

50. Gait
• Combination of movement and
sequential movement task are grossly
affected in parkinsonism.
• Thus parkinsonism patient exhibits severe
difficulty in walking.
• Initially, there is only lack of associated
movements.
• Later on the gait becomes slow, shuffling
gait with small steps.

52. • The initiation of walking is difficult, but after
initiation the patient may walk fast with small steps
in a bend attitude and eventually run as if to catch
up with his center of gravity
• This is called Festinating gait.
• On the other hand, patient may also have freezing
of gait.
• In this case, patient walks quite well initially with
relatively larger steps but eventually shuffles at the
same place. without proceeding further

53. • This is called as Freezing.
• Some patient may have difficulty in stopping
suddenly and needs some external force to bring
their gait to stop.
• Approximately 13% to 33% of patients present with
postural instability and gait disturbances as their
initial motor symptom and comprise a PIGD group.
PIGD means Postural instability and gait disorders

54. Nonmotor Symptoms
Sensory Symptoms
• Patients with PD do not suffer from primary
sensory loss.
• However, as many as 50% experience
paresthesias and pain, including sensations of
numbness, tingling, cold, aching pain, and
burning.
• Pain may be due to the disease’s effect on
central nociception.

55. Proprioceptive regulation of voluntary
movement
may also be impaired. Patients with PD
perform significantly
worse than control subjects on tests of
kinesthesia
and proprioceptive position sense.

56. Conjugate gaze and saccadic eye
movements may also be impaired. Eye
pursuit movements
may have a jerky, cogwheeling quality.
Decreased
blinking can produce bloodshot,
irritated eyes that burn
and itch

57. Dysphagia
• Dysphagia, impaired swallowing, is present in
as many as 95% of patients and is the result of
rigidity, reduced mobility, and restricted range
of movement.
• Dysphagia can lead to choking or aspiration
pneumonia and impaired nutrition with
significant weight loss.
• Excessive drooling has important negative
social implications.

59. Speech Disorders
• Speech is impaired in 75% to 89% of patients and is
the result of primary symptoms of parkinson’s
disease.
• Reduced vital capacity results in reduced air
expended during phonation. In advanced cases, the
patient may speak in whispers or not at all,
demonstrating mutism.
• Sensory problems may also contribute to speech
difficulties.

61. Cognitive Dysfunction
• Impairments in cognitive function can be mild
or severe.
• Parkinson disease dementia occurs in
approximately 20% to 40% of the patients.
• Older patients appear to be at greatest risk
for dementia, with reported rates 4.4 times
higher for individuals 80 years of age or older

62. Depression and Anxiety
• Depression is common in patients with
parkinson disease.
• Major depression is reported to occur in
approximately 40% of patients.
• Anxiety is a common symptom in PD,
occurring in up to 38% of patients.

66. Sleep Disorders
• At night, insomnia (disturbed sleep pattern)
may occur.
• This includes problems in falling asleep,
staying asleep, and good quality of sleep.
• REM sleep behavior disorder (RBD) occurs
early in parkinson disease and affects as many
as 50% to 60% of patients.

69. Hoehn & Yahr
Classification of
Disability

71. Unified
Parkinson’s
Disease Rating
Scale (UPDRS)

73. MEDICAL
MANAGEMENT