PARKINSON’S DISEASE

SAIRA REHMAN
ROLL # 01
IPM&R KMU
Parkinsonism is a generic term used to describe a group of disorders with
primary disturbances in dopaminie systems of basal ganglia (BG)

Parkinson's disease (PD) or paralysis agitants is a neurodegenerative

disorder that affects predominately dopamine-producing (dopaminergic) neurons in a
specific area of the brain called substantia nigra.

General age of onset of symptoms is 60

• SECONDARY PARKINSONISM result from a number of different
identifiable causes including viruses, toxins, drugs and tumors
PATHOPHYSIOLOGY:
• BASAL GANGLIA
controls movement
•DOPAMINE
inhibitory neurotransmitter in the basal ganglia
•ACETYLCHOLINE
excitatory neurotransmitter
Without dopamine, inhibitory influences are lost and excitatory mechanisms
are unopposed so neurons of basal ganglia are overstimulated
Excess muscle tone, tremors and rigidity
• The 2 major neuropathologic findings in Parkinson disease
loss of pigmented dopaminergic neurons of the
substantia nigra pars compacta and the presence of Lewy bodies
(intracytoplasmic eosinophilic inclusions)
CLINICAL PRESENTATION:
PRIMARY MOTOR SECONDARY MOTOR NON-MOTOR SYMPTOMS
SYMPTOMS/ CARDINAL FUNCTIONS
FEATURES
Rigidity Muscle performance Sensory symptoms

Bradykinesia Motor function dysphagia

Tremor Gait Speech disorder

Postural instability Cognitive dysfunction

Depression & anxiety

Autonomic dysfunction

Sleep disorders
PRIMARY MOTOR SYMPTOMS:
1. RIGIDITY:
Increased resistance to passive motions
decreases the ability to move easily
prolonged rigidity decreased ROM , contractures
increased resting energy expenditure and fatigue.
COGWHEEL RIGIDITY: ratchet like resistance to passive movements. It
occurs when tremors coexist with rigidity.
LEADPIPE RIGIDITY constant resistance throughout whole ROM due to
increased tone.
BRADYKINESIA:
• Refers to slowness of movements
• Weakness, tremor and rigidity contribute to it.
• Prolonged reaction time
• Prolonged movement time
• The sign is established by lack or slowness of spontaneous facial
expression and absent arm swing on walking and freezing episodes
(AKINESIA)
• HYPOKINESIA refers to slowed and reduced movements
micrographia
TREMOR
• In 70% of patients.
• Tends to be mild and occurs for short periods. This is known as resting
tremors.
• Tremor in lower limb is most apparent while the patient is supine.
• Postural tremor apparent in upright posture
• Tremor is aggravated by emotional stress or excitement.
POSTURAL INSTABILITY:
• A tendency to be unstable when standing upright
• Develops later in the disease.
• Narrowing BOS or competing attentional demands increases postural
instability.
• People with balance problems may have particular difficulty when
pivoting or making turns or quick movements.
• Some patients are unable to perceive the upright or vertical position,
which may indicate an abnormality in processing of vestibular, visual,
and proprioceptive information contributing to balance
CONTRRIBUTING FACTORS TO POSTURAL INSTABILITY:
• Rigidity
• Decreased muscle torque production and weakness
• Loss of available ROM particularly of trunk motions and axial rigidity
• Medications side effects (e.g postural hypotension and dyskinesia)
CONTRACTURES:
• LE: Hip and knee flexors, hip rotators and add. and PF
• SPINE: dorsal spine and neck flexors
• UE: shoulder add and internal rotators and elbow flexors
 SECONDARY MOTOR SYMPTOMS:
• Reduction in strength (dopamine related)
• Muscle weakness
• Activity limitation
FATIGUE
• Difficulty in sustaining activities
• Experiences increasing weakness and lethargy as the day progresses
• Repetitive motor acts may start out strong but decreases in strength
and amplitude as activity progresses.
• Rest or sleep may restore mobility
MOTOR FUNCTION:

• Motor deficits are evident involving a loss regulatory control of both

automatic and voluntary movement responses
• Paucity with less accurate movement. It becomes more pronounced
with increasing speed of movement
• Difficult to perform dual tasks
• Learning of a new motor skill and fine tuning of skills are intact at
early stage of PD
• Learning is impaired with random practice order while blocked
practice order reduces learning difficulty
 GAIT:
• 13% to 33% of patients presents with postural instability and gait
disturbances as their initial motor symptom
• Also a common feature of advanced disease
SIGNIFICANT GAIT CHANGES:
Abnormal stooped posture contributes to festinating gait
• Anteropulsive gait
• Retropulsive (less common)
• Turning or changing direction is difficult and accomplished by taking small
steps
FOG:
• Disabling and leads to falls
• Off and on medication state
• Compensated by external cues and attentional stratigies
NON-MOTOR SYMPTOMS:

• SENSORY SYMPTOMS:
• Pain and Parasthesis including numbness, tingling, burning
• Postural stress syndrome
• Olfactory dysfunction is common
anosmia
• Visual disturbances
anticholinergic drugs blurred vision/ photophobia
DYSPHAGIA:
• Result of rigidity, reduced mobility and restricted range of
movement
• Experience problems in all four phases of swallowing:
1. Chewing,
2. Bolus formation
3. Delayed swallow response
4. Peristalsis
• Dysphagia can lead to chocking or aspiration pneumonia and
impaired nutrition with significant weight loss
• Sialorrhea (excessive drooling) problematic while sleeping or
initiating speech
SPEECH DISORDERS:

• Speech is effected, with the voice becoming monotonus, exhibiting

reduced volume and a lack of rhythm and variety of emphasis
(hypokinetic dysarthria)
• in advance cases pt. may demonstrate mutism
• Voice quality is degraded with speech described as hoarse, breathy
and harsh
COGNITIVE DYSFUNCTION/ANXIETY:

• Mild (e.g.,mildly impaired memory) or severe (e.g., psychosis)

• PD dementia occurs in approximately 20% to 40% of the patients
• Dementia is associated with increased mortality rates
AUTONOMIC DYSFUNCTION:

1. Thermoregulatory dysfunction
• excessive sweating
• uncomfortable sensations of warmth and coldness  impaired peripheral
vasodilation
2. slow pupillary responses to light
3. Gastrointestinal disorders include poor motility  Constipation
4. Urinary Incontinence
5. diminished heart function
6. Orthostatic hypotension (OH)
7. Restrictive lung dysfunction
SLEEP DISORDERS:

excessive daytime somnolence (sleepiness)

At night, insomnia
Dream-enacting behaviors include agitation and physical activity during sleep
(e.g., talking, yelling, punching, kicking, arm flailing, and grabbing).
ASSESSMENT:

Cognitive function
Psychosocial function
Sensory function
Musculoskeletal function
Muscle performance
Rigidity
Bradykinesia
Tremor
Gait
PHYSICAL THERAPY
MANAGEMENT
MOTOR LEARNING STRATIGIES:
• Internally generated cues are more difficult as compared to externally
generated cues
• Large number repetitions to develop procedural skills
• Pay Attention to desired movement
• Environmental Modifications
• Avoid competitive cognitive demand
• long & complex sequences should be broken down into component parts.
• Blocked Practice order
• Use of structured instructional sets
• External cues: visual and auditory
EXERCISE TRAINING:

• AMPLITUDE-BASED BEHAVIORAL INTERVENTION

Repetitive high amplitude movements yield better improvements in motor
performance and have a neuroprotective effect
• RELAXATION EXERCISES
Slow rhythmic rotational movements reduce muscle tone
e.g hook lying, trunk rotation
• PNF
• Rhythmic initiation to overcome effects of rigidity
• D2 flexion
 FLEXIBILITY EXERCISES:
• Is to improve ROM and physical function
• RESISTANCE TRAINING
• Indicated for muscle weakness
• Strength training improves muscle force, bradykinesia and QOL
HARNESS TREADMILL:
 VIRTUAL REALITY:
• computer-generated,
interactive simulation
that maps the real
environment by
affecting human
senses, and shows all
activity in real time and
with real speed.
• GAIT TRAINER 3 + UNWEIGHING
The Biodex Gait Training System
• The Gait Trainer provides audio and visual
biofeedback of step length and step speed.
The Unweighing Support System provides
assistance, helping patients regain their confidence,
their strength and their stride. The Unweighing
System, combined with the Gait Trainer 3 allows
every patient the opportunity to get an early start
on rehabilitation.
MUSIC ASSISTED THERAPY:
• Teatment of movement
disorders
• repetition of gait training
encourages lasting effects
through neuroplasticity
• The right music, the correct
beats per minute and gait
repetition helps therapists get
patients better, faster. Fit the music to the patient. Select the
correct tempo (bpm) to accommodate
patient’s step speed or steps per
minute (spm)
FUNCTIONAL TRAINING:

When the patient rises, the Assist Force Adjustment System provides graded
concentric and eccentric assistance in a manner that reinforces the three
phases of sit-to-stand motion.
Trunk flexion – the momentum allows for a weight transfer to initiate the lift off.
Lift off and extension – pelvis moves from an anterior to posterior tilt, and the
lower extremity extensor muscles of the ankle, knee and hip are all
progressively engaged as needed by the counterforce.
Stabilization – reach a stable, upright position.
THANK YOU