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PARKINSONISM:
 Itis a chronic, progressive neurological
syndrome due to lesion in basal ganglia
resulting in

 Resting tremors.
 Rigidity.
 Bradikinesia
 Postural instabilities
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PARKINSON DISEASE
 Itis a chronic, progressive, neurological,
degenerative disease that occurs due to
dopamine depletion in basal ganglia of
brain.
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DISCOVERY:
 Parkinson
disease was first discovered by
JAMES PARKINSON in 1817. He named it
PARALYSIS AGITANS means shaking palsy.
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OCCURANCE:
AGE: > 60 yrs.
SEX: male: Female ( 1:1).
INCIDENCE: 1-2 per 1000
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PATHOPHYSIOLOGY:
 Since dopamine is an inhibitory neurotransmitter which is
released in nigrostriatal pathway to perform its functions.

 Due to etiological factors progressive dopaminergic cells

degeneration inside substantia nigra takes place.

 Due to absence of dopaminergic inhibitory response

cholinergic excitatory response superceeds and causes adverse
effects.

 Lewy bodies formation: These are neuronal eosinophillic

inclusions formed due to degeneration in substantia nigra that
cause decreased dopamine production.
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Clinical features
Primary Secondary
1. Resting tremors 1.Psychological problems
2. Bradikinesia 2.Personality problems
3.Autonomic
3. Rigidity disturbances
4. Postural 4.Sensory problems
abnormalities 5.Sleep disturbances
5. Masked face 6.Speech problems
6. Abnormal gait 7.Micrographia
8.Cough
9.Sialorrhea
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TREMORS:
 Involuntary ,oscillatory movements seen in fingers, arms, head, lips,
tongue and jaws.
 Are resting in nature.
 Occur 3-6/sec

 Can be examined by outstretching

patient's arms.
 Tremors of hand are of pill rolling character

 Aggravate by emotional and physical stresses.

 Are unilateral initially later on become
generalized.
 Occur due to 60-80% dopaminergic cell
destruction.
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BRADIKINESIA:
 Slowness of voluntary movements.

 Akinesia: inability to initiate movement.

 Difficulty in repetitive movements

 Hypokinesia
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Gait & posture:

 Shuffling: small stepped gait without arm swing with high
speed.
 Festinating: short quick stepped gait with stooped posture due
to displaced centre of gravity.
 Freezing: sudden brief inability to move during mid stance.
 Flat foot strike instead of heel strike

 Fall: due to balance abnormality.

 45% fall forward.
 20% laterally.
 Stooped flexed posture: due to muscular weakness.
 Turning difficulty due to reduced rotation.
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MASKED FACE:
 Bradikinesia
and facial muscle stiffness
causes vacant masked like facial
appearance.
 Hypomimia: expressionless face.
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SPEECH PROBLEMS:
 Occur in 89% of patients.
 Dysarthria: difficulty in speech articulation.
 Hypophonia: soft low pitched voice.
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PSYCHOLOGICAL:
 Dementia : In 1/3 of
patients.
 Fear.
 Anxiety
 Hallucination
 Confusion
 Motivational loss
 Isolation
 Indecisive
 Dependent
 Loss of intellectual
abilities
 Depression
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AUTONOMIC PROBLEMS
 Statichypotension in standing.
 Bowl & bladder problems.
 Constipation.
 Sweating.
 Urinary urgency.
 Dryness of skin & dandruff.
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SENSORY PROBLEMS
 Pain.
 Parasthesia.
 Numbness.
 Increased temperature.
 Burning sensation.
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SLEEP:
 Altered sleep & wake cycle.
 Excessive day time sleep.
 Insomnia : sleep difficulties.
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INVESTIGATIONS:
 No lab tests as
such. Diagnosis is
made using neuro
imaging
techniques.
 CT.
 MRI.
 Diagnostic criteria:
1.presence of classical symptoms.
2.unilateral onset.
3.symptoms relief by L-DOPA.
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DIFFERENTIAL DIAGNOSIS
 Alzheimer’s disease.
 Brain tumors.
 Cerebellar lesion.
 Toxins exposure.
 Stroke.
 9th nerve palsy.
 Huntington disease.
 Hypothyroidism.
 Multiple sclerosis.
 ALS.
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Management
 Pharmacological

 Physical Therapy

 Psychological

 Surgical
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Pharmacological
 Dopamine

 Leo dopamine

 Carboxylation ….associated side effects

 Carbidopa

 Sinemet (l-dopa 250mg+ carbidopa 25mg)

 Madopar (l-dopa 250mg + benserazide 50mg)

 Antiviral
 MAO inhibitor
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 Physical therapy
 GOALS:
 Maximize patient’s independence.
 Regain patient’s functional potential.
 Minimize secondary complications.
 Regain physical fitness.
 Minimize deformity chances.
 Conserve energy

 MODES:
 Physical agents.
 Exercises.
 Assistive devices.
 Generalized home based rehabilitation programs.
 Group training.
 Energy conservation techniques.
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EXERCISE:
 GOALS: MODES:
1.Strengthening exercises.
 Maintain joint 2.Stretching exercises.
integrity. 3.Flexibility exercises.
 Maintain muscle 4.Balance exercises.
1.Strength. 5.Breathing exercises.
6.Facial mobility exercises.
2.Flexibility. 7.Range of motion
3.Endurance. exercises.
8.Coordination exercises.
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STRENGTHENING EXERCISES:
Of all weakened muscles :
 Especially of:

1.antigravity muscles
2. Back extensors.
3.Shoulder abductors
4.Neck extensors.
5 Hip & knee
extensors.
6.Shoulder external
rotators.
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BALANCE EXERCISES:
 GOALS:
 Maintain balance.
 Prevention of fall.
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RELAXATION EXERCISES:
 Modes:
 Diaphragmatic breathing exercises.
 Yoga.
 Soft music.
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STRETCHING EXERCISES:
 For shortened muscles especially
 Trunk flexors.
 Hip & knee flexors.
 Neck flexors.
 Shoulder internal rotators
 & adductors.
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HYDROTHERAPY:
 GOALS:
 Strengthening
 Relaxation.
 Balance.
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Tremors managements:

Modes:
 Proper sleep.
 Putty squeezing.
 Complete relaxation.
 Fist making.
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MASKED FACIAL MANAGEMENT:

MODES:
 Mirror therapy.
Practice of facial expressions like:
 Surprise.

 Displease.
 Furrowing.
 Nose wrinkling.
 Smiling.
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MICROGRAPHIA MANAGEMENT:
 Usage of weighted
pens.
 Wrapping of tape
for additional grip.
 Use of typewriter &
keyboard typing in
later stages.
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GAIT MANAGEMENT:
 MODES:
 Perform purposeful
targeted movement.
 Walking on cue cards,
floor markings,& blocks.
 Treadmill walking.
 Walk with long stepped
gait having broad base.
 Always walk with arm
swing in a marching style.
 CUES:
 Verbal.( music , counting)
 Auditory
 Visual. (step watching)
 Shoe modification with
hard leathery sole.
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POSTURE MANAGEMENT:
 MODIFIED WALL &
corner PUSH UPS.
 Bilateral upper limb wall
slides.
 Leaning forward with
palms towards wall with
arms over head & feet away
from wall.
 Back & head with wall
from posterior side while
shoulder blades with wall &
chin tuck in.
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AEROBIC CONDITIONING:

 Flexibility exercises.
 Head turns & tilting.
 Ankle circling in air.
 Neck & trunk twisting.
 Walking.
 Stationarybicycling.
 Recreational activities:
 Dancing.
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ADL’S MODIFICATIONS:
 Properly planned short interval important task doing to
avoid fatigue weakness & energy conservation.
 Proper sleeping.
 Transfer techniques.
 Dressing & grooming.
 Eating & writing .
 Bathing & toileting.
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 Bradykinesis

 Musical therapy

 Physical
therapy
 Mood ,gait , posture

 PNF
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Preventing Falls
 DO NOT pivot your body over your
feet when turning. Instead try:
“U-turn” while walking

“U-turn” - Useful for more

open
areas. Move your feet &
body together
in an arc...
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Clock-turn

“Clock-turn” Technique - Useful

in small areas & for when you
are stopped & must turn. Start
at 12PM & take 2 slow steps to
3PM, and so on
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Avoid walking backwards

try:
• ■ Stepping sideways

“Side-step Arc” Technique -

Useful in
small spaces & as a way to
avoid stepping
backwards. Take slow side-
steps in an
arc...
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ASSISTIVE DEVICES:
 STICKS.
 FRAMES.
 WEIGHTED WALKERS.
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Tripods

No
Avoid tripod or
quad canes
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One point cane

Yes

A straight cane with

a rubber tip is better.
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Step over wand ….walker

Psychological counseling
AIMS:
Motivation.
Ideas sharing.
Best feed back.

Helpful for regaining patient’s confidence & strength.

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Minimizing psychological conditions & stresses. Is done in

form of GROUP TRAINING.
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SURGICAL INTERVENTION:
4 common modes are used:
 Pallidotomy (dyskinesia)
 Thalamotomy (tremors)
 Deep brain stimulation.
 Neural transplantation.
 1.EMBRYONIC STEM CELLS GRAFTING.
 2.ABORTED FOETAL CELLS GRAFTING.
 3.Electrode implantation.
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PROGNOSIS:
 Poor prognosis due to:
 Idiopathic cause.
 Secondary
complications.
 Progressive nature.
 Irreversible due to
neurological
damage.
 Variability from
individual to
individual.
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PARKINSONIAN LEGEND:

M .ALI a famous international

boxing champion was diagnosed
as parkinsonian in 1984.
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