PARKINSON’S

DISEASE
Dr M Tariq (PT)

The term P arkinsonism 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.
Secondary Parkinsonism results from a number of different identifiable causes, including
viruses, toxins, drugs, tumors, and so forth.

 Encephalitis Lethargica
 1 year after a bout of encephalitis

 high fever, headache, double vision, delayed physical and mental response, and lethargy

 Toxins
 CO / MPTP

 Drugs
 Metoclopramide
 Nausea/ vomiting

 Reserpine
 Antipsychotic

 Antihypertension
SECONDARY PARKINSONISM
 Vascular disease – multiinfarcts

 Tumours of Basal Ganglia

 Hydrocephalus

 Hemiparkinsonism / Hemiatrophy syndrome

SECONDARY PARKINSONISM
 Metabolic
 Wilson’s disease
 Hepatic Degeneration

 Genetic disorder / copper poisoning

 Hallervorden-spatz disease
 Neurodenergeration with brain iron accumulation
PATHOPHYSIOLOGY
 Parkinson’s disease is defined by
 (1) degeneration of dopaminergic neurons in the BG in the
pars compactus of the substantia nigra that produce
dopamine
 (2) as the disease progresses and neurons degenerate, the
presence of cytoplasmic inclusion bodies, called Lewy
bodies.
 Substantial neurodegeneration occurs in PD before the
onset of motor symptoms with clinical signs emerging
at 30% to 60% degeneration of neurons.
 Loss of the melanin-containing neurons produces
characteristic changes in depigmentation in the
substantia nigra with a characteristic pallor.
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
1. PRIMARY MOTOR SYMPTOMS/Cardinal Features
 Rigidity
 Bradykinesia
 Tremor
 Postural Instability

2. SECONDARY MOTOR FUNCTION

 Muscle Performance
 Motor Function
 Gait

3. NON-MOTOR SYMPTOMS
 Sensory Symptoms
 Dysphagia
 Speech Disorder
 Cognitive Dysfunction
 Depression & Anxiety
 Autonomic Dysfunction
 Sleep Disorders
PRIMARY
MOTOR
SYMPTOMS
1. RIGIDITY

 Clinical hallmarks of PD
 ‘INCREASED RESISTANCE TO PASSIVE MOTION’
 Rigidity is fairly CONSTANT regardless of the task, amplitude, or speed of movement
 Frequent complain of “heaviness” and “stiffness” of limbs
 Asymmetrical  early stages
 Increases as disease progresses
 Affects proximal muscles ( shoulder/neck) first  extremities / face
1. RIGIDITY

 Decreases the ability to move easily  bed mobility / lack of reciprocal arm movement during
gait ( Truncal Rigidity)
 Decreased ROM / contracture / postural deformity
 Increasing Resting energy expenditure / fatigue levels

 Cogwheel Rigidity
 Lead Pipe Rigidity
 2.BRADYKINESIA

 Bradykinesia refers to slowness of movement

 Slowness of thought, brady-phrenia
 Prolonged movement
 Prolonged reaction times
 Hypomimia or masked facial expression
 Freezing Episode:
 confrontation of competing stimuli ( passing through a
narrow space)Freezing of Gait FOG
 2.BRADYKINESIA

 Hypokinesia  slowed and reduced movements

 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.
3. TREMOR
 RESTING TREMOR
 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
 Lower limb tremor  in supine
 Postural Tremor  Upright Posture
 Action Tremors  Advance Stage
 Aggravated by stress / excitement
4. POSTURAL INSTABILITY
 Abnormalities of posture and balance, resulting in postural instability
 Narrowing of the BOS (tandem stance or single-limb stance) or
 Competing attentional demands (divided attention situations) increases postural instability
 Patients also demonstrate difficulty in regulating feed-forward, anticipatory adjustments of
postural muscles during voluntary movements.
 Weakness of antigravity muscles contributes to the adoption of a flexed, stooped posture with
increased flexion of the neck, trunk, hips, and knees
 Older individuals with reduced activity levels and poor diet are likely to develop
osteoporosis.
FREQUENT FALLS
 Fall injuries  Hospitalization (25% with
Hip Fracture)
 70% report of falls in past year / 50% report
of consistent falling
 Risk Factors
1. Disease Severity
2. Postural Instability
3. Gait Impairment
4. Dementia / Depression
5. Postural Hypotension
6. Involuntary Movements

 FEAR OF FALLING  IMMOBILITY 

DEPENDENCY  POOR QUALITY OF LIFE
SECONDARY MOTOR
FUNCTION
Muscle
Performance

Motor
Gait
Function
MUSCLE PERFORMANCE
 Reduction in strength ( Dopamine Dependent )
 Muscle weakness
 Activity limitations

 Fatigue is among the most common symptoms reported

 Difficulty in sustaining activities
 experiences increasing weakness and lethargy as the day progresses
 start out strong but decrease in strength and amplitude as the activity progresses.
 Performance decreases dramatically with great physical effort or stress.
 Rest or sleep may restore mobility
MOTOR FUNCTION
 Loss regulatory Control of both automatic and voluntary movement responses
 Paucity of movement occurs with less accurate movements  speed-accuracy trade-off
 Patients experience difficulty performing complex, sequential, or simultaneous movements
(dual-task control)Both Cognitive & Motor Tasks
 Start Hesitation
 GAIT
 Approximately 13% to 33% of patients present with postural instability and gait disturbances as their
initial motor symptom
 SIGNIFICANT GAIT CHANGES
1. Abnormal stooped posture  festinating gait pattern
 characterized by a progressive increase in speed with a shortening of stride)
 the patient takes multiple short steps to catch up with his or her COM to avoid falling, and may eventually break into a run
or trot
2. Toewalkers : owing to plantarflexion contractures exhibit an additional postural instability from narrowing of
their BOS
3. Turning or changing direction is particularly difficult  multiple small steps
4. FOG
NON-MOTOR SYMPTOMS
Sensory Symptoms
Dysphagia
Speech Disorder
Cognitive Dysfunction
Depression & Anxiety
Autonomic Dysfunction
Sleep Disorders
 SENSORY SYMPTOMS
 50% experience paresthesias and pain, including sensations of numbness, tingling, cold, aching pain, and
burning ( disease effect on central nocioception )
 Olfactory dysfunction is common
 (some studies showing 100% patients affected)
 Anosmia
DYSPHAGIA
 95% of patients  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

 Chocking  aspiration pneumonia  impaired nutrition  significant weight loss

SPEECH DISORDERS
 75% to 89% of patients
 hypokinetic dysarthria, which is characterized by decreased voice volume,
monotone/monopitch speech, imprecise or distorted articulation, and uncontrolled speech rate
 Vocal quality  hoarse, breathy, and harsh
 timing difficulty of vocal onsets and offsets
COGNITIVE DYSFUNCTION /
DEPRESSION AND 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
 Bradyphrenia
 depression is reported to occur in approximately 40%
AUTONOMIC DYSFUNCTION
1. Thermoregulatory dysfunction
 excessive sweating
 uncomfortable sensations of warmth and coldness  impaired peripheral vasodilation

2. Seborrhea
3. slow pupillary responses to light
4. Gastrointestinal disorders include poor motility  Constipation
5. Urinary Incontinence
6. diminished heart function
7. Orthostatic hypotension (OH)
8. 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).
 PHARMACOLOGY
DRUG CLASS EXAMPLE ADVERSE EFFECTS

Tachycardia, dry mouth, nausea,

Anticholinergics Bentropin
vomiting, confusion

Levodopa/carbidopa Dystonia
Dopamine replacement
Sinemet Nausea, vomiting

Lightheadedness, livedo reticularis,

Amantadine Symadine
edema
THANK
YOU