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Definition, Etiology and Pathophysiology

l Parkinson disease
Involuntary tremors motion, with lessened muscular power, in parts not in action wven when supported;
with the propensity to bend the trunk forwards, and to pass from a walking to a running pace; the senses
and intellect being uninjuried.
l Classic signs (TRAP)
1. Resting tremor
2. Rigidity
3. Akinesia
4. Postural dysfunction
l Definitions that need to be clarified
1. Parkinson’s disease
A. Idiopathic (病因不明; paralysis agitans)
B. Primary degenerative condition
C. Occurring in the latter half of life
D. With a progressive course
2. Parkinsonian syndrome
A. Disorders with the same S/S
B. Secondary to another neurological disease
3. Parkinsonism
A. Characteristic S/S of PD
l Etiology
1. Idiopathic (78%)
2. Degenerative (15%)
- Secondary to stroke, Alzheimer's disease (AD), Progressive supranuclear palsy (PSP)
- Mainly involves basal ganglia
3. Infectious: post-encephalitic parkinsoian
4. Intoxication
- Drug indiced parkinsonism
- CO, Mn, MPTP, anti-pressant
l Demographhics
1. Common in elderly
2. Happened all over the world
3. Male > female
4. Races, environment, heredity?
l Pathophysiology
1. Involves degeneration of basal ganglia
- Poverty & slowness of movement
- Involuntary & extraneous movement
- Alternation in postural and muscle tone
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 2. Depletion of CNS dopamine (imbalance of Ach and dopamine)
3. Maybe hereditary or gene linked
4. Tremor, rigidity, bradykinesia: when dopamine is less than 80% of the normal value
Symptoms and Diagnosis
l The stage of PD

l Diagnosis
1. Insidious progression (通常不影響生命長短)
2. Diagnosis is based on S/S; general lab exam & EEG are not useful.
3. Drug therapy & supportive care
- Limited drug effect
- Balance between exercise & rest
- Socialization
- Planned activities
l Clinical features
ü Core symptoms: tremor, rigidity, akinesia, loss of postural reaction
ü Symptoms spread from one side to bith sides of body
ü All movements become slower, smaller amplitude
ü Difficulty in ambulation (feet glued to the floor)
ü Loss of balance ability; easy to fall when pushes
ü Stooped posture; COG moved forward (easy to fall and hard to stop when walking)
ü Walking backward is easier than forward
ü Unable to execute continuous repetitive movement
ü Loss of associated movement
ü Rigid facial muscle, mask face
ü Microphonia, slurred speech
ü Normal mentality
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1. Resting tremor
- Alternative MCP/IP flexion, extension, thumb rests against the index finger.
- Also called pin rolling, pill rolling, shaking palsy.
- Appears in 50% patients
- Occurring unilateral or bilateral, UL > LL
- Frequency 4 – 6 Hz
- Causing cogwheel rigidity
2. Rigidity
- Increased EMG at rest
- Increased resistance to PROM
A. Lead-pipe: smooth or plastic
B. Cogwheel: intermittent
- Equal in all direction, but not necessarily remains constant.
- May contributed by shortened tissue
- May contribute to
A. Flexed posture
B. Respiratory difficulities
C. Slowness of movement
3. Hypokinesia (akinesia + bradykinesia)
- Lack of spontaneous movement
- Delay in initiation / stopping movement
- Slowness of movement
- Reduce movement amplitude
- Unable to sustain repetitive movement
- Intermittent halting of movement
- Difficulty in executing simultaneous or sequential actions (dual-task)
Alinesia ü 動作反應時間變長
ü Abnormal delays in the reaction time
ü Delay in recruiting motor units
ü Deficit in motor planning
ü Reaction time reduced if a cur provided
Bradykinesia ü 動作變慢變小
ü Abnormal increase in the movement time
ü Unable to modify speed to meet the task requirement
ü Intermittent pause (not tremor)
ü Agonist EMG: small amplitude, slow rise, repetitive burst.
ü Unable to use prior experience
ü External sensory cue is necessary
ü Influence of non-neural factors
4. Freezing phenomenon
- Sudden arrestation of particular rhythmical movements (stepping, speaking, writing)
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 - Distribution of rhythm formation adequate to sustain repetitive movement
- Facilitated by periodic stimuli.
5. Posture & balance problem
- Stooped posture, simian posture
A. Slight flexion at all joints.
B. Tends to slump in chair
C. Can be voluntary corrected with great effort but temporarily
D. Partily contributed by/to musculoskeletal problems
- Further limited musculoskeletal abnormalities (kyphosis, scoliosis, dystonia)
- Diminished associated movement
A. Lack of arm swing, handing slightly flexed at elbows.
B. Lack of hand gestures
- Lack of postural fixation
A. Mainly proximal & axial joints
B. Head & trunk sink forward
C. Also in voluntary movement
- Absence of equilibrium & righting reaction
A. Ineffective correction to external disturbances
B. Impaired anticipatory postural adjustment during intentional movements
C. Speed related difficulities
D. Most common difficulities are standing up, walking, turning
6. Gait
- Slow velocity
- Short, shuffling steps
- Lack of arm swing & rotational movement
- Festination
- Difficulties in initiating & stopping
7. Other symptoms
- Automatic system
Blinking, facial expression
Coughing
Constipation
Seborrhoea
Sialorrhea (drooling)
- Weakness: involvement of lentiform nucleus, disuse
- Speech:less variation in tone, microphonia
- Sensory: numbness, tingling, aching, pain
Physical Therapy Assessment
l Background history
Demographic details, past medial history, number of years since onset of PD symptoms, number of years
since diagnosis of PD, presenting problems, current medication/treat,ent/investigations, involvement of
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 other professionals and agencies, contraindications/precautions in relation of physical therapy/carer
issues/social netward, housing, lifestyle.
l Evaluating the difficulitites associated with functional performance
1. Walking (including outdoors)
2. Turning and changing direction
3. Standing up and sitting down
4. Turning in bed
5. Stairs
6. Car transfers
7. Reaching, grasping, and manipulating objects
8. Writing
l Evaluating balance & falls
1. Time up and go test
2. 180 or 360 turn – steps taken to complete
3. Functional reach test or lateral reach test
4. Tinetti balance / gait score
5. Tandem stance/ walking; eyes open/close
6. Stops walking when talking
7. PLM test
8. Multiple-task test

l Postural-Locomotion-Manual Test (PLM Test)

1. Movement capacity of freely moving individuals performing acts to relevance for ADL.
2. Gives an overall estimate of the movement capacity to reflect the condition in different parts of the
motor system
3. The participants picked up the object from the floor, walked forward 1.5 m, and placed it on a shelf.
4. ach motor act from the floor to the shelf included three phases: raising the body ( postural phase),
walking forward (locomotion phase), and the goal-directed arm movement (manual phase).
5. 正常情況下會在 10 – 40 秒內完成測試，且三個階段會有重疊
6. Simultaneously index (SI): the degree of coordination of the PLM phases to a smooth movement.
7. 再服用 dopamine 與沒有服用 dopamine 的病患上可以發現，藥物對帕金森氏症的病人的
postural 及 manual 改善效果最大
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l Multiple-task test
1. 是 TUG 的延伸評估方式
2. 核心施測動作：standing up, undisturbed walking, turning arouns, sitting down
3. 會漸漸加入許多的任務，如回答問題、跨過障礙物等，來見側病人進行雙向任務的程度
Management
l Management of Parkinson’s disease
1. No drug is available to cure the disease
2. Utilize dopamine supplement to maintain the level of dopamine in brain
3. Exercise and life adaption to improve independence and quality of life
l Drug therapy
1. 當病人的 ADL 執行品質與生活品質受到影響時，就建議服用藥物
2. 可以分成 anticholinergics 與 Levodopa (L-dopa)
3. 因此不論病患需不需要服用藥物，都會針對其進行 education, support service, exercise, nutrition
的介入，以延緩惡化速度
l Surgical management
1. Adrenal medulla transplants
2. Fetal tissue implantation
3. Thalamotomy
4. Pallidotomy
5. Deep brain stimulation
6. Genetically-engineered cells
7. Brain derived neurotrophic factors
l Physical therapy
1. Assessment
- Posture (static & dynamic)
- Muscle strength
- Functional activities
- Gait
- Finger dexterity
2. Task analysis
- Timing/ speed/ ROM
- Interaction
- Movement quality
- Compensation strategy
3. General principles
- Postural awareness & positioning
- ROM & relaxation exercise
- Balance training
- Functional training
4. Relaxation exercise
- Should proceed other exercise
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 - Slow, general, rhythmic, rocking/ rotational movement
- Started with big BOS, full supported position
A. Thythmic initiation (PNF)
B. Jacobson’s progressive relaxation technique
C. Lifestyle modification
D. Time management
5. Flexibility exercise
- Early stage may use prone position
- No ballistic stretches; at least maintain 15 – 30 sec, repeat 3 – 5 times.
- May use mechanical stretch (5 – 10% of body weight).
6. Mobility exercise
- Should be based on functional movement
- Include as many joints and segments as possible
- Emphasis on bed mobility, movement transition and incorporating with manual activities
- Adequate strength and endurance should be addressed
- May utilized furniture as exercise equipment
7. Gait training
- visual / auditory / proprioceptive / cognitive cues are useful
- emphasis on initiating, turning, progression, and stopping
- side-stepping and cross-stepping maybe useful
8. Alternative approaches
- Tai-chi: improve relaxation, movement quality and balance
- Yoga: improve strength and flexibility, reduce pressure both physically and psychologically
- Acupuncture
- Massage