What is Parkinson

Disease?
Described by James Parkinson in 1817
as Shaking palsy & Paralysis agitans.
Parkinsons disease is a progressive

neurological disorder of the Basal

Ganglia.
Characterized by fundamental features

(TRAP)
Etiology
Parkinsons disease(primary parkinsonism) is
idiopathic.
Secondary parkinsonism results from a number of
different causes such as Postinfectious,
pharmacological, Metabolic and parkinson-plus
syndromes.
Genetic link in a small number of Parkinson cases.
Larger genetic link is found in young-onset
Parkinson disease.
Research has shown a link between PD and
growing up in a rural areamay be due to
pesticides, insecticide use, and/or well water.
Pathophysiology
Parkinson disease is associated with
degeneration of dopaminergic neurons in the
Substantia Nigra (SNpc).
Depletion of Dopamine leads to motor
disturbance such as:
Reduction in initiating movts.(Patient wants
to move but cannot), Tremor and Rigidity due
to loss of inhibitory influences within the BG.
When 80% of dopaminergic neurons are
degenerated, the signs of disease become
clinically evident.
Pathophysiology
 Onset is 60 yrs.
5-10% of cases occur under the age of

40. Referred to as Young-Onset

Parkinson Disease.
Rarely seen under age 30.
Males are slightly more at risk than

females.
Clinical Manifestations
o Fundamental Features
Rigidity.
Akinesia and Bradykinesia.
Tremor.
Postural Instability.
Clinical Manifestations
o Secondary Impairments or complications
Poverty of Movements.
Fatigue.
Masked Face.
Gait disturbance.
Swallowing and Communication Dysfunction.
Cognitive and Behavioral Dysfunction.
Autonomic Dysfunction.
Cardiopulmonary Dysfunction.
Visual and Sensorimotor Disturbance.
Musculoskeletal Changes.
Clinical Manifestations
o RIGIDITY
An increase in muscle tone leading to a

resistance to passive movement throughout the

range of motion.
Due to loss of inhibitory influences within BG.
Felt uniformly in muscles of both sides of the joint

and in both directions of movement.

Types: Cogwheel and Leadpipe Rigidity.
Affects proximal muscles first and then progresses

to face and extremity.

Results in loss of bed mobility and reciprocal arm

swing, decrease ROM of joints, contractures and

postural deformity.
Clinical Manifestations
o TREMOR
Involuntary oscillation of a body part at a
frequency of about 4-7 cycles/sec.
Due to loss of inhibitory influences within BG.
Resting Tremor, diminished by voluntary
effort and disappear during sleep.
Initially unilateral and mild and become
severe in later stages.
Pill-rolling tremor of the hand, resting tremor
of the feet, lips, tongue, and jaw.
Postural Tremor in some individual.
Clinical Manifestations
o AKINESIA and BRADYKINESIA
Akinesia: Difficulty in initiating movements or

sudden break in voluntary movt.

Deficit in the preparatory phase of movement

Control.
Bradykinesia: Slowness and difficulty maintaining

movts.
Hpokinesia: reduction in the speed, range, and

amplitude of movements.
Results in difficulty of Motor planning, performing

sequential tasks, and decrease Torque production.

Micrographia: Difficulty in fine movement.
Clinical Manifestations
o POSTURAL INSTABILITY
Posture and balance problem: Due to Rigidity,

decrease muscle torque production, loss of available

ROM (particularly of trunk motion) and weakness.
Tandem stance or single limb stance are difficult.
Functional reach, walking and turning activities

become difficult. Postural Instability

Sensory motor adaptation impairment.
Visuospatial impairment.
Loss of perception of upright or vertical position.
Frequent falls and fall injuries are common in PD.
Posture: Flexed, stooped posture with increased

flexion of the neck, trunk, hips and knees.

Clinical Manifestations
o Poverty of Movement
Due to central deficit in motor planning in patients with PD,

overall movements are impaired.

As task complexity increases, movement difficulty increases.
Movements become uniplanar due to loss of rotation

movements.
Automatic movements are impaired e.g. loss of reciprocal

arm swing during gait.

Mental fatigue and loss of motivation.
Fatigue and Masked Face
Difficulty in sustaining activity.

Motor activity may start out strong but decrease in strength

as the activity progress.

Infrequent blinking.

Smiling on command.
Clinical Manifestations
o GAIT DISTURBANCE
Gait pattern: decrease stride length, loss of
reciprocal arm swing , loss of normal heel-
toe progression, lengthened stance phase
and double support and shortened single-
limb support.
Festinating gait: Small shuffling steps with
progressive increase in speed.
Propulsive and Retropulsive gait.
Taking multiple small steps to turn or
change direction.
Clinical Manifestations
o MUSCULOSKELETAL CHANGES
Contractures of contractile and non-
contractile tissues.
Contractures of hip and knee flexors, hip
rotators and adductors, plantarflexors,
dorsal spine and neck flexor,
shoulder adductors and internal
rotator and elbow flexors.
Kyphosis and Scoliosis.
Osteoporosis.
Clinical Manifestations
o Swallowing and communication
Dysphagia: Due to rigidity, reduced
mobility and restricted ROM. (Oral,
Pharyngeal and esophageal phases of
swallowing are affected)
Dysarthria: Decrease voice volume,
monotone and monopitch speech,
distorted articulation and uncontrolled
speech rate.
Mutism: Whispering in advanced cases.
Clinical Manifestations
o Behavioral Dysfunction
Dementia: (Approx. 1/3 of PD patients)
Memory impairment, loss of thinking,
reasoning and judgment.
Bradyphrenia: Slowness of thought
processes with lack of concentration and
attention.
Depression: (25-40%) Apathy, passivity,
loss of ambition or enthusiasm, change in
appetite, lack of sleep and dependency.
Clinical Manifestations
o Autonomic Disorder
Urinary frequency, urgency and

nocturia.
Reproductive Disorder: Impotence
GIT Disturbance: Decrease digestion

and constipation.
Excessive perspiration.
Thermoregulatory abnormalities.
Greasy skin
Clinical Manifestations
o Cardiopulmonary Dysfunction
Orthostatic hypotension (may cause

dizziness and fainting) and Cardiac

arrhythmias.
Airway obstruction (56%).
Restrictive dysfunction (28%) due to

rigidity of trunk muscles and Kyphotic

posture.
Lower FVC and FEV.
Higher RV.
Clinical Manifestations
o Sensory Disturbance
Blurring of vision
Conjugate gaze and saccadic eye

movements.
Paresthesias (numbness and tingling)

and Pain (cramp like ).

Postural stress syndrome e.g. Low

back pain due to stooped posture.

Diagnosis and Prognosis
o Medical Tests
There is no specific medical test used to diagnose
Parkinson disease.
However, MRIs and blood tests are used to rule out
other possible conditions that have similar
symptoms to Parkinson disease.
o Expected Outcomes
Progressive neurological disorder
Drug treatment to reduce severity of symptoms
Adapt lifestyle to maintain function in daily life
activities
Can live a long life with medical treatment and
compensatory techniques
Treatment
o Drug Therapy :
The most commonly prescribed drug is

Levodopa. Brain enzymes modify the drug to

create dopamine. It reduces tremors, slowness,
and stiffness of muscles, and is the oldest and
most effective treatment of PD.
In some patients, Levodopa works very well in

the initial years of taking it; however, it becomes

less effective as the disease progresses.
Wearing Off: Wearing-off is a frustrating

aspect of drug therapy in patients with PD.

Patients experience on times and off times.
Treatment
o Surgical Options
Surgical procedures are now available for

specific patients who no longer respond to

drug treatments.
Pallidotomy

Is a neurosurgical procedure that can reduce

many of the symptoms of Parkinson Disease

Performed by a neurosurgeon, who inserts a

hallow probe into the globus pallidus and

then liquid nitrogen is circulated in the
probe.
Treatment
Pallidotomy (cont.)
The probe destroys part of the globus

pallidus by creating a scar

The patient is awake during the

operation, which takes about six hours.

The hospital stay averages two days.

Not a cure

It can permanently eliminate dyskinesias

Reduces tremor, rigidity, bradykinesia

and shuffling gait

Treatment
o Surgical Options
Deep Brain Stimulation

An electrode is placed in one of several

parts of the brain (thalamus, globus

palladus, or subthalamic nucleus).
The electrode is attached to a

computerized pulse-generator which is

put under the skin in the chest.
Symptoms are relieved through the

regulation of electrical impulses from

those three areas of the brain.
Assessment
oAssess:
Posture
Balance
Tremors
Active/passive ROM
Functional use of hands
Fatigue
Ability to rise from chair, walk 20 ft., return to

chair, and sit back down

Swallowing
Depression
Cognitive status
Assessment
o Assessment tools
Hoehn & Yahr Scale
Unified Parkinson Disease Rating Scale
Schwab & England ADL Scale
Fatigue Severity Scale
Neurobehavioral Cognitive Status Exam
Assessment of the Occupation
Function/Dysfunction Continuum
Schenkman & Butler Videotaping
Assessment
o MODIFIED HOEHN AND YAHR SCALE
Stage Description

0 No signs of disease
1 Unilateral disease
1.5 Unilateral disease with axial involvement
2 Bilateral disease without postural instability
2.5 Early signs of postural instability (recovery on
the pull test)
3 Bilateral disease with postural instability,
physically independent
4 Severe disability, but still able to stand or walk
unassisted
5 Confinement to wheelchair or bed
Assessment
oSCHWAB AND ENGLAND ACTIVITIES OF DAILY LIVING (ADL)
100% - completely independent. Able to do all activities without slowness,
difficulty, or impairment
90% - completely independent. Able to do all activities with some slowness,

difficulty, or impairment. May take twice as long to complete

80% - independent in most activities. Takes twice as long. Consciousness of

difficulty and slowing

70% - not completely independent. More difficulty with activities. Three to

four times as long for some. May take large part of day for chores
60% - some dependency. Can do most activities, but very slowly and with

much effort, but some chores are impossible

50% - more dependent. Help required with half of chores. Difficulty with

everything
40% - very dependent. Can assist with all chores but few alone
30% - with effort, now and then does a few chores alone or begins alone.

Much help needed

20% - cannot do anything alone. Can give some slight help with some

chores. Severe invalid

10% - totally dependant, helpless
0% - vegetative functions such as swallowing,BladderandBowelfunction

are not functioning. Bedridden.

Assessment
Treatment
o Treatment Strategies
First and foremost: help patient

understand purpose/goals of PT, and

allow them to help create purposeful
treatment goals.
General Treatment Goals
Increase movement and ROM
Maintain/improve chest expansion
Improve equilibrium reactions
Maintain/restore functional abilities
Treatment
Develop routine for self care
Help family/care partner, along with

patient, create ideas for adapting home

environment to meet the patients needs.
Modified kitchen

Modified bathroom
Full bathroom and bedroom on first floor

Lift chair

Remove rugs/carpet/furniture that could

be easily tripped over

Treatment
Social Participation
Support groups
Important to encourage continued

involvement in activities important to

their life.
Participation in activities which are not

physically tiring.
Introduce techniques for enhancing

voice volume.
Treatment
ADLs
Patients generally wake in an off state.

Should immediately take medication upon

waking.
Wait until meds take effect before engaging in

challenging ADLs.
Home modifications

Grab bars in bathroom/shower

Shower seat

Kitchen items easily reached

Rugs/carpet/furniture

Clothing considerations
Treatment
Leisure
Spectator sports
Deep breathing & relaxation sessions (at home

or in community)
Activities which are not physically demanding
Explore ways to adapt activities enjoyed prior to

disease onset.
Education
Allow extra time for school work
Decrease class load
Handwriting adaptive devices
Aide for typing/note-taking
Treatment
Keep journal of symptoms
Educate patient and family/care partner on

disease and its progression

Assistance with paying bills and financial

management
Assistance with health care management
Discuss options for care of children/pets
Work
Educate & inform co-workers
Explore work-at-home options
Adapt job requirements as disease progresses