Parkinson Disease

Part one
Dr. Mikhled Falah Maayah
Department of Rehabilitation Sciences
Faculty of Applied Medical Sciences
Jordan University of Science and Technology
 Parkinson’s Disease

• Parkinson's disease (PD) is a chronic,

progressive neurodegenerative
disorder that affects dopaminergic
neurons in substantia nigra and
characterized by tremor, rigidity,
bradykinesia & postural instability
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 Epidemiology
• -The 2nd commonest chronic neurodegenerative disease. -
Affects men and women of all races, all occupations, and
all countries. -Frequency increases with aging. -Peak
onset: 6th to 8th decade
• Onset – typically 55-60 years old
• Cell death occurs causing movement impairment
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 Etiology
• Idiopathic (~80%)
• Secondary: Toxin: MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine), Lithium,
Carbon Monoxide (CO)
• Drugs: Haloperidol, Prochlorperazine, Metoclopramide, Sodium valproate
• Infection: Post viral encephalitis
• Vascular: Multiple Infarct, Trauma
• Metabolic: Wilson’s Disease, Hypoparathyroidism
• Genetic: Huntingtons Disease, Sudden Cardiac Arrest (SCA)
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 Pathophysiology
• The Pathological Hallmarks of PD:
-Depletion of the dopaminergic neurons in the substantia nigra &
-The presence of α-synuclein and other protein inclusions in nigral cells (Lewy bodies)
• Dopamine acts as Inhibitory Neurotransmitter in the Basal Ganglia. It is secreted by neurons originated in
Substantia Nigra ended in Caudate Nucleus & Putamen
• Destruction of Substantia nigra Decreased Dopamine to Caudate nucleus & Putamen Becomes Overly Active
• Continuous excitatory output to Corticospinal Motor Control System Rigidity
• Some feedback circuits easily Oscillate Tremor
• Decreased dopamine in Limbic system
• Reduced psychic drive for motor activity Akinesia
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 Clinical Features (Symptoms)
• Autonomic functions symptoms
• Orthostatic Hypotension
• Constipation
• Urinary frequency & Urgency
• Sexual problems
• Sweating

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 Clinical Features (Signs)
• Gait: 2 variations
• Freezing
• Hesitation to initiate movement, reduced arm swing
• Observed when turning around, walking doorway, stepping around or over objects
• Festination
• Small steps increasing in speed & frequency with forward trunk posture, difficulty in stopping.
• Increase risk of loss of balance or falls on turning

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 Clinical Features (Motor sign )
• Movement impairments (TRAP).
• Tremor (shaking usually starts on one side of the body, often in the hand or
finger)
• Rigidity (stiffness where the limbs feel like lead)
• Akinesia (difficulty in initiating movement and slowness of movement:
Bradykinesia, hypokinesia, shuffling gait)
• Postural instability (Problems with balance)
• Impaired aerobic capacity
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 Evaluation

• History to exclude secondary causes

• Evaluate for osteoporosis and osteopenia (Odds ratio
2.61)
• BMD is lower in Hip, Lumbar spine, Femoral neck
(fracture risk is double)

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 Differential Diagnosis
• Dementia with Lewy Bodies
• Multiple-System Atrophy (MSA)
• Progressive Supranuclear Palsy
• Secondary Parkinsonism
• Drugs
• Stroke
• Toxin
• Wilson’s Disease
• Huntington’s Disease
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 Investigation
• Diagnosis is Clinical.
• Structural imaging is normal.
• Functional dopaminergic imaging is abnormal in early stages (SPECT or
PET)
• To exclude Huntington’s/ Wilson’s disease (in younger patients)

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 Management

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 Problem List
• Reduced joint ROM • Swallowing problem
• Impaired muscle strength • Nutritional deficiency
• Impaired Gait & locomotion - • Fatigue
Impaired Balance & Risk of Falls • Pain
• Abnormal Posture • Reduced aerobic capacity
• Difficulties with transfers
• Difficulties with ADL
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 Goals of Management
• To improve or maintain: Gait, Balance, Mobility & Posture
• To prevent contracture of muscles
• Safer swallowing & maintain nutrition
• To improve ADL activities
• To improve intelligibility of speech & ability to
communicate
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 Management

• Pharmacological
• Surgical
• Rehabilitative

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 Pharmacological Treatment
▪ Levodopa
▪ Dopamine receptor agonists
▪ MAOI-B (Monoamine oxidase-B (MAO-B) inhibitors is an enzyme in the body that breaks down several
chemicals in the brain, including dopamine.)
▪ COMT (Catechol-O-methyl transferase inhibitors) are used primarily to help with “wearing off” —
changes in the ability to move as the effect of levodopa becomes short-lived.)
▪ Amantadine
▪ Anticholinergic drugs
▪ SSRI (Selective serotonin reuptake inhibitors) are a class of drugs that are typically used as antidepressants
in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions.

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 Surgical Treatment
• Deep Brain Stimulation*
• Stereotactic thalamotomy
• Pallidectomy
• Subthalamotomy
• Fetal midbrain or adrenal tissue transplantation in basal ganglia

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 Parkinson’s Rehabilitation

• Exercise will not alter the progression

of Parkinson’s but it is essential for
maintaining your quality of life.
• So: rehabilitation plays a key role
in the overall management plan

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 Rehabilitative Treatment

• Physical therapy
• Occupational therapy
• Speech therapy

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 Rehabilitative Treatment
• Medical and Nursing
• Use of Firm bed
• Low Protein diet
• Gradual changing of positions, elastic stockings, abdominal binder
• Artificial tears
• Bowel & Bladder program

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 Assessment Tools
• Gait: Timed Up and Go Test (TUG) , 6 minutes walk distance (6MWD), Modified
Parkinson’s Activity Scale (M-PAS)
• Balance: TUG, M-PAS, Berg Balance scale (BBS), Five Times Sit to Stand Test (FTSTS)
• Transfer: TUG, M-PAS, FTSTS
• Physical Capacity: 6MWD, FTSTS
• The Movement Disorder Society–Unified Parkinson’s Disease Rating Scale (MDS-
UPDRS) is currently the most widely used assessment tool in physical therapy for PD
worldwide. Although the MDS-UPDRS is a well-established method for the
comprehensive assessment of PD.
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 Timed Up and Go (TUG)
• The Timed Up and Go Test is a performance-based measure of functional
mobility that was initially developed to identify mobility and balance
impairments in older adults.
• The test requires the subject to rise from a chair, walk 3.0 m at a
comfortable pace to a mark placed on the floor, turn around at the 3.0 m
mark, walk back to the starting point, and return to sitting in the chair.
• The test's score is the time it takes the subject takes to complete the test

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 Modified Parkinson’s Activity Scale (M-
PAS)
• he M-PAS aims to identify limitations in activities of daily living for which
rehabilitation can be provided and to assess changes following intervention.
• The M-PAS was introduced as the only rating scale recommended in the physical
therapy guideline for PD and in occupational therapy guidelines for patients with PD.
• The M-PAS consists of 16 items divided into 3 domains that describe core activities
related to functional mobility for patients with PD: Chair Transfer (2 items), Gait
Akinesia (6 items), and Bed Mobility (8 items).
• Each item is scored on a 5-point scale (0–4), with higher scores indicating greater
independence.
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 Berg Balance scale (BBS)
• The BBS Performance-based measure of balance is a and has been
reported to be the most commonly used balance tool by physiotherapists.
• The BBS is a five-point ordinal scale scored between 0 and 4 for each task
and has 14 tasks in total.
• The highest total score a participant may obtain is 56.

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 Five Times Sit to Stand Test (FTSTS)
• The objective of the five Times Sit to Stand Test (5x Sit-To-Stand Test) commonly
abbreviated as 5XSST.
• Used to asses functional lower extremity strength, transitional movements,
balance, and fall risk in older adults.
• 5XSST is designed for adults from 18 to 64 years of age and older adults of 65+.
• In older adults this test is used to assess: lower extremity strength; balance; and
fall risks in people with eg dementia, stroke, vestibular disorder, frailty, balance
disorders, falls history.

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 Five Times Sit to Stand Test (FTSTS)
• Method of Use: The 5XSST scoring is based on the amount of time (to the nearest decimal in
seconds) a patient is able to transfer from a seated to a standing position and back to sitting
five times.
• The equipment need in performing 5XSST test includes: Stopwatch and standard height
chair with straight back (43-45 cm, 17-18 inches high).
• Then the instruction is given by asking the test taker to sit on the chair by resting their back.
• Also, the test taker is instructed to fold their arms across their chest.
• Then the test taker should be instructed to do sit-to-stand five times, as quickly as possible, at
the count of go and without their back or leg resting on the chair between the interval of
repetition.
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 Physical therapy Mobility Training
▪ Relaxation techniques
▪ Slow rhythmic rotation movements
▪ Neck & Trunk rotation exercises
▪ Gentle ROM exercises of the limbs
▪ Stretching Exercise: Trunk flexors, Hamstrings, Tendo Achillis
▪ Strengthening Exercise: Back extensors, Neck Extensors, Hip Extensors,
Quadriceps, Abdominal muscles
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 Exercise is your Medication
• VIDEO: Pre & Post Exercise Treatment Program
http://youtu.be/wElz9jNrqns?t=6s

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 Balance Exercises

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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
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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 Poor Sitting Posture Good Sitting Posture

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 Breathing Exercise

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 Stretching exercises/Flexibility

Seated neck and chest stretch

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Seated rotation stretch Flexibility/Stretching
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 Back Stretch

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 Neck Stretching exercise

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 Upper Back stretching exercise

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 Shoulder Stretches

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 Stretches for Upper Back

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 Stretches for the lower back

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 Physical therapy Mobility Training
▪ Proper sitting & Postural control
▪ Breathing Ex
▪ Functional mobility training
-Bed mobility
-Transfer training
-Learning to rise out of a chair by rocking (with sliding of Hip)
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 Researches

• Studies clearly show that people

with Parkinson’s who do exercise
are better in the long run than the
people with Parkinson’s who do
not exercise

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Body alignment appropriate to quiet standing
and sitting
• Standing alignment
• Head balanced on level shoulders
• Upper body erect, shoulders over hips
• Hips in front of ankles
• Feet a few cm (10 cm) apart
• Sitting alignment
• Head balanced on level shoulders
• Upper body erect
• Shoulders over hips
• Feet and knees a few cm apart Parkinson's Rehabilitation Program (Aga Khan University Hospital (AKUH))
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 Gait

• Gait is the medical term to describe human locomotion,

or the way that we walk.
• Interestingly, every individual has a unique gait pattern.

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 Gait Disorder
• Difficulty initiating walk
• Petit pas (small steps)
• Festination
• Freezing
• Difficulty turning
• Heel-toe gait

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 Physical therapy For Gait Dysfunction
▪ Stationary Bicycle
▪ Standing or Balancing in Parallel Bars with Weight shifting, ball throwing
▪ Slowly progressive Ambulation training:
-Large steps, use blocks, auditory & visual cue
-Proper heel-to-toe gait patterns
-Focus on Foot positioning (12 -15 inch apart)
-Arm swing
-Turn around in wide arc
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 Physical therapy For Gait Dysfunction
(cont.)
▪ Movements with Rhythmic Auditory Stimulus
-Music/ Metronome based rhythm
▪ Assistive device: Cane, Inverted walking stick, Rolator,
Weighted walker
▪ Aerobic conditioning: Swimming, Walking, Cycling, Dancing
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 Gait training

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 Occupational Therapy

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 Occupational therapy
▪ ROM activities with Stretching of UE
▪ Fine motor coordination & training, hand dexterity training; Colored pegs/ beads
▪ Hand cycling
▪ Rocking chair
▪ Safety skills
▪ Adaptive equipment's: Velcro closures, Raised toilet, Grab bars, Eating utensils with
built-up handles, Key holders etc
▪ Family training and home exercise program
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 Rehabilitative Mx
Orthostatic Hypotension
▪ Lifestyle modification and education
-Avoid warm or hot bath / A heavy meal /Excessive straining while defecating and other tasks
-Taking high-fiber diets and stool softeners

▪ Gradual changing of positions (may use Tilt table)

▪ Compression leg stockings and abdominal binders.

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 Speech Therapy
▪ Deep and diaphragmatic breathing exercises
▪ Facial, oral, and lingual muscle exercises
▪ Lee Silverman Voice Therapy (LSVT) Training to shout: very effective
▪ Expiratory muscle strength training (EMST)

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 Speech Therapy
• Lee Silverman Voice Therapy (LSVT)
• -LOUD
• -Making Aaa sound
• -At baseline
• – upscale
• - baseline
• – downscale
• -15 Rep each time
• Expiratory muscle strength training (EMST) -Exhale through a device (the breather) -10 Reps,
2 sets -Twice daily -6 days per week
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 Thank You

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