PARKINSON

1
JAVED'S PRESENTETION ON PARKINSON'S DISEASE
WELCOME
2
PRESENTED BY

M0HD JAVED QUERAISHI

STUDENT PHYSIOTHERAPIST
Pt.J.N.M.MEDICAL
COLLEGE,RAIPUR (C.G.)
PARKINSON'S DISEASE
PARALYSIS AGITANS
SHAKING PALSY
3
Marsden in 1994 has defined Parkinsons
Disease as - A clinical syndrome dominated by a
disorder of movement consisting of Tremor at rest
, Rigidity , elements of Bradykinesia ( Slowness
of movement ), Hypokinesia ( reduced movement ) ,
Akinesia (loss of movement) Postural
abnormalities associated with a distinctive
pathology consisting of degeneration of pigmented
brain stem nuclei , including the Dopaminergic
Substantia Nigra Pars compacta (SNPc) with the
presence of Lewy bodies in the remaining nerve
cells .
DEFINATION
4
( Adapted from Fahn S Jankovic J in 1992) (1)
Primary or Idiopathic Parkinsonism (2)
Secondary or Acuired or Symptomatic
Pakinsonism(3) Parkinsonism plus syndrome or
Parkinsonian syndrome.
CLASSIFICATION
5
It is a Progressive, Disabling, Primary
Neurodegenerative disorder. There are four
cardinal signs-( A ) Tremor( B ) Rigidity( C
) Bradykinesia( D ) Postural instability(A B C
are together called as Classical Triad)
PRIMARY OR IDIOPATHIC PARKINSONISM
6
It is the collective term for a group of
conditions that includes PD as well as several
other degenerative brain disorders. The signs
symptoms includes the four cardinal signs of PD.
Parkinsonism results from a variety of causes
that include infections,toxins,drugs,vascular
leisons, tumors trauma.(Neuroleptic Drugs
are considered to be the commonest cause of
Secondary Parkinsonism today.)
SECONDARY OR SYMPTOMATIC OR ACQUIRED PARKINSONISM
7
It constitute of heterogenous group of
multifaceted disorders characterised by
Parkinsonian features, with various combinations
of Pyramidal , Cerebellar Autonomic
dysfunctions.( The most common form of
Parkinsonism seen by Neurologists today is the
Idiopathic variety of Parkinsons disease)
PARKINSONISM PLUS SYNDROME OR PARKINSONIAN
SYNDROME
8
(1) In 1817 , James Parkinson first described
the PD. His description of the disorder was as
follws - Involuntary tremulous motion , with
lessened muscular power, in parts not in action
even when supported , with a propensity to bend
the trunk forward, to pass from a walking to a
running paces the senses intellects being
uninjured. (2) In 1867, Trousseau noted the
muscular rigidity cog wheeling appearance.
HISTORY
9
(3)In 1877, Charcot named first disease as
Parkinsons Disease he noted the absence of
facial expression (Masked Facies) as a feature of
disorder.(4) In 1880, Charcot listed PD as the
5th most common disease.(5) In 1888, Gower
noted that , the malady usually commences after
40 yrs of age.(6) In 1898, Purves Stewart ,
recognised dystonic posturing of the feet ,
usually provoked by exercise but occasionally
relieved by walking which could be the first
symptom of malady.
10
(7)In 1913 , Lewy first described the
concentric hyaline cytoplasmic inclusion called
it as LEWY BODY.It is observed in the nucleus of
Substantia Innominata.(8) In 1919,
Tretiakoff was the first to observe the
characteristic leisons of Substantia Nigra ie.
Depletion of pigmented cells.(9) In 1937,
Hassler described the anatomy of Substantia Nigra
in 1938 noticed pathological process of PD for
the ventrolateral Pars compacta cell group.
11
(11) In 1960 , Ehringer Hornykiewicz
demonstrated that in PD Dopamine was markedly
reduced in the Substantia Nigra , Caudate nucleus
Putamen.(12) In 1967 , Cotzias shows the
clinical benefits of high doses of Levo-Dopa in
chronic patient with PD.
(10) In 1957, Carlsson showed that cerebral
Dopamine was concentrated in thestriatum.
12
(1) PD occurs in about 1 of the
population older than 55 yrs of age.(2) Males
are slightly more at risk for developing PD than
females. (3) In 10 cases PD occurs before
the age of 40 yrs.(4) Mainly found in
Western countries.
EPIDEMIOLOGY
13
. (A) It consists of regular , rhythmic ,
alternate contraction antagonist agonist
muscles _at_ 4-6 times / second.(B)The tremors
occurs due to uninhibited activity of the basal
ganglia-cortico-thalamus circuit as a result of
degeneration of the striatonigral pathway.(C)
It is a rhythmic involuntary movement
normally affecting the limbs.(D) It is the
1st complain of the patient but in some patient
Bradykinesia is usually the first recognised
symptom. (E) Resting tremor present mainly PIN
/ PILL rolling type as like pin / pill rolls
between the thumb index fingure.
CLINICAL FEATURES
(1) TREMORS -
14




(F) Frequency is 4-6 times / second in early
stage 6-8 times/ second in later stage.( G )
Maximal at periphery affects the arm more
frequently than the leg.(H) Tremor is
increased by stress disappeared during sleep
goal directed movements.
( I ) The hand which is most affected assumes
a posture of flexion of the MCP joints with
extension of the more distal joints.




15


(A) Rigidity is defined
as resistance to passive motion that is not
velocity dependent.(B) It is manifested as
cocontraction of agonist antagonist muscles due
an increase in the supraspinal influences on the
normal spinal system causing increase tone in the
agonist the antagonist.There is an increased
discharge of gamma motor neurons.(C) The
patient usually complains of rigidity as a
sensation of heaviness or stiffness of the
limbs.(D) Present in almost all cases of
PD.(E) Cog wheel type rigidity is present.
There is intermittent resistance throughout
ROM.Lead pipe rigidity is also seen in some
cases. There is constant resistance throughout
ROM.
(2) RIGIDITY -
16


(F) It
affects proximal muscles first, mainly shoulders
neck and then progresse to face extremities
and then the whole body.(G) As the disease
progresses Rigidity becomes more severe.(H)
Rigidity decreases the ability of patients to
move easily. For eg loss of bed mobility , loss
of reciprocal arm swing during gait.(I) Mental
concentration Emotional tension may increase
the amount of rigidity present.(J) Prolonged
rigidity results in decreased available ROM
serious secondary complications of contracture
postural deformity.(K) Rigidity also has a
direct impact on increasing Resting Energy
Expenditure (REE) fatigue levels.
17
(A) Bradykinesia refers to slowness
difficulty in maintaining movements.It is
theoretically presumed that it could be because
of difficulty to the basal ganglia to integrate
sensory information.(B) Movements are typically
reduced in speed,range amplitude termed
hypokinesia.(C) Pateint with PD typically
demonstrate micrographia an abnormally small
hand writing that is difficult to read.(D)
Pateint feels difficulties in ADL such as
bathing,dressing, rising from a chair,turning
over in bed,loss of dexterity making buttoning
etc.(E) Pateint experiences difficulty in
integrating two motor programmes at the same
time(F) Pateint feels hesitation on initiation
of movements early fatigue.
(3) BRADYKINESIA -
18
(A) Simians posture or Stooped
posture.(B) Head protuted forward , flexion at
neck , trunk , elbow , hip knee.(C) Tandem
stance - walking on a single line with narrow
BOS.(D) Balance is poor patient fall if
encounters even minor postural perturbation ( a
slight push ) due to loss of postural
reflexes.
(4) POSTURAL INSTABILITY -
19
(A) Parkinsonian gait / Freezing /
Festinating / Shuffling / Toe heel / Hurrying
gait.(B) Pateint takes small steps on
walking.(C) Pt. feels difficulty in initiating
movement to stop walking once started .(D)
There is loss of normal heel toe progression .
The toe strikes first.(E) The forward leaning
of the trunk moves the bodys COG forward , thus
causing the patient to hasten his/her pace in
order to catch up COG.(F) Loss of arm swing
pelvic rotation.(G) Stride length decreases
speed increased therefore called as festinating
gait.
(5) GAIT -
20
(H) Stance phase double support time are
lengthened while the period of single limb
support is shortened.(I) Pt. are able to stop
only when they come in contact with an object or
a wall.(J) Turning or changing direction is
particularly difficult.
21
(A) Lack of facial
expression.(B) Subsequent loss of
blinking.(C) Smiling may be possible only on
command or volitional effort.(D) This can have
a significant impact on social interaction
social disability.
INDIRECT IMPAIREMENTS COMPLICATIONS
(1) MASKED FACE -
22
(A) Rotational movement are reduced,
resulting in movements that are basically
uniplanar (in one plane of of motion ) eg
flexionextension in saggital plane.(B) There
is an overall decrease in total number of
movements. (C) Movement impoverishment can
lead to mental fatigue loss of motivation.

(2)POVERTY OF MOVEMENT
23
(A) In a patient of PD fatigue is
one of the symptom.(B) The pt. has difficulty
in sustaining activity experiences increasing
weakness.(C) Repetitive motor acts may start
out strong but decrease in strength as the
activity progresses.(D) The 1st few words
spoken may be loud strong but diminish rapidly
as speech progresses.
(3) FATIGUE-
24
(A) Pt. Shows the effects of
generalized musculoskeletal deconditioning.(B)
The more chronic generalised the disease
becomes , the greater the level of muscle
weakness fatigue.(C) Loss of
flexibility.(D) Lack of movement in any body
segement leads to contracture development of both
contractile noncontractile tissue.(E)
Contarctures mainly developes in hip knee
flexors,hip rotators adductors, plantarflexors,
dorsal spine neck flexors, shoulders adductors
internal rotators, and elbow flexors.(F)
Kyphosis is the most common postural deformity.
(4) MUSCULOSKELETAL CHANGES
25
(G) Some pt. may develop Scoliosis from leanning
consistently to one side when sitting or
walking.(H) Scoliosis generally results from
unequal distribution of rigidity in the
trunk.(I) Older pt. with reduced activity
levels poor diet are likely to develop
osteoporosis.
26
(A) Dysphagia ,impaired
swallowing, is present in 50-90 of pt.(B)
Dysphagia can lead to choking or aspiration
pnuemonia impaired nutrition.(C) Dysphagia is
the result of rigidity,reduced mobility
restricted range of movement.(D) Pt.
experiences problems in all four stages of
swallowing- oral preparatory,
oral,pharyngeal esophageal.(E) Pt. typically
experiences excessive drooling (sialorrhea) as a
result of increased salivary production
decreased spontaneous swallowing.
(5) SWALLOWING DYSFUNCTION-
27
(A) Speech is impaired in in 50-
73 of pt. (B) Hypokinetic Dysarthria which
is characterised by decreased volume , monotone
or monopitch speech, imprecise or distorted
disarticulation uncontrolled speech rate. (C)
Speech difficulties are also result of rigidity
bradykinesia.(D) Patients experiences reduced
mobility , restricted range of movement
uncontrolled rate of movement of muscles
controlling respiration , phonation , resonation
articulation.
(6) COMMUNICATION DYSFUNCTION-
28
(A) Visual disturbances are common
in PD. These can include blurring of vision
difficulty in reading which is not coeected by
glasses .(B) Conjugate gaze saccadic eye
movements may also be impaired.(C) Eye
movements may have a jerky cog wheeling
quality.(D) Pupillary abnormalities are also
possible with decreased reflex responses to light
nocciceptive stimuli.(E) 50 patient
experiences paresthesias pain.This can include
sensations of numbness ,tingling, abnormal
temperature pain that is cramp like poorly
localized.(F) Postural stress syndrome.(G)
Akathisia it is often described as painful and
interferes with relaxation sleep
(7) VISUAL SENSORYMOTOR DISTURBANCES -
29
(A) Dementia occurs in
approximately 1/3rd of the patients with
PD.(B) Bradyphrenia, a disorder of intellectual
function, is common in pt. It is characterised by
a slowing of thaught processes with lack of
cocentration attention. (C) Pt. May also
demonstrate learning deficits.(D) Perceptual
deficits also present.(E) Deficits have been
reported in vertical perception, topographic
orientation, body shceme and spatial
relations.
(8) COGNITIVE DYSFUNCTION-
30
(A) Depression is the most
common,occuring in25-40 of pt.(B) Pt. may
demonstrate symptoms of major depression
,including apathy, passivity,loss of ambition or
enthusiasm changes in appetite,sleep and
dependency. Suicidal thaughts may be
present.(C) Dysthymic disorder characterised by
variability in dysphoric mood, or typical
depression characterised by intermittent episodes
of severe anxiety.(D) Drug related psychoses
can occur.
(9) BEHAVIOURAL DYSFUNCTION-
31
(A)Dysautonomia autonomic
nervous system dysfunction occurs in pt.(B)
Commons problems includes excessive
perspiration,greasy skin,increased
salivation,thermoregulatory abnormalities(includin
g uncomfertable sensations of heat or cold).(C)
Bladder dysfunction includes urinary frequecy,
urgency nocturia.(D)Sexual dysfunction
includes impotence.(E) Patient have low
appetites decreased motility of the GIT.(F)
Constipation is also problem seen in pt.
(10) AUTONOMIC DYSFUNCTION -
32
(A) Pulmonary function impairement
is reported in 84 of pateints.(B) Orthostatic
hypotension low resting blood presure.Cardiac
arrhythmias can also occurs as aresult of L-Dopa
.(C) Airway obstruction leads to pulmonary
failure.(D) Bradykinetic disorganisation of of
respiratory movements.(E)Restrictive
dysfunction due to decreased chest expansion that
occurs as a result of rigidity of trunk muscles ,
loss of musculoskeletal flexibility kyphotic
posture.
(11) CARDIOPULMONARY DYSFUNCTION-
33
(F) Decrease in FVC , FEV1 increase in RV ,
RAW (airway resistance).(G) In long standing
disease, the lower extremities may exhibit
circulatory changes owing to venous pooling as a
result of decreased mobility prolonged sitting.
Thus pt. can present with mild to moderate edema
of the feet ankles , which usually subsides
during sleep.
34
(A)Dermatitis can occur due to
increased secretion by sweat sebaceous
glands.
(12) SKIN INFECTIONS -
35
(A) Tapping forehead causes
repititive blinking.
(13) GLABELLAR TAP SIGN -
36
(A) It is present in 75 90 of
pt.
(14) OALFACTORY DYSFUNCTION -
37
ARE YOU SLEEPING.......? DON'T DARE TO SLEEP
38
DEFINITION - The term Basal
Ganglia is applied to group of nuclei (mass of
gray matter) in the fore brain upper part of
the brain stem that have motor function of great
importance . It is the primary motor area in
lower animals ( reptiles birds).
BASAL NUCLEI OR BASAL GANGLIA (BG)
39
The BG includes -(1) Caudate nucleus it
possesses a head and a tail.(2) Putamen a
Latin word for shell.(3) Globus pallidus or
Pallidium or Paleostriatum- it is subdivided
into external internal segment.(4)
Subthalamic nucleus (BODY OF LUYS) it is
located in the diencephalon ventral to the
thalamus lateral to the hypothalamus.(5)
Substantia nigra it has two parts (a)
dorsomedial part is Pars compacta

(b) ventrolateral part is Pars reticulata.(Substa
ntia Nigra Pars compactaSNPc contains
Dopaminergic neurons which produces the Dopamine.
Dopamine has inhibitory action.
40
The scheme of subdivisions of the BG components
is shown as follows -(1) Putamen Caudate
nucleus Neostriatum or striatum.(2) Putamen
Globus pallidus Lentiform nucleus.(3)
Lentiform nucleus Caudate nucleus Corpus
striatum.
41
(A)The corpus striatum has a rich
concentration of Acetylcholine (Ach).(B) Ach is
synthesized released by small striatal neurons,
upon which it has an Exitatory effect.(C)
Dopamine (DA) is synthesized by the pigmented
neurons of SNPc it has Inhibitory effect on
striatal neurons.(D) Dopamine is transported
from SNPc to Corpus striatum via Nigrostriatal or
Dopminergic tract.(E) There is functional
equilibrium exists in the striatum between Ach
Dopamine in the normal physiological condition.
PATHOPHYSIOLOGY IN PD
42
(F) In PD , there is a loss of pigmented neurons
(neuromelanin) in SNPc. As a result , the DA
cocentration in the corpus striatum is markedly
decreased.(G) There is formation of Lewy Bodies
in the remaining neurons.(H) LEWY BODIES are
characteristic intracytoplasmic , eosinophilic
inclusion bodies. These are circular in shape
with the dens central core clear peripheral
halo.(I) There may also be a decrease in
other Neurotransmitter like noradrenaline(NA),
5hydroxytryptamine(5HT),gamma aminobutyric acid
(GABA),Enkephalins substance-P.
43
(J) Involvement of non nigrostriatal system -
Cell loss outside the Substantia
Nigra involves the following major neuron groups
-(1) Midbrain ventral tegmental area.(2)
Pons noradrenergic locus coeruleus.(3)
Midbrain serotonergic dorsal raphe nuclei.(4)
Basal forebrain cholinergic nucleus basalis of
Meynert in substantia innominata.(5) Brainstem
peptidergic nuclei
44
(K) Alteration in noradrenergic serotonergic
system results in Depression in pt.(L) Neuronal
loss in the nucleus basalis , locus coeruleus
ventral tegmental area causes Dementia.(M) Loss
of somatostatin neurons in the cortex results in
Alzheimer disease.
45
(1) IDIOPATHIC.(2) INFECTIONS -
encephalitis lethargica , AIDS, cryptococcal
meningitis and Jacob-Creutzfeldt disease.(3)
NEUROTOXINS - 1-methyl-4-phenyl-1,2,3,6-tetrahydr
opyridine(MPTP)manganese carbonmonoxide,
carbondisulphide, cyanide, methanol.(4) DRUGS
TOXICITY - (a) Neuroleptic
drugs. (b) Antidepressant
drugs. (c) Antihypertensive
drugs.(5) METABOLIC DISORDERS - disturbed
calcium metabolism result in calcification in BG.
AETIOLOGY
46
(6) VASCULAR DISORDERS - atherosclerosis ,
hypertension.(7) HEAD INJURY - RTA , punch
boxers syndrome.(8) MULTIPLE SYSTEM
DEGENERATION - Alzheimer
disease Shy Drager syndrome
Progressive supranuclear palsy.
Wilsosns disease
Amyotrophic lateral sclerosis.
Olivopontocerebellar atrophy.
Huntingtons disease
Hallervorden Spatz disease.
Strionigral degeneration.
Cortico-basalganglionic degeneration.
47
(A) The diagnosis of PD is based on
the clinical symptoms signs.(B) Blood CSF
examination and cerbral imagin such as CT Scan ,
MRI are non cotributory in making the diagnosis
of PD.(C) Positron Emission Tomography (PET)
using fluorodopa has been useful in detecting
loss of dopa uptake in the striatum . It shows
60 reduction of fluorodopa uptake.(D) Single
Photon Emission Computerised Tomography
(SPECT).(E) DNA Analysis - mitochondrial
complex 1 activity is reduced, alterations in
DNA, Monoamine oxidase-B (MAO-B) activity
increased.
DIAGNOSIS
48
(F) The diagnosis is usually made on the basis of
history clinical examination. Handwriting
samples, speech analysis, interview questions
that focus on developing symptomatology
physical examination are used in the preclinical
stage to detect early manifestations of the
disease.(G) The diagnosis of PD can be made if
atleast two of the cardinal features are
present.(H) EMG may done to find out the level
of rigidity also to know the increase in the
reaction time movement time.
49
(A) PD is a progressive disorder but
its rate of progression is variable.(B) Before
L-dopa therapy 28 of pt. became severely
disabled or died with in 5 yrs of diagnosis , 61
with in 10 yrs 83 with in 15 yrs.(C)
Following L-dopa therapy only 9 became disabled
or had died at 5 yrs , 21 at 10 yrs 37.5 at
15 yrs.(D) Death may occur from aspiration
pneumonia ,septicemia from UTI, decubitus ulcer
or from secondary causes like vascukar disease or
neoplasia.
PROGNOSIS
50
PHARMACOLOGICAL TREATMENT(A)
Anticholinergics Trihexyphenidyl ,
Bentropine.(B) Dopamine replacement Levedopa
, Carbidopa , Sinemet , Sinemet CR.(C) Dopamine
agonists Pergolide , Bromocriptine .(D)
Amantadine.(E) MAOI-B Seligiline.
TREATMENT
51
(A) STERIOTAXIC SUEGERY - started
in 1950 before levo dopa not in use.(B)
PALLIDOTOMY - clearing of destructive leisons in
globus pallidus internus (Gpi).(C) THALAMOTOMY
- clearing of destructive leison in the ventral
intermidius nucleus of thalamus.(D) DEEP BRAIN
STIMULATION (DBS)- started in 1997 by using
implantation of electrodes in brain specifically
in ventral interomedial nucleus of thalamus.(E)
TRANSPLANTATION TECHNIQUE - grafting of foetal
cells , autotranplantation with patients own
adrenal medullary cells.
SURGICAL MANAGEMENT
52
(A) PATIENT HISTORY.(B) GENERAL
EXAMINATION.(C) NEUROLOGICAL EXAMINATION.(D)
CARDIORESPIRATORY ENDURANCE.(E) OTHER
ASSESSMENT - (1) Functional
status. (2) General health
measures. (3) Skin integrity
condition.
ASSESSMENT
53
(1) COGNITION -memory function ,
conceptual reasoning , problem solving ability ,
attention and concentration are
reduced.Assessment instrument Mini Mental
Status Exam (MMSE).(2) AFFECTIVE
PSYCHOSOCIAL FUNCTIONING - stress , anxiety ,
sadness , apathy , passivity , insomnia , aprexia
, wt. loss , inactivity , suicidal thaugts may
present.Assessment instrument Geriatric
Dpression Scale.
Beck Depression Inventory.
FINDINGS OF NEUROLOGICAL ASSESSMENT
54
(3) VISUAL FUNCTION --Visual acuity ,
peripheral vision , accomodation , light dark
adaptation are reduced.- Depth perception ,
blurring of vision , cataract , glaucoma , may
present.- Senile macular degeneration , diabetic
retinopathy , homonymous hemianopsia may
present.(4) DYSPHAGIA SPEECH IMPAIREMENT
-- Dysphagia , sialorrhea ( drooling)
present.-Hypokinetic dysarthria
.-Mutism.Assessment instruments The verbal
learning test.
- The verbal comprehension test.
55
(5) MUSCLE PERFORMANCE -- Spasticity-
Strenght reduced.- Endurance decreased.Assessmen
t Instrument MMT
- Modified Asworth scale.
- Isokinetic
Dynamometers.
- Hand Held Dynamometers.(6) RIGIDITY -
-Present in trunk , neck , extremities face.
56
(7) BRADYKINESIA - - Slowness of movement. -
Increased Reaction Time (RT). - Increased
Movement Time (MT). Assessment instrument
Timed test for Rapid Alternating Movement (RAM).
- EMG for
RT MT.(8) JOINT RANGE OF MOTION - - AROM
PROM both decreased. - Loss of hip knee
extension , shoulder flexion , elbow extension
,dorsal spine neck extension and axial rotation
of spine.Assessment instrument Goniometers.
57
(9) TREMORS - - Resting tremors. - Mainly in
periphrey of upper limbs.(10) SENSORY INTEGRITY
- - Blunting of touch sensations. - Loss of
propioception more in lower extremities than
upper , distal than proximal. - Paresthesias (
sensation of numbness or tingling ).(11) PAIN
- Mild aching cramp like. -
Poorly localised. - Potural
stress syndrome.Assessment Instrument The Mc
Gill Pain Questionnaire.
- The Visual Analogue Scale.
58
(12) POSTURAL INSTABILITY - - Disturbed
balance. - Greater problem in single limb
stance.Assessment instrument Timed up go
test. -
Berg balance test.
- Functional reach.
- Clinical Test for Sensory
Interaction in Balance (CTSIB).
- Tinettis Performance
Oriented Mobility Assessment(POMA)(13) POSTURE
- - Flexed or stooped. - Kyphosis cervical
lordosis.Assessment instrument Postural grids
or Plumb lines.
- Still photogarphy.
- Videotapes.
59
(14) GAIT -- Freezing episodes.-
Shuffling gait pattern.- Stride length , step
width decreases.- Cadence increased.( Gait
should be examined during all move,ent directions
forwrad , backward , sideward ).(15)
AUTONOMIC CHANGES - - Excessive drooling (
salivation). - Excessive sweating. - Greasy
skin.
60
Cardiorespiratory endurance may be reduced from
impaired respiratory functions long
standing inactivity.(1)ABNORMAL BREATHING
PATTERNS - - Ribcage compliance chest wall
mobility decreases. - Restrictive breathing. -
Kyphosis present.(2) ALTERED LUNG VOLUMES
CAPACITIES - - FVC , FEV ,decreased. - RV ,
RAW increased. - TLC , VC decreased.
FINDINGS OF CARDIORESPIRATORY EXAMINATION
61
(3) ALTERED VITAL SIGNS - - HRmax reduced. -
Respiratory rate increased. - PaO2 is
decreased. - BP decreased ( orthstatic
hypotension).Assessment instrument PFT
- 6 Minute
walking test.
- Exercise tolerance test.
- Sphygnomannometer.
62
(1) FUNCTIONAL STATUS - -
Difficulty in performing ADL. - Activities
having a rotational component is reduced or
absent. Assessment instrument The functional
independence measure ( FIM).
- Katz index of independece in
activities of daily life.(2) GENERAL HEALTH
MEASURES - - Decrease in physical social
function. - Decrease in emotional well
being.Assessment instrument Rand 36 item
health survey SF 36
- Sickness impact profile.
OTHER FINDINGS
63
(3) SKIN INTEGRITY CONDITION - - Bruising
skin breakdown. - Pressure sore may be present
in patient confined to bed. (4) FINGER
DEXTERITY - - Pt. May unable to button up
three shirt buttons upto 3 minutes.
64
(1) HOEN YAHR SCALE ( 1967).(2)
THE UNIFIED PARKINSONS DISEASE RATING SCALE
UPDRS (1987).(3) THE PARKINSONS DISEASE
QUESTIONNAIRE (PDQ-39).
SCALING OR GRADING OF PD
65
STAGE 1 Disability or functional impairement is
usually absent or minimal. - If
present , unilateral involvement.STAGE 2
Bilateral or midline involvement.
- Balance not disturbed.STAGE 3 Impaired
righting reflexes. -
Functionally restricted in some activities but
pt. can live independently. -
Disabilty is mild to moderate.STAGE 4 All
symptoms present severly disabled.
- Standing walking possible only with
assistance.STAGE 5 Confined to wheelchair or
bed.
HOEN YAHR SCALE
66
(1) It is a rating tool to follow
the longitudinal course of PD.(2) It is made up
of - (a) Mentation
, Behaviour Mood.
(b) ADL. (C) Motor
sections.(3) These are evaluated by
interviewing the pt.(4) A total of 199 points
are possible.(5) 199 points represents the
worst ( total disability) 0 point represnts no
disability.
UNIFIED PARKINSON'S DISEASE RATING SCALE
67
(A) The PDQ is a 39 items
questionnaires. (B) It focuses on the
subjective reports of the impact of PD on daily
life.(C) These are interviewed with
patients.( D) Scored are given summarised as
Parkinsons Disease Summary Index (PDSI).
THE PARKINSON' DISEASE QUESTIONNAIRE (PDQ 39)
68
(1) TO DECREASE THE RIGIDITY.(2) TO
MAINTAIN THE MUSCULOSKELETAL FLEXIBLITY.(3) TO
INCREASE THE JOINT MOBILITY.(4) TO IMPROVE THE
BALANCE.
AIMS OF PT MANAGEMENT
69
(5) TO IMPROVE THE MOTOR LEARNING.(6) TO
IMPROVE THE CARDIORESPIRATORY FUNCTIONS.(7) TO
IMPROVE THE GAIT.(8) TO IMPROVE THE
PSYCHOSOCIAL WELL BEING.
70
MEANS OF PHYSIOTHERAPY TREATMENT
71
(1) Gentle rocking exercises
rotational exercises in slow rhythmic
patterns.(2) PNF (Rhythmic Initiation )
technique in which movement progresses from
passive to active assisted then to active
movements.(A) SUPINE- slow side to side head
rotations.(B) SUPINE - bilateral symmetrical
D2F( flexion,abduction,external rotation) its
reversal D2E pattern ( extension,adduction,interna
l rotation)(C) Hooklying - lower trunk
rotations.(D) Side lying - upper lower trunk
rotations.(E) Side lying - trunk rotations
combined with scapular patterns (shoulder
protraction with elevation retraction with
depression).
(1) TO REDUCE THE RIGIDITY
72
(3) Deep breathing exercises can be incorporated
into rotational exercises to enhance
relaxation.(A) Bilateral symmetrical D2F (BS
D2F) patterns can be combined with
inspiration.(B) Bilateral symmetrical D2E (BS
D2E) patterns can be combined with
expiration.(4) Meditation techniques.(5)
Jacobsons progressive relaxation
techniques.(6) Relaxation audiotapes home
exercise programmes.(7) Feldenkrais relaxation
techniques.
73
(1) Both active passive ROM
exercises.(A) Exercises should focus on
strengthening the patient weak , elongated
extensor muscles while ranging the shortened ,
tight flexors muscles.(B) ROM exercise should be
also emphasize restoring range in the neck
trunk and can be performed in combination with
rotational exercises to promote relaxation.(2)
PNF pattern - muscle inhibition techniques Hold
Relax or Contract Relax. Contract Relax is the
preferred technique because it combines autogenic
inhibition from isometric contraction of the
tight agonist muscles with active rotation of the
limb.(A) For U/L BSD2F L/L hip and knee
extension in a D1 pattren (hip extension ,
abduction internal rotation.
(2) TO MAINTAIN THE FLEXIBILITY OF
MUSCULOSKELETAL SYSTEM
74
(3) TRADITIONAL STRETCHING TECHNIQUES - (A)
Gentle stretching of elbow flexors , hip ,knee
flexors ankle plantarflexors. (B) Stretching
can be combined with joint mobilisation
techniques to reduce tightnessof the joints
capsule or of ligaments around a joint. (C)
Autostretching or Selfstretching.(D) Maintain
the stretch force atleast 15 30 seconds.
Ideally the stretches are repeated atleast 3-5
times.(E) Ballistic stretches ( high intensity
bounding stretches) aggressive stretch should
be avoided.
75
(F) Braces may be used for prolonged stretching
of tight muscles.(G) Calisthenics exercises in
supine , sitting stand.(H) Standing erect
with arms in elevation (over head ) against a
wall or corner of the room the patient should
try to stretch out his body.(I) Lie supine with
pillow under the upper thorax.
76
(4) PASSIVE POSITIONING - it is long duration
technique to improve flexiblity .(A) To avoid
Phantom Pillow Posture pt.should be positioned in
prone position.(B) The pt with a developing
lateral curvature can be positioned in side lying
with a small pillow under the lateral trunk.(C)
Mechanical low load stretching can also be used
. This approach utilizes a weight pulley
traction set up with low load wt. ( eg. 5 15
lbs or 5 10 of body wt.) . Time duration is
20 30 minutes.
77
(D) Mechanical stretching can be achieved through
the use of tilt table . The pt is positioned
with fixed leg straps to reduce hip knee
flexion contractures or toe wedge to reduce
plantarflexion contracture.(E) Braces can be
used for prolonged stretching of tight
muscles.
78
(1) The overall focus is on improving
mobility / controlled mobility function with
specific emphasis on improving segmental mobility
of the head , trunk proximal segments ( hips
shoulders ) . Relaxation exercises are important
pre-requisites to all mobility training.(A) For
thorax neck extension - prone on elbow , prone
extension , standing wall push ups or corner push
ups.(B) For extremities PNF techniques of
Rhythmic Initiation.(C) Bed mobility activities
( rolling , supine to sit etc ).
(3) TO IMPROVE THE JOINT MOBILITY
79
(D) Pelvic mobility ( anterior , posterior side
to side tilt ) exercises on Swiss ball.(E) Wt
shifting exercises upper extremities reaching
activities . Reaching should be practised in all
directions with emphasis on promoting rotational
movement of trunk.(2) PNF patterns for upper
extremity in sitting - (A) D2F D2E patterns
are ideal because they expand the restricted
chest while promoting upper trunk extension.(B)
A lift / reverse lift patterns or chop / reverse
chop pattern can be used to promote upper trunk
extension with rotation in sitting.
80
(C) Static dynamic activities for the lower
trunk pelvis in sitting include crossing one
leg over the other or scooting.(3) The pt can
be instructed to practise lip pursing ,movement
of tounge, swallowing facial movement such as
smiling , frowing etc. A mirror can be used to
provide visual feedback.(4) Movements of
opening closing of mouth , chewing should be
combined with neck stabilisation in a neutral
position.(5) Pool exercises or Hydrotherapy.
81
(1) The balancing training should
always be begin from of lower COG to higher
COG.(2) Training should begin with weight
shifts in both sitting standing in order to
help the pt develop an appreciation of his limits
of stability.(3) By giving the slight the push
to pt. Patient try to maintain the balance.
(4) TO IMPROVE THE BALANCE
82
(4) Reaching activities.(5) Activities on Swiss
ball.(6) Kitchen shink exercises- the pt can
be instructed in standing heel rises toe offs ,
partial wall squats and chair rises , single limb
stance with side kicks or back kicks marching
in place , all while maintaining light touch down
support of the hands.
83
(1) To teach the pt to do one movement
at a time because he feels difficulty in carrying
out simultaneous movements ( dual task).(2) The
combination of movements results in slowing of
movements.(3) Teach the pt rolling , supine to
sitting , sitting to standing etc.(4) Avoid
the movements where attention is divided
because learning activities is also become
difficult. For eg for a pt sitting on chair dont
ask him to walk , first ask him to stand up from
chair then walk.
(5) TO IMPROVE MOTOR LEARNING
84
(1) Diaphragmatic Segmental
breathing exercises.(2) Air shifting
techniques.(3) Deep breathing execises to
improve chest wall mobility vital
capacity.(4) Chest mobility exercises.(5) PNF
- BSD2F BSD2E patterns of upper extremitise
for chest mobility. Execises are performed in
sitting position to promote trunk stabilisation.
(6) TO IMPROVE THE CARDIORESPIRATORY FUNCTIONS
85
(6) Incentive spirometry .(7) Balloon
blowing.(8) Aerobic execises eg. Daily walking
for short distance , ergometry etc.
86
(1) The major goals are to lengthen
stride , broaden BOS , improve stepping , improve
heeltoe gait pattern , increase contralateral
movement arm swing and provide a programme of
regular walking.(2) Weight transfer standing
on single limb.(3) High stepping to strengthen
the flexors.(4) Side stepping or crossed
stepping with or without support.
(7) TO IMPROVE THE GAIT
87
(5) PNF activity of braiding , which combines
side to side stepping with alternate crossed
stepping to improve the lower trunk rotation
with stepping movement.(6) Normal heel-toe
progression.(7) To overcome shuffling pattern ,
draw foot marks or parallel lines with red or
yellow colours then ask the pt to walk on
it.(8) The pt should be practised stopping ,
starting , changing direction turning. Turning
of 180degree should be practised first then 360.
88
(9) Two wands or sticks ( held by pt therapist
one in each hand ) can be used to facilitate
reciprocal arm swing during gait. The therapist
uses his arm swing to assist the patient.(10)
Gait can be vey well trained by using audiovisual
cues/ commands.(11) Auditory cues can be
effective in improving gait reducing episodes
of freezing ( gait block). Pt responds positively
to brisk march music or other similar types of
rhythmic music.
89
(12) Metronome stimulation was found to
significantly reduce the number of freezing
episodes lenthen strides.(13) Use of walker
or parallel bar is not advisable in treatment of
PD because the confined nature of this gait
training only increases the freezing.
90
.(1)Active participation of family
members is required. Patient counselling to
increase the confident independency. (2)
Feeling of hopelessness , dependency depression
should be reduced.(3) Self management skills
should be promoted.(4) Regular participation of
patient into various social activities should be
encouraged.(5) Coping skills ( to compete with
the variety of social environmental factors )
can be facilitated.
(8) TO IMPROVE THE PSYCHOSOCIAL WELLBEING
91
(1) Teach the pt for Relaxation ,
Flexibility , Strengthening , Mobility
Breathing exercises.(2) Avoid prolonged periods
of inactivity.(3) The pt should be cautioned
agianst over doing activity , which could result
in excessive fatigue.(4) Early morning warm-up
Callisthenics execises.(5) Compensatory
techniques or triggering maneuvers to overcome
the crippling effects of bradykinesia freezing.
HOME PROGRAMMES
92
(6) Wall pulleys can be used to improve upper
extremity ROM.(7) Hanging from an overhead bar
can be used to maintain stretch on the upper
trunk and extremity flexors.(8) In standing , a
countertop or sturdy chair should be used to
assist in stabilisation during calisthenics
balance activities.(9) Make the pt to sleep in
the prone position.
93
(1) NATIONAL PARKINSON FOUNDATION
(NPF) , MIAMI.WEBSITE - www.parkinson.org(2)
PARKINSONS DISEASE FOUNDATION (PDF) , NEW YORK
(USA).WEBSITE - www.pdf.org(3) AMERICAN
PARKINSONS DISEASE ASSOCIATION (APDA), NEWYORK
(USA).WEBSITE - www.apdaparkinson.com
USEFUL LINKS
94
(4) CHARTED SOCIETY OF PHYSIOTHERAPY (CSP) ,
LONDON (U.K.)WEBSITE - www.csp.org.uk(5)
AMERICAN PHYSICAL THERAPIST ASSOCIATION (APTA)
U.S.A.WEBSITE - www.apta.org(6) MOHD JAVED
QUERAISHI , STUDENT PHYSIOTHERAPIST.Pt.J.N.M.MEDI
CAL COLLEGE RAIPUR , C.G.E -MAIL -
javed_physio_at_yahoo.co.in
95
THANK YOU
96
(No Transcript)