management of Parkinson disease for physios.pdf

Extrapyramidal

1. MANAGEMENT OF PARKINSONISM
Prof.drEman Fayez
Professor of neurological
physical therapy faculty of
physical therapy
Cairo University

2. COMPONENTS OF EXTRAPYRAMIDAL SYSTEM
2

3. BASAL GANGLIA
The term basal gangliaare masses of grey matter deep
within the cerebral hemispheres.
The term is debatable because these masses are nuclei
rather than ganglia
Anatomically, the basal ganglia include the caudate
nucleus, the putamen, and the globus pallidus.
Together they are called the corpus straitum
Functionally, the basal ganglia and their interconnections
and neurotransmitters form the extrapyramidal system.

6. DESCENDING EXTRA PYRAMIDAL MOTOR TRACT TO SPINAL INTERNEURON AND
MOTOR NEURON
6
&
uncrossed
BRAINSTEM Giving rise to following tracts:
Rubrospinal tract
Vestibulospinal tract
Reticulospinal tract
Tectospinal tract
These tracts terminate on anterior horn interneurons. Occasionally they
terminate directly on anterior horn motor neurons.

7. EXTRAPYRAMIDAL SYSTEM FUNCTIONS
Regulation and integration of voluntary motor activities through
influencing motor instructions sent to the periphery
Has a role in stabilizing the large and complicated systems that
control movement
REGULATION OF TONE

8. 8
Extra pyramidal tracts
•some are excitatory and other are inhibitory to muscle
tone
•overall effect –strong inhibitory effect over Gamma
Motor Neuron in anterior horn cell
What will be the effect of extra pyramidal
lesions ?
Hypertonia-Because strong inhibitory effect
over Gamma motor neuron is lost.

9. PARKINSON’S DISEASE
Parkinson’s disease (PD) is a progressive
neurodegenerative condition affecting mainly
the basal ganglia
Cell death in the substantia nigra (SN) leading to
decrease in brain dopamine (DA). Acetylcholine
will predominate

10. PARKINSON’S DISEASE-INCIDENCE
Increases dramatically with age
Mean age of onset = 60 y/o
Most common onset in 50-79 y/o age groups
Onset <30 y/o rare

11. PARKINSON’S DISEASE-PATHOLOGY
Most common site = substantia nigra SN pigmented neurons
Normal convert endogenous & exogenous Levodopa to Dopamine
striatum via nigrostriatal tract
Abnormal marked deficiency of DA in the striatum
Bradykinesia most closely correlates with degree of
striatal DA deficiency

12. PARKINSON’S DISEASE-PATHOLOGY
Lewy body = intracellular
inclusion body in the SN
-Pathologic hallmark in Parkinson’s brains
Lewy body

13. CAUSES OF PARKINSONISM
1-Idiopathic :
Parkinson’s disease (paralysis agitans).
The cause is unknown
There is degeneration of substnacianigrapigmented cells leading to deacreseof
dopamin

14. OTHER CAUSES OF PARKINSONISM
Vascular (rare)
Trauma (e.g. Mohammed Ali)
Encephalitis
Neoplastic
Environmental toxins
Manganese
Pesticides

15. PARKINSON’S DISEASE-DIAGNOSIS
History & clinical assessment
No specific lab abnormalities
Minimum requirement of 2/3 major clinical features
Resting tremor
Bradykinesia
Rigidity

16. SIX CARDINAL FEATURES
REST TREMOR
RIGIDITY
FLEXED POSTURE
BRADYKINESIA –HYPOKINESIA
LOSS OF POSTURAL REFLEXES
FREEZING PHENOMENON
TO DIAGNOSE: TWO OF ABOVE, WITH AT LEAST ONE
BEING REST TREMOR OR BRADYKINESIA

17. PARKINSON’S KEY FEATURES
Stooped posture
Slow and shuffling gait and Festinating gait.
Pill-rolling tremors static type
Uncontrolled drooling, rare arm swinging with walking
Paucity of facial expression (mask-like faces )and decreased blink
rate .
Micrographia.
Change in voice, dysarthria in form of monotonus speech
Labile and depressed, sleep disturbances
Oily skin, excessive perspiration, orthostatic hypotension

18. PARKINSON’S DISEASE-MOTOR SYMPTOMALOGY
Have to lose 60% of nigral neurons with 80% depletion of striatal DA
before symptoms of PD develop
Insidious onset
Asymmetric
First symptom = tremor
Usually at rest
Pill-rolling, one hand involved
Decreased with purposeful movement

19. PARKINSON’S DISEASE-MOTOR SYMPTOMALOGY (CON’T)
Bradykinesia = slowness in initiating movement
Muscular rigidity
Feel on passive movement of joint
Smooth resistance lead pipe or superimposed ratchet-
like jerks cogwheel rigidity
Postural instability (late)

20. PARKINSON’S DISEASE-MENTAL MANIFESTATIONS
Depression (common)
Bradyphrenia (slowed thinking)
Dementia (20-25%)

21. PARKINSON’S DISEASE
Stages
Initial-hand and arm trembling, weakness, unilateral
involvement
Mild-masklike facies, shuffling, bilateral involvement
Moderate—increased gait disturbances
Severe—akinesia, rigidity
Complete dependence

23. PARKINSON’S DISEASE-TREATMENT GOALS
Adequate symptomatic benefit
Minimize disability
Avoid, delay, or reduce complications/side effects
of treatment
Slow or halt progression
of disease

24. PARKINSON’S DISEASE-NON-PHARMACOLOGIC
TREATMENT
Physical therapy
Occupational therapy
Speech therapy
Social interaction

25. SOME POINTS MUST TAKEN INTO
CONSIDERATIONS
Maintain mobility and flexibility by ROM
Encourage self-care as much as possible
Monitor sleep patterns to avoid injury
Nutrition-may need soft or thickened foods.
Constipation
Speech therapy may be needed
Psychosocial support—impaired memory cognition

27. ROLE OF PHYSICAL THERAPIST
Design an exercise program to meet patient
particular needs.
Evaluate and treat problems of mobility and
walking.
Evaluate and treat joint or muscle pain which
interfere with the activities of daily living.
Help with poor balance or frequent falling.
Treat difficulties accomplishing activities of daily
living
Recommend and teach the correct use of adaptive
equipment.

28. ASSESSMENT OF PD PATIENT
General considerations during assessment
1-to minimize effect of drug induced change in performance
on assessment results it must be performed at the same time of
day
2-assessment is repeated for follow up
3-All activities should be timed
4-considering old age problems as artheritis,decreasedsight
and hearing

29. ASSESSMENT OF PD PATIENT
1-muscle tone
2-functional activities
3-balance
4-posture
5-tremor
6-dextrety
7-respiratory status
8-Range of motion
9-bradykinesia
10-gait assessment

30. COMMON PROBLEMS IN PARKINSONISM
Disturbance of normal postural background to movement as balance and
righting reflexes are absent or impaired which resulting in:
1-difficulty in changing position,
2-inability to rotate the body to follow the head
3-Limitation of trunk lateral flexion, and extension
4-Stooped posture

31. COMMON PROBLEMS IN PARKINSONISM CONT.
5-Respiratory problem lead to poor tolerance to exercise
6-Micrographia -small, cramped handwriting
7-Impaired manual dexterity resulting in difficulty in perform ADL
8-Contracture and deformity secondary to inactivity and muscle
imbalance
9-Weakness due to inactivity

32. ESSENTIAL PD REHABILITATION COMPONENTS IN EARLY AND MIDDLE STAGE
Breathing exercises and exercises connected with breathing
Stretching exercises
Strength training
Rhythmic initiation technique
PNF pattern to enhance rotation and extension
Aerobic activity
Balance training
Posture correction
Speech and Swallowing Rehab
Role of adaptive and assistive devices

35. SPEECH AND SWALLOWING DIFFICULTIES IN PARKINSON DISEASE
The same PD symptoms that occur in muscles of the body--tremor, stiffness, and slow
movement-can occur in the muscles used in speaking and swallowing. This can cause
A soft voice
Mumbled or fast speech
Loss of facial expression
Problems communicating
Trouble swallowing

36. OROFACIAL DYSFUNCTIONS
Masked face -reduced facial expression
Lack of spontaneous blinking of eyes
Poor lip closure and tongue movement result in difficulty in
sowllowing
Dysarthria -lower volume quality of the voice

37. TREATMENT OF OROFACIALFUNCTION
1-ask pt to take deep breath before speak
2-tapping under jaw to stimulate swalwing
3-gentle shaking of inside cheeks to facilitate lip closure
4-PNF

38. SWALLOWING
Always sit upright
Chew small amounts of food well and swallow it all before adding more.
Put your fork down between bites to slow yourself down
Make yourself swallow twice after every bite.
Take small sips when drinking. Alternate bites of food and sips.
Take only one sip at a time. Do not drink gulp after gulp.
Use of straws!!
Keep your chin slightly down or at least parallel to the table.
Don’t try to drink out of a can. Use a glass instead.
Don’t talk with food in your mouth

39. TIPS ABOUT DROOLING
If patient tend to drool,heprobably don’t have more saliva then you used to have;
you are just not swallowing it as automatically as before.
Frequent sips of water or sucking on ice chips during the day can help swallow more
often
Always keep head up, with chin parallel to the floor, and lips closed
Drinking more water will help thinning the phlegm

40. PROBLEM IN GAIT
Decreased arm swing on the affected side
Problems with walking and balance -may experience short
step, slow, shuffling gait and festinating gait or episodes of
"freezing", being unable to initiate a step forward

41. GAIT TRAINING
Goals :
Lengthen stride
Increase arm swing
Overcome shuffling and festinating gait
Increase trunk rotation
Encourage heel toe gait

42. METHODS
Floor marking
Use small obstacles
Emphasis turning movement with small steps and wide
base of support

43. BALANCE, FALLS, AND POSTURE
Balance problems are one of the main symptoms of PD.
Another name for balance problems is postural instability.
Balance problems increase the risk of
falling, especially when combined with other symptoms
and complications of PD, including:

44. POSTURE
PD can cause many changes in the body.
One easily recognizable change is posture.
The characteristic changes in posture can include:
A forward head position.
Rounding of the shoulders and upper back.
A forward trunk position with increased bending
of the hips and knees.

45. SOME TYPICAL POOR POSITIONS
Sitting on the couch watching TV.
Leaning over to work on the computer.
Driving/riding in the car.
Looking downward while reading, or propping your head against the
headboard while reading.

46. EXAMPLE OF POOR SITTING POSTURE

47. EXAMPLE OF GOOD SITTING POSTURE

48. BREATHING EXERCISES

50. STRETCHES

51. SEATED NECK AND
CHEST STRETCH

52. SEATED ROTATION
STRETCH

53. OVERHEAD STRETCH

54. STANDING BACK STRETCH

55. HAMSTRING
STRETCH

56. LYING SHOULDER
STRETCH

57. SEATED SIDE STRETCH

58. STANDING SHOULDER
STRETCH

59. ROTATION STRETCH

60. CALF STRETCH

61. ANKLE CIRCLES

62. STRENGTHENING EXERCISES

63. BRIDGING

64. SHOULDER BLADE SQUEEZE

65. SHOULDER BLADE SQUEEZES

66. QUAD STRENGTHENING

67. QUADRAPED TRUNK

68. PRONE ON ELBOWS

69. AEROBIC ACTIVITY

70. AEROBIC ACTIVITY

71. BALANCE EXERCISES

72. 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...

73. WHAT ARE ASSISTIVE\ADAPTIVE AIDS?
Adaptive aids are items that can help you stay as independent as
possible for as long as possible.
These devices can make your daily life easier and safer, and improve
your quality of life.

74. ASSISTIVE AIDS
A urinal (available for both men and women), bedpan, or bedside
commode can help reduce bathroom trips at night

75. BATHING AND TOILETING AIDS

76. TRIPODS
Avoid tripod or
quad canes
No

77. ONE POINT CANE
A straight cane with a rubber
tip is better.
Yes

78. CONTINU…

80. HELPFUL BEDROOM AIDS
Helping handle/bed rail

81. EATING AIDS

82. TREMOR TREATMENT FIT LIKE A GLOVE
It is a system of sensors and motors that track voluntary
movements and separate them from the involuntary tremors.
The gloves can then suppress the tremor without stopping the
intended movement.