Parkinson's Disease & Physiotherapy Management

-Detailed Introduction, Patho-physiology, Evaluation & Physiotherapy Management of Parkinsonism.
-Clinical classification is discussed.
-Various measures of evaluation and physical therapy is discussed in this.

1. Presentation by : Anumeha Sharma (MPT I st year Neurology)

2. Table of Contents Introduction Definition Incidence Aetiology Pathophysiology Clinical Presentation Medical Diagnosis Management Physiotherapy Rehabilitation

3. Introduction Parkinson’s disease, is named after James Parkinson who in 1817 described it as “ the shaking palsy” a disease for which the reason is still unknown.

4. Definition Parkinson’s disease (PD) is a chronic, progressive disorder primarily affects the basal nuclei of CNS. Cardinal symptoms are rigidity, bradykinesia, tremor , and, in later stages, postural instability . - P hysical rehab 6 th edition by S usan B, O’Sullivan.

5. INCIDENCE PD is a common disease that affects an estimated 7 to 10 million people worldwide . The prevalence in India is roughly 10% of the global burden, that is, 5.8 lakhs. From India, crude prevalence rates (CRP) between 6 to 53/100,000 have been reported. Above the age of 60 years, the PRs were higher being 247/100,000.

6. Contd. The average age of onset is 50 to 60 years. Only 4% to 10% of patients are diagnosed with early-onset PD (less than 40 years of age ). Young-onset PD is classified as beginning between 21 and 40 years of age, and juvenile -onset PD affects individuals less than 21 years of age . Men are affected 1.2 to 1.5 times more frequently than women.

7. ETIOLOGY P arkinsonism is a generic term used to describe a group of disorders with primary disturbances in the dopamine systems of basal ganglia (BG ). Parkinson’s disease , or idiopathic parkinsonism, is the most common form , affecting approximately 78% of patients.

8. Parkinson-Plus Syndromes A group of neurodegenerative diseases can affect the substantia nigra and produce parkinsonian symptoms along with other neurological signs. These diseases include :- S triatonigral degeneration ( SND) Shy-Drager syndrome P rogressive supranuclear palsy (PSPO ) N ormal pressure hydrocephalus (NPH) Cortical – basal ganglionic degeneration (CBGD).

9. Contd. Early in their course , these diseases may present with rigidity and bradykinesia indistinguishable from PD. However, other diagnostic symptoms eventually appear. Another diagnostic feature is that Parkinson-plus syndromes typically do not show measurable improvement from the administration of anti-Parkinson medications such as levodopa therapy (termed the apomorphine test ).

10. Basal Nuclei T he B asal N uclei are the collection of masses of grey matter situated within each cerebral hemisphere. The components of basal nuclei are :- C audate nucleus Putamen G lobus pallidus Claustrum Amygdaloid nucleus

11. Functionally R elated Nuclei Subthalamic nucleus Substantia Nigra

12. Functions of B asal N uclei Helps to regulate initiation and termination of movements . Activity of neurons in the putamen precedes or anticipates body movements; activity of neurons in the caudate nucleus occurs prior to eye movements . The globus pallidus helps regulate the muscle tone required for specific body movements .

13. Contd. The basal nuclei also control subconscious contractions of skeletal muscles . Also helps to initiate and terminate some cognitive processes , such as attention, memory, and planning, they act with the limbic system to regulate emotional behaviors.

14. Direct & Indirect Loop The BG engages in a number of parallel circuits or loops, only a few of which are motor . The direct motor loop through the BG consists of signals transmitted from the cortex putamen globus pallidus ventrolateral (VL) nucleus of the thalamus cortex (supplementary motor area [SMA])

15. Contd. This VL-SMA connection is excitatory and facilitates discharge of cells in the SMA. The BG thus serves to activate the cortex via a positive-feedback loop and assists in the initiation of voluntary movement. An indirect loop through the BG involves the subthalamic nucleus, the globus pallidus interna. This indirect loop serves to decrease thalamocortical activation.

16. Pathophysiology

17. C ontd.

18. Secondary motor Symptoms Muscle Performance Decreased torque production Fatigue Contractures and deformity common Masked face Micrographia Motor Planning Start hesitation Freezing episodes Poverty of movement Speed - accuracy trade - off

19. Contd. Motor Learning Slower learning rates, reduced efficiency Increased context-specificity of learning. Procedural learning deficits for complex and sequential tasks. Gait Reduced stride length; increased step-to-step variability Reduced speed of walking Cadence typically intact; may be reduced in advanced PD

20. Contd. Increased time: double-limb support. Insufficient hip, knee, and ankle flexion: shuffling steps Insufficient heel strike with increased forefoot loading Reduced trunk rotation: decreased or absent arm swing Festinating gait: anteropulsion common. Freezing of gait (FOG) Difficulty turning: increased steps per turn. Difficulty with dual tasking: simultaneous motor and/or cognitive tasks. Difficulty with attentional demands of complex environments.

21. Contd. Posture Kyphosis with forward head. Leaning to one side with tonal asymmetries. Increased fall risk.

22. Non motor symptoms Sensory Symptoms No primary sensory loss Paraesthesia Pain result from postural stress syndrome. Speech, Voice, and Swallowing Disorders Hypokinetic dysarthria Dysphagia Whispers or mutism.

23. Contd. Cognition Function and Behaviour Dementia characterized by loss of executive functions (planning, reasoning, abstract thinking, judgment, and so forth) and changes in Visuospatial skills, memory , and verbal fluency. Bradyphrenia Visuospatial deficits Depression Dysphoric mood

24. Contd. Autonomic Dysfunction Excessive sweating. Abnormal sensations of heat and cold. Seborrhea Sialorrhea Constipation Urinary bladder dysfunction Sleep disorder Excessive daytime somnolence At night, insomnia REM sleep behavior disorder

25. MEDICAL DIAGNOSIS There is no single definitive test or group of tests used to diagnose the disease. The diagnosis is made on the basis of history and clinical examination. Handwriting samples, speech analysis, interview questions that focus on developing symptoms, and physical examination are used. In the preclinical stage, non motor symptoms predominate . There is an increasing focus on use of questionnaires and tests that focus on emerging non motor symptoms.

26. Contd. A diagnosis of PD is typically made if at least two of the four cardinal motor features are present . Exclusion of Parkinson-plus syndromes is necessary. functional imaging [MRI] using chemical markers to identify dopaminergic deficits.

27. CLINICAL COURSE The disease is progressive, with a long subclinical period estimated to be at least 5 years. Mean PD duration is approximately 13 years . Patients with PD who present with postural instability and gait disturbances (the PIGD group) tend to have more pronounced deterioration with a more rapid disease progression.

28. Hoehn-Yahr Classification of Disability Scale

29. Unified Parkinson’s Disease Rating Scale

30. MEDICAL MANAGEMENT Medical management is directed at slowing disease progression using neuroprotective strategies, and symptomatic treatment of motor and non motor symptoms. Management becomes increasingly more challenging over time for patients with moderate and advanced disease

31. Contd.

32. Pharmacological Management

33. Nutritional Management A high-protein diet can block the effectiveness of L-dopa . The dietary amino acids in protein compete with L-dopa absorption . Patients are generally advised to follow a high-calorie, low-protein diet. Generally no more than 15% of calories should come from protein.

34. Contd. T he patient is encouraged to eat a variety of foods and may be advised to take dietary supplements to ensure adequate intake of vitamins and minerals. increase their daily intake of water and dietary fiber to help control problems of constipation. Patient, family, and caregiver education should focus on the importance of maintaining good nutritional intake.

35. Surgical management Thalamotomy Destruction of small group of cells in thalamus. To abolish tremors Pallidotomy Surgical destruction of a group of cells in the internal globus pallidus. Effective in relieving dyskinesias & tremor.

36. Deep brain stimulation Electrodes are inserted into the targeted brain region using MRI and neuro - physiological mapping . Brain electrodes are placed in the subthalamic nucleus (STN) or less frequently the globus pallidus (GPi). An impulse generator (IPG), similar to a pacemaker , is implanted in the subclavicular area and a thin wire goes under the skin to connect to the brain electrodes . High-frequency stimulation is provided.

37. Contd. The patient can control the pacemaker’s “on–off” switch using a controller while the physician determines the amount of stimulation it delivers, tailoring it to the individual’s needs. DBS has been shown to successfully control PD symptoms of motor over activity (dyskinesias ), substantially increase “on” time, and improve ADL scores.

38. Physiotherapy Management

39. PHYSICAL THERAPY EXAMINATION AND EVALUATION Patient/Client History Age , sex, race/ethnicity, primary language, education Social history: cultural beliefs and behaviors, family and caregiver resources, social support systems Occupation/employment/work Living environment: home/work barriers Hand dominance General health status: physical, psychological, social, and role function, health habits

40. Contd. Family history Medical/surgical history Current conditions/chief complaints Medications Medical/laboratory test results Functional status and activity level: premorbid and current

41. Tests and Measures/Impairments Cognition: mental status, memory: hesitation, slowness of thought processes ( MMSE ). Oromotor function: communication ( fluctuations, reduced volume), swallowing Psychosocial function: motivation, anxiety, depression ( Beck Depression Inventory ). Anthropometric characteristics: body mass index, girth, length ; oedema Circulation : response to position change, orthostatic hypotension

42. Contd. Aerobic capacity and endurance: during functional activities and standardized exercise protocols including cardiovascular and pulmonary signs and symptoms Ventilation and gas exchange Integumentary integrity: skin condition, pressure sensitive areas ; activities, positioning, and postures to relieve pressure.

43. Contd. Autonomic nervous system integrity: thermal responses, sweating Sensory integrity and integration Pain : intensity and location Perceptual function: Visuospatial skills Joint integrity, alignment, and mobility: range of motion (active and passive); muscle length, and soft tissue extensibility Posture : alignment and position, symmetry (static and dynamic ); ergonomics, and body mechanics

44. Contd. Muscle performance: strength, power, and endurance. Motor function: motor control and motor learning: tone , voluntary movement patterns; involuntary movements; hesitation , slowness, arrests of movements; poverty of movements. Procedural learning for complex and sequential tasks. Postural control and balance: degree of postural instability, balance strategies; safety.

45. Contd. Gait and locomotion: gait pattern and speed, safety Functional status and activity level: performance-based examination of functional skills (FIM level), basic and instrumental ADL; functional mobility skills; home management skills Assistive or adaptive devices: fit, alignment, function, use ; safety

46. Contd. Environment, home, and work barriers Work , community, and leisure activities: ability to participate in activities, safety Systems Review Neuromuscular Musculoskeletal Cardiovascular/pulmonary Integumentary

47. Disease-Specific Measures Disease-specific measures are designed to determine attributes unique to a specific disease entity . Items are included that provide information about the disease process and outcomes, and ideally document clinically meaningful change over time . Thus , these instruments have greater responsiveness or sensitivity to change than general health measures.

48. Contd. Parkinson’s Disease Questionnaire (PDQ-39 ) is a 39-item questionnaire developed from in-depth interviews with patients with PD . Parkinson’s Disease Summary Index (PDSI ).

49. General goals Patient/client, family, and caregiver knowledge and awareness of the disease, prognosis, and plan of care. Decrease pain. Improve Motor function. Improve Muscle performance (strength, power, and endurance). Improve Postural control and balance. Improve Gait and locomotion. Management of fatigue. Increase Aerobic capacity.

50. Contd. Enhance activity pacing and energy conservation skills. Increase independence in activities of daily living.

51. PHYSICAL THERAPY INTERVENTION A combined approach of physical therapy and pharmacological intervention plays a key role in the management of the patient with PD . Early intervention is critical in preventing the devastating musculoskeletal impairments these patients are so prone to develop . Interventions also focus on improvement of motor function, exercise capacity, functional performance , and activity participation.

52. Motor Learning Strategies Patients with PD typically demonstrate motor learning deficits , including slower learning rates reduced efficiency, and increased context-specificity of learning . Critical elements of practice include a large number of repetitions to develop procedural skills . The environment should also be modified to reduce clutter and competing attentional demands that may trigger freezing episodes . he task should be modified to minimize competing cognitive demands (e.g., dual tasking).

53. Contd. Use of blocked practice order Use of structured instructional sets For example, walking patterns can be improved with focused instructions of “swing your arms ,” “ walk fast,” or “take large steps .” External cues have been shown to be effective in triggering sequential movements and improving movement characteristics in individuals with mild to moderate PD.

54. Contd. Visual cues & dynamic transportable cues (e.g., laser light signals ). Rhythmic auditory stimulation (RAS) includes use of a metronome beat or a steady beat from a musical listening device. RAS has been shown to improve gait speed , cadence, and stride length. Auditory cues such as “Big step” have also been shown to improve gait.

55. Contd. Multisensory cueing (use of both visual and auditory cueing) External cues appear to facilitate movement by utilizing different brain areas . External cues heighten patient attention through a common mode of action, that is, to bypass the diminished internal cueing of the BG.

56. Exercise Training The “Training Big” program, also known as the Lee Silverman Voice Treatment (LSVT) Big program, is based on the concept that repetitive high-amplitude movements yield greater improvements in motor performance and possibly have a neuroprotective effect. Patients are guided by a physical therapist to exercise at a high intensity (8/10 Borg’s RPE Scale) for 1 hour 4 times a week for 4 weeks with large amplitude, multiple repetitions, and whole body movements that increase in complexity

57. Contd. After a 4-week program of LSVT “Big” training the subjects had significant improvements in UPDRS motor scores, TUG, and timed 10-m walking

58. Relaxation Exercises Gentle rocking can be used to produce generalized relaxation of excessive muscle tension owing to rigidity . During therapy, slow , rhythmic, rotational movements of the extremities and trunk can precede interventions such as ROM and stretching, and functional training . The proprioceptive neuromuscular facilitation (PNF) technique of rhythmic initiation (RI), in which movement progresses from passive to active-assistive to lightly resisted or active

59. Contd. The PNF technique of rhythmic initiation (RI), in which movement progresses from passive to active-assistive to lightly resisted or active movement , was specifically designed to help overcome the effects of rigidity in PD . Another strategy to promote relaxation is emphasis on diaphragmatic breathing during exercise . Relaxation audiotapes can be used at home as part of the home exercise program (HEP ). Stress management techniques are an important adjunct to relaxation training.

60. Flexibility Exercise The purpose of flexibility exercise (stretching) is to improve ROM and physical function. A combination of static (PROM), dynamic (AROM), and facilitated PNF exercises is used to achieve maximum ROM . Flexibility exercises should be performed a minimum 2 to 3 days per week and ideally 5 to 7 days per week.

61. Contd. A minimum of 4 repetitions per stretch held for 15 to 60 seconds is recommended. Stretching can be combined with joint mobilization techniques to reduce tightness of the joint capsule or of ligaments around a joint Muscle contractures typically respond well to PNF facilitated stretching techniques such as the hold–relax (HR) or contract–relax (CR) techniques

62. Contd. A 6-second contraction followed by a 10- to 30-second assisted stretch is recommended for these PNF techniques . Patients with PD benefit from additional attention and cueing strategies during active stretching exercises. Patients are instructed to “Think BIG, and move through the whole range” and maintain full focus and attention during each repetition. Additional tactile or visual cueing can assist in maximizing range during active motions.

63. Contd. Positioning can also be used to stretch tight muscles and soft tissues . Positional stretching is prolonged, with times typically ranging from 20 to 30 minutes. Additional mechanical stretching can be achieved through the use of a tilt table, for example, the patient is positioned with fixed leg straps to reduce hip and knee flexion contractures and toe wedges to reduce plantar flexion contractures.

64. Resistance Training Patients who demonstrate primary muscle weakness with impaired motor unit recruitment and rate of force development and disuse weakness associated with prolonged inactivity . Specific areas of weakness are targeted, such as the antigravity extensor muscles . Resistance training is based on the progressive overload principle .

65. Contd. Load can be applied using resistance machines, free weights, elastic resistance bands, or manually . With older adults the recommendation is to begin at a lower intensity (e.g., using an RPE Scale of somewhat hard, 5 to 6 on a 10-point scale), ensuring that a set of 10 to 12 repetitions per set can be completed. Progression is as tolerated. Each repetition should be held for 10 seconds .

66. Contd. Strength training can be performed 2 days per week on non consecutive days . Exercise training should therefore optimally be timed for “on” periods when the patient is at his or her best.

67. Functional Training An exercise program should be based on focused practice of functional skills . The overall emphasis is on improving functional mobility with specific emphasis on improving mobility of axial structures, the head, trunk, hips, and shoulders. Bed mobility skills (i.e., rolling, bridging, supine-to-sit transitions )

68. Contd. Sitting can be enhanced through exercises designed to improve pelvic mobility. Anterior and posterior tilts, side-to-side tilts, and pelvic clock exercises can be practiced while sitting on a therapy ball, which enhances ease of movement. Sit-to-stand (STS) is a difficult activity for many patients with PD, especially with moderate or advanced disease or when in the “off” state.

69. Contd. Forward trunk flexion can be enhanced through initial rocking , which encourages relaxation. Cueing strategies (e.g ., counting, placing one hand between the patient’s shoulder blades) can be used to assist the forward lean . Sitting on an inflated disc can also assist in the forward weight shift and seat-off. Standing-up is enhanced by improved LE muscle strength.

70. Contd. Strengthening of the hip and knee extensors can be achieved using modified wall squats . Practice standing up from a firm raised seat decreases the total excursion and work of extensor muscles and promotes ease of rise. Standing directly in front of the patient should be avoided, because this may block initial standing attempts.

71. Contd. Standing activities can model the progression used in sitting . he patient needs to first gain the fully upright position with symmetrical weight-bearing over the BOS. Tactile cueing or light resistance can be used on the anterior pelvis to encourage movement of the hips forward into full extension. Once standing, weight shifts and rotational movements of the trunk should be practiced

72. Contd. Step-ups using a low platform step (forward, lateral) should be practiced. Backward stepping can be used to strengthen hip and spinal extensors and promote upright posturing. To increase the challenge during stepping, elastic resistive bands can be used.

73. Contd. Patients with PD typically experience a high number of falls and should be taught how to get up after a fall. S kills in quadruped creeping should be practiced so the patient is able to move to a nearby stable chair or couch at home . Mobilizing facial muscles is another important component of the exercise program because the patient will have limited social interaction and poor feeding skills in the presence of marked facial rigidity and bradykinesia.

74. Contd. Massage, stretch, manual contacts, and verbal cueing can be used to enhance facial movements. The patient can be instructed to practice lip pursing, movements of the tongue , swallowing, and facial movements such as smiling, frowning , and so forth. A mirror can be used to provide visual feedback. In cases where eating is impaired by immobility, the movements of opening and closing the mouth and chewing should be combined with neck stabilization in a neutral position.

75. Balance Training An important focus of balance training for the patient with PD is COM and LOS control training . Patients should be instructed in how to improve postural alignment and in ways to avoid postural disturbances and falls . The therapist can assist with postural and safety awareness by using appropriate verbal, tactile, or proprioceptive cues to facilitate the desired responses.

76. Contd. M irror is used to provide feedback concerning upright posture . A standing platform training device (i.e ., posturography system) can be valuable in providing COM position and LOS biofeedback. he patient is instructed in weight shifting that expands the LOS . Nintendo Wii Balance Board

77. Contd. Balance training should emphasize practice of dynamic stability tasks (e.g., weight shifts, alternating unilateral weight-bearing , reaching, axial rotation of the head and trunk , axial rotation combined with reaching, and so forth ). Seated activities can include sitting on a compliant surface (inflatable disc) or a therapy ball.

78. Locomotor Training Locomotor training goals focus on reducing primary gait impairments. P atient walk with vertical poles (pole walking ). Strategies to enhance posture, step length, velocity , and arm swing include the use of verbal instructional sets. Transverse visual–spatial cues (across the gait path) were more beneficial than parallel visual cues (alongside the gait path) in improving gait velocity, stride length, and percentage of leg stance time

79. Contd. Use of floor markers or footprints on the floor . practice marching in place progressing to walking using an exaggerated high stepping pattern . Sidestepping and crossed-step walking can be practiced T he PNF activity of braiding, is an ideal training activity for the patient with early PD because it emphasizes lower trunk rotation with stepping and side-stepping movements.

80. Contd. Reciprocal arm swing during gait can be enhanced by having the patient and therapist hold onto a set of two dowels Patients with PD who practiced locomotor training on a motorized treadmill with an overhead harness demonstrated improvements in postural stability, gait, motor function, and quality of life

81. Contd. Additional challenges include walking in the community (e.g., variable open environments ), stair climbing, up and down curbs, and ramp walking . Foot clearance can be improved with repeated practice of stepping over horizontal floor markers or laser light signals .

82. Spinal Orthotics The Spinomed thoracolumbar corrects faulty posture and also has been shown to increase trunk stability, increase respiratory vital capacity, and improve a patient’s self-report of well-being. When the brace was worn for 6 months the subjects had a 73% increase in back extensor strength and a 58% increase in abdominal flexor strength.

83. Pulmonary Rehabilitation The four main classifications of respiratory disorders in patients with PD are M edication complications Upper airway obstructions R estrictive disorders Aspiration pneumonia

84. Contd. Diaphragmatic breathing exercises Air-shifting techniques, and exercises that recruit neck , shoulder, and trunk muscles. deep-breathing exercises to improve chest wall mobility and vital capacity . Chest mobility exercise Incentive spirometry PNF in respiration

85. Aerobic Exercise An individualized exercise prescription is developed based on the ACSM guidelines for frequency, intensity, duration , and progression . Intensities will be less than normal training intensities or submaximal (i.e., 60% to 80% of maximum HR ) Training modes can include leg and arm ergometry and walking

86. Contd. Recumbent or seated LE ergometry is a suitable alternative. For most patients a program of regular walking is recommended . A supervised aerobic pool program can also provide an acceptable mode of exercise for some patients. he warmth of the water may be relaxing and the buoyancy may enhance stepping movements. The minimum recommended aerobic exercise frequency is 3 sessions per week.

87. Home program & advice Teach the patient for relaxation, flexibility, strengthening, mobility and breathing exercises. Avoid prolong periods of inactivity Cautioned against over doing activity, which could result in excessive fatigue. low-impact aerobics Music is used to provide necessary stimulation to movement and movement pacing .

88. Contd. Early morning warm-up calisthenics Stretching and strengthening exercises are performed in supine, sitting, and standing positions .