Parkinsonism and it's details explanation

Parkinsonism, Parkinson's disease, Parkinson plus syndrome.

1. Parkinson ism ( Nayrin Sk , BPT 4 th year, BIMLS)

2. Differentiate the Terms Parkinsonism Parkinson's disease (PD) or Primary parkinsonism Parkinson plus syndrome (PPS) Parkinsonism Parkinson’s Parkinson plus Disease. syndrome

3. Introduction Parkinsonism or parkinsonism syndrome group is of disorder which manifests as tremor, disturbance in voluntary movement (rigidity, bradykinesia or akinesia ) and impairment in the balance and automatic reactions. This syndrome do occurs in various conditions, of which Parkinson’s disease is quite common. Parkinson’s disease first observed by James Parkinson (1817) and describe in ‘An essay on the shaking palsy’. In the year of 1912 it first recognized as an extrapyramidal disorder by Kinnier Wilson. Treatment of Parkinson’s disease was partially achieved by the introduction of Levo-dopa in the year 1960. Parkinson plus syndrome are characterized by the primary features of Parkinson disease including bradykinesia, ataxia, resting tremor and rigidity but also include additional features such as dementia, cognitive deficit and cranial nerve impairment.

4. Prevalence and incidence In 2022 Parkinson’s Foundation backed study reveals that nearly 90000 people are diagnosed with Parkinson’s disease every year in the U.S. Prevalence In a door to door servey done in Bengaluru district in South Karnataka in India in 2004, the prevalence rate of parkinsonism was found to be 33 per 100000 (crude prevalence) and 76 per 100000 (age adjusted). More than 10 million people worldwide are living with PD. Men are 1.5 times more likely to have Parkinson’s disease than women Incidence:

5. Etiology Parkinson’s disease also called as primary parkinsonism— While the exact cause of Parkinson disease remain unknown, scientists believe a combination of genetic and environmental factors are at play. Genetic causes about 10% to 15% of all Parkinson’s disease causes. Environmental risk factors associated with PD include head injury, area of residence, exposure to pesticide and more. Secondary parkinsonism result from the number of different causes including inherited and acquired neurodegenerative disorder. Post infectious parkinsonism like influenza, encephalitis. Toxic parkinsonism a form of secondary parkinsonism which occurs in individuals exposed to the certain industrial pollutant and chemicals(CO,CN,CS2). High dose of variety of drugs can produce extrapyramidal dysfunction that mimics the sign of PD(antidepressants like amoxepine trazodone antihypertensive drugs like methyldopa reserpine). Parkinsonism can be caused by rare condition by metabolic condition including disorder of calcium metabolism that result in basal ganglion calcification.

6. Pathophysiology Degeneration of neurons in the striatonigral pathway. Deficiency in the level of dopamine. (dopamine is a neurotransmitter in the striatonigral pathway that inhibits the excitation of the cholinergic pathway which has acetylcholine as the neuro transmitter). Decrease in the dopamine level removes the inhibitory influence on the cholinergic pathway. Causing excessive excitation on the of the extrapyramidal system reticulo and rubro . Causes increased tone in the agonist and antagonist muscle, this gives rise to rigidity and bradykinesia

7. Clinical features Rigidity –it is the resistance to passive motion that is not velocity dependent. It affects the agonist as well as antagonist group of muscle therefore it affect the movement in both the directions. Two type of rigidity are common- 1) cogwheel 2) Lead-pipe. Akinesia and Bradykinesia – Akinesia is the difficulty in initiating movement . Bradykinesia refers to slowness and difficulty in maintaining movement. Hypokinesia is the reduced in speed, range and amplitude of the movement. Micrographia –It is abnormally small handwriting what is difficult to be read. Tremors – Tremor is the initial symptoms in 50% of PD patient,it is an involuntary oscillation of body part at frequency of 4-7 cycle per second. Parkinson tremor described as resting tremor like pin rolling tremor of the hand and tremor also be seen in feet,lips,tongue or jaw. Postural Instability – Patient with PD demonstrate abnormalities of posture and balance. Extensor muscle of trunk demonstrates weakness then flexor muscle contributing to adoption of a flexed, stooped posture with increased flexion of neck, trunk, hip and knees. As the BOS is narrow frequent fall and fall injury are common in PD patients. Fatigue –Patient experience increasing weakness and lethargy as the day progresses (prominence during physical effort or mental stress). Rest or sleep may restore mobility.

8. Clinical features Gait Disturbance – Because of abnormal stooped posturing increased the speed of the gait , patient takes multiple short steps to catch up with his or her COM and avoid falling and may eventually break into a run. Masked face – Infrequent blinking and lack of expression,face look like a mask. Smiling may be possible on command. Cognitive and behavioural dysfunction – cognitive deficit include loss of executive function, reasoning, abstract thinking, judgement, memory impairment. Behavioral changes may occurs due to sensory deprivation, depression and anxiety. Swallowing abnormality – Patient demonstrate abnormal tongue control, problems with chewing and bolus formation, delayed swallowing response which leads to chocking or aspiration pneumonia and impaired nutrition with significant weight loss. Impaired speech – Difficulty in initiating and maintaining speech patient may have hypokinetic dysarthria which characterized by decreased voice volume, monotone speech uncontrolled speech rate. Patient also have slurred speech Bladder dysfunction –Increased urinary frequency ,urgency, nocturia . Bowel dysfunction –L ow appetite, decrease motility of GIT, constipation.

9. Investigation SPECT(SINGLE PHOTON EMISSION COMPUTER TOMOGRAPHY) – A SPECT scan is a type of imaging tast that uses a radio -active substance and a special camera to create 3D picture. This scan can show how well the organs are working. TRANSCRANIAL ULTRASOUND – Transcranial ultrasound is a relatively new method which has been proven to be helpful in the diagnosis of Parkinson’s disease. Diagnosis Early diagnosis of PD is difficult. Diagnosis is usually made on the basis of history and clinical examination and handwriting samples, speech analysis and physical examination. A diagnosis of PD can be made if a at least two of the four cardinal features are present (tremor, rigidity bradykinesia, postural instability).

10. Hoehn and Yahr staging of Parkinson’s disease

11. Management Medical management The following drugs are available for the parkinsonism– Levodopa Dopamine agonists COMT(catechol-O-methyl transferase ) inhibitor. anti- cholinergics Surgical management Thalamotomy – It is the destruction of small group of cell in thalamus. This surgery is done to abolish tremors . Pallidotomy – It is the surgical destruction of a group of cell in the internal globus pallidus Deep brain stimulation surgery – During deep brain stimulation surgery, electrodes are inserted into the targeted brain region using MRI and neuro physiological mapping to ensure that they are implanted in the right place. A device called an impulse generator is implanted under the collar bone to provide and electrical impulse to a part of the brain involved in motor function. Those who undergoes the surgery are given a controller which allows them to check the battery and to turn the device on or off and control the abnormal movements.

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