CNS tx, Parkinson's Flashcards
important note about clinic floor
keep clear of any objects/cords to accomodate pt with Parkinson’s disease (note festinating gait)
abdominal massage and parkinson’s disease
abdominal massage for constipation
note prone vs supine position for drooling
prone could have excessive drooling on floor which could be uncomfortable for pt
supine could also be uncomfortable for excessive drooling.
see what patient prefers
parkinson’s disease – is there a a cognitive delay/component?
not in itself
consider using more ____ questions with patients with parkinson’s disease
closed ended questions
esp if open-ended questions are frustrating for patient
parkinson’s and tests
not really any special tests
however, ROM Ax is important – esp for rigidity
—> with some exceptions
sensory testing can also be useful
note also “Bradykinesia Test”
which ROM type is not generally useful if rigidity is present?
RROM
supine, semifowler, side-lying
good positions for parkinson’s disease
pressure during sensory loss
esp if patient cannot communicate well (e.g. non-verbal)
make sure that without a doubt the pressure can not be perceived as too much under any perceivable cirucmstance
table height for patient with parkinson’s (or other CNS/PNS/orthopedic conditions)
lower the table well to make it easy for patient to ge ton the tbale
DO NOT DO THIS FOR PATIENTS WITH PARKINSON’S
DO NOT HOLD DOWN TREMORS
vigorous/painful techniques with patients with parkinson’s disease
avoid
(including vigorous stretches)
HYPERTENSION – WHICH POSITIONS TO AVOID/REDUCE ???
PRONE POSITION –> INCREASES BP
CNS tx sample treatment goals
Maintain proper alignment
Decrease SNS firing
Decrease edema if present
Maintain tissue health
Decrease pain
Address postural changes and muscle imbalances
Limit contractures
Reduce constipation
Address diaphragm muscles
Maintain thoracic mobility
Encourage whole body integration
what about if a patient has tremors in the limb which you are working on?
hold the limb with a loose grip to accommodate the tremors between your grip
recall –> for parkinson’s, like many other PNS/CNS conditions, we are treating ____ not ____
symptoms, not condition itself
NOTE that techniques on diaphragm/thorax can be useful for parkinson’s diseaes (like with intercostal neuralgia tx, or respiratory disorders, or AS)
“Address diaphragm muscles”
“Maintain thoracic mobility”
dopamine’s role in muscle physiology
(considering why mm of respiration can be treated)
“In muscle physiology, dopamine primarily acts as a neuromodulator, influencing muscle tone and movement by activating specific receptors on motor neurons, essentially “triggering” muscle contractions and contributing to smooth, coordinated movement; this function is crucial for motor control and is disrupted in conditions like Parkinson’s disease where dopamine levels are low.”
“Dopamine triggers skeletal muscle tone by activating D1-like receptors on somatic motoneurons”
“Gene expression analysis of the dopamine receptors has demonstrated that the D1-like receptor group is expressed centrally in many areas of the brain and peripherally in blood vessels, the adrenal gland, skeletal muscle and the kidneys [1,4,14-17].”
parkinson’s working on postural dysfunction
stretching one side – strengthening other (if rigidity not present)
consideration for RROM for pt with Parkinson’s disease
can test RROM or resisted isometrics, and ask patient if it is causing discomfort (e.g. rigidity)
—> or perform briefly and follow up the next day to see how they responded
MMT vs Parkinson’s disease?
is OK, but start with establishing grade 3
general swedish massage with some CIs
“Description of CNS condition tx”
—> over-simplification, but has some truth to it
—> The more complicated the patient’s condition, the more simple the treatment will be (generally speaking)
note medication and constipation
many medications can lead to constipation
who can you refer someone with constipation to?
registered dietitian (registered)
& pharmacist
note that nutritionists are not registered
is prone tx incorrect for pt with Parkinson’s
not incorrect, but generally safer to do supine/semi-fowler/side-lying
cervical JM
lateral translations
..
…
Parkinson’s =
Progressive, neurodegenerative disorder
parkinson’s involves
Involves diminishing basal ganglia function
basal ganglia =
millions of nerve cell bodies
—> execute smooth movement
parkinson’s causes ___
Causes slowed movements, tremor, rigidity, and a wide variety of other symptoms.
neurodegenerative
“Neurodegenerative” refers to the degeneration of neurons, which are the basis for all brain activity.
Parkinson’s etiology
Cause of Parkinson’s is unknown
Parkinson’s pathogenesis
Destruction of brain cells in the substantia nigra.
“The movement disorder arises due to the loss of dopaminergic neurons of the substantia nigra pars compacta”
age vs dopamine
Decreased dopamine as we age
what happens to muscle movement in Parkinson’s?
Muscular movement become weaker and more erratic:
walking, writing, reaching, basic movements
primary symptoms of Parkinson’s disease
Bradykinesia
Festinating gait
Tremors
Rigidity
Poor Balance
bradykinesia
impairment of voluntary motor control, slowness or freezing.
Presents in standing up, walking, and sitting down, difficulty initiating movements (esp. walking) and “freezing episodes” once walking has began and something startles them
festinating gait
shuffling gait
tremors
often occur in hands, fingers, forearms, foot, mouth, or chin. Typically occur at rest.
Rigidity
muscle stiffness that produces muscle pain with movement
Poor Balance
takes place because of loss of reflexes that help posture. Unsteady balance often results in falls
PD secondary SSx
Postural changes
Breathing difficulties
Fatigue
Constipation
Difficulty swallowing
Choking, coughing or drooling, speech
Excessive salivation
Loss of bowel/bladder control
Anxiety, depression, isolation
Slow response to questions
Soft whispery voice
PD is there cognitive element
no
indirectly possibly
PD & posture
“Parkinson’s disease primarily affects posture muscles by causing muscle rigidity, leading to a stooped posture, rounded shoulders, and a forward head tilt due to stiffness in the neck, back, and trunk muscles, making it difficult to maintain an upright position; this can significantly impact balance and mobility as the disease progresses. “
PD & diaphragm (breathing)
“The diaphragm’s function is associated with Parkinson’s disease (PD). The diaphragm is a muscle that plays a role in breathing, voice, and postural stability. In PD, the diaphragm’s function may be affected, which can lead to respiratory difficulties. “
PD & mm of speech/swallowing
Choking, coughing or drooling, speech
Excessive salivation
PD & loss of bowel/bladder control (incontinence)
“Loss of bowel control in Parkinson’s Disease (PD) primarily occurs due to the neurological impact on the muscles and nerves controlling bowel movement, causing slowed digestion and impaired rectal sensation, often leading to constipation and, in some cases, fecal incontinence”
“this is primarily caused by the autonomic nervous system dysfunction associated with PD, affecting the smooth muscles of the intestines. “
Parkinson’s disease & voice (soft/whispery)
“Voice change is early in Parkinson’s disease and may herald motor dysfunction.
*
Dysphonia in Parkinson’s disease is primarily due to vocal fold hypoadduction/bowing.
*
Dopaminergic and non-dopaminergic mechanisms may both contribute to voice change.”
“Many people who have speech problems due to Parkinson’s disease don’t realize it. A decrease in dopamine in the brain can affect their perception of how loudly they speak. To them, they speak normally, but to everyone else, they’re speaking too softly to understand.”
“These have revealed numerous abnormalities including incomplete glottic closure and vocal fold hypoadduction/bowing to account for these voice changes. Many of these phenomena are likely related to rigidity or bradykinesia of the laryngeal muscles. The early onset of voice changes is resonant with the pathophysiological insights offered by Braak’s hypothesis and murine models of the disease.”
PD & constipation
“Constipation in Parkinson’s is primarily caused by autonomic dysfunction. The autonomic nervous system, which controls involuntary bodily functions like digestion, is impaired in Parkinson’s, slowing down gastrointestinal motility. This means that food moves more slowly through the digestive tract, making it difficult for the body to pass stools regularly.”
PD Dx/Tx
No specific test for Parkinson’s
A systematic neurological exam will include testing reflexes and observing things like muscle strength throughout their body, coordination, balance, and other details of movement.
These tests are also necessary to rule out other nerve dysfunction, narrowing of the spinal canal, which other treatments are needed. (?)
commonly used medication for PD
Levodopa (Sinemet) & Entacapone (Comtan) – helps improve the effectiveness of levodopa
Dopamine agonists (mirapex) tries to stimulate the bodies natural production of dopamine
PD & ROM
Usual ROM and strength testing protocol attempted
AF ROM should reveal decrease in ROM if rigidity present
P ROM will reveal uniform resistance in the flexor and extensor groups acting on affected joints
May reveal cogwheel rigidity (intermittent resistance)
PD – what about RROM?
R ROM will not be useful if rigidity present
includes resisted isometrics/isotonics during tx
PD & special tests
Sensory testing: results vary depending on the clients sensory impairment
for light touch
deep pressure
pain/temperature perception
two point discrimination
proprioception
what about specific orthopedic tests?
Specific orthopaedic tests depending on the complaint
PD & bradykinesia test
Bradykinesia Test: positive test is movement becomes slower & more difficult
pick movement & instruct patient to quickly repeat movement:
E.g.
open/close fist
dorsi/plantar flex
flex/extend forearm
PD tx CIs/precautions
Prolonged vigorous or painful techniques should be avoided ( no stimulating the SNS)
Areas sensitive to touch are avoided
Pressure and hydro are modified in area of altered sensation
Positioning, techniques, hydro are modified if hypertension present.
Hypotension is a threat due to autonomic dysfunction. (watch during position changes)
PD & sensory feedback
“Parkinson’s disease patients showed a significant increase in tactile and thermal thresholds (P < 0.01), a significant reduction in mechanical pain perception (P < 0.01) and significant loss of epidermal nerve fibres (ENFs) and Meissner corpuscles (MCs) (P < 0.01).”
what about tremors during TX
DO NOT HOLD DOWN TREMORS DURING TX
PD Tx goals
Maintain proper alignment
Decrease SNS firing
Decrease edema if present
Maintain tissue health
Decrease pain
Address postural changes and muscle imbalances
Limit contractures
Reduce constipation
Address diaphragm muscles
Maintain thoracic mobility
Encourage whole body integration
PD homecare
Encourage relaxation with diaphragmatic breathing
Regular, moderate exercise can improve motor control
Encourage them to continue with ADLs
Maintain functional ability by moving joints through simple ROM, and balance activity.
—> E.g. Sidelying do retraction/protraction, trunk rotation exercises
