Masterclass: Parkinson's Disease

Question 1

State facts and aetiology of Parkinson’s disease

Answer 1

• Disease where patients have difficulty making automatic movements
• Progressive and degenerative disease with a slow decline
• General population 3/1000, - >60 y/o 1/100
• Mean age of onset: early to mid 60s
• More common in men > women (3:2)
• 5-10% young-onset

Risk factors
- Multifactorial: interplay between many factors
- Age (increases exponentially until 80 y/o)
- Gender
- Pesticide exposure
- Prior head injuries/concussion
- Family history
- Lewy bodies form in Substantia Nigra – unsure if this is causative or protective

Question 2

Describe the timeframe of clinical symptoms for Parkinson’s Disease

Answer 2

Symptoms may appear up to 20 years before the diagnosis and may extend more than 20 years after diagnosis

Increasing severity of symptoms and disability over time

Parkinson’s starts with mild non-motor symptoms, progresses to motor symptoms and ultimately leads to severe disability in the advanced stages due to both motor and non-motor complications

Before diagnosis symptoms: constipation, depression, fatigue

Early Parkinson’s symptoms: vague and non-specific, bradykinesia (slowness of movement), rigidity and tremor

Advanced Parkinson’s symptoms: postural instability, falls, freezing of gait, dysphagia (difficulty swallowing)

Question 3

List and briefly describe the primary and secondary motor impairments of Parkinson’s Disease

Answer 3

Primary Motor
- Bradykinesia: slowness of movements
- Hypokinesia: small amplitude movement
- Akinesia: difficulty maintaining movement/absence of movement
- Decreased postural stability
- Tremor (resting/action)
o Resting: rhythmic, involuntary and roughly sinusoidal movement of a body part (4-6Hz). Hands, feet, lips, chin most affected
- Rigidity: increased passive stiffness through range. Cogwheel

Primary non-motor
- Decreased autonomic function
- Decreased sensory function

Secondary Motor: occurs after taking dopamine replacement medication for extended period
- Dyskinesia: involuntary movement
- Dystonia: muscle contraction

Secondary non-motor
- Neuropsychiatric features
- Sleep problems
- Pain
- Fatigue

Question 4

Differentiate between tremor and dyskinesia

Answer 4

Tremor is a rhythmic, involuntary and roughly sinusoidal movement of a body part (4-6 Hz). It is a direct cause of PD. Most often affected are hands, feet, lips, chin. It can be suppressed by voluntary activity, sleep and complete relaxation. Regular in direction and amplitude.

Dyskinesia is involuntary movement that can occur in the head or trunk (Writhing/Wriggling). It is irregular in direction and amplitude,

Question 5

Describe the use of Leva-dopa and Deep Brain Stimulation in the Management of Parkinson’s Disease.

Answer 5

Levadopa used as dopamine replacement agent for the treatment of Parkinson’s. Helps to control bradykinetic symptoms apparent in Parkinson’s.
- Problems: after 5-10 years it starts to wear off, dyskinesia, depression, nausea

Deep Brain Stimulation
- Most common surgical treatment
- Used in those that respond to medication but have side effects (dyskinesia)
- Eases symptoms/reduced medication needs

Question 6

Describe the symptoms of Parkinson’s Disease according to the Hoehn and Yahr scale

Answer 6

4 stage: 1 and 2 (early Parkinson’s), 3 (mid-stage), 4 and 5 (advanced stage)

Stage 1: Early
- Tremor in one hand
- Rigidity
- Clumsy leg
- Facial asymmetry affecting facial expression

Stage 2: Early
- Loss of facial expression
- Decreased blinking
- Speech abnormalities
- Rigidity of muscles in trunk

Stage 3: Mid-stage
- Balance is compromised
- Inability to make the rapid, automatic and involuntary adjustments
- All other symptoms of Parkinson’s are present

Stage 4: Advanced
- Patient may be able to walk and stand unassisted, but they are noticeably incapacitated
- Patient is unable to live an independent life and needs assistance

Stage 5: Advanced
- Patients fall when standing or turning
- May freeze or stumble when walking
- Hallucinations or delusions

Question 7

Outline the factors that determine the risk of falls in patients with Parkinson’s Disease

Answer 7

Has patient had previous falls in past 12 months (Yes = 6 points)

Has patient had previous freezing of gait in past 1 month (Yes = 3 points)

Can patient walk 4m in >3.6s (Yes = 2 points)

Three questions used to assess probability of falls
Classified into low, moderate, high risk of falling in next 6 months
- Low: 0
- Moderate: 2-6
- High: 8-11

Question 8

Outline reasons an exercise program may or may not be effective in patients with Parkinson’s Disease

Answer 8

Exercise programs can be effective as they improve mobility, strength, balance and overall quality of life

The effectiveness of exercise can be limited by factors like disease progression, patient motivation, cognitive impairments and medication side effects which can impact adherence and engagement

Studies indicate that individualised and supervised programs yield better outcomes, particularly in reducing fall risk and improving gait

Question 9

Describe physiotherapy Management of Parkinson’s Disease

Answer 9

a. Cueing and attentional strategies
These strategies, including visual and auditory cues, help patients initiate and maintain movement. Cueing is beneficial in addressing gait difficulties and freezing episodes

b. Falls prevention programs and the associated evidence
Falls prevention programs combine balance training, home modifications and multifactorial interventions. Evidence suggests that falls prevention is effective, especially with personalised programs that include progressive resistance and balance training

c. LSVT programs
The LSVT-BIG program focuses on recalibrating movement amplitude rather than speed. This high intensity, effortful approach helps patients with Parkinson’s disease improve movement quality and is particularly restorative, aiming to normalise movement patterns.

Question 10

Discuss the evidence of physiotherapy for managing the Signs & Symptoms of Parkinson’s Disease

Answer 10

Physiotherapy has demonstrated benefits in managing Parkinson’s symptoms, such as improving gait speed, balance and functional reach, as well as restoring disability scores. According to the Cochrane review, significant improvements were seen in outcomes like the Berg Balance Scaled, Unified Parkinson’s Disease Rating Scale (UPDRS) and gait metrics, although most benefits were short-term and depended on the quality of interventions

Question 11

Briefly discuss the role of other health practitioners in the management of people with Parkinson’s Disease

Answer 11

In addition to physiotherapists, a multidisciplinary team is essential in managing Parkinson’s Disease.
- Occupational therapists assist with activities of daily living
- Speech therapists address communication and swallowing issues
- Neurologists manage medication
- Dieticians, social workers and psychologists support nutritional needs, social aspects and mental health respectively
Collaborative case management improves patient outcomes by addressing the comprehensive needs of individuals with Parkinson’s disease.