Rehab of Parkinson's disease Flashcards
Learning outcomes
By the end of this lecture, students should be able to:
- Discuss the epidemiology, aetiology, pathophysiology and clinical course of Parkinson’s
disease.
- Explain the current pharmacological therapy used in the management of Parkinson’s
disease. - Describe the role of the physiotherapist in assisting patients with PD
Discuss the evidence base for physiotherapy management of people with Parkinson’s
disease. - Describe appropriate elements of exercise prescription for the patient with PD.
What is Parkinsonism?
Clinical syndrome characterised by disorders of movement –
tremor, rigidity, bradykinesia and postural abnormality.
What are the 2 main types of Parkinsonism?
- Parkinson’s disease (PD) or primary parkinsonism most common (78%)
- Secondary parkinsonism – various causes
What can cause Parkinsonism?
List of 7
- Degenerative diseases
- Infections
- Drug or Toxin induced
- Vascular conditions
- Trauma (Head injury)
- Cerebral tumour (Alzheimer’s disease)
- Other neurological conditions with Parkinson like features
What is Parkinson’s disease pathophysiology?
• Occurs in basal ganglia (striatum –caudate and putamen; Globus pallidus;
subthalamic N; substantia Niagra)
• Neuro-degeneration occurs mainly in the pars compacta of substantia Niagra – rich
in neuromelanin-containing cells.
- In PD, there is apoptosis of neuromelanin containing neurones
- Immune cells remove these dying cells
- Dopamine is depleted as a consequence of this
- Braak et al. 2006 produced a 6-stage model for the stages of development of PD
- The ↓ dopamine leads to:
- ↑ inhibitory drive to the thalamus, suppressing movement
- Changes in background tone - rigidity
- Releasing of inhibition of tremor
What occurs in Braak Parkinson’s disease stage 1&2?
Lower brainstem & Olfactory bulb.
= Loss of smell, constipation, altered sleep patterns
What occurs in Braak Parkinson’s disease stage 3&4?
Extend to Substantia Niagra.
= Gives rise to cardinal signs of PD
What occurs in Braak Parkinson’s disease stage 5&6?
Later distribution of Lewy bodies in the cortex.
= Cognitive e.g., dementia etc.
What are the cardinal features of Parkinson’s disease (PD)?
- Resting disease
- Rigidity
- Bradykinesia
- Gait disturbance/postural instability
What are some of the non motor features of PD?
- Autonomic dysfunction
- Communication difficulties
- Sensory disturbances including pain
- Mood disorders
- Sleep impairment
- Dementia
- Falls
What are signs of a resting tremor?
- Involuntary oscillation of body parts at slow frequency of about 4-7Hz.
- This can look like they’re rolling a pill in their hands aka “pill-rolling”.
- Postural tremor.
- Aggravated by stress/fatigue.
- Diminished voluntary movement that disappears with sleep.
What are signs of Rigidity?
- Increases stiffness/ passive ROM
- Cogwheel (Jagged resistance) and lead pipe (smooth resistance)
- unequal in distribution
- The rigidity will often affect neck, trunk and knees which leads to a stooped posture.
- Affected by stress, anxiety and posture.
What are signs of Bradykinesia?
- Bradykinesia - used interchangeably with akinesia and hypokinesia
- Hypokinesia –reduced amplitude of movement
- Bradykinesia – slowness of movement
• Akinesia – loss of movement, slowness to initiate, freezing while
moving
• Freezing –refers to the difficulty starting or continuing rhythmic
movement e.g. walking, handwriting , speech
• It is the most disabling manifestation of PD
What are signs of Freezing?
• Freezing – refers to difficulty starting or continuing rhythmic repetitive
movements
• Schools of thought exit which considers it a distinct clinical sign of PD
• Freezing of Gait (FOG) is an episodic gait disturbance typically
experienced when walking
• Festination often occurs prior to freezing
• Feet appears glued to the floor while momentum carries body mass
forward
• Occurs more frequently in cluttered environments, stressful
circumstances or when patient is distracted
• Likelihood of falls increases
What are some motor control and motor performance deficits present in PD patients?
- Reduced reaction and movement time.
- Reduced ability to execute sequential movements.
- Reduced ability to execute simultaneous movements.
What gait abnormalities are typical for PD patients?
- Slow movements.
- Difficult in initiation of gait.
- Decreased stride length.
- Decreased reciprocal arm swing.
- Small shuffling steps.
- Loss of normal heel-toe progression
• festinating gait / propulsive gait
• turning or changing direction is difficult
• Ability to dual task impaired
• Gait ability varies with environmental demand
What are some of the common non-motor symptoms associated with PD?
- Cognitive deficits
- Neuropsychiatric non-motor deficits
- Autonomic non-motor symptoms 60%
Cognitive;
- Dementia (40%)
- Attention/executive function
- memory
Neuropsychiatric;
- Depression (22%)
- Anxiety
- Frontal executive dysfunction
- Dementia (80%)
- Psychosis
- Sleep disorders (90%)
Autonomic;
- Orthostatic hypertension
- Urogenital dysfunction
- Constipation
Fatigue
Clinical staging of PD can involve the use of the modified Hoehn & Yahn scale. What are the signs for each stage of PD; - 1 - 1.5 - 2 - 2.5 - 3 - 4 -5
- 1; Unilateral involvement only
- 1.5; Unilateral; and axial involvement
- 2; Bilateral involvement without impairment of balance.
- 2.5; Mild bilateral disease with recovery on pull test.
- 3; Bilateral disease: Mild to moderate disability with some impaired postural instability; physically independent
- 4; Server disability; still able to walk or stand unassisted.
- 5; Wheelchair bound or bed ridden unless aided.
Another outcome measure to asses a patients PD, is the unified Parkinson’s rating scale aka UPDRS. Its a 50 item questionnaire with each question being rated from 0-4, 0=normal, 4=severe.
What does each of the 4 sections cover?
- 1
- 2
- 3
- 4
- Part I: Non-Motor Aspects of Experiences of Daily Living (13 items)
- Part II: Motor Aspects of Experiences of Daily Living (13 items)
- Part III: Motor Examination including staging (18 items)
- Part IV: Motor complications (6 items)
What medical management is available for PD?
Pharmacological
• Levodopa (L-dopa); mainstay of
therapy
- Usually reserved for patients in middle & late stages
- Initial improvement often dramatic “honeymoon
period”
- Long term use - effectiveness deteriorates
- End-of-dose deterioration; On-off phenomenon
- COMT – catecholamine-Omethyltransferase inhibitors
- Monoamine oxidase (MAO) inhibitors
- Amantadine
• Dopamine agonists e.g., Apomorphine or
rotigotine
• Duodenal levodopa infusions
What would you do in an objective examination of a client with PD?
• Gait assessment
- Speed and distance, forward and backward , stride length, cadence
- Ability to alter speed
• Transfers
- sitting, sit to stand, stand to sit, lying to sitting and back again, rolling in bed, getting in and
out of car
• Passive ROM
- Spine, UL & LL joints, muscles – calf, hamstrings etc
• Postural alignment
- Tragus to wall distance
• General Strength
- Trunk, knee, ankle, hip muscle groups etc
• Chest expansion
- Functional capacity and vital capacity
• Balance
- static & dynamic balance, multi-tasking, freezing - causes
What outcome measure would you use for patients with PD?
- UPDRS
- Montreal cognitive assessment
- Sit to stand 5 minutes (how many reps can they do)
- Functional gait assessment
- 9 Hole peg test
- 6 minute walk
- PDQ-8 (Parkinson’s disease questionnaire)
What is the treatment goal for a physio with a PD patient in stage 1-2.5 (according to the modified Hoehn & Yahn scale AKA HY)
Treatment goal ▪ Prevent inactivity ▪ Prevent fear of moving & falling ▪ Maintain or improve physical capacity
What interventions would a physio use with a PD patient in stage 1-2.5 (according to the modified Hoehn & Yahn scale AKA HY)
Intervention ▪ Promote active lifestyle ▪ Supply info to prevent inactivity & improve physical capacity ▪ Active (group) exercises to improve balance, muscle power, joint mobility, and aerobic capacity ▪ Involve partner or carer
