Stanbridge - T6 - Neuro2 - W7 - Parkinson's Disease

• Parkinson's Disease is a chronic, progressive neurological condition affecting the motor system.

Parkinsonism

• Parkinson's disease categorized under a larger group of disorders called "Parkinsonism".
• Primary Parkinsonism is the same as Parkinson's Disease, also known as Idiopathic Parkinson's Disease (IDP).
• Secondary Parkinsonism occurs due to other conditions.
• Parkinson-plus Syndromes result from long-term medication use for mood and behavior control.

Epidemiology of Primary PD

• Primary PD accounts for 85% of Parkinsonism cases.
• The most common age range is 50-79 years.
• Advancing age correlates with a higher incidence.
• The incidence is 20.5 per 100,000 people in the U.S.

Etiology of Primary PD

• Primary PD is multifactorial, with many contributing factors.
• Risk factors for Primay PD include increasing age.
• There's genetic risk.
• Environmental toxins like pesticides/herbicides contribute to PD.

Pathophysiology

• Symptoms arise from decreased dopamine, a neurotransmitter stored in the substantia nigra (basal ganglia).
• Dopamine serves both inhibitory and excitatory roles.
• Reduced excitation of basal ganglia slows movement and affects its timing.
• Dopamine inhibits acetylcholine to balance muscle contraction during tasks.
• Decreased dopamine leads to decreased inhibition of the excitatory neurotransmitter acetylcholine.
• Excessive acetylcholine results in increased muscle contraction on both sides of a joint, leading to rigidity and bradykinesia.
• Lesions in an individual's basal ganglia can lead to changes in the type of movement seen, not a loss in movement.

Clinical Features ("TRAP")

• Tremor
• Rigidity
• Akinesia/Bradykinesia
• Postural Instability

Bradykinesia

• Bradykinesia means a decreased amplitude of movement.
• Slow oral movements result in poor speech and inadequate breath support.
• Additionally, you can develop impaired swallowing and micrographia, resulting in small handwriting
• Akinesia is the inability to initiate movement such as standing up, crossing legs, or turning in bed.
• A forward-flexed posture typically develops.

Rigidity

• Rigidity involves resistance to passive movement regardless of speed.
• Trunk rigidity impairs breathing and phonation by limiting chest wall motion.
• You will also see increased energy expediture and fatigue.
• Rigity is not limited just to your trunk and can present in the extremities.
• The first sign of rigidity may present as limiting arm swing with walking
• Lead-pipe rigidity is a constant resistance to passive movement in any direction, regardless of speed.
• Cogwheel rigidity presents as jerky, ratchet-like, tense, & then letting go; a combination of lead-pipe and tremor.

Tremor

• Often the first sign of primary PD.
• Tremor begins unilaterally, then progresses bilaterally.
• Resting tremor described as "pill rolling” in the hand, with the speed being 4-7 beats per second.
• Tremor can also occur also in the postural muscles in the head, neck, trunk, and face
• Tremors rarely interfere with ADL's.

Postural Instability

• Loss of postural extension.
• Inability to respond to postural disturbances.
• High fall risk.
• Fall risk increases with disease duration.
• Visuospatial deficits and slow processing of sensory information contribute to this.

Other Clinical Features

• Flexed posture (head, neck, trunk) causes a displaced center of gravity.
• People present with a masked face.
• People may experience dysphagia.
• People experience freezing episodes triggered by changes in environment, such as doorways or changes floor surface..
• Fatigue is a common issue.

Gait

• Festinating gait shows short steps with increased speed to try and "catch up".
• Patient’s speed is slow.
• Patient has a narrow BOS (base of support).
• You can see patients experience freezing episodes triggered by environmental situations (doorway, change of surface, speaking, blinking).
• Patients experience decreased arm swing & trunk rotation d/t bradykinesia & rigidity.
• Trunk flexion increases over time.
• LE ROM is restricted throughout walking.
• Heel strike and toe off are both lost leading to decreased foot clearance.
• Gait is made even more difficult when trying to add a complex task (i.e. carrying laundry while walking).

Falls

• Someone with Parkinson's is twice as likely to fall as a normal elderly person.
• Predictors for falling:
  • Previous Falls
  • Disease duration
  • Dementia
  • Loss of arm swing

Systemic Manifestations

• Dementia is a systemic manifestation.
• Bradyphrenia is defined as the slowing of thought processes, plus difficulty in attending to a task and concentrating.
• Depression is a systemic manifestation
• All are due to neurochemical changes in the basal ganglia.

Secondary Parkinsonism

• Secondary Parkinsonism results from other conditions:
  • Encephalitis
  • Alcoholism
  • Exposure to toxins
  • TBI
  • Vascular Insults
  • Psychotropic medications

Parkinson-plus Syndromes

• Parkinson-plus Syndromes occur from long-term use of medications used to control mood and behavior and includes disorders such as are:
  • Multisystem atrophy
  • Progressive supranuclear palsy
  • Lewy body dementia
• Syndromes produce other neurologic signs such as cerebellar and autonomic dysfunction in addition to classic PD.

Multiple System Atrophy

• Classic signs of PD are seen.
• Autonomic dysfunction is seen (BP, temperature regulation).
• People experience orthostatic hypotension.
• There is urinary dysfunction.
• The tremor is asymmetric in presentation.
• Ataxia is another sign.
• Nystagmus might be present
• Positive Babinski sign and hyperreflexia
• Mean survival is 9-10 years after diagnosis.
• People are often poorly responsive to levodopa or dopamine agonists.

Progressive Supranuclear Palsy

• Bradykinesia
• Patient’s Rarly have a tremor
• Present with early postural instability and falls
• Dementia
• Emotional and personality changes can be seen.
• The disorder has a quicker progression than primary PD
• The Mean survival is 5-6 years after diagnosis.
• Only 20-30% of people respond to levodopa.

Lewy Body Dementia

• Early cognitive changes can be seen in the individual.

• There are also classic signs of PD.

• Patient’s present with a Fluctuating level of alertness and attention

• More severe rigidity than in primary PD

• Neuroleptic sensitivity (can be fatal)

• Heavy sedation

• Fever

• Muscle rigidity

• Autonomic dysfunction

• Mean survival is 8 years after diagnosis.

• The Hoehn and Yahr Classification of Disability is used to stage severity of Parkinson Disease.

Table 13-1 Hoehn and Yahr Staging Scale for Parkinson Disease

• Stage 0: No signs of disease.
• Stage 1: Unilateral symptoms only.
• Stage 1.5: Unilateral and axial involvement.
• Stage 2: Bilateral symptoms, no impairment of balance.
• Stage 2.5: Mild bilateral disease with recovery on pull test.
• Stage 3: Balance impairment, mild to moderate disease, physically independent.
• Stage 4: Severe disability, but able to walk or stand unassisted.
• Stage 5: Needing a wheelchair or bedridden unless assisted.

Diagnosis

• Presence of two of four cardinal features.
• Exclusion of Parkinson-plus syndromes.
  • Do not respond to Anti-Parkinson medication.
  • Neuro-imaging and lab tests are usually normal.

Medical Management

• Medications are implemented to treat the symptoms of Parkinson Disease.
• Sinemet is the brand name and the most common administered drug to replace the lost dopamine by combining levodopa and carbidopa.
• Effective for use after around 4-6 years.
• On/off periods when medication is on and then wearing off.
• Anticholinergics decrease resting tremor by blocking the increase in acetylcholine.

Medical Management: Brand Name Medications and Usage

• Eldepryl enhances levels of dopamine in early PD.
• Sinemet improves bradykinesia and rigidity in PD.
• Symmetrel improves bradykinesia and rigidity in PD.
• Requip improves bradykinesia, rigidity, and motor fluctuations in PD.
• Artane improves moderate tremor and dystonia associated with wearing off in PD.
• Parlodel is used to improve the end-of-dose “wearing off” and dyskinesias in PD.

Surgical Management

• Pallidotomy involves removing the globus pallidus to relieve bradykinesia, tremor, and rigidity.
• Thalamectomy involves destroying the part of the Thalamus that causes tremors.
• Deep Brain Stimulation is used to reduce the symptoms of PD and can be turned on and off by the patient.
• Electrodes are the implanted into the subthalamic nucleus and the stimulation box is implanted in the subclavicular area, similar to a pacemaker.
• Deep Brain Stimulators need the following precautions:
  • E-stim and Ultrasound: Need to call manufacturer of pt's stimulator to see if there are any restrictions. Each stimulator has a different level of compatibility.
  • Diathermy: Contraindicated d/t metal implant and neurostimulator.
  • HILT: Contraindicated over the stimulator site d/t metal implant.

Learning and Memory

• Non-Declarative Learning
  • Procedural: Striatum, motor cortex, cerebellum
  • This type of learning and memory is typically lost in people with damage to the basal ganglia.

Types of Practice to Improve Procedural Learning

• Part practice before whole practice
• Blocked practice
• Faded feedback
• Constant practice
• Distributed practice

Physical Therapy Management

• The primary goal is to maximize function knowing the disease process will progress.
• Focus should be on early intervention.
• The second goal is to prevent indirect impairments: deconditioning, musculoskeletal changes, loss of extension & rotation.
• The third goal is to slow the onset of predictable changes
• Focus on posture, locomotion, and general activity.

Physical Therapy Interventions

• Relaxation exercises
• Example exercises include: neck rolls, shoulder rolls, and slow rocking of the trunk.
• Respiratory exercises: -Deep breathing exercises focusing on rib inhalation/exhalation and rib expansion, pursed lip breathing in functional progression: supine> seated> standing.
• Flexibility exercises can involve:
  • PROM/passive stretching, self-stretching, swiss ball activities, and foam roll activities.
• Mobility exercises can include:
  • Focused on BIG (large amplitude) movements like riding a stationary bike, or AROM exercises as an exercise or in function.
• Balance activities assist in
  • Using the balance sequence and finding where the patient struggles within it
  • Working on improving stability (COG over BOS).
  • Instruct the patient in activities they can challenge their balance within. For example, a patient has trouble maintaining Romberg, and a task is performed in this position.
• Aerobic conditioning activities get the heart pumping and heart rate up.
• For example, stationary bike, stair training. Group and home exercises. This can be achieved by
  • Encouraging the patient to get into a group exercise program in their community
  • Make sure the patient has a good HEP for home maintenance; http://www.parkinson.org

Patient and Family education

• Make sure your patient and family are well educated about:
  • Safety with function/walking
  • Disease prognosis
  • Prevention of falls in home and community
  • Prevention of secondary impairments and maintenance of condition

Cognitive Coaching

• Help patients with PD think about an activity before doing it
• Giving the patient verbal cues to make adjustments:
  • When transitioning from sit to stand, use verbal cues like “get your weight over your bottom first..now stand up.”

Gait Interventions

• One of the major roles of the PTA is to educate the patient and family about the importance of:
• Good posture
• Daily walking
• Sustained activity
• PTA must understand the rationale behind the selected gait intervention.
• Teach the patient to be “BIG” in all their movements.
• Break down gait into components and focus on each part separately.
• Avoid secondary motor tasks with walking.
• Practice all forms of walking like sidestepping, forwards, backwards, turning, braiding, and marching.

Assistive Devices:

• The use of a cane or walker relies on the patient's ability to coordinate using it.
• Any device should promote safety.
• Devices should promote promote trunk extension if the patient demonstrates flexed posture and forward displacement of the COG..
• A reverse walker is commonly used with Parkinson's patients who have a retropulsive gait (falling backwards).

Postural Interventions

• Trunk extension and rotation can be lost early in disease progression, making it important to emphasize exercises to strengthen the extensors.
• The individual also needs also stretch and lengthen tight muscles, typically the pecs, cord cords, hip flexors, and hamstrings.
• Focus on improving posture in all positions, whether seated, standing, during functional transitions from sit to stand and back, and during gait.

Treatment Based on Hoehn and Yahr Stage: HY 1-2.5

• Treatment Goal: prevent inactivity, prevent fear of moving and falling, maintain or improve physical capacity.
  • Intervention: promote active lifestyle, active group exercises to improve balance, muscle power, joint mobility and aerobic capacity, involve partner or caretaker.

Treatment Based on Hoehn and Yahr Stage: HY 2-4

• Treatment Goal: prevent falling, reduce limitations on core areas (transfers, posture, reaching and grasping, balance, gait)
  • Intervention: active and functional-task exercises (at home) using general and PD-specific strategies as well as cognitive movement and cuing strategies; reduce mutlitasking.

Treatment Based on Hoehn and Yahr Stage: HY 5

• Treatment Goal: Maintain vital functions, prevent pressure sores, prevent contractures.
  • Intervention: postural adjustments in bed or wheelchair, assisted active exercise, supply information to prevent pressure sores and contractures.

LSVT BIG Treatment Approach

• This treatment approach should be done by a LSVT BIG certified therapist in the exact protocol listed and needs to be documented as BIG therapy.
• A non-certified therapist may not document doing BIG therapy. -Use concepts of large amplitude movement to produce similar results (even if not certified).

Theory of Calibration

• There is often a mismatch between perception of output and how others perceive it.
• During the approach, the patient’s may say that they are not shuffling when they walk, that they're standing up straight, and that their trying to take big steps feels ridiculous.
• Pre-treatment:
  • The Patient can experience problems in self-perception/awareness and do not recognize their movements are small or slow.
  • Self-cueing deficits continue with scaling reduced amplitude of movement patterns and producing slow, small movements that are have a redunce amplitude of motor output.
• Treatment focus:
  • Improve self-perception/awareness of the amplitude required to produce normal movement amplitude by improving self-cueing/attention to action and scale increased amplitude of movement patters to produce larger movements and increase amplitude movement patterns. The treatment Protocol is 4 consecutive day a week for 4 weeks with 16 sessions in a month for 60 minutes sessions..
• It also needs to focus on maximal daily exercises related to functional component tasks (sit to stand, open car door, going up a curb) and hierarchy tasks (getting out of bed, playing golf, getting in and out of a car).
• Build complexity across 4 weeks of treatment towards long-term goal.
• Walking should also be a focus.