CNS: Parkinson's Disease

• Parkinson's disease is a progressive, neurodegenerative disorder involving diminishing basal ganglia function.
• Neurodegenerative means there is degeneration of neurons, which are fundamental for brain activity.
• The disease causes slowed movements, tremor, rigidity, and a wide variety of other symptoms.

Etiology

• The cause of Parkinson's is currently unknown.
• The condition involves the destruction of brain cells in the substantia nigra, which controls muscular movements by releasing dopamine.
• Dopamine production decreases with age, and in Parkinson's disease, the supply decreases due to necrosis.
• Reduced dopamine leads to weaker and more erratic muscular movement affecting walking, writing, reaching, and other basic movements.

Primary Symptoms of PD

• Bradykinesia is the impairment of voluntary motor control, leading to slowness or freezing.
• Bradykinesia presents as difficulty standing up, walking, sitting, and initiating movements, accompanied by "freezing episodes".
• Tremors typically manifest in the hands, fingers, forearms, foot, mouth, or chin, most often during rest.
• Rigidity causes muscle stiffness that results in muscle pain with movement.
• Poor balance occurs because of loss of reflexes that aid posture, often resulting in falls.
• Festinating gait or shuffling gait is also a primary symptom.

Secondary Symptoms

• Impaired balance is a secondary symptom.
• Other secondary symptoms include:
  • Small handwriting
  • Trouble moving or walking
  • Masked face
  • Postural changes (hyperkyphotic)
  • Breathing difficulties
  • Fatigue
  • Constipation
  • Difficulty swallowing
  • Choking, coughing, or drooling
  • Excessive salivation
  • Loss of bowel/bladder control
  • Anxiety, depression, isolation
  • Slow response to questions
  • Soft whispery voice

Diagnosis & Medical Treatment

• There is no specific test for Parkinson's disease.
• A systematic neurological exam includes testing reflexes and observing muscle strength, coordination, balance, and movement.
• Tests are needed to rule out other nerve dysfunction, narrowing of the spinal canal, and determine required treatments.
• Common medications used for Parkinson's include:
  • Levodopa (Sinemet) & Entacapone (Comtan) to improve levodopa´s effectiveness.
  • Dopamine agonists (mirapex) to stimulate the body's natural production of dopamine.

Parkinson's and ROM

• Range of motion (ROM) and strength testing protocols are attempted.
• Active ROM should reveal decreased ROM if rigidity is present.
• Passive ROM will reveal uniform resistance in the flexor and extensor groups acting on affected joints and may reveal cogwheel rigidity (intermittent resistance).
• Resisted ROM will not be useful if rigidity is present.

Special Tests

• Sensory testing results vary based on the client's sensory impairment regarding light touch, deep pressure, pain/temperature perception, two-point discrimination, and proprioception.
• Specific orthopaedic tests depend on the complaint.
• The Bradykinesia Test is positive if movement becomes slower and more difficult

Contraindications

• Prolonged vigorous or painful techniques should be avoided to prevent stimulating the sympathetic nervous system (SNS).
• Areas sensitive to touch should be avoided.
• Pressure and hydrotherapy are modified in areas of altered sensation.
• Positioning, techniques, and hydrotherapy are modified in the presence of hypertension.
• Hypotension is a threat due to autonomic dysfunction; monitor during position changes.
• Avoid holding down tremors.

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.

Home Care

• Encourage relaxation with diaphragmatic breathing.
• Regular, moderate exercise can improve motor control.
• Encourage continuation with Activities of Daily Living (ADLs).
• Maintain functional ability by moving joints through simple ROM and balance activity. Sidelying retraction/protraction and trunk rotation exercises are helpful.