Parkinson's Disease: Physical Therapy Management

• Physical Therapy management for Parkinson's Disease is presented by Dr. Shereen Ibrahim Taha, Professor of Physical Therapy for Neuromuscular Disorders and its Surgery

Objectives

• Review the anatomy and functions of the extrapyramidal system
• Define Parkinson’s disease
• Identify causes and symptoms of Parkinson’s disease
• Recognize and analyze the physical problems of Parkinson’s disease
• Design a treatment plan for Parkinson's patients

Extrapyramidal System Levels

• Cortical level: Frontal lobe
• Telencephalic level: Basal Ganglia (B.G.)
• Diencephalic level: Thalamus, hypothalamus, and subthalamus
• Mesencephalic level: Red nucleus and Substantia Nigra (S.N.)
• Pontine level: Pontine reticular nuclei
• Cerebellar level

Pathophysiology

• Basal ganglia (BG) are interconnected gray matter nuclear masses deep within the brain

Basal Ganglia

• Slow motor programmer
• Subcortical nuclei surrounding the thalamus
• Three major nuclei and two related nuclei function with them

Major and Related Nuclei

• The three major subcortical nuclei: Cudate, Putamen, Globus Pallidus (GP)
• The two related nuclei: Subthalamus, Substantia nigra
• Cudate + Putamen = Neostriatum
• Putamen + GP = Lenticular nucleus

Cortical Connections

• Cudate circuit (Time, Scale, Cognition, Complex): CC (Associated area) -> Caudate -> GP -> Thalmus -> CC; plans by starting with the associated area and giving the information to the programer premotor and supplament
• Putamen circuit (Subconcious Familiar): CC (Premotor- supplement) -> putamen -> GP -> Thalmus -> CC; starts by the programer to the primary motor area to excute
• Ventroanterior and ventrolateral thalmic nuclei are the only thalmic areas that receive motor impulses

Efferent Pathway

• GP to (mail box): VN, Subthalamic, Substantia nigra, RN, RF
• Then connect with the SC with: vestibulospinal, reticulospinal, and rubrospinal tracts

Chemical Transmitters

• CC -> A. choline (stimulate)
• Neuostriatum -> GABA (inhibit)
• Substantia nigra -> Dopamine (inhibitory)

Basal Ganglia Function

• Cudate nucleus with CC: Planning sequences of cognitive complex movement, control timing (rapid or slow), scale (small or large); as shown by learning, writing, or drawing
• Putamen circuit with corticospinal system: Executes subconscious learned familiar pattern; as shown in hammering a nail, and cutting with scissor
• Initiation and regulation of gross intentional movement including swinging arms and facial expressions
• GP: Posture taken to perform particular movement
• Inhibitory to muscle tone overall
• Basal Ganglia have high oxygen consumption and high CU content

Pathology

• The basal ganglia (BG) are the primary locus of pathology in PD; PD symptoms are due to abnormalities within these circuits
• Lesion: Substantia nigra

Causes

• Cerebral atherosclerosis, dopamine receptors
• D2 Dopamine receptors blockers; e.g. Phenothiathine
• Head trauma

Parkinsonism

• Parkinson's Disease (PD) is associated with degeneration of dopaminergic neurons that produce dopamine
• Clinical signs emerge with 30 to 60% degeneration of neurons
• Nigral cells loss is estimated at 10% per year
• Loss of the melanin-containing neurons produces characteristic changes in depigmentation

Pathways & Effects

• Two pathways in the basal ganglia control fine-tuning of voluntary motor activities: direct excitatory and indirect inhibitory
• These pathways have antagonistic net effects: stimulation of the direct pathway results in activation of the motor cortex, while stimulation of the indirect pathway results in motor cortex inhibition
• Dopamine from the substantia nigra compacta (SNc) binds to D1 receptors of the striatum and stimulates the direct pathway
• D2 is released from the SNc, binds to D2 receptors of the striatum, inhibiting the indirect pathway
• Both pathways aim to stimulate the motor cortex
• Reduction in dopamine in Parkinson's: Reduced activation of the direct pathway through D1 receptors and reduced inhibition of the indirect pathway through D2 receptors
• Motor cortex activity is reduced, resulting in characteristic rigidity
• Loss of dopamine results in an overactive indirect pathway which underlies akinesia and rigidity
• An underactive direct pathway is thought to be responsible for bradykinesia

Characteristics

• Loss of dopaminergic inhibition of the putamen leading to excitation
• Involuntary movement and muscle tone changes
• Static tremors (rhythmic and repetitive) occur during rest and disappear with voluntary movement and sleep
• Hand pill-rolling, and mandible tremors
• Rigidity: More prominent in flexors, characterized by flexor attitude, can be seen as lead pipe (continous) or cogwheel (series of catches)

Parkinson's Disease

• A neurodegenerative disease characterized by depletion of dopamine-producing cells in the substantia nigra compacta (SNc)
• The patient's age, progressive tremor involving both extremities and the lips, improves with intentional movement and sleep
• Signs upon physical examination (resting pill-rolling tremor, bradykinesia, rigidity, and shuffling gait)

Prevalence and Cause

• A progressive degenerative disease of the nervous system affecting mainly the basal ganglia and its connections, with different parts of neuroaxis
• Occurs more in men than women, with a prevalence of two every 1000

Causes of PD (Idiopathic/Symptomatic)

• Idiopathic: Paralysis agitans
• Symptomatic: Inflammatory, Vascular, Toxic, Neoplastic, Traumatic

Clinical Manifestations

• Motor Symptoms: Primary Symptoms and/or Cardinal Symptoms

Primary Symptoms

• Rigidity: A clinical hallmark; increased resistance to agonist and antagonist muscles
• Two types of rigidity: cogwheel & lead pipe
• Rigidity is often asymmetrical (especially early). It typically affects proximal muscles first especially shoulders & neck, and it progresses to involve muscles of the face and extremities
• Prolonged rigidity can result in decreased ROM and secondary complications of contracture and postural deformity
• More in flexors proximally and extensors distally
• Tremors are the initial symptom
• Resting tremors: Pill rolling oscillation tremors with a frequency of about 4 to 7 cycles per second
• Often occur in the hands, fingers, forearms, foot, mouth, or chin; occurs when the limbs are at rest
• Increased with fatigue or emotional stress
• Decreased with sleep or voluntary movement
• Bradykinesia: One of the cardinal manifestations used synonymously with akinesia and hypokinesia
• Bradykinesia describes the slowness of movement, whereas akinesia is the poverty of spontaneous movement (e.g. in facial expression) associated movement (e.g. arm swing during walking)
• Freezing is another manifestation of akinesia
• Hypokinesia is movements smaller than desired, as exemplified in micrographia of patient handwriting
• Bradykinesia may also refer to slowness in formulating instructions to move (programming)
• Slowness and difficulty in maintaining movement which results in increased dependence in daily tasks/ delayed muscles signals is usually the most disabling sympton
• There are five secondary causes of bradykinesia: Muscle weakness, rigidity, tremor, movement variability and slowing of thought/bradyphrenia
• Postural instability: abnormal and inflexible postural responses along with increased body sway
• Narrowing of base of support (BOS) and competing attentional demands increase postural instability
• Difficulty during dynamic stabilizing activities; for example, functional reach, walking and turning
• Patients can have poor balance and are prone to falling

Gait and Disturbances

• Parkinson's Gait: Shuffling, head down, shoulders drooped, lack of arm swing, and unnatural leaning. Initiating walking is difficult and freezing mid-stride is common
• Approximately 13 to 33% of patients present with postural instability
• Gait disturbances are also common features of late-onset PD
• Abnormal posture is common because of festinating gait; progressive increase in speed with a shortening gait which can be either anteropulsive or retro pulsive
• Gait is characterized by short steps, with feet barely leaving the ground which produces a shuffling noise
• Turning "en bloc": Instead of normal neck, trunk, and toe pivoting, PD patients keep the their neck and trunk rigid, requiring multiple small steps to accomplish a turn
• Festination: A combination of stooped posture, imbalance, and short steps, which gets progressively faster, often ending in a fall
• Smaller base of support, shorter steps, narrower stance, and center of gravity shifts forward

More Symptoms

• Forward weight shift, knees and hips are bent and shoulders are tight
• Chin comes forward to achieve horizontal gaze

Freezing

• Gait freezing is akinesia; the inability to move which is characterized by an inability to move the feet, especially in tight, cluttered spaces or when initiating gait.
• Dysphagia (impaired swallowing): Present in as many as 95% of patients as a result of rigidity, reduced mobility, and restricted range of movement is a very early symptom

Consequences

• Abnormal tongue control, problem with chewing and/or bolus formation, as well as a delayed swallow response
• Dysphagia can lead to choking or aspiration pneumonia, in some cases nutritional impairment
• Nutritional inadequacy contributes to fatigue
• Patients experience excessive drooling (sialorrhea) because of increased saliva production and decreased spontaneous swallowing
• Patients with PD experience hypokinetic dysarthria, characterized by a decreased voice volume, monotonous speech, imprecise articulation, and uncontrolled speech rate
• Speech is often hoarse
• Patients experience timing difficulty of vocal on and off sets

Cognitive + Behavior

• Impairments in cognitive function can be mild and only mildly impair memory
• Severe PD dementia occurs in approximately 20 to 40% of patients
• Bradyphrenia, a disorder of intellectual function, is characterized by a slowing of thought, information processing, and selective and shifting attention
• Depression is common because of deficiencies of dopamine, serotonin, and norepinephrine
• Difficulties with social cues
• The clinical examination should include mental status, cranial nerves, motor/muscle strength, reflexes, coordination, habitual activities, posture and gait
• Assessment at peak dose /when “ON” and at end dose/when “OFF”

Hoehn and Yahr Scale Stages of Disability

• Stage I: Symptoms on one side of the body only
• Stage II: Symptoms on both sides of the body with no balance impairment
• Stage III: Balance impairment, mild to moderate disease, but physically independent
• Stage IV: Severely disabled, but still able to walk and stand unassisted
• Stage V: Confinement to bed or wheelchair, unless aided

Unified Parkinson's Disease Rating Scale

• Mentation, behavior, and mood
• Activities of Daily Living (ADL)
• Motor skills
• Complications of therapy
• Hoehn and Yahr disability stage
• Schwab and England Activities of Daily Living Scale

Motor Control Problems

• Loss of automaticity and skilled movements, also includes a loss of activation and continuing sequences of movements
• Akinesia occurs with difficulty initiating movements
• Freezing phenomena: in doorways, microwave ovens, etc.
• Postural instability and falls
• Drooling (especially at night) low in volume and monotone voice
• Masked face and a lack of automatic associated movements
• Gait: forward head, stooped posture, diminished/absent arm swing, lack of heel strike, and flexed throughout
• Cognitive changes: short-term memory, dementia, and depression

Secondary Effects and Consequences

• Increase the time needed to perform ADLs and find turning in bed and getting out of bed more difficult
• Difficulty with hand dexterity for buttoning, holding cards, etc., and a decrease in overall activity
• Musculoskeletal changes: Loss of extension and rotation
• Posturing in flexion: Affects the neck, trunk, hips, and knees
• Decline in respiratory capacity, with a loss of balance, and increased risk of falls

Parkinson Management

• Treatment strategies can improve motor performance by increasing the readiness of neurons within the basal ganglia to signal the supplementary motor area to begin preparation for movement

Treatment Goals

• Increase the readiness of neurons within the basal ganglia to signal the supplementary motor area to begin preparation for movement.
• Increased time to perform ADLs and difficulty turning in bed and getting out of bed.
• Difficulty with hand dexterity for buttoning, holding cards, etc., and a decrease in overall activity.
• Musculoskeletal changes: Loss of extension and rotation, posture in flexion: Affects the neck, trunk, hips, and knees, respiratory capacity is in decline with a loss of balance, and increased risk of falls

Long-Term Goals

• Delay or minimize the progression and effects of the disease symptoms.
• Prevent development of secondary complications and deformity.
• Maintain the functional abilities of the patient to their fullest extent.

Short-Term Goals

• Maintain/increase range of motion in all joints.
• Prevent contractures and correct faulty posture.
• Prevent disuse atrophy and muscle weakness.
• Promote and improve motor function and mobility; and gait pattern
• Improve speech, breathing patterns, chest expansion, and mobility
• Assist in psychological adjustment and lifestyle modification.

Treatment Options

• Gentle rocking and rotational exercise with the help of a vestibular ball, rocking chair and/or cradle can be a use to produce generalized relaxation in rigid group of muscles.
• Passive to active assisted to lightly resisted movements are designed to help overcome the crippling effect of immobility, through PNF Technique of Rhythmic Initiation
• Breathing exercises can be incorporated into rotational exercise to enhance relaxation; Bilateral symmetrical D2 Flexion pattern + inspiration while D2 extension pattern + expiration
• Jacobson’s progressive relaxation techniques. to help with emotional calm
• Meditation and/or cognitive imaging techniques. to provide emotionally calm experience

Flexibility Exercises

• Stretching of elbow, hip, knees, and ankle musculature with joint mobilization technique to reduce joint capsule/ligaments tightness + passive positioning for light musculature/soft tissue
• Bedridden patients can benefit from traction at low setting to reduce contracture and can use tilt table for incorporating
• Focus on strengthening the patient’s weak, elongated extensors muscles while ranging tight flexor musculature
• D2 flexion to extremities helps counteract kyposis
• D1 extension to lower extremities helps counteract flexed and adducted positioning
• Contract Relax technique (isometric contraction of tight agonist muscle with active rotations of limb) preferred because it encourages autogenic inhibition from

Mobility Exercises

• Programs are based around functional movements that engage multiple body segments - Prone activities encourage extension and Standing wall push ups help with mobility.
• Use of Pelvic tilts and swiss ball exercises help with sitting

Movement Training

• Gait training: Lengthening of stride, heel and toe training and balance to promote contralateral trunk extension

Additional Treatments

• Gait; small blocks to step over, Marching, stepping forward and sideways , and PNF activity (braiding)
• Balance weight shifts between various positions challenging the postural control system can also be incorporated in this manner
• Balance is obtained through Externally induced perturbation for promoting
• Sink exercise for balance with heel raises and toes off and a single limb stance

More Exercies

• Respiratory exercises( diaphragmatic, segmental, and deep breathing exercises and Air shifts techniques,)
• PNF is also to be used in symmetrical activities to enhance mobility
• Aerobic exercise to enhance the cardiovascular and metabolic response

Oro-Facial

• Help facilitate movement of facial components via message/exercises of muscles to decrease rigidity
• PNF patterns can be helpful
• Make sure to properly manage nutrition

Mental Health Support

• Psychotherapy: talking/listening to a patient may help the patient to dealing with trauma.
• Cognitive-Behavioral --Interpersonal -- Behavioral --Group therapy
• Also be sure to provide an appropriate environment - which may entail providing a larger space, proper exercise equipment, or a more enriching environment