Parkinson's Disease: Types and Pathophysiology

• Parkinson's prevalence in Canada is two times higher in men than in women aged 65+ and has a slight genetic component.

Pathophysiology of Parkinson's

• The substantia nigra is the region of the brain responsible for producing dopamine.
• Reduced dopamine neurotransmission occurs and there is gradual degeneration of dopamine nigrostriatal system/neurons.
• The cause is believed to be the interaction of the environment and genetics.
• Drugs that individuals with Parkinson's take may prolong dopamine availability or prevent dopamine breakdown.
• The diminished substantia nigra can be seen in Parkinson's disease.
• Parkinson's is primarily a movement disorder with cognitive subtypes

Types/Subtypes of Parkinson's

• Idiopathic (most common)
• Corticobasal degeneration (CBD)
• Drug-induced parkinsonism
• Essential tremor
• Multiple system atrophy (MSA)
• Progressive supranuclear palsy (PSP)
• Vascular arteriosclerotic parkinsonism
• Dementia with Lewy bodies (DLB)

Clinical Manifestation of Disease

• Main Symptoms
• Tremor: Affects distal segments of extremities and face.
• Tremors initially occur unilaterally when the limb is supported or at rest and disappears with movement and sleep.
• Bradykinesia: slowness at initiating and performing movements.
• Causes difficulty initiating walking and turning
• The person may freeze in place while walking.
• Rigidity: the resistance to movement of both flexors and extensors where the muscles around the joints become stiff
• Postural instability: tendency to lose balance and fall backwards

Stages of Parkinson's Disease

• Stages of Parkinson's progresses from early to mid-stage to advanced.
• Stage 1 is characterized as mild symptoms that are only seen on one side of the body (unilateral involvement).
• Stage 2 is characterized as mild symptoms of PD on both sides of the body (bilateral involvement) or at the midline.
• Stage 3 is characterized by a loss of balance and slowness of movement.
• Stage 4 is characterized as severely disabling symptoms, but patients may be able to walk and stand unassisted but are noticeably incapacitated.
• Stage 5 is characterized by severe symptoms and an inability to rise.

Non-Motor Symptoms

• Mood changes
• Cognitive changes (attention, memory problems)
• Anything that requires learning new things requires immense attention: is easy to get tired
• Try not to introduce new things on bad days, save them for the mild days
• Visuo-spatial problems (detecting height of a step)
• Orthostatic hypotension: blood pressure drops when standing up, resulting in a light-headed feeling.
• Bowel and bladder changes (constipation, incontinency urinary urgency)
• Sleep disorders
• A bad night of sleep will impact them the next day
• Sensory changes (pain, tightness, tingling, burning)

Goals

• Choose exercises that will improve physical fitness and include a problem-solving element
• Like a child learning how to move

Flexibility

• Is the first step in the exercise program and can occur at the end of the session
• Is important in helping with muscle rigidity associated with PD

Flexibility Recommendations

• Minimum 10 min/sessions
• 3-4 times/week (daily is better)
• Hold 10-30 sec
• 3-4 reps/stretch
• Should include chest, shoulders, elbows, hamstrings, quads, calves, front of wrists and palms, low back and neck

Aerobic Exercise Recommendations

• For maximum benefit for patients, activity should be moderately high to high intensity.
• Biking is the easiest
• Uses far more hip and knee flexion
• Gets them doing something not normal
• Cycling wires someone differently via an unknown mechanism
• Walking helps with functional daily living

Strength Training

• At least 1 set, 10-15 reps
• 2-3 days/week
• Target core muscles, quads, glutes, hamstrings, back muscles, and triceps
• Stay away from back extension or hyperflexion of the back

Approach for Strength Training

• Movements that mimic daily living
• Rows
• Squats
• Step-ups
• Lunge
• Arrange them in the same order as conventional strength training, start with biggest muscle group, knee dominant, hip dominant, push and pull, core

Strategies to Deal with Freeze Episodes during Walking

• If freeze occurs, stop and take a deep breath
• Play around with different cues
• Tell feet to move (imagine kicking a ball)
• Concentrate on making the first step very big
• Start by marching in place before starting to move forward
• Focus on task, don't rush
• Remove distractions

Specialty Training

• Balance training
• Tips on how to avoid falls (power stance to prevent backwards falls)
• Teaching individual how to turn using smaller steps

FITT

• The intensity is higher
• High intensity for mild-moderate (80-85% HR max)
• Moderate intensity for advanced (60-65% HR max)
• Theory: higher intensity = more oxygenated blood going to brain

Multiple Sclerosis

• Hard to diagnose because there is not one single set of symptoms.
• One thing that clues in a doctor on ms is that symptoms are not consistent.

MS General Facts

• Immune-mediated disorder
• Demyelination of the CNS
• Characterized by inflammation and selective destruction of the CNS myelin
• Peripheral nervous system is not affected
• Age of onset: between 20-40 years
• Women affected twice as frequently as men
• Disease more common in northern latitudes
• More common in European ancestry

Pathophysiology

• Immune-mediated attack of the CNS
• Demyelination of nerve fibers and axonal/neuronal damage
• Lesions apparent under MRI in both white and gray matter

Risk Factors

• Genetic factors make one more susceptible
• You're at greater risk if your mother has MS than if your father had it
• Genetic
  • HLA-DRB1 on chromosome 6, first-degree relative, maternal > paternal effect
• Environmental
  • Europe, Russia, southern Canada, northern United States, New Zealand, Southeast Australia descent, Latitude >40 degrees north, Migration before adolescence to high-risk area or migration after adolescence from a high-risk area, Birth in May, Low vitamin D levels, Smoking, Epstein-Barr virus, Obesity

Clinical Manifestation

• Every system can be impacted

Relapse and Remission Episodes

• Symptoms last for days to weeks then completely or partially resolve.
• After period or relatively normal function, new symptoms appear

General Fatigue

• Described as generalized low energy
• Not linked to depression and weakness
• Big impact on activities of daily living

Strategies to Deal with Fatigue

• Think about when in the day you want to exercise
• Prioritize activities
• Space activities out

Four Disease Categories

• Relapsing remitting MS (RRMS)
• Secondary progressive MS (SPMS)
• Primary progressive MS (PPMS)
• Progressive relapsing MS (PRMS)
• Each type is like a stage

Relapsing Remitting MS (RRMS)

• Clearly defined attacks of new or recurrent symptoms
• Symptoms are quite and can be anything, and come on all of a sudden
• Spacing and time between episodes varies, could be years or months
• Full or partial recovery and lack of disease progression between episodes
• Symptoms may resolve but person never goes back to baseline
• Accounts for approximately 70-80% of initial diagnoses of MS
• Majority of people start at RR and are reclassified as SP

Secondary Progressive MS (SPMS)

• Progressed to a new stage (rate at which it gets worse can accelerate) and linear progression of symptoms (get worse), but can also get episodes
• Initial RRMS occurs
• Gray area on the graph is RRMS
• Followed by progression with or without occasional relapses
• Minor remissions and plateaus
• Approximately 50% of patients with RRMS convert to SPMS within 15 years
• Approximately 90% of patients with RRMS convert to SPMS after 25 years

Primary Progressive MS (PPMS)

• Disease progression from onset with occasional plateaus and temporary minor improvements allowed
• Approximately 15-20% of patients start with this one

ACSM Guideline for MS

• Exercise testing
• Since the MS continuum is rather broad, exercise testing can be a useful tool to establish baseline levels of fitness
• What symptoms and how bad or frequent
• What triggers it?
• Problems with gait?
• Numbness >
• What is the starting point - basic functions
• Note
• Avoid testing during acute exacerbation of symptoms
• Perform exercise earlier in the day due to fatigue
• Use RPE in addition to HR, as HR and BP response may be blunted

Exercise

• Thermoregulation may be more difficult
• Drastic changes in temperature can trigger symptoms
• Aerobic testing and exercise
• Use a bike, requires less balance and coordination
• Airdyne bike spreads exercise load to avoid local fatigue
• Recumbent bike is good for poor balance; foot straps help if a person is not able to keep feet on pedals
• Testing functional abilities includes 6 min walk, balance (FABS testing), 30 sec chair stand, back scratch, 8-foot up and go test
• Testing muscular strength and endurance by testing large muscle groups and all limbs, and weaknesses will present differently between different individuals

Special Considerations

• Focus and incorporate functional activities in exercise program
• Allow for longer recovery time between sets if muscle group or individual are easily fatigued
• Warm up muscles; increase frequency and time of flexibility exercises
• Disease-modifying medication can have flu-like effects (take into consideration)
• There may also exist some level of cognitive deficit: memory, comprehension, etc.

Uhthoff's Phenomenon

• Temporary increase in MS symptoms may occur when your body temperature rises due to a hot environment, fever, hot bath, or exercise
• An increase of just 0.5 degrees Celsius is enough to trigger this.
• Symptom resolution occurs immediately following return to normal physiological state
• Thermoregulation is important
  • Temperature of the environment
  • Clothing
  • Fans to help cool body off
  • Cold packs
  • More rest periods