Parkinson Disease PDF

06-Dec-23 Parkinson disease Dr.Mahmoud elsayed midan PhD. Lecturer for PT for neurology 1 Extrapyramidal system: It includes all the centers and descending tracts that control activity of AHC in spinal cord ot...

06-Dec-23 Parkinson disease Dr.Mahmoud elsayed midan PhD. Lecturer for PT for neurology 1 Extrapyramidal system: It includes all the centers and descending tracts that control activity of AHC in spinal cord other than pyramidal tract. It is also a divers systems extending almost in all levels of CNS with multiple final descending tracts. It includes area 6 and les extend area 8 and 4, basal ganglia, thalamus, subthalamus, red nucleus, substantia nigra, brain stem reticular nuclei and other nuclei, and descending tracts. 2 1  06-Dec-23 Basal ganglia: group of grey matter nuclei at the base or deep in the cerebral hemispheres Caudate nucleus, putamen globus pallidus. Head of caudate and putamen form corpus striatum, putamen with internal part of globus pallidus form lentiform nucleus. main center for regulation of extrapyramidal system. Basal ganglia and their connections almost form the extrapyramidal system. 3 4 2  06-Dec-23 Extra pyramidal tracts: the final pathways of extrapyramidal system that influence the activities of AHC. all originate in brainstem and terminate in spinal cord Through interneuron to the AHC. They include: Rubrospinal tract. Tectospinal tract. lateral and medial Vestibulospinal tracts. pontine and medullary Reticulospinal tracts. 5 Function of extrapyramidal system: Regulation of postural muscle tone. Facilitate initiation of voluntary movement. Control of emotional and associated (involuntary) movement. Regulation of background posture during movement Regulation and scaling of automatic (learned skilled) motor activity. the extrapyramidal do these functions through two pathways; a) Influence cortical activity through its connection with basal ganglia. b) Influence activity of AHC through descending tracts 6 3  06-Dec-23 Basal ganglia and cortical activation: Dopamine is a neurotransmitter for transmitting signals between substantia nigra and corpus striatum it is critical to produce smooth, purposeful movement. Basal ganglia influence cortical motor activity through two circuits: 1. Direct pathway: striatum inhibits the globus pallidus. This pathway is activated via D1 dopamine receptors 2. Indirect pathway: the striatum facilitates globus. This pathway is inhibited via D2 dopamine receptors. 7 1. Direct pathway: activated via D1 dopamine receptors striatum inhibits the globus pallidus globus pallidus originally inhibit thalamic activities. This increases thalamic activities to the cortex So increasing motor activation. 8 4  06-Dec-23 Indirect pathway: striatum facilitates globus pallidus globus pallidus originally inhibits the thalamus. causing inhibition to thalamic activities to cortex so, decreased activity of the cortex. This pathway is inhibited via D2 dopamine receptors. 9 10 5  06-Dec-23 Descending extrapyramidal tracts: acts mainly on interneurons mainly gamma motor neuron overall has facilitatory effect on extensors and some inhibitory effect to flexors. Mediating the postural reaction midline and proximal control on background of movement 11 Descending extrapyramidal tracts: 12 6  06-Dec-23 Disturbances of extrapyramidal system As its diversity, the affection of extrapyramidal system produces several syndromes according to the pathology and site of affection hypokinesia (bradykinesia) decrease unvoluntary associated or automatic postures and movements and slowness of voluntary movements. Hyperkinesia (tremor as in Parkinson, jerks as in chorea and pallismus, posturing as in dystonia). All has disturbances in muscle tone. 13 PARKINSON’S DISEASE most frequent extrapyramidal affection in adults. gradual neurodegenerative disease affecting basal ganglia with degeneration of substantial Nigra (SN) result in decrease in dopaminergic stimulation of nigrostriatal tract. This leads to imbalance of balance between dopamine and acetylcholine transmitters constitute the hallmark of Parkinson’s and parkinsonian diseases. 14 7  06-Dec-23 Causes: Primary Parkinson’s: idiopathic degeneration of SN most commonly in old age after 60y. Secondary parkinsonism (parkinsonian disease): parkinsonism affection of basal ganglia dopaminergic pathways. Vascular: ischaemia. Encephalitis. Traumatic: repeated microtraumas. Toxic: as manganese toxicity and pesticides. Drugs: narcotics, addiction has a permanent damaging effect. Neoplastic 15 Manifestation: Parkinsonism diagnosis depends on clinical presentation of the patient. There are 4 cardinal features in parkinsonism which are: Tremors Bradykinesia Rigidity Postural instability ❑Stooped posture: ❑Gait disturbances: ❑Freezing ❑Cognitive Manifestations: ❑On and off phenomenon 16 8  06-Dec-23 Tremors: Patients suffer from static tremor which occurs at rest Frequency of 4-8 hz. It starts in one limb and then progress to other limbs. In some cases, jaw tremor may be present increases by stress disappears in sleep and with volitional movement. But in delayed cases, it may hinder the movement. It takes shape of ❑counting money with rhythmic thumb movement or ❑bill rolling 17 Bradykinesia poverty, paucity of movement. slowness of voluntary motor activity and decreased or lost automatic, associative, or emotional movement. Decreased or loss of blinking with gazing, staring appearance of the eye. Decreased or loss of facial expression. Mask face Impaired swallowing and sialorrhea. Monotonous speech. Micrographia. Decreased or lost arms swing during gait. Lack of righting and posture reactions. Slow shuffling gait with advanced cases there is freezing of gait. 18 9  06-Dec-23 Rigidity: It represents increased in tone that is characterised by steady resistance to movement not affected by speed described as lead pipe rigidity. Sometimes, tremor superimposed on it cause interrupted resistance called (cogwheel rigidity). Rigidity further hinder movement as if the patient is tied or as a one segment. So, it also affects swinging during gait step length and width, impairment of postural reaction as trunk in advanced cases may act as one segment. Parkinson suffer in breathing due to rigidity and stooped posture as restrictive lung disease. 19 Rigidity: Distribution of rigidity is often asymmetrical especially in the early stages of the disease (start unilateral and also it can vary with medication and stress) It affects flexors more than extensors. It affects proximal and midline muscles more than distal. Precipitate stooped posture with forward head, trunk leaned, upper limbs flexion, hips, and knees flexion (gorilla like attitude). therefore important to determine which body segments affected and the severity of involvement. 20 10  06-Dec-23 Postural instability Extrapyramidal has a tremendous roll in postural control during static and dynamic situations. postural reactions and control primary affected in Parkinson disease in addition to the primary effect, rigidity and bradykinesia disturb postural stability furthermore. NB:Two of the previous 4 cardinal features are required for diagnosis of parkinsonism. 21 E. Stooped posture: F. Gait disturbances: According to distribution of rigidity Several factors affect on gait as Bradykinesia and lack of postural control, Rigidity characterised by: Stooped posture, (ant COM) Forward head. postural instability. (impaired postural reactions) Leaning of trunk characteristic gait pattern. Elbow flexion. starts with decreased step length and width. Flexed hips and knees. Followed with shuffling and impaired balance. Later festination appears (patient forced to take steps in increasingly speed to control COM but with insufficient speed or length as if he tries to catch his COM. end with support or fall. Early it may be recognized by taking few steps before being able to stop on order 22 11  06-Dec-23 Freezing: It is a special condition patient feel as if he is stuck freeze in place unable to initiate new step Occur in advanced cases. Gait starts slow, short steps, narrow base, then shuffling with freezing last. Freezing start to appears in stressful situations as Turning crowded area approaching the target turminal freezing Lastly may occur during level walking. 23 Cognitive Manifestations: specially later in the disease have cognitive disfunctions occur almost affect all cognitive function. One of the first manifestation of cognitive function affection is depression. Other manifestations follow including bradyphrenia narcolepsy awareness disturbances. memory 24 12  06-Dec-23 Cognitive Manifestations: Depression: primary part from the pathology with decreasing dopamine circuits and a reactive part as a response for motor function deterioration. Bradyphrenia: slowness of thinking. adds on motor function disturbances by slowing patient reaction specially found difficulties in dual tasks as counting or traking while walking. Narcolepsy: patient sleepiness. patient may fall asleep during function specially if lacking prominent sensory input. So, during treatment, sharp loud voice should be used with maximal motivation. Memory problem: late as the disease progress memory disturbances occur large percentage develops dementia. 25 On and off phenomenon: in advanced cases on L-dopa treatment the patient experiences a period of good functionality on treatment and a period of bad functioning during fading of its effect. On long term use of medication on and off periods occurs even on the treatment. 26 13  06-Dec-23 Modified Hoehn & Yahr Scale 27 Assessment of Parkinson’s patients 28 14  06-Dec-23 Personal history: Idiopathic Parkinson’s usually manifested after 50,60 ‫الكتاب‬ while atherosclerotic usually manifested at. 70, Below that other causes may be the cause especially encephalitic. Certain habits and occupation may predispose for the disease as Boxing players: due to repeated micro trauma Miners: manganese and copper toxicity may affect basal ganglia. Atherosclerotic may be affected with smoking habits, also some drugs addiction may damage dopamine circuit. 29 Chief complaint: It can differ from a large variety usually: Early as the disease appears include: Later difficulty in walking speech and swallowing difficulties, slowness of movement impaired posture Fatigue Decreased ability to participates in ADL Tremors independently lack of balance. 30 15  06-Dec-23 Present history: Most commonly the symptoms start gradually with a progressive course including those with idiopathic, atherosclerotic and toxic. Less commonly acute onset presents as in encephalitic type and is accompanied with regressive course. Patient with Parkinsonism may have some autonomic manifestation as constipation, postural hypotension. 31 Past history: History of Also previous functional abilities Fever must be considered during Encephalitis sitting treatment goals and plan. Repeated trauma This disease is related to old age so accompanied hip arthroplasty osteoarthritis Must be excluded and cardiac problems considered during treatment. diabetic neuropathy and other diseases 32 16  06-Dec-23 Respiratory assessment: Respiratory assessment is critical for Parkinson patient. Usually, patient has short breath and easily fatigue. rigidity acting as restrictive lung disease. stooped posture affect lung expansion. decreased or lack of functional mobility which lead to deconditioning effect on cardiopulmonary function. 33 Mental examination: Parkinson patient has different cognitive disturbances. Assessment must consider different cognitive function. Assessment scales usually preferred for more comprehensive assessment. Montreal cognitive assessment scale is one of best used scales Assess: executive function Language Memory mathematical abilities. 34 17  06-Dec-23 35 36 18  06-Dec-23 Speech assessment: Cranial nerves assessment Patient find difficulty moving eye ball fast characteristic monotonous speech shifting from target to another. Vertical movements are more difficult. lack any emotional variation Loss of habituation of Glabellar reflex. in addition to low voice whispering speech Loss of automatic movement so sialorrhea may be present. NB: Respiratory impairment added on to speech problem as patient lack sufficient Mask face expiratory volume. orofacial problems 37 Sensory assessment: In Parkinson disease there is no direct sensory affection. However, patient may have difficulty in sensory organization as in that needed for postural control. It is common for old age Parkinson patient to have co-morbidity that affect sensory function as in diabetic neuropathy. So, therapist need to assess sensory function to consider it comorbid affection if present during treatment. 38 19  06-Dec-23 Motor function assessment Inspection: Muscle tone assessment Stooped posture is prominent and obvious as the Using passive movement in relaxed supine position. disease progress. Avoid stress and consider medication effect. Slow shuffling gait and ambulation ability may be lost. Assessment is done in the same time of day for follow Static tremors: up. Kyphosis, knee flexion, equinus may be present. Parkinson patient will show hypertonia in form of rigidity Muscle power assessment: constant resistance through the ROM (lead pipe) Parkinson disease affect initiation and postural control. or intermittent resistance (cogwheel). No primary weakness in the disease pathology Rigidity found to be more in axial and proximal parts rather than distal deconditioning and disuse weakness may develop. affecting both agonist and antagonist but more in flexors. strengthen exercise used for prevention Trunk rotation (rocking) is limited and hard. Acting against impaired posture. Group muscle test used in mild cases Reflexes assessment: functional muscle test may be used in advanced cases hyporeflexia of deep tendon reflexes with marked rigidity. due to over activity of gamma motor neuron and secondary muscle spindle in opposing group of muscles. 39 E) Test for bradykinesia: Bradykinesia appears as a slowness in movements and difficulty to perform simultaneous or repetitive movements. a) Subjective Assessment: b) Functional tests: Quick tests specific for assessment of the speed, control Timed up and go test: and composition of movement as this for diadochokinetic:\ from sitting on a chair , stand up , walk 3m, turn around, walk back, and sit down. Opposition: Observe the patient’s slow movement, shuffling and arm try to do it as fast as possible in (15sec) swing. It takes 10 seconds or less in normal subjects. Fisting and opening the hand: 5 times repetition test from sit to stand: as fast as possible in certain time (15sec) Patient is asked to cross his upper limbs pronation and supination: from sitting try to stand up as fast as he could. as fast as possible in certain time (15sec) Observe mainly the control of movement in the trunk and the Tapping the feet on the ground: Lower limb. as fast as possible in certain time (15sec) Observe the patient how he turns in bed Other functional tasks: buttoning and unbuttoning, writing. 40 20  06-Dec-23 Objective measures: BRAIN test: A sensitive software tool for detecting signs of neurological disease, including Parkinson’s disease (PD) and cerebellar dysfunction which is based on alternate finger tapping test using a computer screen and keyboard. The user must alternately tap the ‘S’ and the ‘;’ keys as rapidly and as accurately as they can over a 30-second. Two tests are done, one for each hand. Brain test assess four variables: 1. Kinesia score (the number of key taps in 30 seconds). 2. Akinesia time (the mean time on each key in milliseconds). 3. Dysmetria (number of incorrectly hit keys). 4. incoordination (variance of time interval bet. Individual keystrokes). 41 Coordination assessment: A) In non-equilibrium coordination: slowness, loss of smoothness of movement and difficulty in doing reciprocal movements. Caused by bradykinesia and rigidity. There are increase in both reaction time and action time. B) In equilibrium coordination: Imbalance or postural instability are one of cardinal signs of Parkinson. Patient has difficulties in realign and right his body in different position specially with rigidity that affect the axial body part and limit trunk movement. This affect static and dynamic balance. Rigidity and bradykinesia added on impaired postural reaction make equilibrium and protective reaction to be in efficient in balancing strategies. 42 21  06-Dec-23 ADL assessment: Patient independence are one of most important patient complaint and goals of treatment. So accurate assessment and follow up with standardized scale as Functional indepennce measure (FIM) is important. NB: General consideration must be taken in assessment of PD patient: Minimize effect of drug induced change in performance on assessment results it must be performed at the same time of day. All activities should be timed. Considering old age problems as arthritis, decreased sight and hearing 43 22