Parkinsonism - Sec 6 Neuro PT PDF

Parkinsonism Definition: -It is a progressive degeneration disease of the nervous system affecting mainly the basal ganglia and its connections with different parts of neuroaxis. - It's a disease of extra- pyramidal system affects male >female, will a prevalence of2 every...

Parkinsonism Definition: -It is a progressive degeneration disease of the nervous system affecting mainly the basal ganglia and its connections with different parts of neuroaxis. - It's a disease of extra- pyramidal system affects male >female, will a prevalence of2 every 1000 -It's due to decrease in dopamine, so the percentage of acetylcholine to dopamine.is increased i.e. The acetylcholine amount does not change. -the prognosis of vascular cause is better than of degenerative causes -most common Age of Parkinsonism is over 60 years old. Cardinal signs of Parkinsonism: (Problems) 1 -Tremors. 2 - Rigidity. 3 - Bradykinesia. 4 - Loss of postural reflexes. 5 - Postural deformities. 6 - Freezing. N. B: To say that this pt. complain from Park.insonism he must has tremors & Bradykinesia (2 at least) 1. Tremors: [slow rhythmical alternating movements) Static tremors, appears during Rest. Disappears by sleep and movement. Frequency of Tremors. Site oftremors:~Distal joints (Forefingers-Thumb- tongue- lips) Characteristics in the form of pill rolling or counting money. *It result from enhanced increase activity in the basal ganglia which result in rhythmic discharge of thalamus 2. Rigiditv: * It is state of increasing tension of the ms causing resistance to passive movement during assessment of ms tone (in 2 directions) in the form of lead pipe or cogwheel. * Lead pipe: The Resistance occurs all over the range of motion. *Cogwheel: * Interrupted resistance during assessment of muscle tone. 181  * It may result from the superimposing of tremors on Rigidity. * Rigidity due to excitation of globus pallidus (lesion in basal ganglia) * It affects the trunk more the extremity and later on, Proximal more than distal & Flexors more than extensors. * It is due to alternation in the activity of the descending extra pyramidal motor pathway in Spinal cord to AHCs. 3. Bradvkinesia: Hypokinesia ,It is manifested by ⇒ Slowness of emotional & associated automatic movements. => Poverty of movement => Inability to initiate movement despite volition (freezing) * It results from a lack of integration of sensory information By basal ganglia with a resulting alteration in motor planning and facilitation of movement. * Fatigue and decrease cardiopulmonary endurance & depression and withdrawal may contribute to Bradykinesia. * Faulty balance may also contribute to Bradykinesia. * An individual may move more slowly for fear of falling. * Causes=> ( l) Lack of integration between sensory and motor feedback. (2) Lack of coordination bet.movement (3) Faulty Posture. (4) Fear of falling (5) Deformities. (6) Contracture (7) Depression (8) Loss of balance * Bradykinesia affects the following l) Face: monotonous Speech and Mask face 2) Writing: Micrographia 182  3) Gait: Short steps then Shuffling gait 4) Swallowing: sialorrhoea (dripping of saliva from the angle of mouth). 5) Eye movement: ! in blinking of eye (associated movement) result in starring appearance of the eye. 6) => Loss of swinging movement of U.L during gait ( associated movement) Bradykinesia finally leads to akinesia 4. Loss of Postural reflexes Loss of Protective reactions (COG out side BOS) Loss of equilibrium reactions (COG within BOS) Loss of righting reaction 5. Postural deformities: A) Flexion attitude: =>Startin U.L =>flexion in elbow and shoulder then trunk flexion => knee & hip flexion I.e. Gorilla like attitude: semiflexion all over the body N.B => U.L is hinged in front of the body B) Ulnar deviation flexion in MCPJ and extension in lP joints. C) Inversion in subtalar joint. D) Round Shoulder E) Forward neck position 6. Freezing: (late stage) lt Affect the following: => Gait: glue feet => Speech: Palilalia N.B: => Kinesia paradoxia: Signs disappears then appears then disappears.... => Parkinsonism pt.: suffers from Restlessness. Common Problems in Parkinsonism: 183 1- Lack of normal postural to Movements: * Inability to change direction or change position. * Inability to turn (prone~ die) * inability to Rotate * Affected balance 2- Diminished postural reactions: (Help person to maintain balance) * Loss of righting reaction * Loss of equilibrium reaction * Loss of Protective reaction (frequent falling) 3- Difficulty in initiating & stopping movement despite volition (freezing) 4- Loss of associated & automatic reactions: * arm swinging * Blinking of the eyes 5- Mal posture * Gorilla like attitude * While sitting often slump to one side 6- Muscle Weakness * Proximal > distal, due to inactivity & Mal position. 7- Skeletal deformities and contractures * Secondary to inactivity: mal position and muscle imbalance * eg.: scoliosis, hyperlordosis... 8- Respiratory problems Contractures rounded shoulder -+ ! of lateral and antero- posterior expansion of the lung -+ ! of chest mobility =>! of vital capacity and lead to pneumonia. Pt. has deep and slow breathing. Chronic restrictive lung disease due to decrease expansion & mobility of chest which may produce infection & lead to COPD. 184  Treatment=> P.N.F. and breathing exercises. 9- Circulatory problems * Blood stasis=> ! YR stagnation of blood=> DVT (or edema). I 0- Autonomic disorders (atherosclerotic) Stool & urinary incontinence.. 11- Behavioral disorders (post encephalitic) Affected mood. Depression due to ! dopamine 12- Orofacial problem: 13- Gait problems:short step, shuffling, festinating 14- Lack of kinesthetic awareness: Which make the patient aware of abnormality of his posture & gait? 15- Rigidity: Hypokinesia. Assessment of Parkinsonism History Personal history ✓ Name: to be familiar with the patient ✓ Age: Parkinson's disease- above 50 years Atherosclerotic (vascular parkinsonism) - over 60 years ✓ Occupation: boxers - repeated trauma to head - traumatic cause CO poisoning - toxic cause Present history ✓ Gradual onset, progressive course except for post encephalitic parkinsonism course may be regressive or stationary. 185 fast histoc,v ✓ Fever in post encephalitic parkinsonism ✓ Cardiac problems, previous heart surgery in Atherosclerotic parkinsonism ✓ Previous drug intake: major tranquilizers----+ Parkinsonism Examination; General examination: examination of vital signs (general appearance, temperature, blood pressure, pulse rate and respiratory rate) ✓ Respiratory assessment; a. Function of respiratory muscles: muscle strength and tone of the diaphragm, abdominals, and intercostals should be assessed and the respiratory rate should be noted. b. Chest expansion: circumferential measurements should be taken at the level of ax ilia and xiphoid process using a tape measure. Chest expansion is recorded as the difference in measurement between maximum exhalation and maximum inhalation. Normally: a. Upper chest~ 1-3 Fingers b. Lower chest ~ 3-5 Fingers c. Breathing pattern: by manual palpation or observation. Particular attention should be directed toward use of accessory neck muscles. d. Cough: the ability to cough to remove secretions. Neurological examination: ✓ Mental functions: cognitive problems (slowed thinking, confusion, and in some cases dementia. (slowed thinking called bradyphrenia) ✓ Speech; Dysartheria in the form of monotonus speech ✓ Cranial nerves; no cranial nerve affection 186 N.,B: No habituation ofGlabellar reflex; blinking continues with the taps as long as the stimulus is applied. ✓ Sensory system examination: no affection as parkinsonism is an extrapyramidal syndrome, but patients may have hypothesia due to associated neuropathy as a result of aging and ! blood supply to extremities. N.B: patient may complain of pain due to muscle shortening (musculoskeletal cause) ✓ The therapist can document specific active range of motion (AROM) and passive range ofmotion (PROM) impairments using goniometric measurement for upper and lower limbs and using tapemeasurements for trunk --+ limitation in ROM of extension and rotation In standing, patient with PD demonstrates the typical flexed, stooped posture with forward head,and hip and knee flexion. In supine, the patient with PD demonstrates the typical flexed posture (pillow head or cushionhead posture). ✓ As all activity should be timed so therapist also should assess action time and reactiontime --+ ask the patient to do any movement and measure Time between order and beginning of movement = reaction time --+ PD patientsshow difficulty to initiate movement Time to perform and complete movement = action time --+ PD patients showslowness of movement (bradykineasia). Micrographia and bradykinesia: Using the normal handwriting, copy out somelines of writing. handwriting becomes smaller and smaller as writing proceeds. (I) orofacial assessment : Normal orofacial function depends on: intact tongue, lips, cheeks, teeth, larynx, jaw soft, hard palate, muscle of face, normal tone, sensation and reflexes also ability to control head and maintains balance in Sitting position * Manifestations => I. Mask Face. 2. Loss of blinking reflex (Put piece of cotton on the lateral angle of the eye) 3. Loss of Glabellar reflex 187  (Tapping between eye brows=> normally blinking of eye occurs) 4. Poor lip & jaw closure &tongue movement resulting in Swallowing and eating difficulties. 5. Jaw, lips &tongue tremors 6. Poor Phonation & articulation result in => Monotonous Speech 7. Breathing type in nose (2) Neck assessment: * Forward neck position * Spasm in Paraspinal muscles * Rounded Shoulder (3) Trunk assessment : Flex ion deformity in the trunk in the form of Gorilla attitude. Both U.L. are hinged in front of him. Both elbows are flexed. Both L.L are in flexion attitude. Hip & knee flexion. (4) Motor System assessment: I. Muscle tone assessment> Rigidity 2. Muscle power assessment : ! In muscle power late due to disuse. 3. Rom assessment 4. Reflex assessment: normal or hyporeflexia, Late hyporeflexia due to rigidity 5. Flexibility assessment: (detect any shortening in muscle) A=> Iliopsoas (Thomas test) B=> Hamstring => calf muscles D=> Trapezius E=> elbow flexors. (Biceps Brachii) => Pectoral is major: pt. Put his hand behind his head & Move backward if Pain occurs => Shortening N. B: Thomas test: * Put pt in Supine with L.L. outside plinth and other leg flexed by the pt * If flex hip+ flexion knee=> Ilio psoas tightness * But ifflexion hip+ extension knee =>rectus Femoris tightness. 188  * Flex + Abduction ⇒ Sartorius tightness. (5) Coordination assessment: * Coordination equilibrium assessment (Static & dynamic) * In static balance⇒decrease BOS ⇒higher COG ⇒ The more difficult the exercise *Protective reactions assessment. * Righting reaction assessment (6) ADL assessment: Yahr classification of disability (8) Gait assessment By inspection (qualitative or descriptive assessment) - slow, shuffling, festinating or short steppage, with propulsion or retropulsion, loss of arm swing...... etc quantitative assessment Distance variables (use foot print) - measures step length, stride length, BOS.... etc, Time variables (use stopwatch) --t measures cadence, stride time......... etc Walking index (number of steps in a given time x time taken to stand, walk a fixed distance and sit down) --tflexion attitude In Standing: - narrow BOS - Loss of balance During walking: a. ⇒(First) Short steps then⇒ shuffling gait then⇒ Fascinating gait (Running to catch his BOS) then ⇒ Freezing Finally occurs. b. loss of imitation of movement and inability to stop his walking at once c- Propulsion (falling forward) 189  d- Retropulsion (falling backward) e- Lateropulsion (falling to the side) f- Loss of associated movement of Upper limb during walking g- Short step length and stride length h- Loss of pelvic tilting i- Loss of trunk rotation j- Decrease in cadence lack of imitation of movement + short steps + Bradykinesia k- Finally in late stage Freezing occurs => glue feet 1- Inability to change direction (9) Hand Function assessment: C: C: Function ' Dexterity Reactions ' Dysfunction C: Grasp ' prehension (I 0) Tremors assessment: * Draw a circle to the pt. & order him to make points inside the circle =>Normally 2-4 point/sec (severe) 6 point/sec (moderate) 8 point/sec (mild) 10 point/see (normal) A:\ QSevere V moderate mild normal iii No. of points inside figure => improving the case. 190 (11) Bradykinesia assessment: * Give him a sentence to write it down ⇒ Normally: he will write it in 1 minute ⇒ Mild case: in 2 minutes ⇒ Moderate case: in 3 minutes ⇒ Severe case: no writing Or Make patient read a certain paragraph (and put a certain a period of time to read it) Treatment of Parkinsonism I-Treatment of orofacial problems: ⇒ Stretching.ex. to neck flexors & lateral flexors * Neck ext: pt. chin in & PT gives pressure on posterior aspect of head. ⇒ P.N.F. to head & neck (eye problem) ⇒ Breathing ex. ⇒Tracheal Shift, Tapping - Swallowing PNF to head and neck: * P.T hand - 2 fingers on jaw & other fingers free - Other on back of head (or fore head) * Start with flexion rotation to Rt+ eye closed + Mouth opened. * End with extension & rotation to the left+ eye opened + Mouth closed Encourage patient to take deep breath before he speaks in order to increase the volume of sound and the number of words to a breath Over pressure is applied to his thorax on expiration in sitting will improve thoracic expansion. Elevation of arms will increase trunk extension and therefore facilitation of thoracic expansion. 191  Vibration of the thorax alter and increase the tone and volume of vocalization. Tapping under the jaw to stimulate swallowing Gentle shaking to the inside of the cheeks to allow lip closure Lateral vibration to the tongue to stimulate muscle of the tongue Pressure on the anterior third of the tongue on downwards and backwards direction to stimulate swallowing Jaw movements - facial mobility Treatment of all problems ( 1) Stretching exercise: Pectoralis major,Trapezius, Hamstring lliopsoas,Head flexors (SCM & Scaleni), Lateral flexors of the neck & trunk (quadratus lumborum), Hip flexors, Knee flexors and planter flexors *Time of Stretch = Time of relaxation (2) Extension program: => Strengthening exercise to muscle opposite to the stretched muscle 192  (3) Rotation program: Aim => strength the lateral flexor of trunk * Any exercises that in trunk Rolling, turning PNF for upper trunk Counter rotation from side lying Mat activities which emphasis rotation Shift opposite Point opposite Sit and clap Fia- (5). Rcciproc:ol motion - point opposites - lL'iing n mirror -1tm I'"· (7): Shifi opposi1c.s (4) Weight shift program: Aim: Break down of freezing * Weight shift during standing => Teach pt. to change direction. Weight shift then order pt. to press on heels and then change the direction 193 => Teach pt to stand from sitting. Break down of freezing in L.L & trunk * ln L.L=> press on heels=> leads to D.F. in ankle--+ Break down of ankle freezing *Trunk=> leans forward & backward extension (Main as he can gain dorsiflexion) Procedure * Pt. press on his heels, trunk leaning while PT is catching pt. from under the axilla and pt. hands on PT pelvis (or shoulders) then stand up... (5) Rocking shoulder against pelvis * Pt. is side lying * PT. hands--+ on pt pelvis,Shoulder * Then Twist the pt. -------------:1.:· side rocking rocking forward andbackward (6) Rhythmic initiation: (specific technique of P.N.F.) Agonist to facilitate agonist. * By one hand only => Passive then active assisted then Resisted & finally active free. - Extension with rotation to the right: Starting position: patient sitting with trunk flexion & rotation to the left, head rotated to the left, right UL in flexion, adduction, internal rotation while the left hand grasp the right one from above wrist. 194 Manual contact: therapist stand on the right side with the right hand on dorsum of patient's right hand and therapist left hand on patient's occiput and upper trunk. Command: open your hand, extend and rotate your trunk to the right looking toward the ceiling or keep your eye follow the movement. (7) Weights: * Aim: ! Tremors * Velcro strap or weights of hand (8) Breathing exercise: Improve cardiopulmonary function (9) Balancing exercise: (10) Conductive education : l. Tasks {divide any task to sub-tasks} 2. Feed backs {visual -auditory - commands - timing of tasks} * It is a group therapy by using stick. * Aiming to: Mobility of trunk & stretching to scapular muscles. From extension elbow & internal Rotation (11) Postural correction (12) P.N.F. of the Upper trunk: * PT hand On Posterior aspect of the head On pt hand 195 Flexion with rotation to left: So the Right hand will catch the left wrist (With thumb upward) (13) Mitronome: Treatment of pt by: patient flexes his arm with music in the count of 3 and extends in the count of 3 (14) Gait training: (use mirror) * Bridging exercise to prepare gait retraining * Rocking shoulder against Pelvis * Foot prints for treatment of short steps, j Bos * Obstacles to treatment shuffling gait * Use weights in hands to encourage swinging of arm & increase Trunk Rotation for treatment of festinating gait (heel wedge -+ Retropulsion gait) * Emphasize turning movements with small steps and wide BOS. => To improve postural reaction+ j Trunk Rotation. * pt. walks between parallel Bars & PT behind him and while pt move his right leg, PT push his left arm treatment of loss in associated movement (arm swing).n Walking in a figure of 8 L- shaped rotation Psychosocial support: I.Motivation 2.Background music 3.Relaxation exercise 4.Using rocking chair 196  Parkinsonism Early stage I Middle stage late stage * Stretching ex. * PL. is crippled * strengthening ex. -in wheelchair * Care of swallowing * Care of respiration * Care of Bed mobility * Medical treatment of Parkinsonism: *L Dopa: begin with small dose (Parkinole) then L-dopa + capidopa => (sinemit) to improve tremors. N.B. => Best time for physical therapy treatment after taking drugs => 100% of pt has depression before Parkinsonism due to ! dopamine which is responsible for emotions & there is j in depressor associated with !! Dopamine 197