Parkinson's Disease | Physiosimplified

PARKINSON'S DISEASE

INTRODUCTION

Parkinson’s disease was first described as “the shaking palsy” by James Parkinson in 1817 is a progressive disorder of central nervous system with both motor and nonmotor symptoms. Motor symptoms include rigidity, tremor, bradykinesia and postural instability. Non motor symptoms are cognitive impairment , fatigue, mood disorders , anxiety, constipation, rapid eye movement ,orthostatic hypotension etc.

Clinical manifestations-

Motor performance-Fatigue , masked face, micrographia, freezing episodes etc.
Gait – festinating gait ,freeze at initiation, reduced swing and stance phase , impaired balance on turning, chases the center of gravity etc.
Posture- kyphotic posture with forward head
Sensation-pain , paresthesia, akathisia.
Speech, voice and swallowing disorders.

IMPAIRMENTS

BODY STRUCTURE

Degeneration of Pars compacta
Affection of extrapyramidal tract.
Formation of lewy bodies in nigral cells.
Rigidity of agonist and antagonist ms groups(lead pipe or cogwheel)
Kyphotic posture with forward head
Muscle weakness due to deconditioning

BODY FUNCTIONS

Tremors (resting -pill rolling type)
Gait (festinating)
Pain due faulty posture
fatigue
Cardiopulmonary dysfunction
Postural instability
Autonomic dysfunction
Bradykinesia
Impaired righting reflexes
Increased or normal DTR

GOALS

Short term

Patient and family education
Pain management
Prevent secondary complications.
Improve functional mobility
Improve joint integrity and mobility
Improve muscle strength and function
Improve balance and coordination
Gait and locomotion training
Normalization of muscle tone
Improve cardiopulmonary function
Improve aerobic capacity
Fatigue management

Long term

Improve quality of life and health status
Maintain all short term goals
Improve functional independency
Enhance activity pacing and energy conservation skills
Increase tolerance of positions and activities
Prevention of disability

MANAGEMENT

Patient and family education

Education about medications (purpose, dosage)
Assist in decision making & behavioral skills to promote optimal self care
Caregivers should be advised not to give too much of assistance & give room for independent performance.
Information is given regarding community support groups

Motor Learning strategies

In early and mild stages patients can improve their performance through practice and by using additional sensory info.
Visual cues include stationary floor markings (brightly color lines on the floor)
Auditory clues- walking patterns can be improved by with instructions of “swing your arms,” “walk fast,” or “take large steps.”
Velocity cues with the help of rhythmic auditory stimulation
Cues should be consistent not rushed and have a rhythmical quality to it.

Exercise training

Relaxation exercises-

Gentle rocking; rocking chair can be used to relax the muscle tension
Slow, rhythmic rotational movements of the extremities and trunk can produce generalized relaxation
For example ,hook-lying ,lower trunk rotation or side lying rolling can be used to promote relaxation.
PNF techniques
Diaphragmatic breathing, meditation, audio-tapes etc.

Flexibility exercises-

AROM & PROM Exs/stretching exs
PNF patterns
PNF stretching

Resistance training-

Specific areas of weakness are targeted, such as antigravity extensor muscles. Strength training can be performed 2 days per week on nonconsecutive days.

Functional training

Bed mobility skills (i.e, rolling, bridging, supine-to-sit, transition)
Side lying Rolling activities i.e segmental rolling
Bridging to improve scooting in bed as well as sit-to-stand transfers
Sitting can be enhanced by exercises to improve pelvic mobility.
standing
The patient needs to first gain the fully upright position with symmetrical weight-bearing over the BOS.
Once standing achieved, weight shifts and rotational movements of the trunk should be practiced (e.g., reciprocal arm swings or reaching movements). Step-ups using a low platform step (forward, lateral) should be practiced. Backward stepping can be used to strengthen hip and spinal extensors and promote upright posturing.

Balance training

Patients should be instructed in how to improve postural alignment and in ways to avoid postural disturbances and falls.
The therapist can assist with postural and safety awareness by using appropriate verbal, tactile, or proprioceptive cues to facilitate the desired responses. For example, the patient is instructed to “sit tall” or “stand tall” and a mirror is used to provide feedback concerning upright posture.
Dynamic stability tasks e.g., weight shifts, alternating unilateral weight-bearing, reaching, axial rotation of the head and trunk, axial rotation combined with reaching Challenges to balance can also be introduced by Altering arm positions (e.g., arms out to side, arms folded across chest, reaching).
Standing on heel rises, on toe offs. Partial wall squats, chair rises Single limb stance, side kicks and back kicks. Marching in one place , all these exercises are termed as ‘Kitchen Sink Exercise’

Locomotor training

Marching in place emphasizing on high stepping.
brisk marching music to enhance pace.
side stepping and crossed-step walking.
Strategies to improve foot placement can include use of ﬂoor markers or footprints on the ﬂoor.
Reciprocal arm swing with 2 wands along with PT.

Pulmonary rehabilitation

DBE & exercise that recruit neck, shoulder & trunk muscles
Upper body resistance exercise may improve respiratory eﬃciency
Chest wall mobility with UE pnf
Exercise in unsupported sitting to improve trunk stabilization
Improve trunk extension is especially important in improving breathing patterns in patients with postural kyphosis.

Aerobic conditioning

Submaximal intensities (50- 70% ) are indicated to improve CV response
Training modes include UL & LL ergometer, walking
Regular exercise is recommended

Group and HEP

Benfit from positive support & communication among group.
Select Pt with similar level of disability
Regular exercise is started but avoid over exercise
Early morning calisthenics will help in reducing morning stiffness

REFERENCES

Susan B.O'Sullivan , et.al, physical rehabilitation, 6th edition