Parkinson's disease, etiology, pathology, symptoms, diagnosis, treatment Physiotherapy.

Parkinson's  disease is a chronic progressive disease of the nervous system characterised by 4 cardinal features

1. Rigidity
2. Tremor
3. Bradykinesia
4. Postural instability. 

Onset is insidious (gradual) with a slow rate of progression. Disruption in daily function, roles& activities and depression are common in individuals with Parkinson's disease. 

Epidemiology:- 

1% - 55 years

2.6% - 85 years 

Males are slightly more at risk than female. 

Etiology:-

The term Parkinson's is used to refer to a group of disorder that produce abnormalities of badal ganglia function

• 1° Parkinson's:- It is the most common cause, it is also known as true or paralysis agitans. Etiology is idiopathic, unknown. 
• Secondary Parkinson's:- In this type, Parkinson's has been reported with cryptococcal meningitis, encephalitis and Jacob- create feldt disease. 
• Parkinson- plus syndromes:- A group of neurodegenerative disease can affect the substantia nigra 
• Toxic Parkinsonism:- Parkinson's syndrome occurs in individuals exposed to certain industrial poisons& chemicals                     eg:-manganese
• Pharmacological Parkinsonism:- a variety of drugs can produce extrapyramidal dysfunction that mimics the signs of PD. 
• Metabolic causes:- it is a rare cause, including disorders of Ca metabolism are hypo &hyperthyroidism, hypoparathyroidism. 

Pathophysiology:-

• The basal ganglia are a collection of nuclear masses deep within the brain. 
• The BG plays an important role in the production of voluntary movement & control of postural adjustments associated with voluntary movements. 
• Information is transferred from cerebral cortex & thalamus through multiple circuits divided into Direct & Indirect pathways. 
• Direct pathway facilitates flow of signals to the thalamus activating some movements. 
• Indirect pathways inhibits information flow & suppress other movements. 
• Damage to the BG results in motor disturbance that can be hyperkinetic ex:- Chorea, Dystonia. Or hypokinetic ex:- Akinesia, bradykinesia. 
• PD associated with degeneration of Dopamine
• Direct & indirect pathways are affected, reduce spontaneous movements. 

Clinical features:-

Rigidity:-

•  the patient complains of heaviness & stiffness of their limbs
• it is felt uniformly in muscle on both sides of the joints & movements in both directions.
• rigidity is present regardless of the task, amplitude or speed of the movements. 2types of rigidity Cog wheel, lead pipe. 

Akinesia & Bradykinesia:-

• Akinesia refers to difficulty in initiating movement & freezing may occur and are characterized by a sudden break or block in the movement. 
• Bradykinesia refers to slowness & difficulty maintaining movement and are reduced in speed, range & amplitude termed hypokinesia. 

Tremor :- 

• It is initial symptom of PD in about 50% of the patient. 
• Tremor is described as an resting tremor, because it is typically present at rest & disappears with voluntary movement 
• Some individual exhibit postural tremor

Postural instability:-

• Patient experience increasing difficulty during dynamic activities such as self- initiating movement ( walking, turning) 
• Frequent falls & fall injury are the result of progressive loss of balance reaction s. 

Indirect impairment & Complications:-

• Poverty of movement
• Fatigue
• Masked face
• Musculoskeletal changes
• Gait disturbances
• Swallowing & Communication dysfunction
• Visual & sensory motor disturbance
• Cognitive & Behavioural dysfunction
• Autonomic dysfunction
• Cardiopulmonary dysfunction

Diagnosis:-

• Early diagnosis of PD is difficult. 
• Diagnosis is usually made on basis of history & clinical examination ex:- Handwriting samples, speech analysis. 
• Diagnosis is made if at least 2 of the 4 cardinal features are present. 
• Lewis bodies can be identified in PET scan in later stage. 

Medical Management:-

• There is no cure for PD Medical therapy is symptomatic & individualised.
• Drug management divided into Early protective therapy, symptomatic treatment in middle &later stage. 
• In early stage Deprenyl - reduce stress on neurons, Selegiline - on disability & motor impairment. Dopamine, levodopa, Sinemet, Deprenyl, Anticholinergics, 
• Moderate to advance PD - Bromocriptine. 

Nutritional management:-

• High calorie & low protein diet is advisable. 
• Patient are advised to increase their daily intake of water & dietary fiber to alleviate problems of constipation. 

Surgical Management:-

• Sterio Toxic Surgery
• Pallidotomy
• Thalamotomy
• Deep brain stimulation

Physiotherapy Management:-

Movements must be carefully balanced with adequate rest periods to ensure that the patient does not fatigue or become exhausted. 

Relaxation exercises:-To reduce rigidity

• Gentle rocking & rotational exercises can be used for excessive muscle tension due to rigidity. 
• Slow rhythmic, rotational movements through small ranges are effective in temporarily reducing rigidity. 
• Exercises should initially performed in fully supported position 

1. ex:- Supine - slow - side to side head rotations.
2. supine - Bilateral PNF patterns, Upper trunk rotation. 
3. Hook lying - Lower trunk rotation. 
4. Side lying - Trunk rotation + scapular movements. 

• Rhythmic initiation ( PNF technique) is effective to overcome immobility in PD. 

Flexibility exercises:-

• Both active & passive ROM exercises are used to improve flexibility. 
• PNF technique Hold Or contract relax
• Stretching technique to elongate muscle
• Stretching can be combined with joint mobilisation technique to reduce tightness of the capsule or ligament around the joint. 

Mobility exercises:-

• Mat exercises. 
• PNF extremity patterns with sitting for ex:-Bilateral symmetrical UE, D2 flexion & D2 extension are ideal as they expand the restricted chest while promoting upper trunk extension. 
• In standing, rotational movements of the trunk should be practiced. 
• Reciprocal arm swing or reaching movements can be used to promise trunk rotation. 
• Mobilising facial muscles:- use of massage, stretch, manual contacts, verbal commands cam be used to enhance facing movements. 
• The patient is instructed to practice lip pursing, movements of the tongue, swallowing & facial movements such as smiling, frowning etc.., 

Balance activities:-

• Weight shifts in both sitting & standing ex:- Picking up an object from the floor, tying shoes, movements transition like sit to stand, half kneeling to stand & stepping are taught. 
• Perturbation, single limb stance, side walking 

Gait training:-

• Goals- To lengthen the stride, broaden BOS, improve stepping, Improve heel toe gait pattern, increase contralateral trunk movement & arm swing. 
• Marching at place to improve hip flexors. 
• Reciprocal arm swing using sticks. 

Respiratory exercises:- 

• Diaphragmatic breathing exercises
• Air shifting technique. 
• Exercises that recruit neck, shoulder & trunk muscles. 

Group exercises:- 

• Provide motivation to the patient. 

Motor learning tasks:-  

• 1st demonstration - repetition by breaking down the task into simpler form.