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Parkinson’s Disease
Supervised by:
Dr.Sameha
Done By:
Basmah Al-Mubarak
Ayat Al-Sinan
Definition:
Parkinson disease ( PD) is a brain disorder. It
occurs when certain nerve cells (neurons) in a
part of the brain called the substantia nigra die
or become impaired. Normally, these cells
produce a vital chemical known as dopamine.
Dopamine allows smooth, coordinated function
of the body's muscles and movement. When
approximately 80% of the dopamine-producing
cells are damaged, the symptoms of Parkinson
disease appear.
Causes:
•
The immediate cause of Parkinson's disease is the
destruction of brain cells in a part of the brain known
as the substantia nigra (SN). The substantia nigra
controls many types of muscular movement by
releasing a neurotransmitter called dopamine. A
neurotransmitter is a chemical that transports
electrical signals between brain cells. Dopamine is
needed to carry nerve messages from one brain cell
to another.
•
When brain cells die in the substantia nigra it doesn't
release enough dopamine. Without dopamine,
signals cannot travel from SN brain cells to cells in
other parts of the brain. The "instructions" that brain
cells need to move muscles do not reach their
targets. Eventually, walking, writing, reaching for
objects, and other basic movements do not occur
correctly. Muscular movement becomes weaker and
more erratic.
•
Researchers have not yet discovered the basic cause
of Parkinson's disease. They do not know why SN
brain cells lose the ability to produce dopamine.
Some scientists think that the disease is hereditary.
They believe that PD can be passed down from
generation to generation. Other researchers think
that environmental factors may be to blame. They
suspect that certain chemicals in the world around us
get into the human body and damage SN brain cells.
•
A few chemicals have been found that cause the
symptoms of PD. One chemical known to cause
symptoms of PD is called MPTP. MPTP is
sometimes found as an impurity in illegal drugs. A
person who accidentally ingests (eats) MPTP begins
to show signs of PD within hours. These symptoms
become permanent.
Signs and Symptoms:
Parkinson’s disease symptoms often begin on one side
of the body. However, as it progresses, the disease
eventually affects both sides. Even after the disease
involves both sides of the body, the symptoms are
often less severe on one side than on the other. The
four primary symptoms of PD are:
•
Tremor. The tremor associated with PD has a
characteristic appearance. Typically, the tremor takes
the form of a rhythmic back-and-forth motion at a rate
of 4-6 beats per second. It may involve the thumb and
forefinger and appear as a "pill rolling"
tremor. Tremor often begins in a hand, although
sometimes a foot or the jaw is affected first. It is most
obvious when the hand is at rest or when a person is
under stress. For example, the shaking may become
more pronounced a few seconds after the hands are
rested on a table. Tremor usually disappears during
sleep or improves with intentional movement.
•
Rigidity. Rigidity, or a resistance to movement,
affects most people with PD. A major principle of body
movement is that all muscles have an opposing
muscle. Movement is possible not just because one
muscle becomes more active, but because the opposing
muscle relaxes. In PD, rigidity comes about when, in
response to signals from the brain, the delicate balance
of opposing muscles is disturbed. The muscles remain
constantly tensed and contracted so that the person
aches or feels stiff or weak. The rigidity becomes
obvious when another person tries to move the
patient's arm, which will move only in ratchet-like or
short, jerky movements known as "cogwheel" rigidity.
•
Bradykinesia. Bradykinesia, or the slowing down
and loss of spontaneous and automatic movement,
is particularly frustrating because it may make
simple tasks somewhat difficult. The person
cannot rapidly perform routine movements.
Activities once performed quickly and easily — such
as washing or dressing — may take several hours.
•
Postural instability. Postural instability, or
impaired balance, causes patients to fall
easily. Affected people also may develop a stooped
posture in which the head is bowed and the
shoulders are drooped.
A number of other symptoms may accompany PD.
Some are minor; others are not. Many can be
treated with medication or physical therapy. No
one can predict which symptoms will affect an
individual patient, and the intensity of the
symptoms varies from person to person.
•
Depression. This is a common problem and may
appear early in the course of the disease, even
before other symptoms are noticed. Fortunately,
depression usually can be successfully treated with
antidepressant medications.
•
Emotional changes. Some people with PD
become fearful and insecure. Perhaps they fear they
cannot cope with new situations. They may not
want to travel, go to parties, or socialize with
friends. Some lose their motivation and become
dependent on family members. Others may become
irritable or uncharacteristically pessimistic.
•
Difficulty with swallowing and chewing.
Muscles used in swallowing may work less efficiently
in later stages of the disease. In these cases, food and
saliva may collect in the mouth and back of the throat,
which can result in choking or drooling. These
problems also may make it difficult to get adequate
nutrition. Speech-language therapists, occupational
therapists, and dieticians can often help with these
problems.
•
Speech changes. About half of all PD patients have
problems with speech. They may speak too softly or in
a monotone, hesitate before speaking, slur or repeat
their words, or speak too fast. A speech therapist may
be able to help patients reduce some of these
problems.
•
Urinary problems or constipation. In some
patients, bladder and bowel problems can occur due to
the improper functioning of the autonomic nervous
system, which is responsible for regulating smooth
muscle activity. Some people may become incontinent,
while others have trouble urinating. In others,
constipation may occur because the intestinal tract
operates more slowly. Constipation can also be caused
by inactivity, eating a poor diet, or drinking too little
fluid. The medications used to treat PD also can
contribute to constipation. It can be a persistent
problem and, in rare cases, can be serious enough to
require hospitalization.
•
Skin problems. In PD, it is common for the skin on
the face to become very oily, particularly on the
forehead and at the sides of the nose. The scalp may
become oily too, resulting in dandruff. In other cases,
the skin can become very dry. These problems are
also the result of an improperly functioning
autonomic nervous system. Standard treatments for
skin problems can help. Excessive sweating, another
common symptom, is usually controllable with
medications used for PD.
•
Sleep problems. Sleep problems common in PD
include difficulty staying asleep at night, restless
sleep, nightmares and emotional dreams, and
drowsiness or sudden sleep onset during the
day. Patients with PD should never take over-thecounter sleep aids without consulting their
physicians.
•
Dementia or other cognitive problems. Some,
but not all, people with PD may develop memory
problems and slow thinking. In some of these cases,
cognitive problems become more severe, leading to a
condition called Parkinson's dementia late in the
course of the disease. This dementia may affect
memory, social judgment, language, reasoning, or
other mental skills. There is currently no way to halt
PD dementia, but studies have shown that a drug
called rivastigmine may slightly reduce the
symptoms. The drug donepezil also can reduce
behavioral symptoms in some people with PD-related
dementia.
•
Orthostatic hypotension. Orthostatic hypotension
is a sudden drop in blood pressure when a person
stands up from a lying-down position. This may cause
dizziness, lightheadedness, and, in extreme cases, loss
of balance or fainting. Studies have suggested that, in
PD, this problem results from a loss of nerve endings in
the sympathetic nervous system that controls heart
rate, blood pressure, and other automatic functions in
the body. The medications used to treat PD also may
contribute to this symptom.
•
Muscle cramps and dystonia. The rigidity and
lack of normal movement associated with PD often
causes muscle cramps, especially in the legs and
toes. Massage, stretching, and applying heat may help
with these cramps. PD also can be associated with
dystonia — sustained muscle contractions that cause
forced or twisted positions. Dystonia in PD is often
caused by fluctuations in the body's level of
dopamine. It can usually be relieved or reduced by
adjusting the person's medications.
•
Pain. Many people with PD develop aching muscles
and joints because of the rigidity and abnormal
postures often associated with the disease. Treatment
with levodopa and other dopaminergic drugs often
alleviates these pains to some extent. Certain exercises
also may help. People with PD also may develop pain
due to compression of nerve roots or dystonia-related
muscle spasms. In rare cases, people with PD may
develop unexplained burning, stabbing
sensations. This type of pain, called "central pain,"
originates in the brain. Dopaminergic drugs, opiates,
antidepressants, and other types of drugs may all be
used to treat this type of pain.
•
•
•
Fatigue and loss of energy. The unusual
demands of living with PD often lead to problems
with fatigue, especially late in the day. Fatigue may
be associated with depression or sleep disorders, but
it also may result from muscle stress or from
overdoing activity when the person feels
well. Fatigue also may result from akinesia –
trouble initiating or carrying out
movement. Exercise, good sleep habits, staying
mentally active, and not forcing too many activities
in a short time may help to alleviate fatigue.
coordination.
– impaired gross motor coordination;
– Poverty of movement: overall loss of accessory
movements, such as decreased arm swing when
walking, as well as spontaneous movement.
Gait and posture disturbances.
– Shuffling: gait is characterized by short steps,
with feet barely leaving the ground, producing
an audible shuffling noise. Small obstacles tend
to trip the patient
– Decreased arm swing: a form of bradykinesia
– Turning "en bloc": rather than the usual twisting
of the neck and trunk and pivoting on the toes,
PD patients keep their neck and trunk rigid,
requiring multiple small steps to accomplish a
turn.
– Stooped, forward-flexed posture. In severe
forms, the head and upper shoulders may be
bent at a right angle relative to the trunk
(camptocormia).
– Festination: a combination of stooped posture,
imbalance, and short steps. It leads to a gait that
gets progressively faster and faster, often ending
in a fall.
– Gait freezing: "freezing" is another word for
akinesia, the inability to move. Gait freezing is
characterized by inability to move the feet,
especially in tight, cluttered spaces or when
initiating gait.
Stages of Parkinson’s Disease:
Parkinson's disease may also be described by five stages:
•Stage I (mild or early disease):
Symptoms affect only one side of the body. Symptoms
are present as inconvenient but not disabling. Usually
tremor of one limb will happen. And changes in posture,
locomotion, and facial expression will be noticed.
•Stage II:
Both sides of the body are affected, but posture remains
normal. The patient has minimal disability, his posture
and gait affected, but responds well to medication.
•Stage III (moderate disease):
Both sides of the body are affected, and there is mild
imbalance during standing or walking. However, the
person remains independent. Balance on walking or
standing is impaired. The patient has generalized
disability, moderately severe. Predictable “wearing off”
effects of medication, on-off fluctuations, and
dyskinesias will be noticed.
•Stage IV (advanced disease):
Both sides of the body are affected, and there is disabling
instability while standing or walking. The person in this
stage requires substantial help. But tremor may be less
than earlier stages
•Stage V:
Severe, fully developed disease is present. The person is
restricted to a bed or chair. There’re motor fluctuations
and cognitive impairment. The patient requires constant
nursing care.
Diagnosis:
Since there is no specific test or marker for PD, To
diagnose PD, the physician will perform a standard
neurological examination, involving various simple
tests of reactions, reflexes, and movements.
•
•
•
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Bradykinesia: is tested by determining how quickly
the person can tap the finger and thumb together, or
tap the foot up and down.
Tremor: is determined by simple inspection.
Rigidity: The physician assesses rigidity by moving
the neck, upper limbs, and lower limbs while the
patient relaxes, feeling for resistance to movement.
Postural instability: is tested with the "pull test," in
which the examiner stands behind the patient and
asks the patient to maintain their balance when
pulled backwards. The examiner pulls back briskly
to assess the patient's ability to recover, being
careful to prevent the patient from falling.
The examination also involves recording a careful
medical history, especially for exposure to
medications that can block dopamine function in
the brain.
•
magnetic resonance imaging (MRI) : can be used to
diagnose the brain lesions
This presents on MRI as a dark area (a loss of signal). This
was demonstrated by a T2 weighted MRI of a Parkinson's
patient's brainstem with signal loss in the substantia nigra.
Assessment:
during assessment of Parkinson's patient focus
should be on the following:
•
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•
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Muscle tone:
it is done on both upper and lower limbs by
passive movement or shaking
these assessments are done to detect if there is
hypotonia (flaccidity) or hypertonia which may
be spasticity or rigidity
Functional Activities:
the activities that include rotation, rolling to
either side, from side lying to sitting, transfer
from bed to chair, from sitting to standing, sitting
up from floor, turning 180º on command,
walking, putting on coat and taking it off and
climbing stairs
Balance:
from sitting and standing unsupported for one
minute
balance on either leg for 5 seconds
Posture:
give the patient time to adopt his normal posture
before rating
•
•
•
•
•
Tremor:
hands relaxed ( held loosely over the end of
armrests) while the patient is under stress induced
for 10 seconds
Micrographia and Bradykinesia:
using the normal hand writing, copy out some lines
of writing
pronation and supination
Dexterity:
e.g. fasten three buttons
Cardiorespiratory status:
vital capacity, forced expiration volume and chest
expansion and mobility
Oro-facial functions:
assessment for the movements of the face and mouth
and problems that occur in this area following
Parkinson's disease
the restoration of orofacial function should be of
paramount importance for the physiotherapist and
speech and language therapist. Problems in this area
can lead to an inability to close the lips, move food
around in the mouth and thus eating can become
embarrassing for the patient. If eye closure is a
problem then eye care is crucial and the eyelid may
require temporary stitching for protection
•
Range of Motion:
to detect presence of deformities both passively and
actively
The normal ROM of the cervical spine include:
•
Gait:
to see the walking pattern, gait description and arm
swing
use mirror to show the patient his gait pattern
Treatment:
Non surgical (Physical Therapy):
Parkinson's disease is a chronic disorder that
requires broad-based management including
patient and family education, support group
services, general wellness maintenance,
exercise, and nutrition. At present, there is no
cure for PD, but medications or surgery can
provide relief from the symptoms.
Medication :
•
Levodopa
• Dopamine agonists
• MAO-B inhibitors
Stalevo for treatment of Parkinson's disease
Parkinson's disease is a chronic disorder that requires broadbased management including patient and family education,
support group services, general wellness maintenance,
exercise, and nutrition. At present, there is no cure for PD,
but medications or surgery can provide relief from the
symptoms.
•
•
•
•
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•
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Postural correction:
Correction and maintenance of proper posture involves the
evaluation of several areas. Some of those include:
Spinal Alignment
Computer Workstations
Muscle Imbalance
Exercise
Extremity Alignment
Footwear
Correct Sitting
balance and coordination of the body's systems
Canes and Walkers :
these can be recommended The therapist can teach
the patient how to use the cane to support his body
weight and move easily
Hot Packs:
The hot pack is applied on the site of pain (neck or
back) for 10 min to:
•improves circulation
• improves cell function (metabolism)
• decreases stiffness in tendons and ligaments
• relaxes the muscles and decreases muscle spasm
• lessens pain
Stretching exercises:
Strengthening exercises:
Flexibility and ROM exercises:
Swiss ball exercises:
These exercises are used to improve
balance
Orthosis and bracing :
Lumbar and lumbosacral brace:
Balance exercises:
These are used to improve balance
Frenkel's exercises:
These exercises are used to improve coordination
Patient Mobility:
work with physical therapist on everyday activities
such as changing positions from sitting to standing,
standing to sitting and getting out of bed
Cardiovascular exercises:
for arms and legs (arms and/or leg cycle, treadmill,
swimming) may be added to build endurance and
improve circulation
•
Walking and going up and down the stairs:
These are cardiovascular exercises for arms and legs
added to build endurance and improve circulation
Proper Alignments:
Proper sitting alignment
Proper sleeping
alignment
Proper weight lifting
Speech therapy:
The most widely practiced treatment for the speech
disorders associated with Parkinson's disease is Lee
Silverman Voice Treatment (LSVT). LSVT focuses
on increasing vocal loudness
Occupational Therapy :
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Occupational therapy includes:
Arm and hand therapy
Handwriting aids
Home modification information
Driver evaluation and vehicle modification
information
Cooking and homemaking adaptations
Eating and dinnerware adaptations
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Computer modifications
Workplace or work equipment modifications
Leisure skill development
Manual or electric wheelchair use
Bathtub and toilet equipment use
Dressing and grooming aids
Surgical interventions :
Treating Parkinson's disease with surgery was once
a common practice. But after the discovery of
levodopa, surgery was restricted to only a few cases.
Studies in the past few decades have led to great
improvements in surgical techniques, and surgery is
again being used in people with advanced PD for
whom drug therapy is no longer sufficient. Deep
brain stimulation is presently the most used
surgical means of treatment.
Illustration showing an electrode placed deep seated in the brain
References:
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Parkinson’s disease. Retrieved on 18-5-2007 from
http://en.wikipedia.org/wiki/parkinson’s_disease
Parkinson’s disease. Retrieved on 20-5-2007 from
www.ninds.nih.gov/disorders/parkinsons_disease
About parkinsons disease Retrieved on 17-5-2007 from
www.parkinson.org
Parkinson's Disease: Physical and Occupational Therapy . Retrieved
on 17-5-2007 from http://www.webmd.com/parkinsons-disease
What’re the stages of Parkinson's disease. Retrieved on 21-52007 from http://www.health-cares.net
Diagnosis of parkinsons disease. Retrieved on 22-5-2007 from
http://www.wemove.org