PD

• Parkinson Disease


  Neurological condition characterized by motor symptoms like tremor, rigidity, bradykinesia, and postural instability

  
• Cardinal Motor Symptoms of Parkinson's Disease


  • Tremor
  • Rigidity
  • Bradykinesia
  • Postural instability

  
• Tremor


  • Involuntary oscillations resulting from contraction of opposing muscles
  • Early stages: distal hand or foot, one side of the body, resting tremor
  • Later stages: increased severity, bilateral, action tremor, interferes with ADLs
• Rigidity


  • Increased resistance to passive motion, not velocity dependent, both agonist and antagonist
  • Cogwheel rigidity: jerky, ratchet-like resistance
  • Lead pipe rigidity: sustained rigidity
  • Progression over disease course: proximal to distal, unilateral to bilateral, increased severity
  • Secondary complications: contracture, postural deformity, fatigue, energy expenditure
• Bradykinesia


  • Akinesia: absence of movement (e.g. freezing, no arm swing)
  • Hypokinesia: decreased movement (e.g. micrographia, reduced arm swing)
  • Slowness of movement (e.g. reduced reaction time, movement time)
  • Insufficient recruitment of muscle force and under scale internally generated movements
• Postural Instability


  • Balance: reduced limits of stability, slow anticipatory postural adjustments, poor reactive balance, abnormal co-contraction, falls
  • Posture: decreased activation of antigravity muscles, flexed posture, center of mass located towards forward limits of stability
  • Gait: slow pace, increased variability and asymmetry, poor postural control, decreased step size, reduced arm swing/trunk rotation, reduced anticipatory postural adjustments prior to stepping, turn en bloc with more steps, festination, freezing of gait
• No primary sensory loss associated with Parkinson's Disease

  
• Nonmotor Symptoms: Sensory


  • Pain: musculoskeletal, dystonic, neuropathic/radicular, central or primary, akathisia (feeling of inner restlessness)
  • Hypersensitivity to pain more common in off state of medication
  • Perception of kinesthesia and proprioception impaired, failure to recognize deficits in movement size
  • Visual perceptual deficits and oculomotor changes
  • Olfactory dysfunction: most have either increased or loss of sense of smell, often occurs years before diagnosis

  
• Nonmotor Symptoms: Dysphagia


  • Results from rigidity and reduced movements, may impact tongue control, chewing, bolus formation, swallowing (delay), peristalsis
  • Complications: choking, aspiration pneumonia, poor nutrition, weight loss, sialorrhea

  
• Nonmotor Symptoms: Speech Disorders


  • Hypokinetic Dysarthria: reduced volume, monotone/monopitch, imprecise articulation, uncontrolled rate of speech, hoarse, mutism
  • Contributing factors: motor symptoms (rigidity, hypokinesia, bradykinesia, tremor) impacting muscles controlling respiration, phonation, resonation and articulation
  • Impacts participation and contributes to social isolation

  
• Nonmotor Symptoms: Cognition


  • Bradyphrenia: slowness of thought, early symptom
  • Mild Cognitive Impairment: processing speed, set-shifting, attention, verbal fluency, planning, abstract reasoning, visuospatial, verbal and visual memory, impacts motor learning and dual task performance
  • Dementia: progression of symptoms from MCI, greatest risk for older individuals, levodopa toxicity (hallucinations, delusions and psychosis)

  
• Nonmotor Symptoms: Sleep Disorders


  • REM sleep behavior disorder: occurs prior to motor symptoms in up to 60% of individuals, incomplete or absent paralysis during REM, dream-enacting behaviors
  • Excessive daytime somnolence
  • Insomnia: difficulty falling asleep, difficulty staying asleep, poor sleep quality
• Nonmotor Symptoms: Depression, Anxiety and Apathy


  • Depression: 40%
  • Anxiety: 31%
  • Apathy: 40%
  • Neurobiological cause: alterations in dopamine, serotonin and norepinephrine
  • Apathy improves initially with dopamine therapy
  • Anxiety and depression worse during "off" medication times
  • Hypomimia: reduced facial expression may be mistaken for depression or apathy

  
• Nonmotor Symptom: Autonomic Dysfunction


  • Seen early in disease and progresses with disease course
  • Symptoms: impaired thermoregulation/hyperhidrosis, slow pupillary response to light, reduced gastric motility/constipation, urinary incontinence, blunted HR response to exercise, orthostatic hypotension, pulmonary dysfunction

  
• Parkinsonism


  Bradykinesia + tremor or rigidity

  
• Parkinson's disease


  Parkinsonism without symmetrical bilateral signs, clear and dramatic benefit from dopamine therapy

  
• Pharmacological Management: Mechanism of Action


  • Dopamine replacement (levodopa/carbidopa)
  • Dopamine agonist (ropinirole, pramipexole, apomorphine)
  • COMT inhibitors (entacapone, tolcapone)
  • MAO-B inhibitors (rasagiline, selegiline)
  • Anticholinergics (benztropine mesylate, trihexyphenidyl)
  • Amantadine
  • Norepinephrine precursors (droxidopa)
  • Cholinesterase inhibitors (rivastigmine tartrate)
  • Atypical antipsychotics (pimavanserin)
• Pharmacological Management: Common Side Effects


  • Wearing-off
  • Dyskinesia
  • Dystonia
  • Low BP
  • Dizziness
  • Nausea
  • Dry mouth
  • Insomnia
  • Constipation
• Deep Brain Stimulation


  • Electrodes implanted in brain with subclavicular impulse generator and external controller
  • Electrode placement: subthalamic nucleus (improve motor symptoms and tremor, reduce medication) or globus pallidus internus (improve motor symptoms, tremor, suppress dyskinesia)
  • Effective for 10-20% of individuals considered "good candidates"
  • Symptoms poorly controlled by levodopa unlikely to improve and may worsen (gait, postural instability, speech, posture)
• Nutrition


  • High protein diet can block levodopa absorption, reduce calories from protein (≤ 15%), eat protein later in day
  • Interdisciplinary collaboration: nutritionist, occupational therapist (adaptive feeding devices), speech-language pathologist (swallowing and dysphagia)
• ICF Framework


  • Health Condition
  • Body Structures and Functions (Primary)
  • Body Structures and Functions (Secondary)
  • Activities
  • Participation
  • Personal Factors
  • Environmental Factors
• Physical Therapy Evaluation, Diagnosis and Prognosis
• Current Evidence Supports: Combined physical therapy and pharmacology management, Early intervention, Maximize function, Minimize secondary complications, Provide education and support, Slow progression of disability, Possibly slow disease progression
• Cumulative number of RCT on the efficacy of physical therapy in Parkinson Disease

  
• Groups – target extensor muscles
• Avoid isometric training – Why??
• Intervention: Flexibility Exercises (CPG)


  1. Physical therapists may implement flexibility exercises to improve range of motion (ROM) in individuals with PD

  2. May be a part of a home program or part of your warm up/cool down

  3. The recommendation is based on expert opinion due to the low quality of the evidence
• Flexibility


  • Improves pain, QOL, improve balance
  • PROM, AROM, facilitated exercise
  • Choose exercises that strengthen extensors and lengthen flexors
  • Combined movements helpful to conserve energy
  • PNF, Stretching
  • Precautions (sedentary, elderly, osteoporosis)
  • Combine with joint mobilization
  • Passive positioning
• Intervention: Relaxation


  1. Gentle rocking can temporarily relax rigidity

  2. Slow, rhythmic rotational movements of extremities and trunk may proceed other interventions

  3. NDT and PNF techniques

  4. Slow rotation / rhythmic rotation

  5. Rhythmic Initiation

  6. Breathing during exercise

  7. Bilateral symmetrical PNF D2 flexion pattern

  8. Relax to move

  9. Deep breathing, audio tapes, meditation, imagery, gentle yoga, Tai chi

  10. Stress management
• Intervention: Balance Training (CPG)


  1. Improve postural control impairments

  2. Improve balance, gait and mobility

  3. Increase balance confidence

  4. Improve QOL
• Balance Training


  • Balance training can significantly improve postural instability (i.e. dancing, tai chi)
  • Exercise without balance training or home programs do not improve postural instability
  • Static and dynamic activities, transition tasks, and perturbations (apply with caution)
  • Center of mass (COM) and limits of stability (LOS) control training
  • Practice under variety of sensory and environmental conditions
  • Practice in a variety of positions
  • Combine with aerobic and gait training
  • Consider safety (gait belt, harness, supervision)
• Intervention: Functional or Task-specific Training


  1. Bed mobility skills

  2. Sitting / Standing

  3. Posture

  4. Mobility

  5. Extension

  6. Rotation

  7. Sit to stand

  8. Transfers

  9. Floor to sit/stand transfers (Falls)

  10. 4 point – creeping, trunk extension

  11. Kneeling to half kneeling
• Intervention: Gait Training (CPG)


  1. Improve stride length, gait speed, mobility and balance

  2. 20-60 min, 3-5 d/wk, for 4-12 weeks

  3. Decline post training so may need to continue

  4. Consider safety / falls risk
• Functional Gait Training


  • Increase step length
  • Increase gait speed
  • Encourage reciprocal arm swing
  • Improve upright alignment
  • Vary task and environmental demands
  • Compensatory Strategies (when necessary)
  • Cues, harness or body weight supported treadmill training, Nordic walking
• Assistive Devices


  • Bed mobility
  • Sit to stand
  • Clothing
  • Gait aids (Cane, walker, walking poles)
  • Special considerations: Height should not promote flexion, Consider safety (i.e. wheels + festinating gait)
• Intervention: Pulmonary Rehabilitation


  1. diaphragmatic breathing, air shift techniques, strengthen accessory muscles

  2. manual techniques

  3. ROM/mobilize chest wall

  4. postural exercise
• Intervention: Community Based Exercise (CPG)


  1. Reduce motor disease severity

  2. Improve nonmotor symptoms

  3. Improve functional outcomes

  4. Improve quality of life
• Community Based Exercises


  • Yoga
  • Tai Chi
  • Pilates
  • Boxing
  • Dance
  • PWR! (Parkinson's Wellness Recovery)
  • Group classes