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Parkinson's Disease (Clinical Presentation (Non-motor symptoms…
Parkinson's Disease
Incidence/Etiology
Average age 50-60
2nd most common neurodegenerative disorder, behind only AD
Parkinsonism - group of disorders that affect dopamine system in basal ganglia
Idiopathic parkinsonism (PD) is most common form; there is also secondary parkinsonism and parkinsonism-plus syndromes
2 clinical subgroups of PD: postural stability and gait disturbances group, and tremor group
Secondary parkisonism caused by toxins, viruses, or medications
Pathophysiology
Degeneration of dopamine-producing neurons and presence of Lewy bodies as disease progresses
Clinical Presentation
Cogwheel (jerky) or Lead pipe (sustained) rigidity that typically affects proximal muscles first
Bradykinesia that can be worsened by bradyphrenia(slowness of thought)
may be ameliorated by external cues
Akinesia ie. hypomimia (masked facial expression), FOG (freezing of gait), which can increase risk of falling or hypokinesia
Resting tremor or action tremor with severe PD
More apparent in LE when supine, can be aggravated by stress
Postural instability
Rare in early PD
Difficulty maintaining COM within BOS that is worsened by narrowing BOS, divided attention
Self-initiated movements and external perturbations will be difficult
Difficulty with anticipatory balance to different conditions, ie. unstable surface, or catching an object
Weak anti-gravity muscles result in stooped posture- brings invidividual close to forward limits of stability
Falls are common - can lead to fractures, FOF (fear of falling
Secondary motor symptoms
muscle weakness, dual-task control impaired/complex sequential task, increased movement preparation, ie. START HESITATION
Context interference is present in learning
Festinating gait pattern - fast shuffling gait w/small steps
Non-motor symptoms
Intermittent paresthesias, sensory loss, pain from postural stress syndrome (secondary to kyphotic posutre)
Proprioception impaired, oflactory impariment
Dysphagia
Can lead to nutrition deficits and sialorrhea(drooling)
Speech: hypokinetic dysarthria, quiet speech, mutism
Depression, anxiety
Autonomic dysfunction: excessive sweating, increased oil secretion, incontience, erectile dysfunction, orthostatic hypotension
Sleeping disorders ie. daytime somnolence, insomnia
Medical Diagnosis
made if 2 of the 4 cardinal features are present; no formal diagnostic tests
Assessment tools
Hoehn-Yahr Classification of Disability scale
charts progression of PD based on functional status
Gold standard: Unified Parkinson's Disease Rating scale (UPDRS)
Mentation/Behavior/mood, ADL's, Motor, Complications of treatment
Medical Management
Pharmacological: L-dopa, dopamine agonists, anticholinergics, MAOI's, deep-brain stimulation
Framework for Rehab
Stages
**Table 18.3: Early, middle, late
Examination
Cogntivie
Psychosocial
Sensory
MSK: joint flexibilityk posture, muscle performance
Motor function: rigidity, bradykinesia, tremor, postural control, gait, fall risk, fatigue, dyskinesias, speech
Autonomic function: cardiorepsiratory function, orthostatic hypotension
Integmentary
Functional status, ie. 5xSit to stand, Profile of function and impairmentlevel experince with PD (Profile PD), global health masures (SF-36), disease-specific measures (PDQ-39)
Intervention
Motor learning strategies
high number of reptiations to develop procedural skills
External cues ie. verbal, tactile
Rhythmic auditory stimulation/beats may help with cadence during movements/gait
You want to use blocked practice order initially over random practice order to limit contextual interference effects
Structure instrucitnoal sets, ie. "swing arms", "big steps"
Exercise training
LVST "Big" program
High-intensity; focuses on large-amplitude movements
Relaxation exercises ie. rocking chair, rhythmic initiation pnf technique, diaphragmatic breathing
Flexibility exercise ie. hold-contract relax stretching Table 18.4**
Resistance training
Functional training
bed mobiilty, sitting control, STS, standing activities ie. WB
Balance training - ie. external cues to control COM over BOS
dynamic stability tasks ie. WB, reaching, rotation
Whole-body vibration is an emerging tx for dynamic postural control
Locomotor training
ie. Walking w/poles, verbal instruction sets ie. "bigs steps, swing arms"
BWS training
Task-specific, varying environments/obstacles
Compensatory strategies taught in severe PD
Pulmonary Rehab
Manual techniques to ensure full exhalation, secretion clearance
Educate on deep breathing exercises, Upper body training exercises
Goal to improve trunk ext to improve kyphotic posture that causes repiratory difficulty
Aerobic exercise
Longer durations for lower intensity and vice versa
Monitor carefully due to autonomic dysfunction
Aquatic therapy can be beneficial for gait training as well as endurance
Group/Home exericse
Pts benefit from support/camraderie
Pts should have similar levels of impairment
low-impact aerobics, recreational activity, relaxation exercise
HEP should include stretching, strengthening in different positions
Patient/Family education
Teach self-management techniues in terms of psychosocial well-being
"Hope tempered with realism"
*Box 18.6 Education for PD
Energy conservation, activity pacing
Community resources
Participation in valued leisure and family activities