Parkinson’s Parkinson’s DiseaseDisease

Parkinson’s Parkinson’s DiseaseDisease

Supervised by:Supervised by:Dr.SamehaDr.SamehaDone By:Done By:

Basmah Al-MubarakBasmah Al-MubarakAyat Al-SinanAyat Al-Sinan

Definition: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: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: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-the-counter 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: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: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.

• 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:Assessment:

during assessment of Parkinson's patient focus should be on the following:

• Muscle tone: it is done on both upper and lower limbs

by passive movement or shakingthese 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 minutebalance 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 writingpronation 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 diseasethe 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 activelyThe normal ROM of the cervical spine include:

• Gait:to see the walking pattern, gait description and arm swinguse mirror to show the patient his gait pattern

Treatment:Treatment:

Non surgical (Physical Therapy):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 :Medication :

• Levodopa

• Dopamine agonists

• MAO-B inhibitors

Stalevo for treatment of Parkinson's disease

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.

Postural correction: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 :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: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:Stretching exercises:

Strengthening exercises:Strengthening exercises:

Flexibility and ROM exercisesFlexibility and ROM exercises::

Swiss ball exercises:Swiss ball exercises:

These exercises are used to improve balance

Orthosis and bracing :Orthosis and bracing :

Lumbar and lumbosacral brace:

Balance exercises:Balance exercises:These are used to improve balance

Frenkel's exercises:Frenkel's exercises:These exercises are used to improve coordination

Patient Mobility: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: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 Walking and going up and down the stairs:stairs: These are cardiovascular exercises for arms and legs added to build endurance and improve circulation

Proper Alignments:Proper Alignments:

Proper sitting alignment

Proper sleeping alignment

Proper weight lifting

Speech therapy: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 :Occupational Therapy :

• 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

• 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 :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:References:

• 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 21-5-2007 from http://www.health-cares.net

• Diagnosis of parkinsons disease. Retrieved on 22-5-2007 from http://www.wemove.org