Parkinsonism

Parkinson disease and parkinsonian syndrome comprise a group of disorders characterized by tremor and disturbance of voluntary movement, posture and balance.

Parkinsonian syndromeParkinson’s disease
Sign and symptom develop secondary to another neurological diseaseIt is a primary degenerative condition irrespective of cause, occurring in the later half of life.

Etiology

  • Disturbance in basal ganglia ( substantia nigra and corpus striatum)
  • Reduction of dopamine at the synapse.
  • Secondary parkinsonism due to phenothiazine drugs or following encephalitis lethargica (rare) is often non- progressive but can be associated with brain damage causing weakness and spasm in muscle and visual impairments.
  • It is a progressive disease with a course from onset to death between 10-15 years. In some cases rapid progression may be seen.
  • Increased immobility leads to weight loss, pressure sores and eventually respiratory failure. 
  • May occur due to severe or repeated brain insult, such cases are drug resistant and do not respond well resulting in reduced effectiveness of treatment. 

Clinical features-

  • The patient generally attributes the symptoms to old age as common symptoms are slowness in walking, disturbance of balance with occasional falls or difficulty in fine movements such as shaving or dressing.
  • Characteristic resting tremors make diagnosis easy if present but are absent in more than 50% of patients.
  • Pain is present commonly but disease is diagnosed as cervical spondylosis, frozen shoulder, backache or osteoarthritis of the hip and so no major pain relief is achieved.
  • Difficulty in specific movements such as writing, turning over in bed and rising from a low chair.
  • Excessive greasiness
  • Inability to raise voice or cough.
  • Unusual tendency to cough.
  • They tend to avoid social engagement as stressful conditions worsen their symptoms.
Fig- Observable clinical features of parkinson’s disease

Signs of Parkinsonism

  1. Posture- Patient stands with slight flexion at all joints (simian posture) specially at knees and hips, rounded shoulders with a forward head posture. In rare cases, posture has the tendency to lean backwards. 

In sitting the patient gets slump in the chair sliding sideways with a forward head posture.

  1. Balance- Patients have the tendency to fall forward as they lack immediate compensatory movements to regain balance. They have a short, shuffling gait pattern. In order to prevent fall they tend to bend forward to chase COG to get their balance back. They have difficulty in turning around and initiating movements due to freezing gait patterns (feets are glued to ground). Getting out of the chair may also be difficult. 
  1. Voluntary movements- Akinesia is seen (reduction in range and speed). Slurry and slow speech with micrographia (writing becomes small and untidy) is seen. Movements affected can include- chopping, cleaning, driving, polishing, stirring, typing etc. 
  1. Automatic movements- They are either reduced or lost completely in parkinsonism. Patients become expressionless, blink less frequently, no swinging of arms during walk, dropping of saliva, affected cough reflex leading to increased chances of respiratory failure. There is no specific treatment in the course that could restore these automatic movements to even the slightest extent.
  1. Rigidity- Increased muscle tone is seen with uniform resistance throughout the ROM. Both cogwheel and lead pipe type of rigidity is seen. Rigidity can be asymmetrical or unilateral and may affect only one group of muscles such as neck, forearm or thighs. Tension and a cold environment increases it.
  1. Tremors- It is also asymmetrical or unilateral. Alternating contraction of opposite muscle groups is present causing rhythmic movement at 4-6 cycles per second. It is maximum at the periphery and more frequently affects the arms. It is even present at rest (resting tremors). Anxiety and self-consciousness increases the incidence of tremors.

Treatment-

Parkinsonism needs a multidisciplinary treatment for various signs and clinical features of the disease. Treatment may include drug treatment, physiotherapy and occupational therapy. 

  • Drug treatment- Treatment is basically focused to replenish dopamine. 

Drugs include

– Levodopa in combination with Carbidopa 

         – Levodopa in combination with benserazide (Madopar). 

Levodopa is the main drug for treating parkinsonism. It slowens the signs and symptoms of the disease. It also reduces rigidity and tremors. As soon as the treatment is stopped the symptoms begin to reappear. It can cause numerous side effects such as- nausea, postural hypotension, vomiting, hallucinations and confusions.

  • Anticholinergics- less effective than levodopa, benefit in treating rigidity but cause dryness of mouth, blur vision and confusions. 
  • Amantadine may be used in treating mild cases. 
  • Bromocriptine , a synthetic compound that mimics levodopa, has a longer period of action.
  • Surgery- Once thalamotomy was performed in 1958 by a surgeon accidentally to treat parkinsonism. It caused the abolition of tremors and reduced rigidity on one side of the body. Still, levodopa is considered the best and the most effective way to treat parkinsonism and its symptoms in most cases.
  • Physiotherapy Management- 

Physiotherapy is the best way to manage patients with parkinsonism. The sooner the physiotherapy starts, the better the patient recovers. A proper physiotherapy programme can slowen the symptoms of the disease and delay its progression. Physiotherapy protocol is based on the patient’s condition and symptoms. Main emphasis is on improving speed, mobility and coordination. Reassessment and improvisation of therapeutic programmes should take place from time to time.

  1. Rigidity and balance-
  • Application of ice prior to exercise regimen may be helpful.
  • Proprioceptive neuromuscular facilitation (PNF) is effective for both limb and trunk.
  • Isotonic exercises for both upper and lower limbs
  • Rhythmic stabilization 
  • Start with passive movements, progressing to assisted and active movements.
  • Gradually increase the range and speed of movements. 
  • Practice movements rapidly and smoothly.
  • While walking encourages patients to swing arms and take appropriate step lengths.
  • Balance training with parallel bars and BAPS-board should be encouraged.
  • Slow sustained stretching exercises.
  • Proper stepwise gait training.
  • Relaxation and breathing exercises
  • Hydrotherapy 
  • Yoga
  1. Head and neck control activities-
  • Patients generally tend to have forward head posture with flexion of thoracic spine. 
  • PNF stretching of neck and head.
  • Slow reversals while gradually increasing the range is encouraged.
  • Breathing and respiratory muscle exercises are important to prevent chest complications.
  • In advanced cases, cervical collars may be used.
  • Chin tuck in exercises.
  • Patient is asked to stand straight with head extended.
  1. For mastication, deglutition and speech-
  • Inactivity of facial muscles; particularly buccinator muscle is seen, resulting in clogging of food in the mouth while eating causing dripping of saliva and even food.
  • Stimulation of tongue and facial muscles is helpful.
  • Icing inside mouth
  • Light massage to activate facial muscles with percussion on the chest to avoid respiratory complications and help vocalization.
  • Maintain proper head posture while having meals. Head should not drop forward.
  1. Home care programme-
  • Help motivate the patient and promote them for group exercises.
  • Walking in the morning can be difficult, so assist them to stand and rotate their trunk to stand.
  • Clothes should be comfortable with velcro on it for easy removal.
  • Patients can help loosen their bodies way swaying in different directions before standing.
  • Encourage active movements and ADLs. 
  • Occasional visits by relatives and friends can help boost their moral and social life.
  1. Tremors-
  • Aerobic exercise 
  • Relaxation technique
  • Comfortable positioning of patient with pillows
  • Yoga
  • Breathing exercise
  • Exercise with resistance
  1. Prevent chest complication-
  • Maintaining erect posture
  • Breathing exercise
  • Morning walks
  • Regular exercises 
  • Ankle toe movements
  • Aerobic exercises is very effective (15-20 min)
  1. Coordination exercises-
  • Peg board 
  • Finger to nose touch 
  • Frenkel’s exercises

Reference-

  • Susan B. O’Sullivan, Thomas J. Schmitz and George D. Fulk ( Physical rehabilitation)
  • Glady Samuel Raj ( Physiotherapy in neuro conditions)
  • Patrica A. Downie ( Cash’s textbook of neurology for physiotherapists )
  • Jayant Joshi and Prakash Kotwal ( Orthopedics and applied physiotherapy)