management of Parkinson disease for physios.pdf
- 1. MANAGEMENT OF PARKINSONISM Prof.dr Eman Fayez Professor of neurological physical therapy faculty of physical therapy Cairo University
- 2. COMPONENTS OF EXTRAPYRAMIDAL SYSTEM 2
- 3. BASAL GANGLIA The term basal ganglia are masses of grey matter deep within the cerebral hemispheres. The term is debatable because these masses are nuclei rather than ganglia Anatomically, the basal ganglia include the caudate nucleus, the putamen, and the globus pallidus. Together they are called the corpus straitum Functionally, the basal ganglia and their interconnections and neurotransmitters form the extrapyramidal system.
- 6. DESCENDING EXTRA PYRAMIDAL MOTOR TRACT TO SPINAL INTERNEURON AND MOTOR NEURON 6 & uncrossed BRAINSTEM Giving rise to following tracts: Rubrospinal tract Vestibulospinal tract Reticulospinal tract Tectospinal tract These tracts terminate on anterior horn interneurons. Occasionally they terminate directly on anterior horn motor neurons.
- 7. EXTRAPYRAMIDAL SYSTEM FUNCTIONS Regulation and integration of voluntary motor activities through influencing motor instructions sent to the periphery Has a role in stabilizing the large and complicated systems that control movement REGULATION OF TONE
- 8. 8 Extra pyramidal tracts • some are excitatory and other are inhibitory to muscle tone • overall effect – strong inhibitory effect over Gamma Motor Neuron in anterior horn cell What will be the effect of extra pyramidal lesions ? Hypertonia- Because strong inhibitory effect over Gamma motor neuron is lost.
- 9. PARKINSON’S DISEASE Parkinson’s disease (PD) is a progressive neurodegenerative condition affecting mainly the basal ganglia Cell death in the substantia nigra (SN) leading to decrease in brain dopamine (DA). Acetylcholine will predominate
- 10. PARKINSON’S DISEASE-INCIDENCE Increases dramatically with age Mean age of onset = 60 y/o Most common onset in 50-79 y/o age groups Onset <30 y/o rare
- 11. PARKINSON’S DISEASE-PATHOLOGY Most common site = substantia nigra SN pigmented neurons Normal convert endogenous & exogenous Levodopa to Dopamine striatum via nigrostriatal tract Abnormal marked deficiency of DA in the striatum Bradykinesia most closely correlates with degree of striatal DA deficiency
- 12. PARKINSON’S DISEASE-PATHOLOGY Lewy body = intracellular inclusion body in the SN - Pathologic hallmark in Parkinson’s brains Lewy body
- 13. CAUSES OF PARKINSONISM 1- Idiopathic : Parkinson’s disease (paralysis agitans). The cause is unknown There is degeneration of substnacia nigra pigmented cells leading to deacrese of dopamin
- 14. OTHER CAUSES OF PARKINSONISM Vascular (rare) Trauma (e.g. Mohammed Ali) Encephalitis Neoplastic Environmental toxins Manganese Pesticides
- 15. PARKINSON’S DISEASE-DIAGNOSIS History & clinical assessment No specific lab abnormalities Minimum requirement of 2/3 major clinical features Resting tremor Bradykinesia Rigidity
- 16. SIX CARDINAL FEATURES REST TREMOR RIGIDITY FLEXED POSTURE BRADYKINESIA – HYPOKINESIA LOSS OF POSTURAL REFLEXES FREEZING PHENOMENON TO DIAGNOSE: TWO OF ABOVE, WITH AT LEAST ONE BEING REST TREMOR OR BRADYKINESIA
- 17. PARKINSON’S KEY FEATURES Stooped posture Slow and shuffling gait and Festinating gait. Pill-rolling tremors static type Uncontrolled drooling, rare arm swinging with walking Paucity of facial expression (mask-like faces )and decreased blink rate . Micrographia. Change in voice, dysarthria in form of monotonus speech Labile and depressed, sleep disturbances Oily skin, excessive perspiration, orthostatic hypotension
- 18. PARKINSON’S DISEASE-MOTOR SYMPTOMALOGY Have to lose 60% of nigral neurons with 80% depletion of striatal DA before symptoms of PD develop Insidious onset Asymmetric First symptom = tremor Usually at rest Pill-rolling, one hand involved Decreased with purposeful movement
- 19. PARKINSON’S DISEASE-MOTOR SYMPTOMALOGY (CON’T) Bradykinesia = slowness in initiating movement Muscular rigidity Feel on passive movement of joint Smooth resistance lead pipe or superimposed ratchet- like jerks cogwheel rigidity Postural instability (late)
- 20. PARKINSON’S DISEASE-MENTAL MANIFESTATIONS Depression (common) Bradyphrenia (slowed thinking) Dementia (20-25%)
- 21. PARKINSON’S DISEASE Stages Initial-hand and arm trembling, weakness, unilateral involvement Mild-masklike facies, shuffling, bilateral involvement Moderate—increased gait disturbances Severe—akinesia, rigidity Complete dependence
- 23. PARKINSON’S DISEASE-TREATMENT GOALS Adequate symptomatic benefit Minimize disability Avoid, delay, or reduce complications/side effects of treatment Slow or halt progression of disease
- 24. PARKINSON’S DISEASE-NON-PHARMACOLOGIC TREATMENT Physical therapy Occupational therapy Speech therapy Social interaction
- 25. SOME POINTS MUST TAKEN INTO CONSIDERATIONS Maintain mobility and flexibility by ROM Encourage self-care as much as possible Monitor sleep patterns to avoid injury Nutrition-may need soft or thickened foods. Constipation Speech therapy may be needed Psychosocial support—impaired memory cognition
- 27. ROLE OF PHYSICAL THERAPIST Design an exercise program to meet patient particular needs. Evaluate and treat problems of mobility and walking. Evaluate and treat joint or muscle pain which interfere with the activities of daily living. Help with poor balance or frequent falling. Treat difficulties accomplishing activities of daily living Recommend and teach the correct use of adaptive equipment.
- 28. ASSESSMENT OF PD PATIENT General considerations during assessment 1-to minimize effect of drug induced change in performance on assessment results it must be performed at the same time of day 2- assessment is repeated for follow up 3-All activities should be timed 4-considering old age problems as artheritis,decreased sight and hearing
- 29. ASSESSMENT OF PD PATIENT 1-muscle tone 2-functional activities 3- balance 4-posture 5-tremor 6-dextrety 7-respiratory status 8-Range of motion 9-bradykinesia 10-gait assessment
- 30. COMMON PROBLEMS IN PARKINSONISM Disturbance of normal postural background to movement as balance and righting reflexes are absent or impaired which resulting in: 1-difficulty in changing position, 2-inability to rotate the body to follow the head 3- Limitation of trunk lateral flexion, and extension 4-Stooped posture
- 31. COMMON PROBLEMS IN PARKINSONISM CONT. 5-Respiratory problem lead to poor tolerance to exercise 6-Micrographia - small, cramped handwriting 7-Impaired manual dexterity resulting in difficulty in perform ADL 8-Contracture and deformity secondary to inactivity and muscle imbalance 9-Weakness due to inactivity
- 32. ESSENTIAL PD REHABILITATION COMPONENTS IN EARLY AND MIDDLE STAGE Breathing exercises and exercises connected with breathing Stretching exercises Strength training Rhythmic initiation technique PNF pattern to enhance rotation and extension Aerobic activity Balance training Posture correction Speech and Swallowing Rehab Role of adaptive and assistive devices
- 35. SPEECH AND SWALLOWING DIFFICULTIES IN PARKINSON DISEASE The same PD symptoms that occur in muscles of the body--tremor, stiffness, and slow movement- can occur in the muscles used in speaking and swallowing. This can cause A soft voice Mumbled or fast speech Loss of facial expression Problems communicating Trouble swallowing
- 36. OROFACIAL DYSFUNCTIONS Masked face - reduced facial expression Lack of spontaneous blinking of eyes Poor lip closure and tongue movement result in difficulty in sowllowing Dysarthria - lower volume quality of the voice
- 37. TREATMENT OF OROFACIAL FUNCTION 1- ask pt to take deep breath before speak 2-tapping under jaw to stimulate swalwing 3-gentle shaking of inside cheeks to facilitate lip closure 4-PNF
- 38. SWALLOWING Always sit upright Chew small amounts of food well and swallow it all before adding more. Put your fork down between bites to slow yourself down Make yourself swallow twice after every bite. Take small sips when drinking. Alternate bites of food and sips. Take only one sip at a time. Do not drink gulp after gulp. Use of straws!! Keep your chin slightly down or at least parallel to the table. Don’t try to drink out of a can. Use a glass instead. Don’t talk with food in your mouth
- 39. TIPS ABOUT DROOLING If patient tend to drool,he probably don’t have more saliva then you used to have; you are just not swallowing it as automatically as before. Frequent sips of water or sucking on ice chips during the day can help swallow more often Always keep head up, with chin parallel to the floor, and lips closed Drinking more water will help thinning the phlegm
- 40. PROBLEM IN GAIT Decreased arm swing on the affected side Problems with walking and balance - may experience short step, slow, shuffling gait and festinating gait or episodes of "freezing", being unable to initiate a step forward
- 41. GAIT TRAINING Goals : Lengthen stride Increase arm swing Overcome shuffling and festinating gait Increase trunk rotation Encourage heel toe gait
- 42. METHODS Floor marking Use small obstacles Emphasis turning movement with small steps and wide base of support
- 43. BALANCE, FALLS, AND POSTURE Balance problems are one of the main symptoms of PD. Another name for balance problems is postural instability. Balance problems increase the risk of falling, especially when combined with other symptoms and complications of PD, including:
- 44. POSTURE PD can cause many changes in the body. One easily recognizable change is posture. The characteristic changes in posture can include: A forward head position. Rounding of the shoulders and upper back. A forward trunk position with increased bending of the hips and knees.
- 45. SOME TYPICAL POOR POSITIONS Sitting on the couch watching TV. Leaning over to work on the computer. Driving/riding in the car. Looking downward while reading, or propping your head against the headboard while reading.
- 46. EXAMPLE OF POOR SITTING POSTURE
- 47. EXAMPLE OF GOOD SITTING POSTURE
- 50. STRETCHES
- 51. SEATED NECK AND CHEST STRETCH
- 53. OVERHEAD STRETCH
- 59. ROTATION STRETCH
- 60. CALF STRETCH
- 61. ANKLE CIRCLES
- 63. BRIDGING
- 67. QUADRAPED TRUNK
- 68. PRONE ON ELBOWS
- 69. AEROBIC ACTIVITY
- 70. AEROBIC ACTIVITY
- 72. PREVENTING FALLS DO NOT pivot your body over your feet when turning. Instead try: “U-turn” while walking “U-turn” - Useful for more open areas. Move your feet & body together in an arc...
- 73. WHAT ARE ASSISTIVEADAPTIVE AIDS? Adaptive aids are items that can help you stay as independent as possible for as long as possible. These devices can make your daily life easier and safer, and improve your quality of life.
- 74. ASSISTIVE AIDS A urinal (available for both men and women), bedpan, or bedside commode can help reduce bathroom trips at night
- 75. BATHING AND TOILETING AIDS
- 76. TRIPODS Avoid tripod or quad canes No
- 77. ONE POINT CANE A straight cane with a rubber tip is better. Yes
- 78. CONTINU…
- 80. HELPFUL BEDROOM AIDS Helping handle/bed rail
- 81. EATING AIDS
- 82. TREMOR TREATMENT FIT LIKE A GLOVE It is a system of sensors and motors that track voluntary movements and separate them from the involuntary tremors. The gloves can then suppress the tremor without stopping the intended movement.