Rehabilitation Management of Parkinsons Disease.ppt
- 1. Rehabilitation Management of Parkinsons Disease by dr/ Khaled alsayani
- 2. Parkinsons Disease Is a chronic, progressive neurodegenerative disorder with a multifactorial etiology. It is superseded only by Alzheimer’s Disease as the most common neurodegenerative disorder
- 3. Demographics of Parkinsons Disease Prevalence of 0.3 % in the US population 1 – 2% of all persons > 65 yrs old 4 – 5% of all persons > 85 yrs old In US : > 1 million have diagnosis of Parkinsons – Usual age at onset – early 60s 10% of all those affected are < 45 yrs old – referred to as young onset Parkinsons Lifetime risk of Parkinsons for men : 2.0% Lifetime risk for women : 1.3%
- 4. An Interesting Fact The Chinese have the lowest rates of Parkinsons Disease It has been suggested by Fahn & Jankovic that this is may be due to consumption of large amounts of green tea by the Chinese which contains antioxidants
- 5. Etiology Parkinsonian symptoms can arise from either the neuropathological condition PD (idiopathic PD) or other forms of Parkinsonism For neuropathological PD, 90% of cases are sporadic 10% are of genetic origin – 6 different gene mutations have been identified – the Parkin genes Genetic forms of PD are seen more frequently in young onset PD
- 6. Differential diagnosis of parkinsonism Parkinson disease (idiopathic or genetic) Parkinson-plus degenerations (dementia with Lewy bodies, progressive supranuclear palsy, corticobasal degeneration, multiple system atrophy) Drug-induced parkinsonism (anti-dopaminergics) Rare but treatable in young people: Wilson disease and Dopa-responsive dystonia Other: “vascular” parkinsonism, brain trauma, CNS infection
- 7. BASAL GANGLIA The BG is a collection of nuclei, mainly situated near the base of the brain, that communicate particularly with the cortex, thalamus and cerebellum. The BG is referred to collectively as the automatic processor ‘cruise control’ of the brain (Kirkwood 2006). To perform normal activities of daily living the BG needs to be functionally normally. This requires it to converse with the thalamus and cerebellum to provide coordinated movement.
- 9. BG dysfunction Impaired performance of well learned motor skills and movement sequences Problems maintaining sufficient movement amplitudes Difficulty performing two or more well learned tasks simultaneously Difficulty shifting motor and cognitive sets Increased time for mental processing
- 10. Risk Factors for Parkinsons Disease The most important risk factor for Parkinsons is advancing age. Other environmental or lifestyle risk factors associated with Parkinsons include : Toxins Recreational drug abuse Head trauma
- 11. Idiopathic Parkinsonism Most common form of Parkinsonism : Idiopathic form first described by James Parkinson, A British surgeon & paleontologist in 1817 in his “Essay on the Shaking Palsy”
- 12. Pathophysiology of Idiopathic Parkinsons Pathological hallmark of PD : degeneration of dopaminergic neurons in the substantia nigra compacta, resulting in depletion of striatal dopamine This neurotransmitter regulates excitatory & inhibitory outflow from the basal ganglia Some of the dopaminergic neurons survive, and these are found to contain Lewy Bodies
- 13. Pathophysiology of Parkinsons Lewy Bodies are eosinophilic intracytoplasmic inclusions, composed of numerous proteins Protein accumulation plays a prominent role in the pathogenesis of both sporadic & familial forms of PD Lewy bodies may actually be cytoprotective
- 14. The neurodegenerative process in PD is not limited to the substantia nigra compacta Neuronal loss also happens in other brain regions, which accounts for the motor & non motor features of the disease
- 16. Diagnosis Currently, there is no specific test for PD. A doctor may diagnose PD based on: a neurological exam and medical history blood and other laboratory tests brain scans DaTscan
- 17. Parkinsons Disease – The Six Cardinal Features 1. Tremor at rest 2. Rigidity 3. Bradykinesia 4. Loss of postural reflexes 5. Flexed Posture 6. Freezing (Motor Block)
- 18. Early Non - Specific Signs of Parkinsons Generalized stiffness Pain or Paresthesias of the limbs – in particular, shoulder pain Constipation Low Uric Acid Levels Sleeplessness Reduction in volume of the voice Loss of sense of smell Seborrheic Dermatitis – see photo on the right These symptoms precede onset of the motor symptoms of Parkinsons
- 19. Common Non - Motor Features of Parkinsons Neuropsychiatric Impulse Control Disorders Sleep Disorders Autonomic Dysfunction – orthostatic hypotension, hyperhidrosis, hypohidrosis, sexual impotence can be seen in Parkinsons – but if these features are noted early in disease process, your patient may have MSA Sensory Symptoms – paresthesias, oral & genital pain are common – as is olfactory dysfunction Other – Fatigue, Seborrhea, Diplopia, Blurred Vision, Weight Loss
- 20. Neuropsychiatric Disorders in Parkinsons Disease Depression Anxiety, including panic attacks Cognitive Dysfunction Dementia Psychosis Confusion or delirium Apathy
- 21. Treatment of Motor Symptoms In PD There is no cure for Parkinsons Disease No therapy has been shown to slow or reverse progression of the disease The most effective agent, levodopa / carbidopa has been associated with an increased risk of motor fluctuations The risk of motor fluctuations is greatest in younger patients
- 22. Surgery for PD Pallidotomy is no longer performed in the management of Parkinsons – it is not as effective as Deep Brain Stimulation (DBS) DBS is indicated for patients with drug resistant motor fluctuations Bilateral Deep brain stimulation (DBS) of the subthalamic nucleus (STN) reduces both the primary symptoms of PD and its motor complications including tremor, bradykinesia, wearing off, dyskinesias, and dystonia
- 23. Effects of DBS Reduction in daily levodopa dose by 55% 69% reduction in dyskinesias 34.5% improvement in quality of life
- 24. Patient Selection for DBS & Potential Complications Patient Selection – Medically refractory motor fluctuations or tremor Stable medical problems Normal cognitive function Complications : Hemorrhage Stroke Infection Failure of stimulator Memory Loss
- 25. Aims of Physiotherapy Maintain and improve levels of function and independence, which will help to improve a person’s quality of life Use exercise and movement strategies to improve mobility Correct and improve abnormal movement patterns and posture, where possible Maximize muscle strength and joint flexibility Correct and improve posture and balance, and minimise risks of falls Maintain a good breathing pattern and effective cough Educate the person with Parkinson’s and their carer or family members Enhance the effects of drug therapy
- 26. Exercise has been proven to maintain health and well- being in Parkinson’s and now importantly it is shown to play a big role in addressing secondary prevention (focusing on strength, endurance, flexibility, functional practice and balance). Exercise for neuroprotection focuses on endurance and uses motor learning principles approaches, such as mental imagery and dual task training Exercise undertaken in a group setting has the added value of providing a social connection to those becoming increasingly isolated as the condition progresses, or for those who are newly diagnosed, so they can see the benefits of maintaining exercise and activity
- 27. Physical activity, in particular, aerobic exercise might slow down the motor skill degeneration and depression. Furthermore, it increases the quality of life of patients with Parkinson’s Inspiratory muscle training on lung functions in patients with mild-to-moderate Parkinson's suggests a better outcome Quality of life may be increased when performing strength training against an external resistance.
- 28. with Motor-Cognitive Dual-Task training
- 29. The European Guideline provides a section that describes the use of motor Visual cueing Auditory cueing Attention . Proprioceptive cueing
- 30. Exercise Interventions in Parkinsons Disease A meta – analysis found that physical & occupational therapy improved gait speed, stride length, and ADL, but no change in the neurological cardinal signs – De Goede et al, Archives of PM&R, 2001 Train your patient to perform gestes antagonistes, such as marching with the metronome – this is not frequently done by therapists
- 31. Weight Supported Ambulation Training Weight supported ambulation training with Lite Gait or Biodex has been shown to improve gait in Parkinsons patients, as published in the Archives of PM&R
- 32. Speech & Language Pathology Services Helpful in the management of dysarthria associated with Parkinsons For PD related hypomimia, training the PD patient to shout has been found to be effective – this is known as the Lee Silverman technique
- 33. Equipment for the Parkinsons Patient Rolling Walkers are best – canes & standard walkers are frequently carried by the patient Shower chairs Grab Bars Raised Toilet Seats with armrests – ie Versaframe Chairs with arms to assist patient to lower themselves to the chair without falling
- 34. Considerations for the Primary Care Physician Parkinsons patients have a lower incidence of cancer than the general population with the exception of malignant melanoma – Parkinsons patients are at 2 x greater risk of developing melanoma than the general population.