2. Parkinson’s disease (PD) is a chronic
progressive disease of the nervous
system characterized by the cardinal
features of rigidity, bradykinesia
, tremor and postural instability.

3. EPIDEMIOLOGY
 Parkinson's disease, which was first described
in "An Essay on the Shaking Palsy" in 1817 by a
London physician James Parkinson, has
probably existed for thousands of years.
 In India, the crude age-adjusted prevalence
rate of Parkinson's disease per 100,000
population is 14 in northern India, 27 in the
south and 16 in the east, while it is 363 for
Parsis in Mumbai.

4. ETIOLOGY
 PARKINSONISM: Refers to a group of disorders that produce
abnormalities of basal ganglia (BG) function.
 PARKINSON’S DISEASE or IDIOPATHIC PARKINSONISM is the
most common form.
 SECONDARY PARKINSONISM results from number of
identifiable causes, including virus, toxins, drugs, tumors.
 PARKINSONISM-PLUS SYNDROMES: refer to those
conditions that mimic PD in some respects, but the
symptoms are caused by some other neurodegenerative
disorders.

5. PATHOPHYSIOLOGY
BASAL GANGLIA
NORMAL PHYSIOLOGY :

6. FUNCTIONS OF BASAL GANGLIA
 Plays an important role in planning and
programming of movement by selecting and
inhibiting specific motor synergies.
 Plays an important role in cognitive
processes, primarily the caudate
nucleus, including the awareness of the body
orientation in space, ability to adapt behavior as
task requirements change and motivation.

7. Degeneration of
dopaminergic
neurons that
produce
dopamine.
Loss of the melanin
containing neurons
produce
characteristic
changes in
depigmentation.
Formation
of LEWY
BODIESLoss of dopamine
results in
akinesia, rigidity
and bradykinesia.
What happens in Parkinson’s Disease?

8. CLINICAL PRESENTATION
Rigidity  One of the clinical hallmarks of Parkinson's disease.
 Defined as increased resistance to passive motion.
 Felt uniformly in agonists and antagonist muscles in
both directions.
 Spinal stretch reflexes are normal.
 Two types: Cogwheel and Lead pipe rigidity.
 Cogwheel rigidity: jerky, ratchet like resistance to
passive movement and muscles alternately tense
and relax.
 Lead pipe rigidity: no fluctuations, more sustained
resistance to passive movements.
 Prolonged rigidity results in decreased range of
motion and serious secondary complications of
contractures and postural deformity.

9. Bradykinesia
 Akinesia: absence of movement.
 Moments of freezing may occur and are characterized by
a sudden break or block in movement.
 Hypokinesia: reduced amplitude of the movement.
 Bradykinesia: slowness and difficulty maintaining
movement. Movements are typically reduced in
speed, range, and amplitude. Rigidity and depression can
also influence bradykinesia. It is the most disabling
symptom of PD.

10. Tremor  It is an involuntary oscillation of body
part occurring at a slow frequency of
4 to 6 Hz.
 Parkinsonian tremor is described as
resting tremor, as it is typically
present at rest and disappears with
voluntary movement.
 Manifests as pill-rolling tremor of
hand.
 Resting tremors may also be seen in
the forearm, jaw, or tongue.
 Lower limb tremors are apparent
when the patient lies supine.
 Postural tremor is seen in head and
trunk when patient tries to maintain
upright position against gravity.
 Completely diminish during sleep. Pill-rolling tremor

11. Postural instability
 Narrowing of base of support.
 Competing attentional demands increases
postural instability.
 Increasing difficulty during dynamic
destabilizing activities like walking, turning
and functional reach.
 Contributing factors are rigidity, decreased
muscle torque production, loss of available
range of motion particularly of trunk
motions, and weakness .
 Extensor muscles of the trunk demonstrate
greater weakness than flexor
muscles, contributing to the adoption of a
flexed, stooped posture with increased
flexion of the neck, trunk, hips, and knees.

12. MOTOR PLANNING AND MOTOR LEARNING
 Start hesitation is evident especially when the
disease progresses.
 PD patients typically demonstrate
micrographia, an abnormally small handwriting
that is difficult to read.
 Freezing episodes occur and can be triggered by
confrontation of competing stimuli.
 Poverty of movement is demonstrated by
patients of PD in the form of hypomimia i.e. the
reduction in expressiveness of the face (masked
face).
 This leads to mental fatigue and loss of
motivation.
 Procedural learning deficits are common in
patients with PD while declarative learning is
usually intact.
micrographia

13. Gait
 An abnormal stooped posture contributes
to development of a festinating
gait, characterized by a progressive
increase in speed with a shortening of
stride.
 Gait can be anteropulsive (a forward
festinating gait) or retropulsive (a backward
festinating gait).
 Some patients are able to stop only when
they come in contact with an object or a
wall.
 Plantarflexiorn contracture leads to toe
walking and adds to postural instability.

14. Sensation
 No primary sensory loss.
 50% may experience paresthesias and
pain, numbness, tingling, coldness, aching pain and
burning.
 Some of the pain and discomfort can result from postural
stress syndrome secondary to lack of movement, muscle
rigidity, faulty posture, or ligamentous strain.
 Some can experience Akathisia, a sense of inner
restlessness and need to move.
 Proprioceptive regulation of voluntary movement may
also be impaired.

15. Speech, Voice, and Swallowing
 Dysphagia : Impaired swallowing as a result of rigidity, reduced mobility
and restricted range of movement. This can lead to choking or aspiration
pneumonia and impaired nutrition with significant weight loss.
 Nutritional inadequacy contributes to fatigue and exhaustion.
 Presence of sialorrhea (excessive drooling) as there is increased salivary
production and decreased swallowing.
 Hypokinetic dysarthria: characterized by decreased voice
volume, monotone/ monopitch speech, imprecise or distorted
articulation, and uncontrolled speech rate. Speech is hoarse, breathy and
harsh.
 Reduced mobility, restricted range of movement, and uncontrolled rate of
movement of muscles controlling respiration, phonation, resonation and
articulation is present.
 In advanced cases patients demonstrate mutism.

16. Cognitive function and behavior
 Dementia: Occurs in approximately 20-40% of the PD
patients. It is characterized by loss of executive functions
like planning, reasoning abstract thinking and judgment
and changes in visuospatial skills, memory and verbal
fluency.
 Bradyphrenia: disorders of intellectual function. It is
characterized by a slowing of thought and information
processing.
 Patients demonstrate problems with selective attention
and in shifting attention.
 Hallucinations and delusions are common complications
owing to L-dopa toxicity.
 Depression in PD patients is common.

17. Autonomic Nervous System
 Dysautonomia: ANS system dysfunction occurs with PD.
 Thermoregulatory dysfunction : excessive sweating and
abnormal or uncomfortable sensations of warmth and
coldness.
 Seborrhea and seborrheic dermatitis are common.
 PD patients exhibit abnormally slow pupillary responses to
light and pain.
 Gastrointestinal dysfunction includes poor motility, changes
in appetite, sialorrhea, constipation and weight loss.
 Urinary bladder dysfunction occurs with common symptoms
of urinary frequency, urgency, urge incontinence, and
nocturia.
 Sexual dysfunction also present.

18. Cardiopulmonary Function
 Orthostatic hypotension.
 Low resting blood pressure.
 Compromised cardio vascular reflexes.
 Cardiac arrhythmias.
 Airway obstruction.
 Restrictive lung dysfunction.
 Decreased chest expansion.
 Lower forced vital capacity (FVC), forced expiratory volume
(FEV1) and higher residual volume.
 Cardiopulmonary deconditioning.
 Venous pooling in lower extremities in long standing cases as
a result of decreased mobility and prolonged sitting.

19. MEDICAL DIAGNOSIS
 Accurate diagnosis is possible only with continued
observation of evolving clinical signs and symptoms.
 The diagnosis is made on the basis of history and clinical
examination, handwriting samples, speech
analysis, interview questions that focus on developing
symptoms, and physical examination are used in the
preclinical stage to detect early manifestations of the
disease.
 A diagnosis of PD can be made if at least two of the four
cardinal features are present.

20. FRAMEWORK FOR REHABILITATION
 A combined approach of physical therapy and
pharmacological intervention plays a key role in
management of the patient.
 Physical therapist should be fully aware of the
medications the patient is taking and its
potential adverse effects.
 Optimal performance can be expected at peak
dosage (on-state) whereas worsening
performance is associated with end of dose
cycle (off-state).

21. ASSESSMENT
Hoehn and Yahr Classification of Disability

22. EXAMINATION AND EVALUATION
1. Patient History.
2. System review:
a. Neuromuscular.
b. Musculoskeletal.
c. Cardiovascular/ pulmonary.
d. Integumentary.

23. PHYSICAL THERAPY INTERVENTION
Motor learning strategies
 Large number of repetitions to develop procedural skills.
 Random practice order should be avoided.
 Environment should be clutter free to avoid freezing
episodes.
 Structured instructional sets should be used.
 External cues like Visual cues, Rhythmic auditory
stimulation, Auditory cues, Pulsed cues and Multisensory
cueing facilitate movement by utilizing different brain
areas.

24. EXERCISE TRAINING
Relaxation exercises
 Gentle rocking to produce
relaxation.
 PNF technique of Rhythmic
Initiation.
 Relaxation audio tapes.
 Gentle yoga and Tai chi
exercises.
 Lifestyle modifications and time
management techniques.
Flexibility exercises
 Emphasize on active range of
motion exercises.
 ROM exercises in
physiological patterns of
movement.
 Traditional stretching
techniques.
 Passive positioning to correct
phantom pillow posture.
 Mechanical stretching by the
use of tilt table.

25. Strength training
 Strengthening
exercises are indicated
for patients with
primary muscle
weakness and
insufficient central
activation of the motor
unit as well as for
disuse weakness
associated with
prolonged inactivity.
Functional training
 Mobility in bed.
 Exercises in sitting posture
to improve pelvic mobility.
 Sit-to-Stand transitions.
 Standing training.
 Teach how to get up after
a fall.
 Mobilizing facial muscles.
 Correcting eating
impairments.
 Verbal skills practiced with
breath control.

26. Balance training
 Emphasize practice on dynamic
mobility tasks.
 Seated activities on a therapy
ball.
 Challenge the balance by
stepping of marching in
place, and functional reach.
 Standing exercises including
heel-rises and toe off, partial
wall squats and chair
rises, single-limb stance with
side-kicks or back-kicks and
marching in place.
 “Kitchen sink exercises” as
important components of HEP
for patients with balance
deficiencies.
Locomotor training
 Training programs are
designed to lengthen
stride, broaden base of
support, improve
stepping, improve heel-toe
gait pattern, increase
contralateral trunk
movement and arm
swing, increase speed, and
provide a program of regular
walking.
 Trick movements or
rotational stimulationssuch
as dropping a tissue that the
patient must step over can
be successful in reducing
freezing.

27. Cardiopulmonary
training
 Diaphragmatic
breathing exercises, air-
shifting
techniques, and
exercises that recruit
neck, shoulder and
trunk muscles.
 Improving chest wall
mobility by PNF
techniques.
 A supervised aerobic
pool program can be
administered.
Group and Home
exercises
 Patients benefit from the positive
support, camaradie, and
communication the group
situation offers.
 Stretching exercises or
calisthenics involving large joints
can be used as initial warm-up
activities.
 A self supervised home exercise
program is effective in improving
motor symptoms same as
therapist- supervised programs
do.

28. Therapists need to provide a message of hope tempered with realism.
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