Chapter 18 Physical Rehabilitation
Prepared by: Pethuel M. Pomaloy
• Progressive disorder of CNS
• Disturbance in the dopamine system of basal nuclei
• Both motor and non-motor symptoms
• Cardinal Features:
• Rigidity
• Bradykinesia
• Tremor
• Postural instability
• 1 million Americans
• 7 – 10 people worldwide
• Average age of onset: 50 – 60 years old
• 4 – 10%: Early onset PD (< 40 years old)
• Juvenile onset (< 21 y.o.)
• Young onset PD (21 – 40 y.o.)
• Men: 1.2 to 1.5 times more frequent
• Parkinsonism
• Generic term used to describe a group of disorders with primary
disturbances in the dopamine system of the basal ganglia (BG).
• PD/ Idiopathic parkinsonism
• most common form (78%)
• Secondary parkinsonism
• results from a number of identifiable causes including viruses, toxins,
drugs, tumors etc.
• Parkinson-plus syndromes
• Conditions that mimic PD in some respects but are caused by other
neurodegenerative diseases
1. Parkinson’s Disease
• first described as “shaking palsy” by James Parkinson in
• Refers to cases where etiology is unknown or genetically
• Clinical subgroups:
• Postural Instability and Gait Disturbed (PIGD)
• Tremor Predominant
2. Secondary Parkinsonsim
• A. Postencephalitic Parkinsonism
• influenza epidemics of encephalitis lethargica (1917 to 1926)
• onset of parkinsonian symptoms typically occurred after many
2. Secondary Parkinsonsim
• B. Toxic Parkinsonism
• Environmental toxins (pesticides)
• Industrial chemicals (carbon disulfide, carbon monoxide, cyanide,
• Most common: Manganese
2. Secondary Parkinsonsim
• C. Drug induced parkinsonsim (DIP)
• drugs that produce extrapyramidal dysfunctions that mimics sign
of PD
• interfere dopaminergic mechanisms
• Neuroleptic drugs: chlorpromazine, haloperidol, thirodiazine
• Antidepressant drugs: amitriptyline, amoxapine, trazodone
• Antihypertensive drugs: methyldopa (aldomet), reserpine
3. Parkinson-Plus syndrome
• Neurodegenerative diseases that affects substantia nigra and
produce parkinsonian symptoms along with other neurological
• Striatonigral degeneration (SND)
• Shy-Drager syndrome
• Progressive supranuclear palsy
• Olivopontocerebellar atrophy
• Cortical basal ganglionic degeneration
3. Parkinson-Plus syndrome
• Multi-infarct vascular disease
• Alzheimer’s disease
• Diffuse Lewy body disease
• Normal pressure hydrocephalus
• Creutzfeldt-Jakob disease
• Wilson’s disease
• Juvenile huntington’s disease
• Diagnostic feature: do not show measurable improvement to anti-
parkinson medication such as levodopa (apomorphine test)
• Degeneration of the dopaminergic neurons in the BG in
the pars compactus of the substantia nigra
• As neurons degenerate, presence of cytoplasmic
inclusion bodies called Lewy Bodies
• Onset of motor symptoms 30-60% degeneration
• Direct Motor Loop
• Ventrolateral thalamus to Cortex (Supplementary Motor Area)
• Excitatory and facilitates discharge of cells in the SMA
• Indirect Motor Loop
• Involves the subthalamic nucleus, globus pallidus interna and
substantia nigra pars reticulata to midbrain tegmentum
• Inhibits/ decreases thalamocortical projections
Clinical Presentation
Primary Motor Symptoms
• Rigidity
• Increased resistance to passive motion that is constant regardless
of the task, amplitude or speed of movement
• Both agonist and antagonistic muscles
• Often assymmetrical during early stage
• Proximal muscles first
• Active movement, mental concentration, emotional stress increase
• Types:
• Cogwheel: jerky, ratchet like, muscles alternate tense and relax
• Lead pipe: sustained resitance, (-) fluctuations
Clinical Presentation
Primary Motor Symptoms
• Bradykinesia
• Slowness of movement
• Insufficient recruitment of muscle force during initiation of
• Akinesia – poverty of spontaneous movements; ex. Hypomimia
• Freezing episodes
• Hypokinesia – slowed and reduced movements (micrographia)
Clinical Presentation
Primary Motor Symptoms
• Tremor
• involuntary shaking or oscillating movement of a part or parts of the
body resulting from contractions of opposite muscles
• Resting tremor: suppressed by rest and disappears with sleep
• Postural tremor
• Action tremor – seen in advanced PD
Clinical Presentation
Primary Motor Symptoms
• Postural Instability
• Rare in first 5 years
• Abnormal and inflexible postural responses
• Difficulty in regulating feed forward and anticipatory judgements
• Weakness of antigravity muscles: adoption of a flexed, stooped
posture with increased flexion of trunk, neck, hips and knees
• LE: hip and knee flexors, hip rotators, adductors, PFors
• Spine: dorsal spine and neck flexors
• UE: shoulder adductors and IR, elbow flexors
• Frequent falls and fall injuries
Clinical Presentation
Secondary Motor Symptoms
• Muscle performance
• Reduction in strength that may be dopamine related
• EMG studies: motor unit recruitment delayed with
under-recruitment of muscles
• Disuse weakness
• Fatigue: difficulty in sustaining activity and experiences
weakness and lethargy as the day progresses
Clinical Presentation
Secondary Motor Symptoms
• Motor Function
• Motor planning deficits: loss of voluntary and automatic movement
• Speed – Accuracy Trade-off
• Dual-task control problems
• Start Hesitation
• Motor learning deficits may be seen but not universal
Clinical Presentation
Secondary Motor Symptoms
• Gait
• 13-33% of patients presents with postural instability and gait
disturbance as their initial motor symptom
• Reduction in arm swing with assymetry
• Festinating gait
• progressive increase in speed with shortening of stride
• anteropulsive / retropulsive
• Problems in turning and changing direction
Clinical Presentation
Nonmotor Symptoms
• Sensory Symptoms
• Do not suffer primary sensory loss
• 50% experience paresthesias and pain, sensation of numbness, tingling,
cold, aching pain and burning
• Postural stress syndromes
• Proprioceptive and Visuospatial deficits
• Olfactory dysfunction: Anosmia
• Visual disturbance caused by conventional drugs (anticholinergics): blurred
vision, sensitivity to light (photophobia), eye pursuit may be jerky
• Decreased blinking
Clinical Presentation
Nonmotor Symptoms
• present in 95% of patients with PD
• Result of rigidity, reduced mobility and restricted range
of movement
• Excessive drooling (sialorrhea): increased saliva
production, decreased spontaneous swallowing
• Can be present in all stages
Clinical Presentation
Nonmotor Symptoms
• Speech Disorders
• Hypokinetic dysarthria
• Decreased voice volume, monotone, imprecise articulation, uncontrolled speech
• Mutism
Clinical Presentation
Nonmotor Symptoms
• Cognitive Dysfunctions
• mild (mildly impaired memory) or severe (psychosis)
• PD dementia occurs in approximately 20% to 40% of
the patients
• Bradyphrenia
Clinical Presentation
• Depression and anxiety
• Feelings of guilt, hopelessness, worthlessness, loss of energy, poor
concentration, deficits in short term memory, loss of ambition and
enthusiasm, suicidal thoughts
• Hypomimia
• Dysthmic d/o: chronic depression, poor appetite or overeating,
insomnia or hypersomnia, low energy, low self-esteem
• Panic attacks
• Social phobia
• Agoraphobia
• OCD, panic d/o
Clinical Presentation
• Autonomic dysfunction
• direct manifestation of disease
• thermoregulatory dysfunctions
• seborrhea and seborrheic dermatitis
• slow pupillary responses
• GI disorders: constipation, urinary incontinence
• erectile dysfunction
• diminished heart function
• orthostatic Hypotension
Clinical Presentation
• Autonomic dysfunction
• airway obstruction: (air trapping, lung inflation) most frequently
reported pulmonary problem
• restricted lung disease
• low FVC, low FEV1 and higher RV
• moderate edema d/t immobility
Clinical Presentation
• Sleep disorder
• excessive daytime sleepiness
• insomnia
• dream enacting behaviors such as agitation, physical activity
during sleep
Medical Diagnosis
• Made on the basis of history and clinical examination
• Diagnosis is made if at least two of the four cardinal
features are present
• Apomorphine testing
Clinical Course
• Progressive, long sublicinical period
• Patients at young age/ tremor predominant: more benign
• cardiovascular disease and pneumonia: MC of death
Hoehn-Yahr Classification of Disability Scale
• Most widely used severity staging scale in clinical
I – minimal or absent, unilateral if present
II – minimal bilateral or midline involvement, balance not impaired
III – Impaired righting reflex, unsteadiness when turning or rising from
Some activities are restricted but patient can live independently
IV – all symptoms present and severe, standing and walking only
possible with assistance
V – confined to bed or wheelchair
Unified Parkinson’s Disease Rating Scale
• “Gold Standard” for measuring progression of PD
• Part I: Mentation, Behavior, Mood
• Part II: ADL
• Part III: Motor Examination
• Part IV: Complications of therapy
Medical Management
• Management is directed at slowing disease progression
• Increasingly more challenging over time as disease
Pharmacological Management
• Starting medication early has been shown to be
beneficial in slowing progression of disease
• 1. Levodopa/ Carbidopa (Sinemet)
• Levodopa: Gold standard drug therapy for PD
• Levodopa (L-dopa): precursor of dopamine, more than 99% of
levodopa is metabolized before reaching the brain
• Carbidopa: Decarboxylase inhibitor
• Available in Immediate release (IR) and Controlled release (CR)
Pharmacological Management
1. Levodopa/ Carbidopa (Sinemet)
• Primary benefits: controlling PD motor symptoms of bradykinesia
and rigidity, initial burst of motor activity, increased strength
Honeymoon period: initial dramatic improvement in functional
status, presence of clear cut drug effectiveness
4-6 years therapeutic window, then wearing off state
Dyskinesias – involuntary movements that appear as facial
grimacing, twitching, puckering of lips and may progress to
choreathetoic movements of shoulders, arms and hands
On-off phenomenon
Pharmacological Management
1. Levodopa/ Carbidopa (Sinemet)
• Dyskinesias – involuntary movements that appear as facial
grimacing, twitching, puckering of lips and may progress to
choreathetoic movements of shoulders, arms and hands
• Dystonia
• On-off phenomenon
Pharmacological Management
1. Levodopa/ Carbidopa (Sinemet)
• unsupervised reduction or sudden discontinuation is
• dose related changes:
• Disabling psychiatric toxicity
• Depression
• GI changes
• CV changes
• Genitorurinary changes
• Sleep disturbance
Pharmacological Management
2. Dopamine Agonists
• designed to directly stimulate postsynaptic dopamine receptors
• pt.’s with declining response to levidopa and carbidopa may
• adverse effects similar with levodopa
• increased risk for impulse control disorders: (pathological
gambling, compulsive shopping, hypersexuality, overeating)
• Bromocriptine
Pharmacological Management
3. Anticholinergics
• Most benefit moderating tremor and dystonia
• have little or no effect on other PD symptoms
• Anticholinergic adverse effects include blurred vision, dry mouth,
dizziness and urinary retention
• trihexyphenidyl (Artane) and benztropine mesylate (Congentin)
• adverse effects: blurred vision, dry mouth, dizziness and urinary
Pharmacological Management
4. Monoamine Oxidase B Inhibitors (MAO-B)
• MAO-B is the major enzyme that acts to degrade dopamine in the
• Selegiline (deprenyl) and Rasagiline (Azilect)
• Permits lower dose of levodopa
• Adverse effects: mild nausea, dry mouth, dizziness, orthostatic
hypotension, confusion, hallucinations, and insomnia
Pharmacological Management
Implications for Physical Therapy
• Fully aware of the medications and potential adverse effects
• It is important to remember that patients on dopamine replacement
will develop motor complications at some point
• Timing of PT examination and intervention
Nutritional Management
• High protein diet can block effectiveness of L-Dopa
• High calorie – low protein diet (no more than 15% of
Deep Brain Stimulation
• implantation of electrodes in
brain blocking signals
• effective in treatment of
advanced PD
• Possible adverse effects:
Confusion, Headache, Speech
problem, gait disturbance
Physical Therapy Examination and
• 1. Cognitive Function
• Mini Mental State Examination
• 2. Psychosocial Function
• Geriatric Depression scale, Beck depression Inventory
• Hospital Anxiety and Depression Scale
• 3. Sensory Function
• 4. Musculoskeletal Function
• Joint Flexibility and posture
• Spinal ROM
• Muscle Performance
Physical Therapy Examination and
• 4. Musculoskeletal Function
• Muscle performance
• Strength and Endurance
• MMT, handheld and isokinetic dynamometry
• 5. Motor Function
• Rigidity
• Bradykinesia
• Movement time
• Reaction time
• Rapid alternating movements
• Dexterity
Physical Therapy Examination and
• 5. Motor Function
• Tremor
• Location, persistence, severity (amplitude)
• Postural control and balance (Berg balance Scale, Timed up and
Go test)
Fall Risk (Fall Risk diary)
Fatigue (Multidimensional Fatigue Inventory, Fatigue Severity
Dyskinesia (Rush dyskinesia Scale)
Physical Therapy Examination and
• 5. Motor Function
• Tremor
• Location, persistence, severity (amplitude)
• Postural control and balance (Berg balance Scale, Timed up and
Go test)
Fall Risk (Fall Risk diary)
Fatigue (Multidimensional Fatigue Inventory, Fatigue Severity
Dyskinesia (Rush dyskinesia Scale)
Swallowing and speech
Physical Therapy Examination and
• 6. Autonomic Function
• Cardiorespiratory Function
• 6 Minute/ 12 minute walk test
• Orthostatic Hypotension
• drop in systolic BP of 20 mmHg and 10 mmHg in diastolic BP and 10-
20% increase in pulse rate
• Integumentary Integrity
• Seborrhea and Seborrheic Dermatitis
• 7. Functional status
• Functional Independence Measure
Physical Therapy Examination and
• Disease Specific Measures
• Parkinson’s Disease Questionnaire (PDQ-39)
• Focuses on subjective report of the impact of PD on daily-life
• Parkinson’s Disease Summary Index
• 0-100
• provides useful indication of global impact of PD on health
Physical Therapy Intervention
• Motor Learning Strategies
• blocked practice rather than random practice
• structured instructional sets
• external cues
• Visual
• Rhytmic Auditory Stimulation (metronome)
• Multisensory cueing
Physical Therapy Intervention
• Exercise Training
• “Training big” program (High amplitude movements)
• Relaxation exercises
• Slow rocking
• Rhythmic Rotation
• Rhythmic Initiation (counters effects of rigidity)
• Bilat. Symmetrical PNF D2 flexion pattern with diaphragmatic breathing
• Flexibility Exercises
• Resistance Training
Physical Therapy Intervention
• Exercise Training
• Functional Training
• Bed Mobility Skills: Emphasize segmental rotation patterns than a log-
rolling pattern
• Sitting
• Standing
• Balance Training
• Should emphasize practice of dynamic stability tasks
• Locomotor Training
• Walk Tall, Walk fast, Take Large steps
• Braiding
Physical Therapy Intervention
• Spinal Orthotics
• Spinal bracing for postural deformities
• Pulmonary Rehabilitation
• breathing exercises
• exercise that recruit neck, shoulder and trunk muscles
• Manual techniques such as vibration and shaking
• Speech Therapy
• Aerobic Exercise
• Minimum: 3 sessions per week
• Daily walking with short multiple bouts (20-30) minutes throughout the
day for Pt.’s with lower functional capacity
Physical Therapy Intervention
• Group and Home Exercises
• Taichi classes

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