Parkinson’s Disease

Advanced Neurological Physiotherapy (8027651) MPT

Dr. Hadeel Halaweh
Learning Objectives
• Describe the etiology, pathophysiology, clinical manifestations of Parkinson’s
disease.
• Identify and describe the examination procedures used to evaluate patients with
Parkinson’s disease to establish a diagnosis, prognosis, and plan of care.
• Explain the role of the physical therapist in assisting a patient with Parkinson’s
disease through direct interventions and patient and family/caregiver-related
instruction to maximize function.
• Outline appropriate elements of exercise prescription for patients with
Parkinson’s disease.
• Identify the neuropsychological effects and social impact of Parkinson’s disease
and describe appropriate interventions to maximize quality of life.
• Analyze and interpret patient data, formulate realistic goals and outcomes, and
develop a plan of care when presented with a clinical case study.
Parkinson’s Disease (PD)
• Definition: PD is a progressive
disorder of the central nervous
system (CNS) with both motor
and non-motor symptoms.
• Motor Symptoms:
• Tremor
• Bradykinesia (slowness of
movement)
• Rigidity
• Postural instability (in later stages)
Non-Motor Symptoms of Parkinson’s Disease
• Early Symptoms (Often Precede
Motor Symptoms):
• Loss of sense of smell
• Constipation
• Sleep behavior disorder
• Mood disorders
• Orthostatic hypotension
• Other Non-Motor Symptoms:
• Altered bladder function
• Excessive saliva production
• Integumentary changes
• Difficulty speaking and swallowing
• Cognitive issues (slowed thinking,
confusion, possible dementia)
Parkinson’s Disease (PD)
• Age & Onset:
• Over 2% of people older than 65 have PD
• Second most common neurodegenerative disorder after Alzheimer’s disease
• Average age of onset: 50 to 60 years
• Early-onset PD (21–40 years): 4% to 10% of cases
• Juvenile-onset PD (under 21 years): Very rare
• Gender Differences:
• Men are affected 1.2 to 1.5 times more frequently than women
Etiology of Parkinson’s Disease
• Pathophysiology:
• PD involves primary disturbances in the dopamine system of the basal ganglia
• Causes:
• Idiopathic Parkinsonism: Most common form (78% of patients)
• Secondary Parkinsonism: Results from identifiable causes:
• Viruses
• Toxins
• Drugs
• Tumors
• Parkinsonism Syndromes: Conditions that mimic PD but result from
other neurodegenerative disorders
History and Clinical Subgroups of Parkinson’s
Disease
• Historical Background:
• First described as “The Shaking Palsy” by James Parkinson in 1817
• Refers to cases with idiopathic (unknown) or genetically determined causes
• Clinical Subgroups:
• Postural Instability and Gait Disturbance (PIGD):
• Dominant symptoms include balance issues and walking difficulties
• Tremor-Predominant:
• Primary feature is tremor
• Fewer issues with bradykinesia (slowness of movement) or postural instability
Genetic Factors in Parkinson’s Disease
• Genetic Forms:
• Represent less than 10% of overall PD cases
• Several gene mutations identified in a small number of families:
• Examples: PARK1, PINK1, PARK2, GBA (glucocerebrosidase), and others
• Gene Categories:
• Causal Genes: Directly produce the disease
• Associated Genes: Increase the risk of developing PD but do not directly
cause it
Secondary Parkinsonism
• Encephalitis Lethargica
• Associated with the influenza epidemic
• Parkinsonian symptoms often appeared years after infection
• Led to the theory of a slow virus affecting the brain
• No longer seen due to the absence of recent outbreaks
Secondary Parkinsonism – Environmental and
Chemical Causes
• Toxins Linked to Parkinsonian Symptoms:
• Pesticides: Permethrin, beta-HCH, paraquat, maneb, Agent Orange
• Industrial Chemicals: Manganese, carbon disulfide, carbon monoxide, cyanide,
methanol
• Occupational Hazard: Prolonged manganese exposure poses serious risk for miners
• Synthetic Drug Exposure:
• MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) found in contaminated
synthetic heroin
• Known to cause severe and permanent parkinsonism
• Important Note: Simple exposure to these toxins alone is not enough to
cause the disease
Drug-Induced Parkinsonism (DIP)
• Cause: Certain drugs interfere with dopaminergic mechanisms, either
presynaptically or postsynaptically
• Drug Categories:
• Neuroleptic Drugs:
• Antidepressant Drugs:
• Antihypertensive Drugs:
• Effects: High doses are particularly problematic in the elderly
• Reversibility: Symptoms usually reverse within weeks of
discontinuing the drugs, but in some cases, effects persist and may
reveal underlying subclinical Parkinson’s disease
Parkinson-Plus Syndromes and Metabolic Causes
• Parkinson-Plus Syndromes:
• Conditions with rigidity and bradykinesia, often indistinguishable from
Parkinson’s disease initially
• Key Differences:
• Additional symptoms like cognitive impairment (e.g., in Alzheimer’s disease)
• Poor or no response to anti-Parkinson medications like levodopa (referred to as
"Levodopa Resistance")
• Metabolic Conditions Causing Parkinsonism: (Rare)
• Disorders of calcium metabolism leading to calcification, including:
• Hypothyroidism
• Hyperparathyroidism
• Wilson’s disease
Pathophysiology of Parkinson’s Disease
• Basal Ganglia and Striatum:
• Network of subcortical nuclei:
• Caudate nucleus and putamen (together called the striatum)
• Globus pallidus, subthalamic nucleus, and substantia nigra
• Motor control through parallel circuits or loops
• Motor Loops:
• Direct Motor Loop:
• Cortex → Putamen → Globus Pallidus → Ventrolateral (VL) Nucleus of Thalamus → Cortex
(Supplementary Motor Area)
• Function: Excitatory feedback loop, facilitating voluntary movement
• Dysfunction in PD: Reduced activation leads to hypokinesia
• Indirect Motor Loop:
• Subthalamic Nucleus → Globus Pallidus Interna → Substantia Nigra → Superior Colliculus and Midbrain
Tegmentum
• Function: Decreases thalamocortical activation, regulating movement inhibition
• Role: Controls saccadic eye movements and trunk/limb musculature via extrapyramidal pathways
Pathophysiology of Parkinson’s Disease
• Degeneration of dopaminergic neurons in
the pars compacta of the substantia nigra
that produce dopamine.
• Presence of cytoplasmic inclusion bodies
called Lewy bodies as the disease
progresses and neurons degenerate.
• Substantial neurodegeneration occurs
before the onset of motor symptoms,
with clinical signs emerging when 30% to
60% of neurons are lost.
• Loss of melanin-containing neurons leads
to characteristic changes in
depigmentation of the substantia nigra,
resulting in a distinct pallor.
Stages of Parkinson’s Disease
• Stage 1: Lesions are found in the medulla oblongata (dorsal motor nucleus or
intermediate reticular zone).
• Stage 2: Involvement of the caudal raphe nuclei, gigantocellular reticular
nucleus, and coeruleus-subcoeruleus complex.
• Stage 3: Apparent involvement of the nigrostriatal system (pars compacta of
the substantia nigra).
• Stage 4: Lesions extend to the cortex, specifically the temporal mesocortex
and allocortex.
• Stage 5: Pathology spreads to the sensory association areas of the neocortex
and prefrontal neocortex.
• Stage 6: Pathology further extends to involve the sensory association areas of
the neocortex and premotor areas.
Clinical Presentation of Parkinson's Disease (PD)

Rigidity: Defined as increased resistance to passive movement.

• Patients often complain of "heaviness" and "stiffness."
• Resistance felt uniformly in both agonist and antagonist muscles, in both
directions.
• Types of rigidity:
• Cogwheel: Jerky ratchet-like resistance.
• Lead Pipe: Sustained resistance with no fluctuations.
• Rigidity is constant regardless of task amplitude or speed.
• Influenced by:
• Degree of rigidity
• Disease stage
• Fluctuations in drug action
• Attention and depression levels.
Bradykinesia and Tremor in PD
• Bradykinesia: Slowness and reduction in movements, often seen with
handwriting that starts strong but diminishes.
• Tremor: Involuntary shaking or oscillation in parts of the body due to
muscle contractions.
• Common in early stages, often at rest (Resting Tremor).
• Tremor can affect the head, arms, and legs, especially when maintaining
posture.
• Freezing of Gait: Sudden stop or difficulty initiating movement, often
triggered by competing stimuli or narrow spaces.
• Progression: Tremor becomes more severe with disease progression,
impacting daily activities.
Postural Instability and Impaired Balance
• Postural Instability: Difficulty maintaining balance due to abnormal
postural responses.
• Narrowing of stance or divided attention increases instability.
• Difficulty with dynamic activities (e.g., walking, turning) and
perturbed balance.
• Postural Deformities:
• Flexed posture develops with increased flexion in neck, trunk, hips, and
knees.
• Musculoskeletal constraints limit function.
• Leads to postural deformity (stooped posture) and progressive immobility.
Falls, Osteoporosis, and Risk Factors
• Falls:
• Become more frequent as disease progresses, especially in middle stages.
• Approximately 70% of patients experience falls in the past year.
• 25% of patients develop hip fractures within 10 years of diagnosis.
• Postural instability, gait impairment, and freezing significantly increase fall
risk.
• Risk Factors:
• Dementia, depression, postural hypotension, and dyskinesias from
medication.
• Falls contribute to immobility, dependency, and deteriorating quality of life.
Secondary motor Symptoms
• Strength and Muscle Weakness in Parkinson's Disease
• Reduction in strength observed in patients with Parkinson's Disease (PD).
• Torque production decreases at all speeds, leading to muscle weakness and
activity limitations.
• Dopamine replacement therapy increases strength during the "on" state
compared to the "off" state.
• Electromyography (EMG) shows delayed motor unit recruitment and
underrecruitment in muscles.
• Characterized by multiple bursts, synchronization issues, and difficulty in
smooth contraction increases.
Fatigue and Motor Performance in Parkinson's
Disease
• Fatigue is a common symptom, with difficulty sustaining activity and
increasing weakness as the day progresses.
• Repetitive motor tasks start strong but decrease in strength and
amplitude as activity continues.
• Physical stress or effort worsens performance; rest or sleep may
restore mobility temporarily.
• Fatigue improves initially with therapy but returns in advanced
disease or with long-term drug therapy.
• Increased effort perception and difficulty in sustaining movements.
Motor Planning and Motor Learning Deficits
• Striatum (caudate nucleus, putamen, nucleus accumbens) receives
cortical input, affecting motor planning.
• Motor planning deficits in PD result in loss of regulatory control over
automatic and voluntary movements.
• Difficulty performing complex, sequential, or simultaneous
movements becomes more pronounced.
• Prolonged movement preparation times and slowness in initiating
movement.
• Motor learning deficits occur, especially in advanced disease or
complex tasks.
Gait Disturbances and Postural Instability
• Postural instability and gait disturbances are common in advanced PD.
• Gait changes include reduced arm swing, asymmetry, abnormal posture,
and a "shuffling" gait.
• Patients may break into a run to avoid falling, or exhibit forward or
backward-leaning gaits.
• Turning and changing direction is difficult, often requiring multiple small
steps.
• Gait deterioration increases in the "off" state but can improve with peak
medication levels.
• External cues and attentional strategies can help compensate for mild gait
deficits.
Non-Motor Symptoms in Parkinson’s Disease (PD)
• Sensory Dysfunction:
• No primary sensory loss, but 50% experience paresthesias and pain
(numbness, tingling, cold, aching pain, burning).
• Proprioception and kinesthetic sense are impaired, affecting voluntary
movement and spatial perception.
• Visual-spatial errors: More errors in visual tasks, spatial organization, and
perception.
• Olfactory Dysfunction:
• Loss of sense of smell (anosmia) often precedes motor symptoms, affecting
diagnosis and nutrition.
Impaired Swallowing and Speech in PD
• Swallowing Issues:
• 95% of PD patients have swallowing impairments, affecting oral preparatory,
oral, pharyngeal, and esophageal phases.
• Results in difficulty chewing, delayed swallowing, aspiration pneumonia, and
weight loss.
• Speech Impairments:
• 75-89% of PD patients experience speech difficulties (monotone, low volume,
distorted articulation).
• Contributes to social isolation and participation limitations.
• Motor issues affect respiratory, phonation, and articulation control.
Cognitive and Emotional Impairments in PD
• Cognitive Decline:
• Cognitive dysfunction ranges from mild (memory issues) to severe (psychosis,
dementia).
• Dementia affects executive functions, spatial skills, memory, and verbal
fluency.
• Hallucinations, delusions, and slowed thinking are common in the “off” state.
• Depression and Anxiety:
• 40% of PD patients experience major depression, often before motor
symptoms.
• Symptoms include guilt, hopelessness, and energy loss.
• Anxiety manifests as panic attacks, social withdrawal, and obsessive-
compulsive behaviors.
Autonomic and Respiratory Dysfunction in PD
• Autonomic Dysfunction:
• Includes thermoregulatory issues (excessive sweating, abnormal sensations of
hot/cold).
• Issues with heart rate, blood pressure, and urinary problems (frequency,
urgency).
• Respiratory Impairments:
• 84% of patients report respiratory issues, including decreased lung function.
• Impaired vital capacity, reduced lung expansion, and air trapping due to
rigidity.
• Increased risk of pulmonary failure and reduced exercise capacity.
Sleep Disturbances in Parkinson’s Disease
• Excessive Daytime Sleepiness: Common symptom in individuals with
Parkinson’s disease (PD).
• Night Insomnia: Includes problems falling asleep, staying asleep, and
overall sleep quality.
• Sleep Behavior Disorder: Occurs early in PD, affecting 50-60% of
patients.
• Symptoms: Vivid, intense dreams, physical activity during sleep (talking,
kicking, punching, etc.)
Medical Diagnosis of Parkinson's Disease
• Challenges in Early Diagnosis: Diagnosis often made after observing
evolving clinical signs.
• Key Early Symptoms:
• Loss of smell, sleep disturbances, vivid dreams, dystonia, cramps.
• Autonomic symptoms like orthostatic hypotension and constipation.
• Diagnosis Criteria: At least two of the four cardinal motor features
must be present.
• Exclusion of Parkinson Plus Syndromes: Important for accurate
diagnosis.
Clinical Course and Progression of Parkinson's
Disease
• Disease Progression:
• The disease is progressive with a long subclinical period (at least 5 years).
• Mean PD duration is approximately 13 years.
• Factors Affecting Progression:
• Age of onset and type (tremor predominant vs. postural instability).
• Neurobehavioral disturbances and dementia are more common in those with
postural instability and gait disturbances.
• Impact of Dopaminergic Therapy: Slows progression and improves
mortality rates.
Staging Parkinson's Disease
• Hoehn and Yahr Classification: Widely used for staging disease
severity.
• Stage I: Minimal disease involvement.
• Stage V: Severe disease, patient confined to bed/wheelchair.
• Gold Standard for Measuring Progression: Staging scales help assess
functional status and track disease progression over time.
Medical Management

• Goal: Slow disease progression using neuroprotective strategies and

symptomatic treatments for motor and non-motor symptoms.
• Challenges: Management becomes harder over time (moderate to
advanced stages).
• Individualized Care: Medication choices based on patient
characteristics, weighing benefits and risks.
• Timing: Starting medications early is beneficial for slowing disease
progression.
• Medication Schedule: Consistency is key – avoid peaks and valleys in
drug delivery. Stress importance to patients, families, and caregivers.
Levodopa/Carbidopa (Sinemet) Therapy
• Gold Standard: Levodopa is the primary drug for Parkinson's, introduced in
1961.
• Mechanism: Levodopa is a dopamine precursor, metabolized in the brain.
Carbidopa inhibits decarboxylation to allow more dopamine to enter the
brain.
• Forms: Immediate-release and controlled-release formulations.
• Benefits: Controls motor symptoms like bradykinesia, rigidity, and tremors
(though tremor reduction varies).
• Challenges: Long-term use can lead to "wearing-off" and dyskinesias,
including involuntary movements (e.g., facial grimacing, limb movements).
Other Medications & Adverse Effects
• Dopamine Agonists: Ropinirole, pramipexole, bromocriptine.
Benefits: reduce rigidity, bradykinesia, and motor fluctuations.
• Side Effects: Nausea, dizziness, hallucinations, impulse control disorders.
• Anticholinergic Agents: Used early to treat tremor and dystonia.
• Examples: Trihexyphenidyl, benztropine.
• Side Effects: Blurred vision, dry mouth, memory issues.
• MAO-B Inhibitors: Selegiline, rasagiline.
• Role: Enhance dopamine levels and may slow disease progression in early
stages.
• Side Effects: Nausea, dizziness, insomnia.
Deep Brain Stimulation (DBS) for Parkinson's
Disease
• Mechanism: Electrodes are implanted in the brain to block nerve signals causing
symptoms. Typically placed in the subthalamic nucleus (STN) or globus pallidus (GPi).
• Device: An impulse generator (similar to a pacemaker) is implanted in the subclavicular
area, connected to the brain electrodes by an under-skin wire.
• Patient Control: The patient can control the "on/off" switch using a controller, while the
physician adjusts stimulation levels based on individual needs.
• Effectiveness:
• Highly effective for advanced Parkinson's disease.
• 90% of patients show improvement in tremor and motor symptoms (e.g., dyskinesias, akinesia,
rigidity).
• Reduces medication needs and improves motor function (e.g., walking speed).
• Side Effects: Possible temporary effects include confusion, headache, speech problems,
gait disturbances, and falling. Surgical risks (e.g., intracerebral hemorrhage, infection)
and mechanical device issues (e.g., lead breakage, generator malfunction) can occur.
Nutritional Management
• Dietary Considerations: High-protein diets can interfere with
levodopa absorption.
• Recommendations: Low-protein, high-calorie diet; protein intake in the
evening; increase fiber and water intake to manage constipation.
Framework for Rehabilitation
Role of Rehabilitation:
• Reduces activity limitations and promotes participation and independence.
• Prevents and manages complications, promoting quality of life.
• Optimal management involves a coordinated interdisciplinary team addressing individual patient
clinical problems.
• The team typically includes:
• Physician, Nurse, Physical Therapist, Occupational Therapist, Speech-Language Pathologist, Social Worker.
• Additional referrals: Psychologist, Nutritionist, Gastroenterologist, Urologist, Pulmonologist, etc.
• Patient-Centered Care:
• The patient is the central figure, with family and caregivers as key members.
• Ideal programs consider:
• Disease history, impairments, activity limitations, participation restrictions, abilities, priorities, and resources
(family, home, community).
• Address deterioration, medication-induced fluctuations, and common concerns like depression and anxiety.
Therapeutic Care Continuum and Disease Stages

Therapeutic Care Stages:

• Restorative: Improve impairments, activity limitations, and participation.
• Preventative: Minimize complications and indirect impairments.
• Compensatory: Modify tasks or environments to improve function.
• Stages of Disease Progression:
• Early Stage:
• Minimal impairments, patient is independent.
• Outpatient referrals for physical therapy to improve fitness and delay impairments.
• Middle Stage:
• Increased activity limitations, still functional but slower.
• Outpatient or home care with emphasis on exercise and family instruction.
• Late Stage:
• Severe impairments and dependency in daily functions.
• Focus on preventative care, compensatory training, and maintaining function with caregiver support.
Physical Therapy Examination and Intervention
• Examination Procedures: Based on the patient’s unique status (e.g.,
severity, stage of disease, age, rehabilitation setting).
• Reexamination: Performed at specified intervals to track changes in
status and treatment effects.
• Sensation Screening: Includes superficial, deep, and cortical
sensations. Changes in sensation can indicate comorbid pathologies
like stroke or neuropathy.
• Impairment Measures: Stable during early and middle stages of
Parkinson’s Disease (PD) but fluctuating in late stages.
Examination of Visual and Postural Changes
• Vision: Assessment of acuity, peripheral vision, tracking, and depth
perception.
• Common issues in PD: Blurred vision, difficulty reading, and eye pursuit issues
(cogwheeling).
• Medications may affect vision (e.g., antidepressants).
• Posture: Use grids, plum lines, or video to document postural
changes.
• PD patients may present with flexed, stooped posture or forward head.
• Spinal postural changes should be assessed in both standing and supine
positions.
Musculoskeletal and Spinal Mobility Examination
• Flexibility & ROM: Active and passive range of motion (AROM and
PROM) using goniometers.
• Common impairments in PD: Loss of hip/knee extension, ankle dorsiflexion,
shoulder flexion, etc.
• Spinal Mobility: Assessment of cervical, thoracic, and lumbar spine
mobility.
• Important to assess rotation, flexion, and extension of the spine, including
axial rotation.
Strength, Endurance, and Additional Measures
• Strength & Endurance: Measured via manual muscle testing (MMT),
handheld dynamometry, and isokinetic dynamometry.
• PD patients often show impairments in muscle strength and endurance.
• Use of dynamometry to measure peak force and document muscle
endurance.
• Tremor Assessment: Use slow-speed movement and low torque
measurements for tremor quantification.
Rigidity and Its Impact on Movement
• Rigidity is typically equal in both agonist and antagonist muscle
groups.
• It can be sustained (leadpipe) or intermittent (cogwheel).
• Distribution of rigidity is often asymmetrical, especially in early stages
of disease.
• Variability in rigidity occurs throughout the day, medication cycles,
and with stress.
• Determine which body segments are affected and severity of
involvement.
Assessment of Rigidity and Muscle Tone
• Therapist should position the patient in a relaxed seated or supine
position.
• Extremities are moved through full passive motion (PM) to assess
rigidity.
• Evaluation includes:
• Neck, shoulders, trunk, and extremities.
• Difficulty with full passive motion indicates severe rigidity.
• Facial mobility should also be examined (e.g., hypomimia or masked
face).
Bradykinesia and Impairment in Functional Mobility
• Bradykinesia leads to slower movements with decreased amplitude
(hypokinesia).
• In later stages, movements may become arrhythmic with frequent
hesitations (akinesia).
• Timed Tests: Measure movement speed and response time (e.g.,
stopwatch for reaction time).
• Difficulty in repetitive tasks such as tapping, writing, and dressing.
• Key Example: Impaired coordination and asymmetry in arm swing
during walking.
Tremor and Postural Control Evaluation
• Tremor: Recorded based on location, persistence, and severity.
• Resting tremor: Typical early pattern.
• Action tremor: Severe long-standing disease.
• Functional tasks (e.g., drinking, dressing, writing) test tremor effects.
• Postural Control:
• Observation of resting posture in sitting and standing.
• Use of clinical measures such as the Berg Balance Scale and Timed Up and Go
(TUG).
• Sensitivity to balance in functional performance and postural reactions.
Gait and Locomotor Performance Assessment
• Gait: Examined for speed, stride length, and stability.
• Reduced trunk rotation, difficulty initiating gait, and smaller steps.
• Difficulty adapting walking speed in response to attentional demands.
• Functional Testing:
• Timed Up and Go (TUG), 6-Minute Walk Test (6MWT), and other assessments
for gait performance.
• Dual-task interference testing (e.g., walking while performing cognitive tasks).
• Freezing episodes may occur in early and advanced disease stages.
Stepping and Fall Risk in Parkinson’s Disease
• Stepping as Intervention: Improves quality of life and reduces fall risk
in PD patients.
• Assessment Challenges: Unpredictability of freezing episodes makes
assessment difficult.
• Triggers: Narrow passages, turning in tight spaces, walking under stress.
• Early stages: Freezing occurs more during "off" times.
• Advanced stages: Freezing can occur during "on" times.
• Freezing of Gait Questionnaire: A reliable tool to detect and rate
freezing severity.
Fall Risk and Fatigue in Parkinson's Disease
• Fall Risk Factors: History of falls, postural hypotension, dementia,
dyskinesias.
• The Fall Risk IAR tool can track fall events and associated factors (e.g., activity,
medication timing, fatigue).
• Fatigue in PD: A common symptom that impacts quality of life.
• Fatigue Rating Scales: Used to assess general fatigue, physical fatigue, and its
functional impact.
• Movement Disorders Society's Fatigue Scale: Includes mental fatigue and
reduced motivation.
Physical Therapy Intervention in Parkinson’s
Disease
• Role of Physical Therapy:
• Key in managing Parkinson’s Disease (PD) to maximize functional ability and minimize
complications.
• Combined approach with pharmacological interventions.
• Focus on functional improvement, exercise capacity, motor function, and activity
participation.
• Early Intervention:
• Prevents musculoskeletal impairments.
• Addresses secondary complications, such as motor dysfunction.
• Goals & Outcomes:
• Improve movement, exercise capacity, functional performance.
• Educate patients, caregivers, and families for optimal care.
Interventions & Strategies for Motor Function
• Motor Learning & Practice:
• External cues (e.g., visual or auditory) improve movement.
• Techniques like “swing your arms,” “take large steps” to improve walking patterns.
• Repetitive drill-like practice for advanced disease and cognitive deficits.
• Use of Sensory Cues:
• Visual cues (e.g., floor markings, laser lights) help with stride length and velocity.
• Auditory cues (e.g., metronome or “big step” verbal cues) enhance gait performance.
• Improving Movement with External Cues:
• Sensory training improves motor control and supports coordination.
• Enhances brain activity in areas like the premotor cortex and supplementary motor
area.
Challenges & Considerations in PD Physical Therapy
• Motor Learning Deficits:
• Patients with PD show slower learning and reduced efficiency.
• Cognitive deficits impact therapy outcomes, especially in advanced stages.
• Considerations for Treatment:
• Modifications needed based on disease stage and cognitive abilities.
• Avoid dual-tasking and complex sequences to reduce cognitive load.
• Focused attention with cueing may not be suitable for dementia or severe
cognitive decline.
• External Cues:
• Effective for many patients, but not universally.
• Long-term benefits depend on cue type and individual responses.
Exercise Training
• LSVT BIG Program
• Introduction to LSVT BIG:
• Also known as the Lee Silverman Voice Treatment (LSVT) BIG program.
• Based on the concept that repetitive, high-amplitude movements yield greater
improvements in motor performance and may have a neuroprotective effect.
• Training Details:
• Patients guided by physical therapists to exercise at high intensity (8-10 on Borg’s RPE scale).
• Sessions: 1 hour, 4 times a week, for 4 weeks.
• Emphasis on large-amplitude, multiple-repetition, whole-body movements increasing in
complexity.
• Exercise Examples:
• “Step out and land BIG, pushing the left foot into the floor while reaching with bilateral BIG
arms, hands open, and palms up. Return to start and repeat on the other leg.”
• “Reach left arm across the body to the opposite side, keep hand open, palm up, right leg fully
extended, toe pushing into the floor. Alternate legs.”
LSVT BIG Program Benefits and Complementary
Techniques
• Benefits of LSVT BIG:
• Significant improvements in motor scores.
• Enhanced timed 10m walking performance.
• Complementary Relaxation Techniques:
• Gentle rocking to reduce excessive muscle tension and rigidity.
• Inspired by historical observations of patients with Parkinson’s benefiting from rhythmic, bumpy carriage
rides.
• Proprioceptive Neuromuscular Facilitation (PNF) Techniques:
• Slow, rhythmic rotational movements of extremities and trunk preceding interventions.
• Lower trunk rotation or side-lying rolling for relaxation.
• Diaphragmatic breathing paired with PNF patterns for chest expansion and shoulder ROM.
• Stress Management Strategies:
• Cognitive imaging and meditation techniques (e.g., relaxation response).
• Relaxation audio tapes for home use.
• Lifestyle modifications and time management strategies to reduce anxiety and accommodate movement
difficulties.
Flexibility Exercises
Purpose and Types of Flexibility Exercises
• Purpose: Improve movement and physical function.
• Types of Exercises:
• Static (Passive Range of Motion)
• Dynamic (Active Range of Motion)
• Facilitated (Proprioceptive Neuromuscular Facilitation - PNF)
• Frequency Recommendations:
• Minimum: 2–3 days per week
• Ideal: 5–7 days per week
• Stretching Guidelines:
• 2–4 repetitions per stretch
• Hold each stretch for 15–60 seconds
Special Considerations and Techniques
• Addressing Common Limitations:
• Stretching common areas of tightness
• Combining stretching with joint mobilization to reduce joint capsule or ligament
tightness
• Enhanced effectiveness when muscles are warmed with active exercise or external
heating
• Techniques:
• PNF Techniques (e.g., Hold-Relax, Contract-Relax)
• Recommended: 6-second contraction followed by 10–30 second assisted stretch
• Caution:
• Avoid ballistic (bouncing) stretches to prevent injury
• Be mindful of elderly patients and those with long-term diseases (e.g., risk of
osteoporosis, edematous tissue)
Application for Patients with Parkinson’s Disease
• Benefits:
• Promotes relaxation and reduces tightness
• Improves posture and core stability
• Uses physiological movement patterns emphasizing rotation
• Effective Exercises:
• Bilateral symmetrical flexion patterns for upper trunk extension
• Bridging exercises for hip flexor stretch and spinal/hip extensor strengthening
• Unilateral and bilateral bridging with trunk rotation
• High kneeling with anterior pelvis translation
• Positional Stretching:
• Prone lying for daily positioning
• Side-lying with support for lateral curvature
• Mechanical stretching via tilt tables for contracture reduction
• Cueing Strategies:
• Encourage patients to focus on full range of motion and movement control
• Use tactile and visual cues to maximize range and effectiveness
Resistance Training and Muscle Weakness in
Parkinson’s Disease
Primary Muscle Weakness:
• Impaired motor unit recruitment
• Reduced rate of force development
Disuse Weakness:
• Associated with prolonged inactivity
Targeted Areas of Weakness:
Importance of Strength Training:
• Improves muscle force and reduces bradykinesia
• Enhances balance, mobility, and gait function
• Reduces fall risk and postural instability
• Optimal training during “on” medication periods
Functional Mobility and Motor Activity Progression
• Focus on Functional Skills: Exercise programs should emphasize improving overall
functional mobility, particularly focusing on axial structures like the head, trunk,
hips, and shoulders.
• Gradual Progression: More severely involved patients may benefit from starting
with assisted movements, progressing gradually to active movements (e.g., PNF
techniques) to improve initial motor performance.
• Bed Mobility Skills: Essential for functional independence. Skills like rolling,
bridging, and supine-to-sit transitions are often difficult due to truncal rigidity
and bradykinesia.
• Segmental rotation activities (upper and lower trunk rotations) should be practiced over log-
rolling patterns.
• Stiff-trunk patients may benefit from compensatory rolling strategies using upper
extremities.
• Practice on different surfaces, progressing from firm to soft and simulating the patient’s
home bed surface.
Sitting and Sit-to-Stand Training
• Sitting Mobility: Exercises to improve pelvic mobility are critical as patients with
Parkinson’s often sit with a stiff, posteriorly tilted pelvis and flexed upper trunk.
• Practice anterior/posterior tilts, side-to-side tilts, and pelvic clock exercises.
• Sitting on a therapy ball enhances ease of movement and can progress to stationary surfaces
or no apparatus.
• Weight shifting, upper trunk rotations, and reaching exercises should be included.
• PNF extremity patterns in sitting (e.g., bilateral symmetrical D2 patterns) promote trunk
extension and mobility.
• Sit-to-Stand Training: Challenging due to poor dynamic stability and inadequate
limb support, especially during advanced disease or “off” states.
• Start by having patients scoot to the mat’s edge, place both feet under knees and apart.
• Forward trunk flexion can be facilitated through rocking and cueing strategies.
• Strengthening hip and knee extensors through modified wall squats improves standing
performance.
• Practice from raised seats, gradually lowering seat height as control improves.
Standing and Facial Mobility Training
• Standing Mobility: Achieving an upright position with symmetrical weight-
bearing is essential.
• Use tactile cueing or light resistance on the anterior pelvis to encourage hip extension.
• Practice weight shifts, rotational trunk movements (e.g., reciprocal arm swings), and reaching
movements.
• Step-ups (forward and lateral) and backward stepping strengthen hip and spinal extensors
and promote upright posture.
• Increase difficulty with elastic resistive bands.
• Wall-supported weight-bearing activities promote upper trunk extension.
• Facial Mobility: Important for enhancing social interaction and feeding skills.
• Techniques include massage, stretching, manual contacts, and verbal cueing.
• Practice lip-pursing, tongue movements, swallowing, and facial expressions (smiling,
frowning) with visual feedback (e.g., mirror).
• Combine mouth opening/closing and chewing with neck stabilization.
• Verbal skills should be practiced alongside breath control.
Balance Training
• Learning is task and context-specific, so balance training should
include a variety of activities that alter task demands and expose the
patient to varying environmental conditions.
• Therapists should aim to replicate real-life conditions patients will
encounter to enhance the transfer of skills from rehabilitation to daily
life.
• It’s crucial to balance the level of challenge with patient safety by
understanding the patient’s limitations and the specific demands of
the task and environment.
Strategies for Balance Training in Patients with
Parkinson’s Disease
• Emphasize posture and control training: Patients should learn how
muscle tone influences balance and how to improve posture in
sitting, standing, and during dynamic movements.
• Practice expanding movement range: Patients with Parkinson’s often
show restricted forward displacement of center of foot pressure —
training should focus on improving postural alignment and avoiding
disturbances.
• Use tools like mirrors for visual feedback and devices like the
Nintendo Wii Balance Board to provide real-time biofeedback on
weight shifting and center of pressure.
Practical Activities and Environmental Challenges
• Dynamic stability tasks: Include weight shifts, unilateral weight bearing,
reaching, and axial rotations of the head and trunk.
• Practice on compliant surfaces: Therapy balls, inflatable discs, and foam
surfaces challenge stability.
• Vary positions and movements: Try arm position changes, leg positioning,
voluntary movements (e.g., arm clapping, trunk rotations, single-leg
raises), and stepping.
• Strength and movement training: Heel raises, partial squats, single-limb
stances, and chair rises improve balance and readiness for daily activities.
• Introduce environmental variability: Use different visual inputs (e.g., eyes
closed) and settings (e.g., busy clinic) to simulate real-world conditions.
Locomotor Training Goals and Gait Impairments
• Goals:
• Reduce primary gait impairments
• Increase functional mobility and prevent falls
• Common Gait Impairments:
• Slowed speed and decreased stride length
• Shuffling gait with lack of heel-to-toe sequence
• Diminished trunk movement and arm swing
• Overall flexed posture while walking
Effective Strategies for Gait Improvement
• Techniques to Improve Upright Alignment and Safety:
• Pole walking with vertical poles
• Verbal cues: “Walk tall,” “Walk fast,” “Take large steps,” “Swing both arms”
• Visual and auditory cues to enhance gait speed and step length
• Enhancing Step Height and Foot Placement:
• Floor markers and exaggerated high stepping practice
• Music and rhythmic cues to improve pacing
• Side-stepping and crossed-step walking
Advanced Locomotor Training Techniques
• Treadmill Training:
• Motorized treadmill with overhead harness for postural stability
• High-intensity practice for improved gait rhythm and reduced variability
• Task-specific training for community participation
• Obstacle Navigation and Safety:
• Practicing stepping over floor markers and laser light cues
• Caregiver training for assisted walking and fall prevention
• Use of therapy dogs for balance and external cueing
Spinal Bracing and Postural Correction
• Spinal bracing as an adjunct to therapy for postural deformities in PD
• Benefits:
• Corrects postural issues (thoracic kyphosis, forward head posture)
• Increases trunk stability and respiratory capacity
• Enhances patient’s self-reported well-being
• Study Results:
• 73% increase in back extensor strength
• 58% increase in abdominal flexor strength
Respiratory Dysfunction and Treatment
• Four main respiratory disorders in PD:
• Medication complications
• Upper airway obstructions
• Restrictive disorders
• Aspiration pneumonia
• Importance of respiratory function in reducing disability and mortality
• Treatment components:
• Diaphragmatic breathing exercises
• Air shifting techniques
• Exercises for neck, shoulder, and trunk muscles
• Manual techniques for secretion clearance
Breathing and Chest Wall Mobility
• Strategies to improve chest wall mobility and vital capacity:
• Deep breathing exercises
• Basal lung expansion through side-lying positioning
• Manual stretch and resistance
• Upper body resistance training with light weights
• PNF (Proprioceptive Neuromuscular Facilitation) patterns
• Coordination of breathing with movement for trunk stabilization
Speech and Voice Therapy
• Speech deficits in 80% of PD patients
• Characteristics:
• Breathy, monotone voice
• Perceived normal loudness despite being soft
• LSVT (Lee Silverman Voice Treatment):
• Intensive, high-effort exercises focusing on loudness
• Recalibration of self-perceived vocal loudness
• Improved facial expressions and speech clarity
Aerobic and Strength Training
• Individualized exercise prescription based on disease stage and fitness
• Training modes:
• Leg and arm ergometry
• Walking with safety measures
• Recumbent or seated ergometry
• Supervised indoor walking programs
• Aerobic pool programs for relaxation and mobility
• Recommended frequency: 3 sessions per week or daily short bouts
Group and Community-Based Exercise
• Benefits of group classes:
• Positive support, camaraderie, and motivation
• Focus on functional exercises with large movements
• Use of music for movement stimulation and pacing
• Activities: stretching, calisthenics, balance training
• Recreational elements: line dancing, ball games
Home-Based Exercise and Adaptive Devices
• Importance of daily exercise and avoiding inactivity
• Home exercise strategies:
• Stretching and strengthening in various positions
• Use of adaptive equipment (e.g., overhead bars, chair supports)
• Safety devices: raised seats, toilet rails
• Psychosocial considerations:
• Education and stress management
• Family support and reducing social isolation
• Emphasis on patient empowerment and self-management
Patient, Family, and Caregiver Education
• Role of the Interdisciplinary Team:
• Provides information on living with Parkinson’s disease.
• Uses diverse intervention formats:
• One-on-one instruction
• Group sessions
• Printed materials
• Video or computer presentations
• Emphasizes a positive and supportive approach.
• Community Support Groups:
• Offer information and opportunities to discuss common issues and management tips.
• Provide stabilizing influence, promoting healthy behaviors, coping skills, and self-management.
• Support groups tailored to early-stage patients and similar age groups can be more helpful.
• Educational Resources:
• Pamphlets and newsletters
• Information on local and national support groups available through Parkinson’s associations