1. Intro
   1. – Is a chronic, progressive disease of the and as characterized by the cardinal features of rigidity, bradykinesia, tremor & postural instability – onset is insidious with a flow rate of progression
2. Epidemiology
   1. – Affects more than 2% of the population older than 65 – average age onset = 50-60 y.o – Young-onset PD: defined by the appearance of an initial symptoms before the age of 40 – affected: ~ men = women
3. Etiology
   1. 1. Parkinsonism –def: used to refer to a group of disorders that produce abnormalities of basal ganglia fnx 2. Secondary parkinsonism – results from a number of identifiable causes including virus, toxins, drugs, tumors, vascular disease, normal pressure hydrocephalus, hemiparkinsonism, hemiatrophy, & metabolic 3. Parkinsonism-plus Syndromes – condition that mimic PD in some respects, but the symptoms are caused by other neurodegenerative disorders
   2. Classification of Parkinsonism Box 21.1 p. 854
   3. PD
      1. Idiopathic with 2 Distinct Clinical Subgroups:
         1. Postural Instability Gait disturbed (PIGD)
            1. Individuals whose dominant Sxs include postural instability & gait disturbances
         2. Tremor Predominant
            1. Individuals with trimmer as the main feature
   4. Secondary Parkinsonism
      1. Postinfectious Parkinsonism
         1. – Influenza epidemics of encephalitis lethargica that occurred from 1917 – 1926 – slow virus was infecting the brain
      2. Toxic Parkinsonism
         1. – Sx ouccured in Pts. exposed to certain industrial poisons & chemicals (manganese, carbon disulfide, carbon monoxide, cyanide, methanol) – most common = manganese – represents a serious occupational hazard to many minors – severe & lasting classic Parkinsonian has been inadvertently produced in individuals who injected a synthetic heroin containing the chemical MPTP
         2. Drug-Induced Parkinsonism (DIP)
            1. These drugs are thought to interfere with dopaminergic mechanisms either presynaptically or post synaptically and include:
            2. Neuroleptic Drugs:
            3. Thorazine, Haldol, Mellaril, Navene
            4. Antidepressant Drugs:
            5. Triavil, Asendin, Desyrel
            6. Antihypertensive Drugs:
            7. Aldomet & Reserpine
      3. Metabolic Causes
         1. Including: Disorders of calcium metabolism that result in basal ganglia calcification. These include: – hypothyroidism – hyperparathyroidism – hypoparathyroidism – Wilson's disease
   5. Parkinson-Plus Syndromes
      1. A group of neurodegenerative diseases that affect the substantia nigra & produce Parkinsonian symptoms along with other neurological symptoms:
         1. 1. Striatonigral degeneration (SND), Shy-Drager syndrome, Progressive Supranuclear Palsy (PSPO), Olivopontocerebellar Atrophy (OPCA) & Cortical-Basal Ganglionic Degeneration (CBGD) 2. In patients with multi-infarct vascular disease, Alzheimer's disease, diffuse Lewy Body disease (DLBD), normal pressure hydrocephalus (NPH), Creutzfeldt-Jakob disease (CJD), Wilson's Disease (WD), & juvenile Huntington's disease
      2. Apomorphine Test
         1. Diagnostic feature = Parkinson-plus syndromes typically do not show measurable improvement from the administration of anti-Parkinson's medications (L-dopa)
4. Pathophysiology
   1. Basal Ganglia (BG)
      1. Collection of interconnected gray matter nuclear masses deep within brain Composed of – caudate & putamen (striatum), – globus pallidus, – subthalmic nucleus & – substantial nigra
   2. Input/Output
      1. Main Input Structure=Striatum
         1. Also receives input from the substantia nigra
      2. Output Structure:
         1. Globus Pallidus & Substantia Nigra==>Thalamus ==>Cortex
      3. Pathways:
         1. Direct
            1. Facilitate basal ganglia output to the thalamus & motor areas of the cortex
         2. Indirect
            1. Provide disinhibition to the Subthalmic nucleus (STN) & in turn suppression of some movements *Parts fot he globus Pallidus project to the brainstem & in turn to the motor neurons in the brainstem & spinal cord
   3. Important Roles of BG
      1. 1. Planning & programming of movement by selecting & inhibiting specific motor strategies 2. In some cognitive processes, primarily the caudate nucleus, including awareness of body orientation in space, ability to adapt behavior as task requirements change, & motivation
   4. PD:
      1. – assoc. w/ the generation of dopaminergic neurons that produce dopamine – they have their cell bodies in the substantia nigra & send their axons to the striatum
      2. Clinical Signs:
         1. emerge w/30-60% degeneration of neurons
5. Clinical Presentation
   1. Cardinal Feats.
      1. Rigidity
         1. Def: increased resistance to passive motion – felt uniformly and both agonist & antagonist muscles & in movements in both directions – affects proximal muscles first & it progresses to involve muscles of the face & extremities
         2. 2 Types:
            1. Cogwheel Rigidity
            2. jerky, ratchetlike resistance to passive movement as muscles alternately tense & relax
            3. Leadpipe Rigidity
            4. is more sustained resistance to passive movement, w/no fluctuations
      2. Bradykinesia
         1. Akinesia
            1. – Absence of movement – represents a deficit in the preparatory phase of movement control & can be directly influenced by the degree of rigidity as well as stage of disease & fluctuations and drug action – movements of freezing = a sudden break or block and movement
         2. Hypokinesia
            1. – Reduced amplitude of movement
         3. Bradykinesia
            1. – Slowness & difficulty maintaining movement
      3. Tremor
         1. – And involuntary oscillation of a body part occurring at a slow frequency of 4-6 Hz – Parkinsonian tremor – resting tremor because it is typically present at rest & disappears w/voluntary movement; manifests as pill-rolling tremor of hand – tremor of head & trunk = Postural Tremor – seen when muscles are used to maintain an upright position against gravity – tremor diminishes by voluntary effort & disappears completely during rest
      4. Postural Instability
         1. –Abnormal & inflexible postural responses along with increased bodies way are seen – narrowing of the BOS or complete attentional demands (divided attention situations) increases postural instability – patients who are in an "off" state, characterized by reduced levels of L-dopa medication & diminished effectiveness, typically experience increased muscle weakness, especially in extensor muscles
         2. Pt. experiences:
            1. 1. Increased difficulty during dynamic destabilizing activities such as self initiated movements (functional reach, walking, turning) & perform poorly under conditions of perturbed balance 2. Difficulty in regulating feed forward, anticipatory adjustments of postural muscles during voluntary movements 3. Extensor muscles of trunk demonstrate greater weakness than flexor muscles = flexed, stooped posture with increase flexion of neck, trunk, hips & knees; thus positioning the individual at the forward limits of stability 4. Inability to adapt movement strategies to changing sensory conditions, a problem and sensorimotor adaptation 5. Visuospatial impairment 6. Fatigue – most common Sx reported 7. Contractures – commonly develop in hip, knee flexors, hip rotators & adductors, plantar flexors, dorsal spine & neck flexors, shoulder adductors & internal rotators & elbow flexors 8. Kyphosis – most common postural deformity 9. Scoliosis – result of unequal distribution of rigidity and trunk 10. Osteoporosis
   2. Clinical Manifestations: Box 21.2 p. 860
      1. Motor Performance
         1. 1. Decreased torque production 2. Fatigue 3. Contractures & deformity common
      2. Motor Planning:
         1. 1. Start hesitation 2. Freezing episodes 3. Poverty of movement 4. Masked face 5. Micrographia
      3. Motor Learning
         1. 1. Procedural learning deficits for complex & sequential tasks
      4. Gait:
         1. 1. Reduced stride links; increased step to step variability 2. Reduced speed of walking 3. Cadence (steps per minute) typically intact; may be reduced in advanced PD 4. Increased time: double limb support 5. Insufficient hip, knee & ankle flexion: shuffling steps 6. Insufficient heel strike with increased forefoot loading 7. Reduce trunk rotation: decreased or absent arm swing 8. Festinating gait: anteropulsion common 9. Freezing of gait (FOG) 10. Difficulty turning: increased steps per turn 11. Difficulty with dual tasking: simultaneous motor and/or cognitive tasks 11. Difficulty with attentional demands of complex environments
      5. Posture
         1. 1. Kyphosis with forward head 2. Leaning to one side with tonal asymmetries 3. Increased fall risk
      6. Sensation
         1. 1. Paresthesias 2. Pain 3. Akathisia
      7. Speech, Voice, and Swallowing
         1. 1. Hypokinetic dysarthria 2. Dysphagia
      8. Cognition Function & Behavior
         1. 1. Dimension 2. Bradyphrenia 3. Visuospatial deficits 4. Depression 5. Dysphoric mood
      9. ANS
         1. 1. Excessive sweating 2. Abnormal sensations of heat & cold 3. Seborrhea 4. Sialorrhea 5. Constipation 6. Urinary bladder dysfunction
      10. Cardiopulmonary Function
          1. 1. Low resting BP 2. Compromise cardiovascular response to exercise 3. Impaired respiratory function
   3. Motor Planning
   4. Motor Learning
   5. Gait
   6. Sensation
   7. Speech,Voice, & Swallowing
   8. Cognitive Fnx & Behavior
   9. ANS
   10. Cardiopulmonary Fnx
6. Medical Dx
   1. – Dx is made on the basis of Hx & clinical exam – Can be made if at least 2 of 4 cardinal features are present – Imaging can be used to rule out other pathologies – exclusion of Parkinson plus syndromes is necessary: – presence of extrapyramidal signs that are bilateral symmetrical & do not respond to L-dopa & dopamine agonists (apomorphine test)=suggestive of these syndromes, not PD
7. Clinical Course
   1. – Disease is slowly progressive, with a long subclinical. (Without apparent clinical manifestations), estimated to be at least 5 years – overall the mean survival has increased by about 5 years since the introduction of L-dopa – Pts w/young age @ onset or who are tremor predominant typically demonstrate a more benign progression & a relatively good prognosis – Pts w/PD who present with postural instability & gait disturbances (PIGD group) tend to have more pronounced attenuation with a more rapid disease progression – mortality is usually due to cardiovascular disease or pneumonia
   2. Scale that estimates the stage & severity of the disease; useful measure for charting the progression of the disease:
8. Medical Mgmt
   1. Pharmacological Mgmt
      1. Neuroprotective Therapy
         1. Monoamine Oxidase Inhibitors (MAOs)
            1. – In early stages of PD patient may be given MAOs (Selegiline) to improve metabolism of intracerebral dopamine – Selegiline= shown to delay primary endpoint at which patients need to start taking L-dopa by about 9 months & missile the overall progression of the disease – mild symptomatic benefits in early PD, improving performance on measures of disability & motor impairment – adverse effects: increase and dyskinesias & orthostatic hypotension (when taken in combo with L-dopa therapy)
      2. Symptomatic Therapy
         1. Levodopa
            1. – Is a metabolic precursor of dopamine that is able to cross the BBB & raise the level of striatal dopamine in the basal ganglia, thus reps an attempt to correct the essential neurochemical imbalance – most of L-dopa (~99%) is metabolized before reaching the brain, requiring administration of high doses that can produce numerous side effects – to combat this, lower doses of L-dopa can be used with fewer adverse affects when administered with carbidopa (a decarboxylase inhibitor that allows a higher percentage of L-dopa to enter the CNS). – SINEMET= most common carbidopa/L-dopa medication – Primary benefit: alleviating bradykinesia & rigidity with less effect on tremor
            2. THERAPEUTIC WINDOW B4 OPTIMAL BENEFIT WEARS OFF:
            3. 5-7 YEARS
            4. 1. Honeymoon Period – initial functional improvement that is often dramatic; in which there is clear-cut drug effectiveness 2. End-of-dose deterioration – wearing off state; is a worsening of symptoms during the expected timeframe of medication effectiveness 3. On-off phenomenon – random fluctuations and motor performance (treated more than 2 yrs) – DEPRENYL: can be administered with L-dopa to control mild wearing "off" phenomena
            5. Most Common Side Effects:
            6. 1. G.I. (anorexia, nausea, vomiting, constipation) 2. Cognitive (confusion & hallucinations) 3. Cardiovascular (hypotension & arrhythmias) 4. Genitourinary (dysuria) 5. Neuromuscular (motor fluctuations & dyskinesias) 6. Sleep disturbances (insomnia, sleep fragmentation)
         2. Dopamine Agonists
            1. – Class of drugs designed to act directly on the postsynaptic dopamine receptors – administer along with L-dopa, allowing lower doses to be administered with prolonged effectiveness – dopamine agonist drugs: Parlodel, Requip, Mirapex – Greatest benefit = reducing rigidity & bradykinesia; used to reduce motor fluctuations – Adverse effects = similar to L-dopa; most common = orthostatic lightheadedness & nausea
         3. Anticholinergic Agents
            1. – Used in early, untreated PD or as adjunct for patients on L-dopa – they block cholinergic function and present have the most benefit moderating tremor & rigidity; little effect on bradykinesia & postural instability – most commonly prescribed drugs: Artane, Bogentin, Parsidol, Kemadrin – Adverse effects: blurred vision, dry mouth, dizziness, constipation, & urinary retention – Central toxicity = indicated by impaired memory, confusion, hallucinations & delusions – Amantadine (Symmetrel)= antiviral agent that has anti-Parkinson's effects – potentiate the action of dopamine in the CNS – pts taking it demonstrate modest improvement in tremor, rigidity & bradykinesia
      3. Implications for the PT
         1. 1. Optimal performance can be expected at peak dosage whereas worsening performance associated with and of those cycle & medication depletion 2. PTs= involved in monitoring drug effectiveness of motor performance, function & activity participation 3. As the disease progresses, patients may develop a tolerance for particular medication, necessitating a change in prescription 4. Often it's the PT first notices a change in functional status as the patient's system adapts to either the amount or type of drug prescribed
   2. Nutritional Mgmt
      1. – High protein diet can block the effectiveness of L-dopa – generally advised to follow a high calorie, low protein diet. Generally no more than 15% of calories should come from proteins – may recommend shifting intake of daily protein to evening meal when patients are less active to minimize motor fluctuations & maximize responsiveness to L-dopa therapy – may advise and increased to daily intake of water & dietary fiber to alleviate constipation – OT: improve feeding & recommend adaptive eating devices – Speech language pathologist: recommend strategies to assist with swallowing dysfunction
   3. Surgical Mgmt
      1. Ablative Surgery
         1. Stereotactic Surgery
            1. – Surgical lesion in of the brain
         2. Pallidotomy
            1. – Involves producing a destructive lesion in the sensory motor portion of the Globus pallidus internus – Lesions reduce excessive Globus pallidus internus inhibitory activity that results in tonic thalmic hypoactivity – Indicated for: – L-dopa-induced dyskinesias, severe "on-off" state fluctuations, rigidity, & tremor (while balance, gait disturbances, freezing, & hypophonia are less responsive) – Effects are contralateral & benefits appear to be long lasting
         3. Thalamotomy
            1. – Involves producing a destructive lesion within the ventral intermediate nucleus (VIM) of the thalamus – effectively reduce long-standing tremor that is unresponsive to drug treatment & may offer some improvement of rigidity
         4. Adverse Effects:
            1. 1. Hemorrhage 2. Infarction 3. Infection 4. Seizures 5. Confusion 6. Depression 7. Dysarthria 8. Death
      2. Deep Brain Stimulation
         1. – Involves the implantation of electrodes into the brain where they block nerve signals that calls symptoms – stimulation of the ventral intermediate nucleus (VIM) of the thalamus is commonly done with severe & uncontrolled UV tremors that are unresponsive to medication – A pacemaker is implanted in the chest with a thin wire that goes under the scan to the brain electrodes – not indicated for: other PD symptoms – major advantage: 1. Potential to alter trimmer without producing and irreversible brain lesion 2. Significantly improve patient performance on IADL
         2. DBS of the Globus Pallidus & Subthalmic Nucleus (STN)
            1. Has been used to successfully control other PD symptoms of motor overactivity (on-state dyskinesias, akinesia, rigidity) along with tremor
         3. Subthalmic Nucleus Stimulation:
            1. Shown to reduce the medication requirements in PD
      3. Neural Transplantation
         1. Is Experimental & Under Investigation
         2. – Transplantation of cells capable of surviving & delivery dopamine into the stratum of patients with advanced PD – Studies involve the grafting of embryonic stem cells from umbilical cord blood or fetal cells – Adverse side effects: such as serious dyskinesias in more than 50% of patients have been reported
9. Framework for Rehab
   1. PD Management via Continuum of Care Based on Disease Stage p. 866
   2. Interventions are:
      1. Restorative
         1. Aiming at improving impairments, functional limitations & disabilities
      2. Preventative
         1. Aimed at minimizing potential complications & indirect impairments
      3. Compensatory
         1. Aimed at modifying the task, activity, or environment to improve function
10. PT Exam & Eval
    1. Elements of the Exam for a Pt. w/PD Box 21.3 p. 867
    2. Cognitive Fnx
       1. Examine the following:
          1. 1. Memory 2. Orientation 3. Conceptual reasoning 4. Problem-solving 5. Judgment
       2. To determine if Bradyphrenia is suspected:
          1. 1. Speed of information processing 2. Attention 3. Concentration
       3. Tools:
          1. 1. Mini-Mental Status Exam (MMSE)
    3. Psychosocial Fnx
       1. Determine and ask Pt. the following:
          1. 1. Determine overall levels of stress & anxiety 2. Determine available coping strategies 3. Asked patient about presence of depressive symptoms (sadness, apathy, passively, insomnia, anorexia, weight loss, inactivity & dependency, inability to concentrate & impaired memory or suicidal ideation)
       2. Tools:
          1. 1. Geriatric Depression Scale 2. Beck Depression Inventory
    4. Sensation
       1. Examine the following:
          1. 1. Screen sensation: superficial & deep sensations, combined cortical sensations) 2. Ask about presence of paresthesias (sensations of numbness or tingling) 3. Examined vision (determination of acuity, peripheral vision, tracking, accommodation, light & dark adaptation, & depth perception) 4. Examine presence of pain 5. Examined for postural stress syndrome (pain linked to lack of movement, faulty movements are posture, & ligamentous strain)
       2. Tools:
          1. 1. The McGill Pain Questionnaire 2. VAS
    5. Musculoskeletal Fnx
       1. Flexibility
          1. PD Pts are likely to present with losses in:
             1. 1. Hip & knee extension 2. Dorsiflexion 3. Shoulder flexion 4. Elbow extension 5. Dorsal spine & neck extension 6. Axial rotation
          2. Particularly Important to Examine:
             1. 1. Spinal ROM (ability to rotate, flex & extend the spine) 2. All segments of the spine should be examined 3. Hamstring linked
       2. Posture
          1. – Patient usually presents with a flexed, stooped posture (kyphosis with forward head) with the COM placed forward within the limits of stability – Exam of resting posture & changes in posture that occur with movement is indicated
       3. Muscle Performance
          1. Tools:
             1. 1. MMT 2. Hand-held & Isokinetic dynamometry
             2. Isokinetic DYNANOMETERY can also be used to document muscle endurance & been suggested for documenting tremor, using slow speeds of movement (25 mm/s) & low torques
          2. PD Pts. have been shown to exhibit impairments in:
             1. 1. The rate of force development 2. Maximum torque production capability
    6. Motor Fnx
       1. Rigidity
          1. Examine & Determine the following:
             1. 1. Usually rigidity is equal in both agonist & antagonist muscle groups but it can be sustained (leadpipe) or intermittent (cogwheel) 2. Determine which body segments are affected & the severity of involvement 3. Examined for facial immobility (hypomimia or masked face) 4. Examined for the ability to smile or use of muscles of facial expression 5. Determine severity of rigidity which can be done based on criteria of resistance the passive movement & availability of ROM (appendix A p. 889) 6. Inspection of voluntary repetitive movements to determine active limitations imposed by rigidity
       2. Bradykinesia
          1. 1. A stopwatch can be used to quantify detectable slowing of movement (movement time) & movement hesitancy or reaction time (elapsed time between patients desire to move & actual movement response) 2. Examine overall amplitude of movement & changes and amplitude 3. Timed tests for rapid alternating movements (RAM) can be used to determine the effects of bradykinesia which include: repeated opposition of the for finger & thumb, alternating pronation-supination, opening & closing of hands & tapping (finger or foot tapping); even Bilateral/simultaneous motor tasks should be examined 4. Examined dexterity and complex motor tasks (i.e. writing, dressing, skilled object manipulation; use of Purdue Peg Board Test) 5. EMG has been used to quantify the effects of rigidity & bradykinesia on motor performance
       3. Tremor
          1. Location, persistence, and severity (amplitude) of tremor should be recorded
       4. Postural Instability
          1. Examine the following:
             1. 1. Examination of balance 2. Examination of orientation to vertical 3. Asked to maintain steady standing while varying the BOS 4. Perturbation tasks that can be used to challenge balance and include self initiated movements (arm race, bending reach; dual tasking) 5. Self initiated tasks with the timing component (number of steps per minute) will also likely reveal balance impairments as will responding to unexpected perturbations 6. Examine sensory organization
          2. Tools:
             1. 1. Functional Reach Test (FR) 2. Multidirectional Reach Test (MDRT) 3. Retropulsion Test 4. Dynamic Posturography-uses a standardized & reproducible postural perturbation from a moving platform that can reveal deficits and placement of the COM, increase postural sway & unstable responses to platform perturbations – patient typically exhibits coactivation patterns (rigid body) with an inability to recover a stable posture 5. Clinical Test for Sensory Integration and Balance (CTSIB) 6. Modified Test for Sensory Integration in Balance (m-CTSIB) 7. Timed Up and Go Test 8. Tinetti's Performance-Oriented Mobility Assessment (POMA)
       5. Gait
          1. Examine the following:
             1. 1. Parameters & characteristics of gay: speed of walking, stride length, cadence, stability, variability & safety 2. 10 Meter wAlk Test-determine speed, average stride & cadence or more sophisticated kinetic analysis can be obtained from embedded force plates, body markers & computerized equipment (motion analysis systems) 3. Examine kinematic or qualitative changes including reductions in hip, knee & ankle motions that result in a short step, shuffling gait pattern with reduced trunk rotation & arm swing 4. Examined all movement directions: forward, backward & sideward 5. Examine complex gait pattern my cross stepping or braiding to examine deficits in motor planning 6. Examine using varied surfaces or negotiating an obstacle course 7. Examine using dual task walking, turns on command, walking in response to varying attentional demands/sets 8. Freezing episodes should be investigated and documented 9. Determination of fall history & fall injuries (keep a fall risk diary)
          2. Typical Gait Impairments seen:
             1. 1. Slowed speed, 2. Shuffling gait patterns, 3. Diminished arm swing and trunk movements, and an 4. Overall attitude of flexion while walking
          3. Tools:
             1. 1. 10 meter walk Test 2. Use of Computerized Motion Analysis System 3. Walkie-Talkie Test
       6. Swallowing & Speech
          1. Examine:
             1. Swallowing fnx, feeding & speech
    7. Autonomic Fnx
       1. Such as:
          1. 1. Excessive drooling 2. Excessive sweating (during "on" state=linked to dyskinesias) 3. Greasy skin 4. Abnormalities in thermal regulation 5. Orthostatic hypotension 6. BP –change > 15 mm Hg=significant –Adv PD: BP=lower in "on" state than "off" state==>frequent hypotension & c/o dizziness
    8. Cardiopulmonary Fnx
       1. Examine:
          1. 1. Respiratory function: inspection of rib cage compliance, chest wall mobility & thoracic expansion 2. Visual inspection of breeding patterns & influence of posture on breathing 3. Ventilation parameters (respiratory rate, minute ventilation, inspiratory time) 4. Changes in breathing pattern with activity 5. Objective measurements: circumferential measurements of chest & abdomen 7. Relevant pulmonary function tests 8. Exertional symptoms (dyspnea, dizziness or confusion, excessive fatigue, pallor etc) 9. Determine Knowledge & use of energy conservation & activity pacing strategies
       2. PD Pts (mod-severe) exhibit:
          1. Reduced maximal heart rate & maximal oxygen consumption along with higher submaximal heart rates with deconditioning
       3. Tools:
          1. 1. Pulmonary function tests: –Spirometry: –Flow-volume –Lung volumes –Airway Resistance – (ie: forced vital capacity (FVC), forced expiratory volume (FEV), maximal expiratory flow (MEF), maximal inspiratory flow (MIF), total lung capacity (TLC), residual volume (RV) & airway resistance (RAW) 2. 12- Minute Walk Test; 6- Minute Walk Test; 2- Minute Walk Test 3. Borg's Rating of Perceived Exertion Scale (RPE scale)
    9. Integumentary Integrity
    10. Functional Status
        1. Examine:
           1. 1. Performance of functional mobility skills; BADLs & IADLs 2. Each skill should be analyzed to determine the impact of direct & indirect impairments on performance 3. The time it takes to initiate & complete inactivity should be recorded 4. Repeat session should be undertaken at the same time of day & at the same time in the medicine cycle 5. Functional performance in the home/work environment 6. Exam and physical environment for barriers, access & safety
        2. Tools:
           1. 1. Functional Independence Measure (FIM)
    11. Global Health & Disease-Specific Measures
        1. Global Health Measures:
           1. – Global health measures can be used to determine individual outcomes across a broad spectrum – insurance typically include items that examine ability to perform routine daily activities & quality of life – are most useful in determining long-term health outcomes
           2. Most Commonly used Measures of General Health Status:
              1. 1. Rand 36-Item Health Survey SF-36 2. Sickness Impact Profile
        2. Disease-Specific Measures:
           1. – Designed to determine attributes you need to a specific disease entity – Have greater responsiveness or sensitivity to change than general health measures
           2. Tools/Instruments:
              1. Unified Parkinson's Disease Ratin Scale (UPDRS) p. 871
              2. – Most commonly used scale to examine PD disease severity & progression as well as the patient's response to drug therapy – good interrater reliability (r=0.98)
              3. Parkinson's Disease Questionnaire (PDQ-39) p. 872
              4. – Focuses on the subjective report of the impact of PD on daily life & addresses 8 health-related quality of life dimensions – provides a useful indication of the global impact of PD on health status – internal & test retest reliability = 0.68- 0.96 – construct validity – significant & high correlations between PDQ-39, SF-36, & Hoehn and Yahr Staging Score
           3. General Goals & Outcomes Box 21.4 p. 872
11. PT Intervention
    1. A Variety of Interventions are used to achieve goals & outcomes including:
       1. 1. Direct interventions 2. Supervision of assistive personnel 3. Patient/family/caregiver instruction 4. Environmental modification 5. Supportive counseling
    2. – Early intervention = critical and preventing devastating musculoskeletal impairments – Interventions also focus on improvement of motor function, exercise capacity, functional performance & activity participation – education of patients/family members/caregivers = critical to attaining optimal outcomes
    3. Motor Learning Strategies
       1. Impairments:
          1. 1. Learning long & complex movement sequences 2. Simultaneous motor/cognitive tasks 3. Movements dependent on internally generated cues vs external cues
       2. Critical Elements of Practice:
          1. 1. Large number of repetitions to develop procedural skills 2. Task broken down into component parts (Avoid Long & complex movement sequences) 3. Blocked Practice (avoid random practice order); thus reducing the effects of contextual interference 4. Task = modified to minimize competing cognitive demands 5. Environment = modified to reduce clutter & competing attentional demands that may trigger freezing episodes 6. Have patient focus for attention on the desired movement 7. Use of structured instructional sets – shown to improve movement speed & consistency 8. External cues
       3. Cueing:
          1. External Cues in General:
             1. –External cues have been shown effective in triggering sequential movement & improving movement characteristics (mild to mod PD) – appear to facilitate movement by utilizing different brain areas – heighten patient attention through a common mode of action that is, to bypass the diminished internal cueing of the basal ganglia. Thus focus is shifted to less automatic movement using alternative, more conscious motor control pathways
          2. Visual Cues
             1. also helps reduce freezing episodes
          3. Rhythmic Auditory Stimulation (RAS)
             1. – Includes use of a metronome beat or a steady beat from a musical listening device – auditory cues have also been shown to improve gait – stimuli appear to have greater influence on temporal components of movement rather than on spatial components
          4. Pulsed Cues
             1. To the earlobe or hand, a form of tactile cueing, have also been shown to improve gait
          5. Multisensory Cueing
             1. Use of both visual & auditory cueing
    4. Exercise Training
       1. Relaxation Exercises
          1. Overview:
             1. 1. Gentle rocking 2. Slow rhythmic rotational movements (hook line, lower trunk rotation, or sidelying rolling, or upper & lower trunk segmental rotations 3. Rhythmic initiation (RI)-PNF pattern 4. Diaphragmatic breathing 5. Cognitive imaging or meditation techniques 6. Conscious recognition & release of muscle tension (Progressive relaxation techniques) 7. Gentle yoga & tai chi 8. Stress management techniques 9. Lifestyle modifications & time management techniques
          2. Gentle Rocking:
             1. Used to produce generalized relaxation of excessive muscle tension due to rigidity
             2. Rocking Chair:
             3. Can be used to temporarily reduce rigidity & enhance sit to stand transfers
          3. Slow, Rhythmic, Rotational Movements
             1. – Should be perform during therapy to the extremities & trunk – should proceed intervention such as our OEM, stretching & functional training – i.e. hooklying, lower trunk rotation or sideline rolling, or upper & lower trunk segmental rotations – used to promote relaxation
          4. PNF: Rhythmic Initiation (RI)
             1. – In which movement progresses from passive to active-assistive to lightly resisted or active movement – Specifically designed to help overcome the effects of rigidity in PD
          5. Gentle Yoga & Tai Chi
             1. Can be affected because of the emphasis on combining slow, steady stretching with maintenance of postures & movement forms
          6. Lifestyle Modifications & Time Management Techniques
             1. Reduce anxiety associated with movement difficulties & prolonged time required to complete basic functional tasks
       2. Flexibility Exercises
          1. Overview:
             1. 1. AROM & PROM exercises 2. PNF patterns: UE D2 Flexion; LE D1 Extension 3. PNF Hold-Relax (HR) or Contract-Relax (CR) techniques 4. Traditional stretching techniques 5. Passive positioning 6. Mechanical low load stretching
          2. Focus/Emphasize on:
             1. 1. Strengthening the weak, elongated extensor muscles, while lengthening be shortened, type flexor muscles 2. Emphasize restoring range in the neck & truck (can be performed in combination with rotational exercises to promote relaxation)
          3. PNF Patterns
             1. Since PD pts have a minimum of energy to expand & multiple clinical problems, they may benefit from our oh and exercises and physiological patterns of motion: PNF patterns
             2. UE (B) Symmetrical D2 Flexion Pattern
             3. Ideal in promoting upper trunk extension & in counteracting kyphosis
             4. LE D1 Extension Pattern
             5. Ideal to counteract the typical flexed, adducted position of the LEs
             6. Specific muscle contractures may respond to active muscle inhibition techniques such as PNF Hold-Relax (HR) or Contract-Relax (CR) Techniques
             7. Contract-Relax:
             8. Preferred because it combines autogenic inhibition from isometric contraction of the tight agonist muscle with active rotations of the limb
          4. Traditional Stretching:
             1. – Gentle stretching of elbow flexors, hit & knee flexors, & ankle plantar flexors – stretch force= ~20-30 sec, repeated 3-5x – use caution when stretching edematous tissue
          5. Passive Positioning
             1. – A longer duration technique to improve flexibility; can also be used to stretched tight muscles & soft tissues – "Phantom pillow" posture – the head & shoulders are flexed as if there were a pillow present
             2. Early on:
             3. Daily positioning in PRONE
             4. Pts w/a developing lateral curvature:
             5. SIDELYING positioning w/small pillow under lateral strunk
       3. Strength Training
          1. Overview:
             1. 1. Strength training (machines over free wts; isokinetic contractions over isometrics) 2. Functional training activities 3. Pool exercises
          2. Indicated for Pts. :
             1. 1. Primary muscle weakness & insufficient Centro activation of the motor unit 2. Disuse weakness associated with prolonged inactivity
          3. – Studies have shown that frail elderly improvement measures of strength, functional ability, balance, gait, fall risk, & QOL following interventions that include strength training; has also shown to improve strength & motor function in mild to moderate PD – Exercise training should therefore optimally be time for "on" periods when the patient is at his/her best (i.e. 45 minutes – 1 hour after medication has been taken) – Patient should consistently exercise at same time after he medication does on alternate days – Greater changes in force production during isokinetic contractions rather than isometric contractions – PD Pts. demonstrate too much coactivation so isometric training may be contraindicated – exercise machines may be safer than free weights – functional training activities & pool exercises = effective interventions to improve strength
       4. Functional Training
          1. Overview:
             1. 1. PNF patterns (ie: RI) 2. Sideline rolling activities 3. Transitions to sitting activities 4. Sitting posture activities 5. Sit-to-Stand Transitions 6. Standing training activities 7. Getting up after a fall activities 8. Transitions activities 9. Mobilizing facial muscles
          2. PNF technique of RI
             1. May be beneficial to be more severely involve patients (going from assisted movements progressing to active movements) to improve initial motor performance
          3. Rolling Activities:
             1. – Sidelying rolling activities that emphasize segmental rotation patterns (i.e. isolated upper & lower trunk rotations) should be practiced rather than a log rolling pattern – Rolling should be practice on different surfaces progressing from firm to soft & finally simulating patient's bed surface at home
          4. Transitions to Sitting
             1. That utilize the sidelying on elbow position as an in town posture to improve the level of trunk rotation & lateral flexion
          5. Sitting Posture/Activities:
             1. – Facilitated through the improvement of pelvic mobility: 1. Anterior & posterior tilts 2. Side to side tilts 3. Pelvic clock exercises (all on therapy ball) – Sitting activity should include: 1. Weight shifting emphasizing upper trunk rotations & reaching 2. PNF extremity patterns and sitting to enhance trunk mobility – UE D2F & D2E patterns – Lift/Reverse lift pattern
          6. Sit-to-Stand Transitions
             1. 1. Initial rocking forward & backward to promote relaxation & enhance patient's ability to move weight forward 2. Practice from a farm raised seat can help promote ease of rise then progress to lower, standard height seats 3. Modified wall squats = important preparatory lead up activity to sit-to-stand training 4. Standing up to a modified plant to grade position w/UEs extended foreard on a wall to improve initial stability in standing for the patient who is unable to stop forward progression
          7. Standing Training Activities:
             1. 1. Once standing, weight shifts & rotational movements of the trunk 2. Weight shifting & stepping movements and incorporate pelvic rotation 3. Lateral side steps or step ups using a low platform step to improve abductor fnx 4. Standing wall push-ups or corner push-ups to promote upper trunk extension
          8. Get up after a Fall
             1. 1. Skills in quadruped creeping should be practice of patient is able to move to a nearby stable chair/couch at home
          9. Transitional Movements:
             1. Quadruped to kneeling to half-kneeling & finally standing w/UE support
          10. Mobilizing Facial Muscles:
              1. 1. Use of massage, stretch, manual contacts & verbal queuing to enhance facial movements 2. Practice lip pursing, movements of tongue, swallowing & facial movements such as smiling, frowning etc.
       5. Adaptive & Supportive Devices
          1. 1. Assume a sitting position by elevating the head of bed with commercially available blocks or using an electric hospital bed, or attaching a knotted rope to the end of the bed to pull on to assist in bed mobility 2. Use of a rocking chair to facilitate independent sit to stand transfers 3. A raised toilet seat & toilet rails to facilitate sit to stand transitions in bathroom 4. Loosefitting clothing & sneakers with Velcro –Pts w/shuffling gait: whether or hard composition soles are needed b/c shoes w/crepe or rubber soles will not slide easily & can result in false 5. Modified heel or shoe wedge -Flat heel/toe wedge=may slow down propulsion of gait -Raised heel/heel wedge=may diminish retropulsive gait pattern 6. A cane or walker (inverted walking stick-balance or cue stepping) 7. Vertical poles (poles striding) to improve upright posture during walking 8. Use of Reachers 9. Specially adapted utensils, play cards & enlarged handles; heated plates are pads to keep food warm & palatable 10. Protective clothing due to drooling or spills
    5. Balance Training
       1. Overview:
          1. 1. Standing platform training device (i.e. posh drug of the system) = valuable and providing COM position & LOS biofeedback 2. Seated activities 3. Standing exercise: Kitchen Sink Exercises
       2. Focus/Emphasis on:
          1. 1. COM & LOS control training 2. Dynamic stability tasks (i.e. weight shifts, reaching, axial rotation of head & trunk, axial rotation combined with reaching etc.) 3. Achieving faster initiation & execution movement time supported by the use of appropriate cueing strategies
       3. PD Standing Presentation:
          1. Restricted LOS with forward displacement of center of foot pressure
       4. PT can:
          1. Assist with postural & safety awareness by using appropriate verbal, tactile or proprioceptive cues to facilitate the desire responses
       5. Seated Activities:
          1. 1. Sitting on compliant surface (inflatable does) or therapy ball 2. Challenge: varying arm position (arms out to side, arms folded across chest) 3. Challenge: varying foot/leg position (feet apart, feet together) 4. Challenge: adding voluntary movements (arm clapping, arm overhead, single leg raises, head & trunk positions) 5. Addition of Stepping are marching in place & functional reach
       6. Varying Environmental Demands:
          1. 1. Altering the support surface (standing on phone) 2. Altering visual inputs (reducing lighting, eyes closed) 3. Challenging patient with a variable open environment
       7. Standing Exercises (Kitchen Sink Exercises)
          1. 1. Heel rises & toe off 2. Partial wall squats 3. Chair rises 4. Single limb stance with sidekicks or back kicks 5. Marching in place
    6. Locomotor Training
       1. Focuses on Primary Gait Impairments:
          1. 1. Slowed speed 2. Shuffling gait pattern 3. Diminished arm swing & trunk movements 4. Overall attitude of flexion while walking
       2. Training Programs=Designed to:
          1. 1. Lengthen stride 2. Broad and BOS 3. Improve stepping 4. Improve heel-toe gait pattern 5. Increase contralateral trunk movement & arm swing 6. Increase speed 7. Provide a program of regular walking
       3. Strategies for Improving Upright Alignment
          1. 1. Having the patient walk with vertical poles (Pole walking) 2. Verbal cues to "walk tall" 3. Overhead harness (BWS) – study show the combined use of overhead harness with walking on a motorized treadmill, both walking speed & stride length were improved
       4. Strategies to Normalize Step Length, Velocity, and Arm Swing Excursion:
          1. 1. Use of verbal instructional sets (i.e. "walk fast", "take large steps", "walk while swinging both arms" 2. Visual & auditory cues are also effective in improving gait speed & step length
       5. Strategies to Improve Foot Placement:
          1. 1. Use of floor grids or footprints on floor
       6. Strategies to Improve Step Heigh:
          1. 1. Practice marching in place progressing to walking using an exaggerated high stepping pattern 2. Brisk marching music can be used to enhance pace 3. Sidestepping & cross step walking 4. PNF activity of braiding – ideal training activity for patients with PD because it emphasizes lower trunk rotation with stepping & sidestepping movements 5. 2 dowels (held by patient & PT, one in each hand) can be used to facilitate reciprocal arm swing during gait. PT uses his/her arm swing to assist the patient's
       7. Task Specific Training Should include:
          1. Practice in changing directions, teres & negotiating obstacles
       8. Strategies for Varying Environmental Demands:
          1. 1. Altering the support surface 2. Stepping on & off varied surfaces 3. Visual inputs should be varied 4. Walking in a variable open environment 5. Practice stairclimbing, up & down curbs & ramp walking
       9. Compensatory Training Strategies
       10. Strategies for Unfreezing Gait
           1. ie: Rotational stimulation or "trick" movements such as dropping a tissue that the pt. must step over can be successful in reducing freezing
    7. Cardiopulmonary Training
       1. – Respiratory dysfunction is linked to morbidity & mortality in patients with PD – Both obstructive & restrictive ventilatory deficits are present as of the disease becomes more advanced – mild to moderate PD patients demonstrate a maximal exercise capacity that is similar to healthy adults as well as demonstrate a peek aerobic capacity that occurs at a lower work level than healthy adults – individualized exercise prescription is developed based on ACSM guidelines for frequency, intensity, duration, & progression – minimum recommended exercise frequency is 3-5 days/wk – Intermittent exercise with repetitive exercise-rest periods is indicated for those patients who are elderly & deconditioned & who present with pulmonary dysfunction – Aerobic training programs have been shown to be safe & effective for patients with PD in improving aerobic capacity
       2. Training Components:
          1. 1. Diaphragmatic breathing exercises 2. Air shifting techniques (promoted to lesser-ventilated areas of the lung 3. Exercises that recruit neck, shoulder & trunk muscles 4. Instructed in deep breathing exercises to improve chest wall mobility & vital capacity 5. Upper body resistance training exercises including raising & lowering a dowel with light weights added to increase resistance 6. Chest wall mobility can be improved by using PNF UE bilateral symmetrical D2 flexion & extension patterns
       3. Training modes:
          1. 1. LE ergometry 2. UE ergometry 3. Walking
    8. Group & Home Exercise
12. Psychosocial Issues
    1. Some of the changes associated w/PD:
       1. 1. Socially isolating: masked face, progressive immobility & unintelligible speech 2. Distressing & socially embarrassing: salvation, perspiration, decreased sexual fnx'
    2. Principal goal for team members:
       1. 1. Assist patient/family and their understanding of the disease 2. Assist in the development of insights & adjustments that lead to more effective self-management 3. Education – to assist patients & family members in assuming responsibility
    3. Self management skills to be promoted:
       1. 1. Planning of activities 2. Effective time management strategies 3. Stress management techniques
    4. AN OVERALL EMPHASIS ON WHAT THE PATIENT "CAN DO" RATHER THAN WHAT THEY CAN'T DO HELPS EMPOWER THE PATIENT
13. Pt, Fam, & Caregiver Education
    1. – Interventions can take the form of direct one-on-one instruction, group sessions, printed materials & video or computer presentations – community support groups – educational pamphlets, newsletters & location of support groups
    2. Community Support groups Benefits:
       1. 1. Disseminate information & offer a chance to discuss common issues, problems & management tips 2. Provide a stabilizing influence, assisting patients & families to focus on healthy behaviors, coping skills & effective self-management
    3. Variety of topics related to living w/PD that the team provides to the pt:
14. Mgmt Considerations by Stage of Disease
    1. During Early Stages
       1. Interventions are indicated the focus on prevention or reversal of musculoskeletal & cardiorespiratory impairments & improvement of general health status
    2. During Middle Stages
       1. Exercise training programs have been shown to be effective for patients with mild to moderate PD in improving motor performance
    3. During Late-Stages
       1. – Family & community resources are vital in maintaining the patient in the home – PT needs to focus on skin care to avoid breakdown & pressure wounds, pulmonary hygiene to avoid pneumonia, & assistance in positioning & feeding to avoid malnutrition, aspiration, & pneumonia