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Physiotherapy


Parkinson’s disease

Parkinson’s disease (PD)/ Shaking palsy/ Paralysis agitan’s is a chronic progressive neurodegenerative movement disorder.

It is characterized by muscle rigidity, tremor, slowing or loss of physical movement. It affects nerve cells or neurons, in a part of brain that controls muscle movement. Parkinson’s result from degeneration of nuclei in a number of dopamine-producing nerve cells in the brain system. Dopamine is a neurotransmitter that stimulates motor neurons that control the muscles. When this dopamine production is depleted, the motor system nerves are unable to control movement and coordination.

Parkinson’s usually begins around age 60 and may be little earlier. It is seen more common in men than women. This disease is not contagious.

Causes:

• Mostly due to unknown cause.

• Genetic factors 

• Brain tumors

• Stroke

• Pick’s disease

Environmental factors (Exposure to certain toxins affect PD)

      - Pesticides

      - Herbicides

      - Transition metal ions (Manganese, Iron, Carbon, Carbon monoxide, Cyanide)

      - Synthetic narcotic agents (MPTP 1- methyl 4-phenyl 1, 2, 3, 6-tetrahydropyridine)

Degenerative disorders

      - Alzheimer’s disease

      - Corticobasal degeneration

      - Motor neuron disease

Demyelinating diseases

      - Dementia

      - Multiple sclerosis

Pharmacological causes (over usage of these drugs)

      - Phenothiazines (Block dopamine)

      - Butyrophenomes

      - Tetrabenazine

      - Lithium

Metabolic causes

      - Hypothyroidism

      - Hyper and Hypo parathyroidism

      - Wilson’s disease

Infections

      - Meningitis

      - Encephalitis

Symptoms:

PD generally progresses slowly and the symptoms vary person to person depending on the condition.

Shaking tremors (Initial symptom)

  - These are more or less rhythmical involuntary oscillation of a part/limb.

  - Tremors mostly occur at rest (Resting tremor) and are absent during sleep. Seen in feet, lips chin and tongue.

  - Aggravated when tired, excited and stressed. Tremors stop during movement.

Rigidity (Stiff arms and legs)

  - Cog-wheel rigidity (Jerky movements)

  - Lead-pipe rigidity (Slight resistance during passive movement)

  - It increases during tension and cold environment.

Bradykinesia (Slowness and weakness of movement) while Walking, Standing and Sitting.

Stooped posture/ Simons posture

  - Flexion of arms, fingers and legs. Extended wrists.

Mask like face

  - Reduced facial expression.

  - Saliva drooling from mouth and difficulty while swallowing.

  - Decreased eye blinking.

  - Decreased arm and leg swing while walking.

Postural instability while walking, sitting. Shuffling gait.

• Speech affected Slow and quieter speech with monotone voice. Slurred speech. Whispery voice.

Fine movements are lost.

  - Difficulty while writing (Micrographia)

  - Difficulty while eating

Loss of intellectual capacity.

• Autonomic dysfunctions include

  - Dementia, Depression, Confusion.

  - Constipation, Urinary difficulties, Sexual dysfunction.

• Fatigue

• Sleeping disorder

• Anxiety

• Stress

• Hallucinations

Diagnosis:

Physical examination – shows

     - Difficulty in performing voluntary movements

     - Postural instability

     - Jerky and stiff resisted movements

     - Muscle weakness

     - Mask-like face.

Blood test - to check for liver damage, abnormal thyroid hormone levels.

CT scan - to check signs for stroke or brain tumor.

MRI scans - it’s an imaging test which uses diagnostic camera and recording device to produce organs present inside the body.

• PET scan - to detect low levels of dopamine in the brain.

Note: There is no known cure for Parkinson's disease. The goal of treatment is to control symptoms.

Treatment:

• Eating healthy nutritious food is essential. (Fruits, Vegetables, Fish, Lean meats, Dairy products. High fiber diet can help in reducing constipation.

Medications

  - Levedopa therapy - it is the most effective medicine commonly used for PD. Some of the names of this type are Stalevo, Parcopa.

  - Dopamine Agonists like - bromocriptine (Parlodel), Pramipexole (Mirapex) and Ropinirole (Requip).

  - Anticholinergics like - Trihexyphenidyl, Benztropine mesylate, Procyclidine

  - MAO-B inhibitors like -  Selegiline  (gives neuro protective effect for dopamine neurons)

  - COMT inhibitors like -  Entacapone (Comtan).

Surgical treatment

  - Deep brain stimulation (DBS) – electrodes are inserted into targeted brain region with the help of MRI and neurophysiologic mapping to ensure that they are implanted in right place. Then a device called impulse generator (IPG) similar to pacemaker is implanted under collar bone which helps in providing electrical impulses to part of brain involved in motor function.

  - Pallidotomy

  - Thalamotomy

  - Transplantation

Note: Before starting exercise program, consult your doctor. Stop exercise if you feel pain or any other unusual symptoms.

Exercises:

Physiotherapy helps the person to-

  - Learn new and energy conservation techniques to carryon his daily activities.

  - Improve quality of life.

  - Relieves Pain and Postural instability.

  - Make the person independent.

  - Improves coordination.

  - Improves gait and balance.

  - Improve bowel and bladder movement.

Stretching exercises

  - All the muscles of the body are to be stretched. Stretching is to be done regularly.

  - Hold the stretch for few seconds and do all the exercises as many as possible.

Strengthening exercises

Should be done using light weights. They help in improving balance, co-ordination, strengthen muscles, decrease fractures.

  - While sitting/standing hole a rod horizontally with hands

     1. Raise it over head and lower it

     2. Push rod away from chest and return towards the chest.

  - While sitting

     1. Sit on edge of chair and keep hands over your head locking thumbs. Bend forward, hold and relax.

    

     2. Sit in a chair comfortably and touch the floor with your hand and repeat with other hand.

     

     3. Sit in a chair and fold your arms. Raise the elbows till chin level and lift your right knee to touch the left elbow. Hold and repeat with to the other side.

  - While standing

     1. Holding chair stand on toe for few seconds and relax. Repeat many times till your comfort level.

     2. Stand holding chair in front, move one foot away for few seconds and repeat with other foot.

     3. Stand straight holding a chair with foot apart and your hands on hips. Then slowly bend your knees 90 degrees with straight spine.

 

Aerobic exercises

   - Walking (especially Heel to toe walking, Long stride walking, Short step walking with feet apart while turning, Walking with arms swinging)

   - Cycling/Stationary cycling

   - Dancing

   - Swimming

Aquatic exercises

   - Walking in water till waist depth helps in improving balance. A person should be there to assist if balance fails.

   - Breathing exercise in shallow water with help of assistant.

   - Arm stroke in shallow water with the help of assistant.

Finger and hand exercises

   - Lift arms to shoulder level and press palms against each other. Hold and relax.

   - Making a fist slowly and with slight force, opening it slowly.

- Extend and flex the each finger along with stretching them slightly.

  

- Flex and extend the thumb slowly.

   - Ball squeezing, Spread fingers apart and bring them close, Typing action. 

   - Touching all the fingers with each one by one.

Ball exercises

   - Back lift: Keep a exercise ball behind your back leaning against it and move up and down controlling the ball.

   - Front lift

   - Pass it back: This is a group exercise. Lift the exercise ball over your head and pass it back to another person. Hold the ball until other person gets hold of the ball. Repeat it several times.

Postural balance exercises

Facial exercises

Deep breathing exercises

• Singing, Reading loudly with concentration in front of mirror may help.

• Chewing on both sides help in strengthen facial and jaw muscles.

• Yawning with opening whole mouth helps in improving swallowing and speech.

Occupational therapy helps the person in

  - Maintain good handwriting and fine movements of arm and hands.

  - Modify house according to the needs.

  - Eating adaptations.

  - Dressing and grooming.

  - Use of wheel chairs.

  - Speech therapy.

Safety tips

• Swing both arms while walking as it provides better balance and stability.

• Walk lifting the feet to avoid shuffling and tripping.

• Stand and walk with legs apart.

• Wear correct footwear.

• Move slowly while getting off chair and get stable while initiating walking. (Wait for few sec).

• Avoid getting distracted while walking. Use walking aids like sticks, frames is needed.

• Should not walk on slippery floors. While walking, the floor area should not have any tiny objects as this may cause fall of the person.

• Ensure enough lighting all over the area.

• Mostly avoid using stairs. Both sides railing should be present to climb stairs.

• Children, Pets, Extension cords, Wires should not come in the way when the person is walking as this may lead to fall.

• Furniture should be in proper places and enough walking area should be present.

• Grip bars and non skid area should be there.

Prevention

• Healthy nutrition and good life style changes.

• Regular exercising with an idea of one’s own capabilities to perform the exercise.

• Regular rest.

• Avoiding stress and tension.

• Early physical therapy, Speech therapy and Occupational therapy.

• Psychological well-being without depression due to the symptoms.

• Railings, Banisters, Comfort chairs to be used in the house.

• Use special eating utensils to your comfort.

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