Parkinsons Disease

History and Background


Parkinsons Disease is a neurologic condition caused by loss of dopamine in the basal ganglia.

Parkinsons Disease is an umbrella term for a group of symptoms that occur because of a loss of the neurotransmitter, dopamine. Neurotransmitters are chemicals that allow nerves to communicate with each other.  Dopamine is responsible for getting movement related messages from the brain to the body.

What Causes Parkinson Disease?

Many factors can cause the loss of dopamine in the brain. Some scientists theorize that losing dopamine is a normal part of the aging process and that the rise in the prevalence of parkinson disease in the US is due to increase in the average life span. This would not account for the growing number of younger individuals, most notably, Michael J Fox who have a form of parkinson disease call early onset parkinson disease. More established and widely agreed upon causes include environmental toxins, internal toxins, certain psychotropic medications, street drugs, and certain blood vessel disorders (ie: stroke), and alcohol abuse. However, no definitive cause has been linked to the cause of parkinson disease.

What are the symptoms of Parkinson Disease?

Bradykinesia: Slow movement

Hypokinesia: Small movement

Muscle Rigidity

Tremors

What are the stages of Parkinson Disease?

Stage 1
During this stage, symptoms are mild and typical can only be detected on one side of the body (unilateral). These symptoms may include mild tremor or shaking. Additional symptoms that may be noticeable by family and friends is a forward flexed posture, mild balance disturbances, decrease in facial expressions, and handwriting becomes small.
Stage 2
During stage 2, symptoms can be noticed on both sides of the body (bilateral), balance disturbances increase (and may include falls), and daily tasks come more difficult.
Stage 3
In stage 3, symptoms become more severe. Assistance is needed for walking, performing sit to stand and for completing daily activities.
Stage 4
In this stage symptoms become more severe. Clinical presentation is marked with significant muscle rigidity and bradykinesia (slow movement). Patients in this stage require assistance and usually are unable to live on their own. It is common for tremors noted in the earlier stages to decrease.
Stage 5
A person in this stage of the disease typically requires 24 hour care and may be confined to a bed or wheelchair.

Medical Treatment


Medication

Currently no cure exists for parkinsons disease, however, medication can help with the symptoms. Like many medications, there are side effects and tolerence to the medication may occur decreasing the effectiveness of the medication. The decision to start medication to manage the symptoms is sometimes a difficult decision. The following questions are great questions to discuss with a neurologist. They are also great questions for each individual to ask themself prior to discussing this with the neurologist.

  1. What symptoms do I have related to my parkinsons disease?
  2. Do these symptoms interfere with my quality of life?
  3. If so, to what degree? Are the side effects of the medication worth it in order to have some releif from the symptoms.

The most commonly prescribed medication is a combination of Levodopa and carbidopa. Levadopa metabolizes dopamine in the body. Carbidopa helps prevent Levadopa from breaking down so it has a chance to get to the brain where it is effective for treatment of parkinsons symptoms. Over time, it will require a higher dose for the medication to be effective. This is important when deciding when to start on the medication.

Additional information related to parkinsons disease medications

Deep Brain Stimulator (DBS)

Deep brain stimulation is a device implanted under the skin with electrodes that attach to the surface of the brain.  The device delivers electrical stimulation that essentially “turns off” certain areas of the brain that cause some of the symptoms associated with parkinsons disease. This is usually only consisdered once it is determined that medication is no longer effective. For more detailed information on the device and the surgical procedure can be found at the National Institute of Neurological Disorders and Stroke website (A part of the national institute of health).

Physical Therapy


Parkinsons disease is primarily a movement disorder.  Meaning the primary symptoms are related to balance, coordination, motor control, muscle tone, and initiating/terminating movement. Physical therapy can help to manage many of these symptoms.

Traditional Physical Therapy Protocol

A skilled physical therapy plan will typically include the following:

Stretching tight/rigid muscles: Muscle rigidity usually effects trunk muscles which effect breathing and posture, hip muscles which effect the ability to walk normally, and the upper extremities which have a tendency to flex forward following the line of the forward flexed trunk

Breathing Exercises: A forward flexed posture decreases tidal volume (colume of air moved into or out of the lungs) and the inspiratory reserve volume (the maximal volume that can be inhaled). Breathing techniques can improve these volumes.

Posture Re-education: Retraining postural muscles can improve breathing, prevent falls, improve balance and walking, improve swallowing, and decrease neck and back pain.

Balance retraining: balance requires quick reactions which can be challenging for those with parkinsons disease who struggle with initiating movement or who present with hypokinesia.  This can be addressed with  a variety of balance retraining exercises, high amplitude movement retraining, and compensatory strategies that will be specific to each individual based on lifestyle, activity level, and home envirnment.

Equipment recommendations: Several products have been developed specifically to assist patients who suffer from freezing episodes, difficulty stopping movement, poor posture….etc. Each patient will be educated in any equipment recommendations.

LSVT Big Movement Retraining

Scientists and clinicians have found that hypokinesia (small movements) are the underlying cause of problems with balance, coordination, and difficulty moving the arms and legs. A decrease in dopamine, seems to correlate with a decrease in the signal getting from the brain to the body.  This could explain why some of the initial symptoms include smaller steps, small handwriting, “small” (forward flexed) posture, and fatigue with cutting food, brushing teeth and tying shoes.

The LSVT Big Movement retraining exercises focus on increasing the amplitude of movement combined with multiple repetitions in an effort to recalibrate the brain.  The goal is to retrain the brain to put more effort (attempt to create bigger movements then what “feels normal”) into movement. Doing the exercises multiple times per week and at high repetitions creates neuroplastic changes in the brain. These exercises have been found to be very effective in the early stages (most effective in stages 1-3).  An LSVT Big certified physical therapist is trained in the exercises as well as, how to progress the exercises to include more functional activities.  By the end of the 4 week protocol, each patient should be able to do the exercises independently as well as be comfortable incorporating the new movements into functional activities. This typically results in walking with a larger step length, improved posture, and less fatigue with dressing, bathing, cutting food, and performing grooming activities

Answers To Common Problems


Hot Topics


U-step Walker For Parkinsons Disease

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The U-step walker was designed by a patient with parkinsons disease and has several unique features that address many common movement related  problems.

Features:

1. Reverse Breaks: When steps become small, this places the body in a slight forward lean, similar to what would happen if walking down hill.  This creates a forward momentum. PD can sometimes make it difficult to stop this momentum once it starts. The breaks on this walker activate when you release the breaks.  These Reverse breaks making it possible to stop this momentum by just releasing the grip.

2. Laser Light: The walker is equiped with a laser light that can shine on the ground.  This laser light beam on the ground works by creating a visual target on the ground as a visual cue of where the foot should strike the ground for a normal step length. As the walker advances, so does the light beam.

3. Metronome: The walker has a button near the handle to start the metronome.  For those who struggle with freezing, metronomes work extremely well to get back into a rhythmic stepping pattern.  Stepping to the beat of a metronome requires much less motor planning (requiring the work of the basal ganglia) and works well when freezing episodes occur.

4. Seat and basket: Similar to other walkers these to features are extremely valuable to continue walking in the community

NPTS Just received a demo walker.  An evaluation will include equipment recommendations.  If the therapist feels this walker is appropriate, it is available to trial prior to ordering.