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Definition
- A chronic, progressive disease of the CNS
- Degeneration of dopaminergic subtantia nigra neurons and nigrostriatal pathways
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Etiology
- Several different causes identified:
- Infectious/postencephalitic
- Atherosclerosis
- Idiopathic
- Toxic
- Drug induced
- Deficiency of dopamine within basal ganglia corpus striatum with degeneration of substantia nigra
- Loss of inhibitory dopamine → excessive excitatory output from cholinergic system (acetylcholine) of basal ganglia
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Characteristics
- Rigidity (leadpipe or cogwheel)
- Bradykinesia (hypokinesia)
- Resting tremor
- Impaired postural reflexes
- Slowly progressive with emergence of secondary impairments and permanent dysfunction
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Stages
- I: minimal or absent disability, unilateral symptoms
- II: minimal bilateral or midline involvement, no balance involvement
- III: impaired balance, some restrictions in activity
- IV: all symptoms present and severe, stands and walks only with assistance
- V: confined to bed/WC
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History
- Symptoms
- Disease progression
- Functional deficits
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Cognitive/Behavioral Status
- Intellectual impairment/dementia occurs in advanced stages
- Memory deficits
- Bradyphrenia (slowing of thought processes)
- Depression
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Examination: Communication
- Dysarthria
- Hypophonia (decreased volume)
- Mutism (in advanced stages
- Mask-like face with infrequent blinking and expression
- Writing progressively smaller
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Examination: Oromotor Control/Nutritional Status
- Dysphagia common
- Problems chewing and swallowing
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Examination: Respiratory Status
- Breathing patterns
- Vital capacity
- Decreased chest expansion
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Examination: ROM/Deformity
- Contractures common in flexors and adductors
- Persistent posturing in kyphosis with forward head
- Many its osteoporotic with high risk of fracture
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Examination: Sensation/Perceptual Function
- Aching/stiffness
- Abnormal sensations (cramp-like, poorly localized)
- Problems in spatial organization, perception of vertical
- Extreme restlessness (akathisia)
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Examination: Vision
- Blurring
- Cogwheeling eye pursuit
- Eye irritation from decreased blinking
- Decreased pupillary reflexes
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Examination: Skin Integrity and Circulatory Changes
- Edema may occur in LE's
- Increased sweating (ANS dysfunction)
- Decubitus ulcers in late stages
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Examination: Muscle Tone, Strength, and Motor Function
- Rigidity
- Weakness (associated with disuse and atrophy)
- Bradykinesia/akinesia
- Ability to initiate movement (freezing)
- Reaction time vs movement time
- Tremor/pill-rolling (resting, during movement may occur in advanced stages)
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Examination: Balance
Impaired postural reactions common (worse with severe rigidity of trunk, lack of trunk rotation)
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Examination: Gait
- Generalized lack of extension
- Festination common (abnormal, involuntary increase in the speed of walking, often with forward acceleration - may occur with backward progression)
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Patients on Levodopa
- Examine for fluctuations in symptoms related to dosing (end of dose deterioration, on-off phenomenon, dyskinesia)
- Common with disease progression and long-term use of levodopa (2-3 years)
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Standardized Tests and Measures
- Revised Unified Rating Scale for Parkinsonism: documents overall effects of disease on individual
- Parkinson's Disease Questionnaire: QOL questionnaire that focuses on subjective report of impact of Parkinson's disease on daily life
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Medical Management
- Sinemet (levodopa/carbidopa) or sustained-release Sinemet: provides dopamine (crosses blood-brain barrier) and decreases effects of disease
- Dopamine agonist drugs: enhance effects of Sinemet therapy
- Anticholinergic drugs: for control of tremor
- Amantadine: enhances dopamine release
- Selegiline (deprenyl): monoamine oxidase inhibitor increases dopamine, used during early disease to slow profession
- Deep brain stimulation in thalamus or subthalamic nucleus
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Sinemet Adverse Effects
- Nausea and vomiting
- Orthostatic hypotension
- Cardiac arrhythmias
- Involuntary movements (dyskinesias)
- Psychoses and abnormal behaviors (hallucinations)
- On-off phenomenon - its experience sudden changes from normal function to immobility to severe dyskinetic movements
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PT Goals, Outcomes, and Interventions
- Monitor changes associated with disease progression and pharmacological interventions
- Prevent/minimize secondary impairments associated with disuse and inactivity
- Teach compensatory strategies to initiate movement (unlock freezing episode), repetitive auditory stimulation
- Improve strength, improve overall mobility, rotational patterns (PNF, rhythmic initiation)
- Improve postural control and balance
- Improve gait
- Promote independence in FMS and ADLs
- Improve cardiovascular endurance
- Teach energy conservation
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