L5 Neurodegenerative-Disorders-Understanding-Assessment-and-Management_6d934e2fdb88ae0fc8ba17c01ff6a1e7

Neurodegenerative diseases are conditions that primarily affect neurons in the brain, posing a major threat to human health due to their increasing prevalence in aging populations. These disorders lead to permanent damage or death of neurons, which do not reproduce or replace themselves, resulting in significant clinical, social, and economic challenges for healthcare systems worldwide.

Neurons are the building blocks of the nervous system, including the brain and spinal cord. Their inability to reproduce or replace themselves means that any damage or death is permanent, which is critical in understanding the impact of neurodegenerative diseases as they lead to irreversible loss of function.

Alzheimer's Disease is the most common form of dementia, characterized by:

• Amyloid plaques
• Neurofibrillary tangles

The key components assessed in coordination include:

1. Involuntary movements
2. Hesitation
3. Slowness
4. Arrests of movements
5. Poverty of movements

Aspects evaluated in gait and locomotion include:

1. Gait pattern
2. Gait speed
3. Safety

• Retropulsion tests
• Functional reach test
• One-leg-stance test

• Instrumented walkway
• Motion analysis system
• Force plate
• Electromyography
• Body-worn sensors

A comfortable gait speed of <1.1 m/s, along with a history of falling in the previous year and experiencing freezing of gait (FOG) in the past month, indicates a higher risk of falls.

A TUGT score greater than 11.5 seconds suggests a risk of falls and indicates poor functional mobility and balance.

A score of 0 indicates that the individual is normal, with no problems and recovers with one or two steps.

The cut-off score for fall prediction in the Functional Reach Test is 31.8 cm.

The Montreal Cognitive Assessment (MOCA) is a 16-item screen designed to evaluate multiple cognitive domains to detect mild cognitive impairment in individuals with Parkinson's disease. It provides a total score with cutoff scores indicating mild cognitive impairment (<26/30) and dementia (<22/30).

The Mini Balance Evaluation Systems Test (Mini-BESTest) is a 14-item clinical balance assessment that evaluates balance across 4 domains. It uses a 3-point scoring scale (0-2) for a maximum total score of 28. The Minimal Detectable Change (MDC) is 17.1% or 5.52 points, and the Minimal Clinically Important Difference (MCID) is 4 points for balance disorders.

The Nonmotor Symptoms Scale (NMSS) is a 30-item scale that assesses the frequency and severity of nonmotor symptoms in Parkinson's disease across 9 dimensions based on the previous month. Scores are calculated by multiplying severity and frequency scores for each item and summing them within each domain.

Parkinson's Disease is a movement disorder characterized by:

• Tremor
• Rigidity
• Bradykinesia
• Postural instability

Inherited genetic changes involve the transmission of faulty genes from parents to children, leading to disorders that run in families. Examples include Huntington's disease, rare familial forms of motor neuron disease, and Alzheimer's disease.

Complex genetic influences involve multiple genetic and environmental factors interacting, which complicates the prediction of disease development. This complexity makes it challenging to understand the exact causes and to develop effective preventive strategies and targeted treatments.

Long-term exposure to pesticides, toxins, and industrial chemicals is linked to Parkinson's disease. Other neurodegenerative conditions may also have unidentified environmental triggers.

Advancing age is the greatest known risk factor for many neurodegenerative disorders because the cellular mechanisms that protect neurons from damage become less efficient as we age.

Neurodegenerative disorders can be classified by their primary symptoms into three main categories:

1. Dementia
2. Parkinsonism
3. Motor neuron disease

This classification aids in initial diagnosis and treatment planning.

The molecular classification focuses on specific protein abnormalities and molecular mechanisms underlying neurodegenerative diseases. This approach:

• Identifies potential targets for disease-modifying treatments.
• Enhances the development of effective diagnostic tools and therapeutic strategies.

Amyloids are insoluble fibrous proteins with specific ẞ-sheet-rich secondary structures. They typically form amyloid-like filamentous aggregates within the cytoplasm of neurons and glia, and can also lead to extracellular deposits in the brain parenchyma (plaques) or blood vessel walls (amyloid angiopathy).

Conditions associated with amyloid pathology include:

1. Gerstmann–Sträussler–Scheinker disease (GSS)
2. Creutzfeldt–Jakob disease (CJD)
3. Alzheimer's disease

These conditions exhibit the formation of abnormal protein aggregates, which is a hallmark feature of neurodegenerative diseases.

• Tauopathies develop when normal tau proteins become altered into pathological forms.
• Abnormal tau proteins disrupt nerve impulse transmission.
• They form neurofibrillary tangles inside neurons.
• Most tauopathies develop in later life, though some can appear in middle age.

• Alzheimer's Disease
• Progressive supranuclear palsy (PSP)
• Corticobasal degeneration (CBD)
• Frontotemporal dementia
• Argyrophilic grain disease (AGD)

The key disorders associated with synucleinopathies include:

• Parkinson's disease (PD)
• Dementia with Lewy bodies (DLB)
• Pure autonomic failure (PAF)
• Multiple system atrophy (MSA)

The clinical challenges in diagnosing synucleinopathies include:

• Significant clinical overlap between conditions
• Indistinguishable parkinsonism in PD, DLB, and MSA
• Need for careful observation over time for differential diagnosis
• Similar pathogenic mechanisms suggesting potential for common therapeutic approaches

The major conditions with TDP-43 pathology include:

• Motor Neuron Disease (the vast majority of cases)
• Frontotemporal lobar degeneration
• Limbic-predominant age-related TDP-43 encephalopathy (often clinically diagnosed as Alzheimer's dementia)

Understanding TDP-43 pathology helps physiotherapists by:

• Explaining the overlapping clinical features between conditions like motor neuron disease and frontotemporal dementia.
• Informing comprehensive assessment and treatment approaches tailored to the specific needs of patients with these conditions.

• Progressive, fatal, and currently untreatable neurodegenerative conditions
• Affect both humans and animals
• Result from misfolding of a normal cell-surface brain protein (PrPC)
• Misfolded proteins (PrPSc) can trigger normal proteins to misfold
• Create a cascade effect leading to neurodegeneration

• Creutzfeldt-Jakob disease (CJD)
• Variant CJD (linked to bovine spongiform encephalopathy)
• Gerstmann-Sträussler-Scheinker syndrome
• Fatal familial insomnia
• Kuru

The primary motor symptoms of Parkinson's disease include:

1. Tremors - Involuntary shaking, often starting in the hands.
2. Bradykinesia - Slowness of movement, making daily activities more difficult.
3. Rigidity - Stiffness in the limbs and trunk, leading to discomfort and reduced range of motion.
4. Postural Instability - Difficulty maintaining balance, increasing the risk of falls.

Understanding the mechanisms and progression of Parkinson's disease is crucial for physiotherapists because it allows them to:

1. Develop Effective Assessment Strategies - Tailoring evaluations to the specific needs of patients.
2. Create Targeted Intervention Plans - Designing rehabilitation programs that address motor and functional impairments.
3. Enhance Quality of Life - Implementing strategies that improve daily functioning and overall well-being.
4. Monitor Progression - Adjusting treatment plans based on the disease's progression and patient response.

Approximately 1% of the population over age 60 is affected by Parkinson's disease.

Men are 1.5 times more likely to develop Parkinson's disease than women.

About 10-15% of Parkinson's disease cases have a family history. Key genes identified include SNCA, LRRK2, PARK7, PINK1, and PRKN.

Environmental factors associated with increased risk include:

• Exposure to certain toxins (pesticides, herbicides)
• Rural living
• Well water consumption
• Exposure to industrial chemicals

James Parkinson first described Parkinson's disease in 1817, referring to it as 'the shaking palsy.'

The clinical subtypes of Parkinson's disease are:

1. Tremor-dominant: Main feature is tremor, with less bradykinesia and rigidity.
2. Postural Instability and Gait Disorder (PIGD): Characterized by balance and walking difficulties.
3. Mixed type: Features of both tremor and PIGD.

Prognostically, tremor-dominant PD generally follows a more benign course compared to PIGD-dominant PD.

The main components of the basal ganglia include:

• Caudate nucleus
• Putamen (collectively known as the striatum)
• Globus pallidus (internal and external segments)
• Subthalamic nucleus
• Substantia nigra (pars compacta and pars reticulata)

The basal ganglia are critical for:

• Initiating and executing voluntary movements
• Inhibiting competing motor programs
• Procedural learning and habit formation
• Sequencing complex motor actions
• Modulating muscle tone

The direct pathway facilitates movement by promoting desired actions. It involves the striatum projecting to the GPi/SNr, then to the thalamus, and finally to the cortex, resulting in an excitatory effect mediated by D1 dopamine receptors.

The indirect pathway inhibits competing movements, suppressing unwanted actions. It involves the striatum projecting to the GPe, then to the STN, GPi/SNr, thalamus, and cortex, leading to an inhibitory effect mediated by D2 dopamine receptors.

Dopamine from the substantia nigra maintains a balance between the direct (excitatory) and indirect (inhibitory) pathways in the basal ganglia circuitry.

Dopamine depletion leads to:

1. Reduced dopamine availability in the striatum.
2. Decreased D1 receptor activation in the direct pathway.
3. Increased D2 receptor inhibition in the indirect pathway, resulting in circuit imbalance.
4. Excessive inhibition from GPi/SNr output, which inhibits thalamo-cortical motor circuits, causing bradykinesia, rigidity, and tremors.

The main functional divisions of the basal ganglia include:

1. Striatum
   • Caudate nucleus
   • Putamen
2. Pallidum
   • Globus Pallidus Interna (Gpi)
   • Globus Pallidus Externa (Gpe)
3. Thalamus
4. Subthalamic Nucleus
5. Substantia Nigra

The substantia nigra is significant in Parkinson's disease because:

• It contains dopamine-producing neurons in the pars compacta that project to the striatum.
• In Parkinson's disease, 60-80% of these dopaminergic neurons are lost before clinical symptoms appear, indicating a critical site of pathology.
• The loss of these neurons leads to impaired movement control and reward processing.

The direct pathway facilitates desired movements by being activated by dopamine through D1 receptors, which leads to the striatum inhibiting the GPi/SNr directly. This reduces inhibition of the thalamus, allowing for cortically initiated movements. In Parkinson's disease, this pathway is deficient, contributing to movement difficulties.

The indirect pathway suppresses unwanted movements by being inhibited by dopamine through D2 receptors. The striatum inhibits the GPe, which disinhibits the STN, leading to increased excitation of the GPi/SNr and greater inhibition of the thalamus. In Parkinson's disease, this pathway is overactive, resulting in excessive inhibition of movement.

The main nuclei of the basal ganglia include the striatum, globus pallidus, subthalamic nucleus, and substantia nigra. Their primary function is movement modulation.

The direct pathway facilitates movement by promoting excitatory signals from the motor cortex to the thalamus, leading to decreased inhibitory output from the globus pallidus internus (GPi) and substantia nigra pars reticulata (SNr). This results in increased activity in the thalamus, which enhances motor activity.

The direct pathway primarily involves the neurotransmitters glutamate (excitatory) from the motor cortex, dopamine (modulatory) from the substantia nigra, and GABA (inhibitory) from the GPi and SNr.

The indirect pathway of the basal ganglia primarily functions to inhibit motor activity. It involves several key structures:

1. Motor Cortex sends excitatory signals (Glutamate) to the Striatum.
2. The Striatum then sends inhibitory signals (GABA) to the GPe and GPi.
3. The GPe inhibits the Thalamus, reducing its activity.
4. The STN stimulates the GPi, which further inhibits the Thalamus.
5. The overall effect is a decrease in thalamic activity, leading to reduced excitation of the motor cortex, thus inhibiting movement.

The indirect pathway interacts with the direct pathway by providing a balance between inhibition and excitation of motor activity. While the direct pathway facilitates movement by sending excitatory signals from the Striatum to the Thalamus, the indirect pathway counteracts this by inhibiting the Thalamus through the GPi and GPe. This balance is crucial for fine-tuning motor control and preventing excessive movement, which is particularly relevant in conditions like Parkinson's disease where this balance is disrupted.

The main structures involved in the Nigrostriatal Pathway include:

1. Substantia nigra (pars compacta)
2. Subthalamic nucleus
3. Thalamus
4. Globus pallidus (internal and external segments)
5. Striatum (Caudate and Putamen)

The Nigrostriatal Pathway is crucial for the regulation of movement. In Parkinson's Disease, degeneration of the Substantia nigra leads to a decrease in dopamine production, which disrupts the communication within this pathway, resulting in motor symptoms such as tremors, rigidity, and bradykinesia.

The two main types of dopamine receptors in the striatum are D1 and D2. D1 receptors, when activated by dopamine, result in neuronal excitation, while D2 receptors lead to inhibition when stimulated by dopamine.

Dopamine enhances the activity of the direct pathway through D1 receptor activation, facilitating movement initiation and execution. Conversely, it inhibits the indirect pathway via D2 receptor activation, reducing the suppression of competing movements. This creates optimal conditions for voluntary movement execution.

The nigrostriatal pathway contributes to:

1. Motor Learning: Involvement in procedural learning and habit formation through the activity of substantia nigra pars compacta neurons related to behavioral stimuli and rewards.

2. Reward Processing: Dopaminergic neurons respond to unexpected rewards and adjust their activity to cues predicting rewards, reinforcing beneficial behaviors.

3. Motivational Control: Influences the motivational aspects of movement, which can lead to apathy and reduced drive in Parkinson's patients.

The nigrostriatal pathway affects motivation by contributing to the motivational aspects of movement. In individuals with Parkinson's disease, this pathway's dysfunction can lead to symptoms such as apathy and a reduced drive to initiate activities, highlighting its role beyond just motor control.

The primary pathological features of Parkinson's disease include:

• Neuronal Loss: Selective degeneration of dopaminergic neurons in the substantia nigra pars compacta.
• Lewy Bodies: Abnormal protein aggregates primarily composed of alpha-synuclein within remaining neurons.
• Lewy Neurites: Abnormal alpha-synuclein deposits in neuronal processes.
• Neuroinflammation: Microglial activation and inflammatory processes.

The cellular mechanisms contributing to the pathophysiology of Parkinson's disease include:

1. Protein Misfolding: Abnormal folding and aggregation of alpha-synuclein.
2. Mitochondrial Dysfunction: Impaired energy production and increased oxidative stress.
3. Impaired Protein Degradation: Dysfunction in ubiquitin-proteasome and autophagy systems.
4. Oxidative Stress: Excessive production of reactive oxygen species.

The Hoehn and Yahr Scale indicates the stages of progression in Parkinson's Disease, ranging from:

1. Stage 1: Unilateral involvement with minimal or no functional disability.
2. Stage 2: Bilateral involvement without balance impairment.
3. Stage 3: Mild to moderate disability with impaired postural reflexes.
4. Stage 4: Severely disabling disease but still able to walk or stand unassisted.
5. Stage 5: Confinement to bed or wheelchair unless aided.

This scale helps in assessing the functional abilities and disability levels in patients as the disease progresses.

1. Rigidity: Increased muscle tone, presenting as 'lead-pipe' or 'cogwheel' rigidity.

2. Bradykinesia: Slowness of movement, difficulty initiating movement, and reduced facial expression.

3. Tremor: Rhythmic movement at rest, often starting unilaterally, commonly a 'pill-rolling' tremor.

4. Postural Instability: Impaired balance and righting reflexes, leading to falls, usually appearing later in the disease.

Rigidity affects both flexors and extensors equally and presents as uniform resistance ('lead-pipe') or ratchet-like resistance ('cogwheel'). In contrast, spasticity typically involves increased tone in specific muscle groups, often leading to a more variable resistance during passive movement.

Common motor manifestations include:

1. Start hesitation and freezing episodes
2. Poverty of movement
3. Masked facial expression
4. Micrographia (small handwriting)
5. Fatigue
6. Contractures and deformities
7. Impaired gait
8. Kyphotic posture
9. Dysarthria (speech difficulties)
10. Dysphagia (swallowing problems)
11. Akathisia (inability to remain still)

Significant non-motor symptoms include:

• Visuospatial deficits
• Depression and anxiety
• Bradyphrenia (slowed thinking)
• Excessive sweating
• Abnormal hot and cold sensations
• Sialorrhea (excessive drooling)
• Seborrhea (excessive oily skin)
• Constipation
• Orthostatic hypotension
• Urinary bladder dysfunction
• Dementia (in advanced stages)

Parkinson's disease leads to:

• Delayed reaction times and difficulties in movement preparation.
• Start hesitation that becomes more evident as the disease progresses, indicating impaired basal ganglia function in motor planning.

• Felt uniformly in both agonist and antagonist muscles
• Present throughout the full range of passive movement
• Spinal stretch reflexes remain normal
• Relatively constant regardless of task, amplitude, or speed of movement
• Both 'cogwheel' and 'lead-pipe' rigidity can be observed
• Often begins in the neck and shoulders before affecting the face and extremities
• May be more prominent on the initially affected side
• Can be enhanced by asking the patient to perform voluntary movements with the contralateral limb (Froment's maneuver)

• Parkinsonian rigidity is present throughout the range and affects flexors and extensors equally.
• Spasticity is velocity-dependent and predominantly affects specific muscle groups.

Common postural deformities include:

• Flexed Posture: Forward flexion of the head and neck
• Kyphosis: Increased thoracic curvature
• Stooped Stance: Forward flexion of the trunk
• Flexed Knees: Slight flexion at the knees
• Striatal Hand: Ulnar deviation with flexion of the metacarpophalangeal joints
• Striatal Toe: Extension of the great toe with flexion of the other toes

Severe postural deformities include:

• Camptocormia: Extreme forward flexion of the thoracolumbar spine
• Anterocollis: Forward flexion of the neck
• Pisa Syndrome: Lateral flexion of the trunk

• Slowness of movement initiation and execution
• Reduction in movement amplitude, range, and speed
• Progressive reduction in speed and amplitude with sequential movements
• Difficulty with simultaneous and sequential tasks
• Akinesia: absence of movement or difficulty initiating movement
• Freezing: sudden, temporary blocks in movement
• Hypomimia: reduced facial expression ('masked facies')
• Hypophonia: soft, monotonous speech

• Finger tapping: Decreased speed, amplitude, and rhythm
• Hand opening/closing: Progressive slowing and reduction in amplitude
• Pronation/supination: Decreased speed and range
• Foot tapping: Reduced speed and amplitude
• Handwriting: Micrographia (progressively smaller writing)
• Gait: Reduced stride length and arm swing

• Initial symptom in approximately 70% of patients
• Resting tremor: occurs when the affected body part is relaxed and supported against gravity
• Frequency: slow, typically 4-6 Hz
• Classic 'pill-rolling' appearance in the hands (thumb-to-index finger motion)
• Often begins unilaterally, commonly in a hand or arm
• May involve the forearm, jaw, lips, tongue, or lower extremities
• Typically disappears or diminishes with voluntary movement
• Increases with stress, anxiety, or concentration
• May reappear when maintaining a posture (re-emergent tremor)

Some patients may have predominantly tremor-dominant PD, which often has a more benign prognosis than the postural instability and gait difficulty (PIGD) subtype.

• Typically appears later in disease progression (≥5 years after diagnosis)
• Results from loss of postural reflexes
• Characterized by abnormal and inflexible postural responses
• Increased body sway in quiet stance
• Difficulty adapting to changing environmental demands
• Worsened by narrowing base of support
• Exacerbated by divided attention and dynamic activities
• Responds poorly to dopaminergic medication

• Rigidity limiting compensatory movements
• Decreased muscle torque production
• Loss of available range of motion, particularly in trunk
• Weakness, especially in extensor muscles
• Abnormal sensory integration
• Altered internal representation of verticality
• Impaired anticipatory postural adjustments
• Reduced limits of stability

Increased fall risk in Parkinson's Disease is due to a combination of factors including postural instability, freezing, poor gait, cognitive impairment, depression, orthostatic hypotension, and medication-induced dyskinesias.

Long-term complications from falls in Parkinson's Disease include:

1. Progressive immobility
2. Contractures
3. Deformities
4. Osteoporosis
5. Increased dependence

These complications significantly reduce quality of life and increase caregiver burden.

Motor planning deficits in Parkinson's disease result in:

• Micrographia: Difficulty in handwriting.
• Poverty of movement: Impaired execution of everyday movements.
• Hypomimia: Reduced facial expressions.
• Freezing episodes: Challenges in transitioning between activities, particularly during turning and rotational movements.

• Reduced stride length and walking speed
• Normal or increased cadence in early stages, decreased in late stages
• Increased double limb support time
• Insufficient hip, knee, and ankle flexion
• Shuffling steps with minimal ground clearance
• Insufficient heel strike with forefoot loading
• Reduced trunk rotation and arm swing
• Festinating gait: accelerating steps with forward lean
• Freezing of gait: sudden inability to move forward

• Difficulty initiating gait, especially from sitting
• Problems navigating doorways and narrow spaces
• Significant difficulty with turning
• Impaired performance with dual tasking
• Deterioration with increased attentional demands
• Problems adapting to changing environments
• Difficulty with obstacle negotiation
• Poor adaptation to surface changes

The primary causes of death in Parkinson's disease patients include:

• Pneumonia (often aspiration-related)
• Cardiovascular disease
• Complications from falls
• General frailty and debility

The tremor-predominant subtype of Parkinson's disease generally has a more benign progression, while the postural instability and gait disturbance (PIGD) subtype is associated with more rapid progression.

The Hoehn and Yahr scale measures the progression of Parkinson's disease through five stages based on motor symptoms and disability.

Stage 3 is characterized by:

1. Mild to moderate disability
2. Impaired postural reflexes
3. Physically independent
4. Balance impairment
5. Significant slowing of body movements

The primary clinical criteria for diagnosing PD include:

1. Presence of at least two of the four cardinal features.
2. Asymmetric onset of symptoms.
3. Good response to levodopa therapy.
4. Absence of features suggesting Parkinson-plus syndromes.
5. Absence of identifiable causes of secondary parkinsonism.

Imaging techniques used in the diagnosis of PD include:

• Conventional MRI: Typically normal in early PD; helps exclude other conditions.
• DaTscan (123I-ioflupane SPECT): Shows reduced dopamine transporter binding in the striatum.
• PET imaging: Can detect dopaminergic deficits.
• Transcranial sonography: May show hyperechogenicity of substantia nigra.
• CSF biomarkers: Under investigation (e.g., α-synuclein, DJ-1, tau).

MAOIs like selegiline and rasagiline may slow disease progression by reducing oxidative stress. They inhibit the breakdown of dopamine, extending its availability in the brain.

Levodopa is the mainstay of symptomatic treatment as it crosses the blood-brain barrier and converts to dopamine, effectively replacing the depleted neurotransmitter. It is usually combined with carbidopa (Sinemet) or benserazide to prevent peripheral conversion and reduce side effects.

• COMT Inhibitors: Entacapone and tolcapone extend the effect of levodopa by inhibiting its breakdown.
• Amantadine: Helps with dyskinesias and has mild antiparkinsonian effects.
• Apomorphine: A rapid-acting injectable dopamine agonist used for 'rescue' during severe 'off' periods.

• Duodopa: Intestinal gel form of levodopa-carbidopa delivered directly to the small intestine via a pump.
• Apomorphine pump: Continuous subcutaneous infusion.
• Extended-release formulations: Provide more stable dopaminergic stimulation.
• Transdermal patches: Used for some dopamine agonists.

The Parkinson's Disease Questionnaire-39 (PDQ-39) is a 39-item self-report questionnaire that evaluates health-related quality of life in 8 dimensions based on the previous month. Scores are calculated by summing the scores for each dimension, dividing by the maximum possible score, and multiplying by 100. The overall summary index is the sum of dimension total scores divided by 8.

The main types of surgical management options include:

1. Ablative Surgery

   • Thalamotomy: Destroys a small group of cells in the thalamus, effective for tremor.
   • Pallidotomy: Destroys cells in the internal globus pallidus, effective for dyskinesias, tremor, and rigidity.

2. Deep Brain Stimulation (DBS): Involves implantation of electrodes in specific brain targets (STN, GPi, or VIM nucleus of thalamus) connected to a pacemaker-like device, providing continuous electrical stimulation.

3. Neural Transplantation: An experimental approach that involves transplanting dopamine-producing cells into the striatum to replace lost dopaminergic neurons.

Patient selection for surgical interventions is critical and typically considers the following factors:

• Diagnosis: Best candidates usually have idiopathic Parkinson's Disease (PD).
• Response to Medication: Good response to levodopa is essential.
• Motor Symptoms: Presence of troublesome motor fluctuations or medication-resistant tremor.
• Cognitive and Psychiatric Health: Absence of significant cognitive impairment or psychiatric issues is crucial for eligibility.

The UPDRS consists of four main components:

1. Part I: Mentation, Behavior, and Mood (13 items)
2. Part II: Activities of Daily Living (13 items)
3. Part III: Motor Examination (14 items)
4. Part IV: Complications of Therapy (11 items)

The UPDRS is significant for several reasons:

• Documenting disease progression
• Evaluating treatment effectiveness
• Standardizing clinical assessments
• Facilitating communication between healthcare providers

Factors in a patient's/client's social history include:

• Cultural beliefs and behaviors
• Family and caregiver resources
• Social support systems

Important aspects of a patient's/client's general health status include:

1. Physical health
2. Psychological health
3. Social health
4. Role function
5. Health habits

Key components include:

• Diagnosis: Year of diagnosis and disease stage
• Motor complications: Motor fluctuations, unpredictable on and off states, dyskinesias, and off state dystonia
• Mental complications: Executive dysfunction, anxiety, apathy, depression, illusions, hallucinations, impulse control disorders
• Pain: Time of day, location, quality, and severity
• Comorbidity: Conditions like heart failure, osteoporosis, COPD, arthritis, diabetes
• Current treatment: Type, intensity, and adverse events
• Earlier treatments: Type and outcomes of previous treatments for referred problems.

Factors to assess include:

• Problems with relationships: Impact on social interactions
• Profession and work: How the disease affects occupational functioning
• Social life: Engagement in leisure activities and community involvement.

Key components include:

• Physical capacity and pain: Observe muscle power, tone, joint mobility, and pain types.
• Transfers: Assess ability to sit down, rise from a chair, get up from the floor, and other daily activities.
• Manual dexterity: Evaluate reaching, grasping, and moving objects, noting any limitations.
• Balance: Identify any balance impairments during various activities.
• Gait: Observe gait pattern impairments, including speed, trunk rotation, arm swing, and stride length.

Recommended tools include:

• 6MW & Borg 6-20: For endurance assessment.
• 5TSTS: 5 times sit-to-stand test.
• M-PAS: Modified Parkinson's activity scale for various settings (bed, chair, gait).
• TUG: Timed Up and Go test for mobility.
• DGI: Dynamic gait index.
• FGA: Functional gait assessment.
• Mini-BESTest: Mini-balance evaluation systems test.
• 10MWT: 10-meter walk test.
• BBS: Berg Balance Scale for stationary balance assessment.

The key components include:

1. Demographic information: age, sex, race/ethnicity, primary language, education
2. Social history: cultural beliefs and behaviors, family and caregiver resources, social support systems
3. Occupation/employment: work information
4. Living environment: home/work barriers
5. Hand dominancen6. General health status: physical, psychological, social, role function, health habits
6. Social and health habits: current and past
7. Family history
8. Medical/surgical history
9. Current conditions/chief complaints
10. Medications
11. Medical/laboratory/clinical test results
12. Functional status and activity level: premorbid and current

Important tests and measures include:

1. Aerobic capacity and endurance: during functional activities and standardized exercise protocols
2. Anthropometric characteristics: body mass index, girth, length; edema
3. Assistive or adaptive devices: fit, alignment, function, use; safety
4. Autonomic nervous system integrity: thermal responses, sweating, gastrointestinal signs, urinary urgency/incontinence
5. Cognition: mental status, learning, memory, attention, visuospatial processing
6. Functional status and activity level: performance-based examination of functional skills
7. Gait and locomotion: gait pattern and speed, safety
8. Motor function: motor control, voluntary movement patterns, tone
9. Pain: intensity, quality, behavior, and location
10. Postural control and balance: degree of postural instability, balance strategies

Cognitive impairments include mental status and memory, characterized by hesitation and slowness of thought processes, often evaluated using the Mini-Mental State Examination (MMSE).

Psychosocial functions assessed include motivation, anxiety, and depression, commonly measured using the Beck Depression Inventory.

The key components assessed include cardiovascular and pulmonary signs and symptoms during standardized exercise protocols.

Muscle performance is evaluated in terms of strength, power, and endurance.

The Dynamic Gait Index is an 8-item walking test that examines changing task demands when walking, such as head turns, changes in speed, obstacles, turns, stops, and stairs. It is scored from 0 to 3 for a maximum score of 24.

The Timed Up and Go test measures dynamic balance by recording the time it takes for an individual to stand from a chair, walk 3 meters, turn, and return to sitting in the chair. It is a crucial assessment tool for evaluating balance in Parkinson's disease patients.

Common problems include:

1. Impaired muscle strength - Weakness in muscles surrounding the joint.
2. Abnormal posture - Changes in body alignment due to joint restrictions.
3. Impaired balance - Difficulty maintaining stability while standing or moving.
4. Impaired gait and locomotion - Altered walking patterns and reduced mobility.
5. Fatigue - Increased effort required for movement can lead to tiredness.
6. Pain - Discomfort in the affected joints during movement.
7. Impaired aerobic capacity - Reduced ability to perform physical activities due to joint limitations.

Impaired muscle strength can lead to:

1. Reduced joint range - Limited movement in joints due to weak muscles.
2. Abnormal posture - Compensatory mechanisms may lead to poor alignment.
3. Impaired balance - Weak muscles can affect stability and increase fall risk.
4. Impaired gait and locomotion - Difficulty in walking and performing daily activities.
5. Fatigue - Increased energy expenditure for movement can cause tiredness.
6. Pain - Strain on joints and muscles can lead to discomfort.
7. Impaired aerobic capacity - Limited physical activity can reduce cardiovascular fitness.

The primary goals of physiotherapy include:

1. Improve joint range and mobility
2. Strengthen weak muscles
3. Improve posture
4. Improve balance
5. Improve gait
6. Reduce fatigue
7. Reduce pain
8. Increase aerobic capacity

• Self-management support
• Prevent inactivity
• Prevent fear to move or fall
• Improve physical capacity
• Reduce pain
• Delay onset activity limitations (motor learning, up to H&Y3)

• Maintain vital functions
• Prevent pressure sores
• Prevent contractures
• Support carers/nurses
• Address bedbound related complications

The key domains for physiotherapy within PD include gait, balance, posture, and transfers.

Physiotherapy is unlikely to impact the three key motor signs of PD: bradykinesia, rigidity, and resting tremor. However, evidence is strongest for gait re-education and improving Activities of Daily Living (ADL) scores.

The images depict various rehabilitation exercises including:

1. Walking on a treadmill in a virtual reality environment.
2. Stepping over obstacles on the floor.
3. Walking between parallel lines on the floor.
4. Using parallel bars for exercise.
5. Utilizing a cane equipped with a laser pointer for guidance.

Virtual reality contributes to rehabilitation by:

• Providing immersive environments for exercises, enhancing engagement.
• Allowing for controlled and safe practice of mobility tasks.
• Facilitating gait analysis and feedback through integrated technology.
• Offering personalized rehabilitation experiences tailored to individual needs.

The closed-loop control system in rhythmic auditory stimulation is designed to automate rhythmic gait training by detecting the cadence of a person walking and adjusting the music tempo accordingly to enhance entrainment with the desired cadence target.

Music delivery using bone conduction allows individuals to receive auditory cues directly through their bones, which can enhance the perception of rhythm and improve gait training outcomes without obstructing ambient sounds, thus facilitating better engagement during therapy.

Strategies for enhancing walking include:

• Instructing to walk with long steps
• Swinging arms
• Placing lines on the floor spaced at appropriate step lengths for the person's age and height
• Incorporating starting and stopping techniques

To improve turning around, individuals can:

• Use a large arc of movement or clock pattern
• Practice different turn activities related to home and community environments

1. Gentle rocking: Produces generalized relaxation of excessive muscle tension due to rigidity.

2. Slow rhythmic rotational movements: Can be applied to the extremities and trunk to precede interventions like ROM, stretching, and functional training. Examples include:

   • Hooklying
   • Lower trunk rotation
   • Sideline rolling
   • Upper and lower trunk segmental rotations

3. PNF technique of rhythmic initiation: Movement progresses from passive to active assistive to lightly resistive or active movement, specifically designed to help overcome the effects of rigidity.

The PNF technique of rhythmic initiation assists patients by:

1. Progressing movement: It starts with passive movement, then transitions to active assistive, lightly resistive, and finally active movement.

2. Overcoming rigidity: This gradual progression helps to reduce muscle tension and improve mobility, making it easier for patients to engage in therapeutic exercises.

3. Enhancing motor control: It promotes better coordination and control of movements, which is crucial for patients experiencing rigidity.

Rotational exercises in supine are used to increase range of motion of the neck and trunk. Any combination of motions can be utilized to achieve this goal.

In the advanced exercise, the head, shoulders, and lower extremities are rotated simultaneously. The head rotates opposite to the hips, allowing for counterrotation within the trunk. The upper extremity on the face side is externally rotated, while the other arm is internally rotated.

Rotational activities in side-lying help to obtain a stretch of the trunk and improve thoracic mobility. The movement involves slowly rotating the thorax forward and backward relative to the pelvis, while the upper extremity is protracted and retracted relative to the thorax.

In section A, the top figure is lying on their side with the torso rotated upwards and head facing the viewer, while the bottom figure has the torso rotated downwards with an arm reaching out. In section B, the top figure has a slight upward torso rotation with their back towards the viewer, and the bottom figure has the torso rotated downwards.

The key types of flexibility exercises include:

1. ROM Exercises
2. Passive Stretching
3. Hold & Contract Relax
4. Passive Positioning

Considerations for strengthening exercises include:

1. Training during 'on' periods when the patient is at their best (45 minutes to 1 hour after medication).
2. Focus on force production during isokinetic contractions rather than isometric contractions, as isometric training may be contraindicated.
3. Use of exercise machines is safer than free weights.
4. Incorporating functional training and pool exercises as effective methods.

Key activities include:

1. Moving in bed – rolling and transitioning from supine to sitting.
2. Side lying exercises – incorporating rotation and weight bearing to enhance the transition to sitting.
3. Pelvic tilt exercises – anterior, posterior, side to side, and using a pelvic clock on a ball.
4. Sit-Stand activities – practicing the transition from sitting to standing.
5. Standing training – including rotations to improve balance and stability.
6. Training to get up after a fall – teaching techniques for safe recovery.
7. Facial exercises – to enhance facial muscle control and coordination.

Side lying and pelvic tilt exercises contribute to functional training by:

• Enhancing mobility: Side lying exercises improve rotation and weight bearing, facilitating easier transitions to sitting.
• Strengthening core muscles: Pelvic tilt exercises engage and strengthen the core, which is essential for stability and movement control.
• Improving balance: Both types of exercises help in developing better balance and coordination, crucial for daily activities.
• Facilitating movement patterns: These exercises promote proper movement patterns that are necessary for functional tasks like standing and walking.

Dynamic stability tasks in balance training include:

1. Weight shifts
2. Reaching
3. Axial rotation of the head and trunk
4. Axial rotation combined with reaching

Challenges to balance can be introduced by:

1. Varying arm position (e.g., arms out to side, arms folded across chair)
2. Varying foot/leg position (e.g., feet apart, feet together)
3. Adding voluntary movements (e.g., arm clapping, arms overhead, single leg raises, head and trunk rotations)

Effective exercises include:

1. Stepping or marching in place
2. Functional reach exercises
3. Posturography with feedback on Center of Mass (COM) and Base of Support (BOS)
4. Kitchen sink exercises
5. Movement transitions (e.g., sit-to-stand, half-kneeling to standing)
6. Standing exercises (e.g., heel-rises, toe-offs, partial wall squats, chair rises)
7. Single-limb stance with side-kicks or back-kicks.

Movement transitions such as:

1. Sit-to-stand
2. Half-kneeling to standing

These transitions can be used to challenge the postural control system, thereby improving balance and stability in patients.

The LSVT Big program is based on the concept that repetitive high-amplitude movements yield greater improvements in motor performance and may have a neuroprotective effect.

The key components of the LSVT Big training program include:

1. High intensity exercises (8/10 on Borg's RPE Scale)
2. Duration: 1 hour sessions, 4 times a week for 4 weeks
3. Focus on large amplitude movements
4. Multiple repetitions of exercises
5. Whole body movements that increase in complexity

After completing the program, subjects showed significant improvements in UPDRS motor scores, TUG, and timed 10-m walking.

• Lengthen stride
• Broaden base of support
• Improve heel-toe gait pattern
• Increase speed
• Increase trunk rotation and arm swing
• Use verbal cues to encourage patients to 'walk tall' for better upright alignment.
• Implement gait training with an overhead harness to assist with posture and reduce upper extremity reliance.
• Utilize visual and auditory cues to enhance attention during movement tasks.

The overhead harness assists with maintaining upright posture during gait training by:

• Eliminating the need for upper extremity support.
• Allowing patients to focus on improving their gait mechanics without the fear of falling.
• Facilitating a more natural walking pattern, which can enhance overall gait performance.

The combined use of a harness and treadmill increases both walking speed and stride length in patients with Parkinson's Disease.

To improve foot placement, strategies include using floor grids or footprints on the floor. For step height, practicing marching in place and progressing to walking with an exaggerated high stepping pattern is effective.

Alternative walking patterns include:

• Sidestepping
• Walking backwards
• Marching to various rhythms

Verbal cues can help normalize:

• Step length
• Velocity
• Arm swing excursion

Examples of verbal cues include:

• "Walk fast"
• "Take large steps"
• "Walk while swinging both arms"

The primary outcome measured was the Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor score.

The brisk walking group showed significant decreases in MDS-UPDRS motor score and improvements in timed-up-and-go (TUG) time, fast gait speed (FGS), six-minute walk distance (6MWD), and Mini-Balance Evaluation Systems Test (Mini-BEST) score compared to the control group.

Nordic walking provides several benefits for individuals with mild to moderate Parkinson's Disease, including:

• Full-body aerobic exercise: Engages multiple muscle groups, enhancing overall fitness.
• Improved stability: The use of poles helps maintain balance and stability during walking.
• Enhanced gait symmetry: Promotes a more symmetrical walking pattern.
• Increased speed and step size: Encourages larger steps and faster walking speed, which can improve mobility.
• Positive impact on functional mobility: Evidence suggests it may lead to better functional mobility outcomes compared to free walking.

The study found that both Nordic walking and free walking training led to improvements in balance among participants with Parkinson's Disease. Key findings include:

• Sample Size: 25 individuals completed the study (14 in Nordic walking group, 11 in free walking group).
• Balance Improvement: Approximately 5% improvement in functional balance for both groups (p=0.04).
• Neuroprotective Effects: Aerobic training, including Nordic walking, has a neuroprotective effect, enhancing the proprioceptive system and functional balance over nine weeks of training.

• Exercises to strengthen postural extensors
• Stretching exercises for tight pectorals
• Transverse Abdominis (TA) stretching
• Rotational exercises of the trunk and limbs
• Rhythmic initiation
• Functional task training (mat)
• Postural corrections using feedback mechanisms

Stretching exercises aim to alleviate tightness in specific muscle groups, such as the pectorals, which can improve overall posture and facilitate better movement patterns during rehabilitation.

Diaphragmatic breathing exercises help improve chest wall mobility and vital capacity. They also engage neck, shoulder, and trunk muscles, enhancing overall respiratory function.

Recommended aerobic training includes:

1. Upper Extremity (UE) Ergometry
2. Lower Extremity (LE) Ergometry
3. Aerobic Pool Programs

These activities are beneficial for improving cardiovascular fitness and overall endurance.

Fatigue can be both a cause and a result of inactivity in individuals with Parkinson's Disease (PD).

It is recommended to begin aerobic conditioning as soon as a diagnosis of PD is made, along with strategies like DBE (Daily Balanced Exercise) and activity pacing.

Examples include:

1. Raised toilet seat and toilet rails for easier access.
2. Loose fitting clothing and sneakers with Velcro closures for ease of dressing.
3. Shoes with leather or hard composition soles for those with a shuffling gait to prevent falls.

Shoes with leather or hard composition soles are important because they allow for easier sliding, which can help prevent falls. In contrast, shoes with rubber soles do not slide easily and can increase the risk of falling for individuals who shuffle while walking.

Examples of adaptive devices include:

1. Reachers - Assist in dressing by extending reach.
2. Adapted utensils - Facilitate eating for those with limited dexterity.
3. Slicing aid - Holds food items in place for safer cutting.
4. Door handle extenders - Improve accessibility by providing better leverage.
5. Long-handled shoehorns - Help put on shoes without bending over.
6. Shirt holder - Assists in dressing by holding clothing in place.
7. Sippy cups - Designed with handles for easier gripping.
8. Toothpaste tube dispensers - Reduce effort in squeezing toothpaste.
9. Sock aids - Help users put on socks without bending.

Adaptive devices improve quality of life by:

• Enhancing Independence: Allowing individuals to perform daily tasks without assistance.
• Reducing Physical Strain: Minimizing the effort required for activities like dressing and eating.
• Increasing Safety: Providing tools that prevent accidents during tasks such as cutting food.
• Promoting Accessibility: Making environments more navigable for those with mobility challenges.
• Encouraging Participation: Enabling individuals to engage in social activities and self-care routines more easily.

Examples of low impact aerobic exercises include:

1. Marching in place (both sitting and standing)
2. Large high steps
3. Line dancing
4. Ball activities
5. Bean bag toss

Recreational activities that can follow the aerobic portion include:

• Line dancing
• Ball activities
• Bean bag toss