1. Parkinson's disease ♦ Develops around age 50
♦ Is a neurodegenerative disorder
♦ Develops around age 50
* incidence rises with age
* affects 1-2% of population > age 65
♦ Higher incidence in men (62%) compared to women (38%)

2. Early Signs and Symptoms
Cardinal Characteristics
Resting tremor
Bradykinesia
Rigidity
Postural instability
Other
Micrographia
Masked face
Slowing of ADLs
Stooped, shuffling gait
Decreased arm swing when walking
In contrast to tremor and bradykinesia, rigidity is rarely a patient-reported symptom. Assessment of rigidity involves passive movement of the neck, upper limbs, and lower limbs, to assess for an increase in tone throughout the range of motion. In mild cases, rigidity may be increased by “activation” of the contralateral limb by opening and closing the hand, or other repetitive tasks. Rigidity should be distinguished from spasticity because this increase in tone is more prominent with initiation of movement and is greater in one direction than the other.
Although usually not an early sign or symptom of idiopathic Parkinson’s disease, postural instability emerges with disease progression. On examination, the examiner should stand behind the patient and ask the patient to maintain their balance when pulled backwards. The examiner should pull back briskly to assess the patient’s ability to recover, being careful to prevent the patient from falling.

3. Additional Signs and Symptoms
Difficulty arising from a chair
Difficulty turning in bed
Hypophonic speech
Sialorrhea
Loss of the sense of smell
Foot dystonia
There are numerous other signs and symptoms of Parkinson’s Disease that are often brought to the physician’s attention by the patient or family members. Micrographia is a common early sign, characterized by a slowness or smallness to the handwriting. Mask facies is another bradykinetic symptom characteristic of Parkinson’s disease. Slowing of activities of daily living occurs, including such activities as dressing, bathing, turning in bed, getting in and out of a chair, or in and out of a car. Gait is often characterized by some shuffling or dragging of a leg, and the posture may be stooped with flexion of the knees, hips, trunk, and neck.
Bulbar symptoms include bradykinetic or hypophonic speech, which may require the patient to repeat himself frequently. Drooling is common. Choking may occur. Although nonspecific, the loss of the sense of smell, or anosmia, has been well-documented in Parkinson’s disease. Some patients will present with a foot dystonia in which the foot will turn in and there will be involuntary curling of the toes, especially in the morning.

4. Criteria for Diagnosis
At least two of three: rest tremor, bradykinesia, rigidity
Absence of a secondary cause—drugs, metabolic, etc.
Definitive diagnosis can only be made by autopsy
The diagnosis of Parkinson’s disease requires at least two of the three cardinal features of rest tremor, bradykinesia, or rigidity. Since postural instability is usually a later sign of Parkinson’s disease, that cardinal feature is often not included as a criteria for diagnosis.
Furthermore, the diagnosis of idiopathic Parkinson’s disease necessitates ruling out secondary causes of parkinsonism. Certainly drug induced parkinsonism, metabolic etiologies, and other secondary causes must be eliminated. Unfortunately, there are currently no lab tests or neuroimaging studies to confirm a diagnosis of idiopathic Parkinson’s disease. Rather, a definitive diagnosis of Parkinson’s Disease can only be made by autopsy, with neuropathologic findings of substantia nigra depigmentation, neuronal loss, and the presence of Lewy bodies in the substantia nigra.

5. Pathophysiology
: Deficiency of the brain chemical dopamine occurs in the basal ganglia.
Degeneration of nigrostriatal pathway (Substantia Nigra to corpus striatum.

6. Drug Classes in PD Dopaminergic agents Anticholinergics Amantadine
Levodopa
Dopamine agonists
Anticholinergics
Amantadine
Dopaminergic therapy with levodopa or dopamine agonists is the cornerstone of symptomatic management of Parkinson’s disease. As can be seen in the next slide, levodopa replaces dopamine presynaptically, while dopamine agonists act directly on receptors post-synaptically. Levodopa is administered with a peripheral decarboxylase inhibitor, either benserazide or carbidopa. The newest class of drugs, the COMT inhibitors, also increase the bioavailability of levodopa, by inhibiting peripheral or central catechol O-methyl transferase. Other agents are anticholinergics, the MAO-B inhibitor selegiline, and the antiviral amantadine.

7. Surgical Treatments for Parkinson’s Disease
Ablative
thalamotomy
pallidotomy
Electrical stimulation
VIM thalamus, globus pallidus internus, sub-thalamic nucleus
Transplant
human fetal, genetically engineered transplants
Surgical treatments can be roughly divided into three separate categories. The first is ablative, in which stereotactic lesions are made in very specific anatomical locations within the brain. The second is deep brain stimulation, where an electrode is placed within specific areas of the brain and a high-frequency pulsatile voltage is used to mimic the effects of ablation. The third is cell transplantation where extraneous cells are placed into the striatum of the brain in an attempt to mimic the function of substantia nigra cells which perish in Parkinson’s disease.

8. Treatment Plan Maintain or increase ROM in all joints
Efforts to improve postural control and standing balance
Prevent disuse atrophy and muscle weakness
Improve motor function and mobility

9. Physical Therapy: Goal
Maintain or increase activity level
Decrease rigidity and bradykinesia
Facilitate movement and flexibility; optimize gait
Maximize gross motor coordination and balance
Maximize independence, safety, function

10. Rehabilitation Hoehn and Yahr Rating scale
Divided into five stages
Stage 0 = no visible disease;
Stage I = disease that involves only one side of the body;
Stage II = disease that involves both sides of the body. but does not impair balance:
Stage III = disease that impairs balance or walking;
Stage IV = disease that markedly impairs balance or walking: and
Stage V = disease that results in complete immobility. 10

11. Cardiopulmonary Impairment
The patient's flexed posture can lead to kyphosis, cause a reduction in pulmonary capacity, and produce a restrictive lung disease pattern.
Breathing exercises, postural reeducation, and trunk exercises may be helpful.
Institution of a general conditioning program can increase the patient's endurance.
If pulmonary function progressively worsens, assisted coughing techniques, incentive spirometry, and respiratory therapy intervention may be required.

12. Physical Therapy
Static and dynamic postural controls emphazing whole body movements sitting and standing
Stationary bike training to help reciprocal movements
Exercise: walking(1+mile/day),swimming,golf,dancing
Use of assistive devices, mobility aids, orthotics
Family training and home program
Proper and energy conservation techniques
After 6 mths benefit of therapy if not coninued will be gone
Exercises for the patient with PD should emphasize trunk extension, as well as lateral and rotational mobility, weight shifting, and balance training. Addressing how to fall safely and get up from the floor is important for patients with PD and their families. The physical therapist should instruct them in proper transfer techniques and try to improve their overall safety awareness during everyday activities. A general conditioning program also should be included in physical therapy to improve the patient's endurance. In addition, the physical therapist may instruct the patient and family members in a home exercise program.

13. Aerobic activities such as:
Using a treadmill
Using a stationary bike or rowing machine
Walking
Swimming

14. MAKE GOOD POSTURE A HABIT
Stand against a wall and be sure your lower back and shoulder BLADES are touching the wall

15. MAKE GOOD POSTURE A HABIT
lie flat on your back, with just enough support to keep your head and neck from tipping back for 5 minutes.

16. FLEXIBILITY OR STRETCHING

17. FLEXIBILITY OR STRETCHING

18. STRENGTHENING EXERCISES

19. STRENGTHENING EXERCISES

20. Alzheimer's Disease
Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills, symptoms first appear after age 60.