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Parkinson’s Disease
Parkinson’s disease (PD) is a progressive condition involving the extrapyramidal
part of the nervous system ( part of the motor system causing involuntary
movements ) , causing impairment in motor function.
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The most common form of PD is an idiopathic neurodegenerative disorder that
usually occurs after the age of 50, is found slightly more frequently in men than in
women, and is less prevalent in African blacks and Asians.
The vast majority of PD cases are sporadic and are probably caused by interaction
of environmental and genetic factors.
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Approximately 20% of PD patients have a family history of PD.
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Parkinson’s Disease
Individuals with PD have problems with many aspects of movement. Tremors are
common, both at rest and with action, as is rigidity of the spine, trunk, and
extremities.
The ability to rapidly move fingers, hands, arms, or legs is drastically reduced
(bradykinesia), while standing posture becomes kyphotic and flexed.
PD patients often have difficulty initiating the first step in walking (known as
start hesitation) and have a gait that is typically slow and shuffling, with shortened
steps that are involuntarily hurried (festinating gait).
Episodes of freezing can occur during walking, and postural righting reflexes cause
problems with frequent falls.
Fine motor functions can also be severely affected, which can make it very difficult
to communicate and perform activities of daily living (ADLs) that require manual
dexterity. Many people require assistance with dressing, bathing, and preparing
and eating meals.
All of these abnormalities are independent of cognitive functions, which are
unaffected by PD, making these problems very frustrating to someone with the
condition
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Video – Basic Pathophysiology of /and PD signs/symptoms
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Video – Parkinson’s Gait Demonstration
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Parkinson’s Disease
Basic Pathophysiology
(See previous video for more detailed information)
PD is associated with a reduction in the neurotransmitter dopamine, primarily
in the substantia nigra, a component of the basal ganglia.
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The reduction of dopamine results from the death of dopaminergic cells that
live within the basal ganglia and produce dopamine, but symptoms do not
occur until loss of these dopaminergic cells is greater than 80%.
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Basic Pathophysiology
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The following are the symptoms (VIDEO) caused by the loss of dopamine:
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Resting and action tremors
Rigidity
Bradykinesia
Standing kyphosis with flexed extremities
Start hesitation with festinating gait
Dynamic postural instability
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Tremors can be evident both at rest (spending energy needlessly) and with
action (impairing coordination).
Rigidity often begins in the neck and shoulders and spreads to the trunk and
extremities, and rigidity combined with bradykinesia causes many individuals
to have difficulty rising from a chair, or getting into or rising from bed or both
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Parkinson’s Disease
Basic Pathophysiology
Fine motor control is also affected. Many people develop micrographia
(minute, illegible handwriting), are unable to cut food or handle utensils, and
have difficulty swallowing food.
Many have trouble speaking loudly or understandably enough to
communicate, a difficulty that can be exacerbated by a loss of facial expression
(hypomimia).
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The Hoehn and Yahr Scale is a commonly used system for describing how
the symptoms of PD progress. Individuals who have a Hoehn and Yahr
disability level of 3.0 are unable to recover balance on a pull test, increasing
fall risk.
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Parkinson’s Disease
Management and Medications
PD is clinically classified in a number of categories related to the gross
features of the person’s condition:
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• Age at onset (<40 [juvenile], between 40 and 70, or >70)
• Predominant symptom (tremor, akinetic
[absence, loss, or impairment of the power of voluntary movement ]rigidity,
postural instability–gait difficulty)
• Mental status (dementia present, absent)
• Clinical course (prognosis) – response to medications, rate of disease
progression
• Level of disability (Hoehn and Yahr stages 1.0-5.0)
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Medications are the most successful way to treat the symptoms of PD. Drug
management is aimed at correcting or preventing neurochemical
imbalances in relation to dopamine, epinephrine, and norepinephrine
deficiencies and the relative increase in acetylcholine.
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A key drug for PD is levodopa, which is a metabolic precursor to dopamine that can
pass through the blood–brain barrier. In the brain, levodopa is metabolized into
dopamine and thereby increases the amount of dopamine available in the basal
ganglia.
Levodopa is also metabolized in peripheral muscle, which reduces the bioavailability
of levodopa for the brain. Carbidopa, which is a modified form of levodopa, is often
administered with levodopa because carbidopa is less rapidly metabolized by
skeletal muscle and thereby has more bioavailability for crossing the blood–brain
barrier.
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Management and Medications
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Anti-Parkinson medications have both peripheral and central side effects;
the following are the most common (see also table 29.2):
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Gastrointestinal upset
Confusion
Delusional states
Hallucination
Insomnia
Changes in mental activity
More than 50% of all those who have
taken medication for Parkinson’s disease
for more than five years have reduced
responses to their medications and
experience fluctuation of motor
disability. There is very little knowledge
on how exercise training affects drug
efficacy
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Effects on the Exercise Response
The effect of PD on exercise is quite difficult to characterize because no two
people with the disease are alike and even the same person can be different
from day to day.
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The motor control abnormalities adversely affect many aspects of movement
and result in poor physical functioning:
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Episodes of decreased movement or freezing during walking
Increased difficulty getting through doorways or narrow spaces
Difficulty getting into and rising from bed or getting out of a chair
Need for assistance with dressing and bathing
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In addition to these motor control difficulties, autonomic nervous system
dysfunction is common in Parkinson’s disease.
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This dysfunction can cause problems with thermal regulation, and altered
heart rate and blood pressure responses with postural changes and during
physical activity.
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Parkinson’s Disease
Effects of Exercise Training
Aerobic training can improve function, can fail to affect function, or can
reduce function in individuals with Parkinson’s.
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PD patients s can experience direct, indirect, and what are called composite
effects of PD.
Direct effects are those that occur directly as a result of PD—for example,
tremor and rigidity.
Indirect effects, such as aerobic deconditioning or loss of range of motion
from inactivity, occur along with the disease.
Composite effects may be a combination of the direct central nervous
system changes and compensatory musculoskeletal symptoms, such as
changes in axial mobility (mobility of neck and back) and balance problems.
Exercise interventions could have a minimal effect on the symptoms
resulting directly from the disease process, but appropriately designed
interventions may alter the indirect or composite effects of musculoskeletal
and cardiovascular or metabolic deconditioning
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Effects of Exercise Training
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Because exercise training is a chronic activity that is predicated on a predictable
dose–response relationship in order to yield anabolic effects and improvements
in function, to a given individual with Parkinson’s one cannot assume that
exercise training will always prove beneficial .
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In effect, each person is in a trial-and-error situation, so the therapist
must have a great deal of mastery in the art of exercise management.
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Recommendations for Exercise Testing
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Recommendations for exercise testing for people with PD are based on Hoehn
and Yahr class:
• People in Hoehn and Yahr class 1 and 2: follow the ACSM Guidelines.
• People in Hoehn and Yahr class 3 or higher: use the Basic CDD4 (see Table
2.4, pg. 21, text) Recommendations, with modifications for Parkinson’s
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Recommendations for Exercise Testing
Because rigidity and gait-balance are so commonly affected and have adverse
impacts on physical functioning, these are often the most important evaluations
to do in someone with PD.
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Because the spine and proximal joints have great impact on function of
extremities, evaluation of neck, trunk, and more proximal joint flexibility is also
important.
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Evaluations of exercise assessment include :
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Pull test
Timed tandem stand and 360° turn
Functional reach or chair sit and reach
Reaction time
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Recommendations for Exercise Testing
Gait and physical functioning should be evaluated to determine competency with
ADLs; assessment can include these measures:
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Gait speed
Timed walk
Walking cadence and step length
Sit to stand
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Together, these measures, which are a minor modification of the Basic CDD4
Recommendation, establish a baseline to determine progress or decline, classify
Hoehn and Yahr disability level, define existing balance deficits, reveal quadriceps
weakness or poor motor control.
People in Hoehn and Yahr stages 3, 4, and 5, in addition to having lower functional
capacities, have greater inter- and intra-individual variability in physical
functioning.
If an PD patient in one of these groups mainly seeks a low to moderate level of
physical functioning, focused more on maintaining ADLs, graded exercise testing
with an electrocardiogram (ECG) may not be indicated
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Parkinson’s Disease
Recommendations for Exercise Testing
There are a number of condition- and medication-related concerns to be aware of
during exercise in people with PD:
• Use a cycle ergometer or treadmill with a safety harness if balance is poor.
• Prevalence of cardiac dysrhythmias is high (drug side effect and age of
population).
• Autonomic dysfunction is common (poor temperature, orthostatic, and heart
rate regulation).
• All exercise should be started 45 to 60 min after medication has been taken.
• Some individuals demonstrate a brief, intense tachycardia or dyskinesia at peak
drug levels.
• Caution should be used after a change in medications; the impact may be
unpredictable.
• Individuals who fluctuate dramatically may need to be evaluated on and off
medications.
• Face masks are recommended if there is a need to do respired gas analysis
(many people have difficulty sealing lips on mouthpiece)
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Recommendations for Exercise Programming
Exercise program recommendations for people with PD are based on the Hoehn
and Yahr classification:
• Persons in Hoehn and Yahr class 1 and 2: follow the ACSM Guidelines.
• Persons in Hoehn and Yahr class 3 or higher: use the Basic CDD4
Recommendations, with modifications for Parkinson’s.
The Basic CDD4 Recommendations are applicable for people with PD, particularly for
maintaining
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strength and flexibility,
gait and balance,
physical functioning (sit to stand and transfer exercises), and
orofacial and manual dexterity (speech and occupational therapy).
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Recommendations for Exercise Programming
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• PD can interfere with motor planning and motor memory.
• Repeated demonstrations along with written and visual cues are needed to
ensure adherence.
• Supervision may be necessary for participation in an exercise program.
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Recommendations for Exercise Programming
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Additional considerations for PD exercise :
• Some individuals have an impaired chronotropic response and have difficulty
achieving target heart rates.
• Heart rate responses to the same activity may vary greatly from day to day.
• Heart rates should be carefully observed for evidence of this variability.
• Training benefit may depend on consistently exercising after the same period
of time following a dose of medication.
• The time to peak drug effect may thus be useful for exercise training, and
should be note
• Developmental Model of Exercise and Movement Training for PD Patients :
LSVT BIG Therapy (VIDEO) (VIDEO 2)
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Recommendations for Exercise Programming
Important considerations
• All exercise should be started about 45 to 60 min after medication has been
taken.
• If balance is poor, always use an ergometer with a seat or a treadmill with a
safety harness.
• Heart rate responses and exercise efficiency may vary greatly from day to day.
Because of variable chronotropic response to exercise, use rating of perceived
exertion for estimating intensity.
• People may have poor temperature regulation and orthostatic intolerance.
• Caution is urged after a change in medications, as the impact may be
unpredictable.
• Monitor for increases or decreases in Parkinsonian symptoms and signs
(dyskinesia, bradykinesia, dystonias, freezing, tremor).
• Arthritis is common in people over 50 years old and exercise may help, but
dyskinesia and dystonia can aggravate degenerative joint disease.
• Painful dystonias may interfere with exercise and sleep.
• Mask-like facies and communication difficulties can make it difficult to interpret a
person’s reaction or perceived exertion.
• Depression is a common comorbidity.
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Recommendations for Exercise Programming
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Some desired outcomes in PD Patients :
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Increased physical fitness in Hoehn and Yahr stages 1 and 2
Increased physical functioning in higher Hoehn and Yahr stages
Improved gait and balance
Better function in ADLs
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Additional Resources:
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National Parkinson Foundation
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Parkinson's Disease Foundation
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The Michael J. Fox Foundation
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