COMMERCE PAGE OF PARKINSON DISEASE

Introduction: Parkinson Disease is a Neurodegenerative disorder and progressive in nature. It generally occurs at the later stage of life (in elderly people). It is nearly the second most common disease in the world. PD is something which shows up in different ways in different people, but generally the first symptom which may get noticed is Tremor (just in one hand), along with slowness of movement (Bradykinesia).

Parkinson Disease affects the nervous system and other parts of the body controlled by it. PD is caused by a loss of Nerve cells in the part of the brain called the Substantia Nigra and are responsible for producing a chemical called Dopamine.

Early stages symptoms of Parkinson’s disease:-

1. Arms may not swing while walking.
2. Little or no expression face (Mask like).
3. Speech getting slurred or soft can be seen.

There are four primary elements to focus for the diagnosis.

1. BRADYKINESIA
2. RIGIDITY
3. TREMOR
4. GAIT AND BALANCE

The following three are also important, but not necessary one should have to have it for the diagnosis of PD.

A) OBSERVATION :- It is also necessary because we have to look at all the movements that are happening , when patient is not performing the exam.(like when telling history , or asking questions)

The main points to observe are:

1. Spontaneous movements
2. Eye blink (normal or not)
3. Fidgeting
4. Crossing /Uncrossing legs
5. Hand to gesture
6. Tremor

1. BRADYKINESIA

It is the first and most important element because one should have to have it in order to get diagnosed.
* When we make patient do –
- Test with rapid alternative movements
- Big and fast movements (It is important to go with)
(#If we don’t give these instructions they might go really big but slow or really small but fast)
- Look for change:-
* Does the movement go to:
- Slower over time
- Smaller over time
(To detect, at least 10 repetitions is enough)
* MOVEMENTS (Upper Extremity)
- Finger Tapping
{Imp. Note: Like when people have arthritis they cannot do finger tapping.}
- Fist open and close
- Pronation/Supination
[If we see these movements, there will be slight reduction in amplitude and speed].That is what we are looking for.
* MOVEMENTS (Lower Extremity)
1. Toe Tapping: It is the most sensitive movement to detect Bradykinesia.
2. Heel Tapping:
#Smaller movements tends to pick up Bradykinesia the most.

2. RIGIDITY {Muscle tone increase}

- Not velocity dependent (whether we go slowly or fast we get same amount of resistance)

- Not directionally dependent (we can get it with both flexion and extension movements)

*Led pipe rigidity (very subtle in early disease) or when patient is fully medicated we might not notice it. So we can do activation maneuver to bring out subtle rigidity when we are just diagnosing someone new. The key thing is to get right amount of relaxation. So a therapist instructs the patient to relax his arm as much as possible. The therapist generally holds patient’s arm in his hand and can feel the weight of patient’s arm.

The most sensitive place to look for rigidity is to look in wrist. Then the therapist will rotate wrist while holding the arm. When therapist is not able to catch the rigidity, therapist might instruct the patient for activation maneuver to tap his opposite hand on knees making big movements
LOWER EXTREMITY
-The way to get patient relaxed is to put the weight of their leg on to therapist’s arm themselves.
-Looking at ankle and knee movements
Imp Note: If the movement is loose and is not detectable, therapist will again instruct the patient for activation maneuver to tap opposite hand on the knees, to make big movements.
# We are looking for:
1. Resistance to movement
2. Tremor within rigidity called Cogwheel Rigidity.
Note: Cogwheel rigidity: Tremors superimposed with rigidity.

3. TREMORS

i) Rest Tremor:- Observe through the entire exam to see any tremor .
-Ask patient to place hand in better position i.e on the side line position, when they are relaxing their hand. Reason for this being, they can hide movements by supressing the tremor. This they may do by positioning their hand, either by holding them or sitting on them.
-therapists have to observe when talking to them and during other parts of exam
To see the Rest tremor:
-Small movements in thumb or the fingers
-Rotational movement.

ii) Postural Tremor - We ask patient to put their hand in front of their body and spread their fingers wide and hold for few minutes. - Postural tremor does not come out immediately and can re-emerge after holding for some time

iii) Action Tremor (KINETIC)
This denotes tremor during continuous movements. Therapist can instruct the patient to perform finger to nose touch movement as slow as they can, in order to detect the tremor.
(Note: Resting tremor is more common in PD then postural and action tremor).

4. GAIT AND BALANCE

It is an important characteristic for observation
If we see changes in balance and gait part of exam, therapist can probably change the intervention of physical therapy. Reason for that is when we see patient having difficulty in mobility and balance that puts them in higher risk of fall.
i) STANDING FROM CHAIR
We will see if patient can stand up without using the support of their hand.
(Imp. Note: Therapist must stand along with the patient for support if they might feel difficulty in balancing.
(to reduce risk of injury)
ii) FREE WALKING
Therapist instructs the patient to walk back and forth several times.
* OBSERVE NORMAL SIGNS
- Making turns with no loss of balance
- Normal Step length ( not small )
- Heel strike present ( no shuffling )
- Arm swing present
(Imp. Note: If these normal signs are absent, patient is prone to risk of falling.)
* PULL TEST FOR BALANCE
i) To test balance a therapist performs pull test by pulling off patient from their centre of gravity and see whether they can correct themselves by taking one or two steps.
ii) Therapist must make sure that there should be a wall behind the patient even though he stands close to him, so that if the latter loses balance he doesn’t fall.
iii) Instruct and show the patient what to do before performing the exam
(so that they can understand)
iv) Even before any gait and balance problem it is really important to get in an aggressive physical therapy. It can improve balance and reduce risk of fall and even slow the progression.