What is Parkinson's disease?

What is Parkinson's disease?

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Parkinson's disease (PD) is a chronic progressive neurodegenerative disorder that primarily affects movement. It is named after Dr. James Parkinson, who first described the condition in 1817. Parkinson's disease is characterized by the progressive loss of dopamine-producing cells in the brain, particularly in a region called the substantia nigra. Dopamine is a neurotransmitter that plays a crucial role in regulating movement and coordination.

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Movement disorder is the hallmark of Parkinson's disease, although other symptoms are evident and may actually precede the impairment of movement. The ability to move is not lost, but there is a problem with movement activation and loss of reflexive or automatic movement.

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The cardinal features of this condition are rigidity, tremor, bradykinesia and in later stages, postural instability. Onset is insidious with a slow rate of progression. Disruption in daily functions, roles and activities, as well as depression, are common in individuals with PD.

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Common symptoms of Parkinson's disease

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Common symptoms of Parkinson's disease include motor and nonmotor symptoms:

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1. Motor symptoms: The hallmark motor symptoms of Parkinson's disease include tremors (usually starting in the hands or fingers), rigidity or stiffness of the muscles, bradykinesia (slowness of movement), and postural instability (abnormalities of posture and balance). These symptoms can affect one side of the body initially and then progress to both sides.

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• Bradykinesia: Refers to slowness of movement and is one of the cardinal features of PD. It can manifest as difficulty initiating movement, a reduction in the amplitude or size of movements, and a general slowing down of motor activities. The principle deficit is the result of insufficient recruitment of muscle force during initiation of movement. It is one of the most disabling symptoms of PD. 

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• Rigidity: It is defined as an increase in resistance to passive motion. Patients frequently complain of “heaviness” and “stiffness” of their limbs. Rigidity may initially affect the left or right side, eventually spreading to involve the whole body. It decreases the ability of an individual to move easily. 

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•  Resting tremor: A resting tremor is a common early sign of Parkinson's disease. It involves involuntary shaking or oscillating movement of a part or parts of the body resulting from contractions of opposing muscles. In the early stages of the disease, it tends to be mild and occurs only in short periods.  

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• Postural instability: Individuals with PD demonstrate abnormalities of posture and balance, resulting in postural instability. These changes are rare in the early years. As the disease progresses, a number of problems become more evident. Impaired balance and coordination can lead to difficulties with posture and gait, increasing the risk of falls.

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2. Non-motor symptoms: Parkinson's disease can also cause non-motor symptoms, including cognitive changes (such as problems with memory and thinking), mood disturbances (such as depression and anxiety), sleep disturbances, constipation, urinary problems, and changes in speech and swallowing.

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• Sensory symptoms: Patients with PD do not suffer from primary sensory loss. However, as many as 50% experience paresthesias and pain, including sensations of numbness, tingling, cold aching pain and burning. Symptoms are typically intermittent, and vary in intensity and location.

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• Dysphagia: Impaired swallowing is present in most patients and is the result of rigidity, reduced mobility and restricted range of movement.

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• Speech disorders: Patients with PD experience “hypokinetic dysarthria”, which is characterized by decreased voice volume, monotone/monopitch speech, imprecise or distorted articulation and uncontrolled speech rate. In advanced cases, the patient may speak in whispers or not at all, demonstrating mutism. 

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• Cognitive dysfunction: Impairments in cognitive function can be mild or severe. Dementia associated with PD is characterized by loss of executive function (e.g. planning, reasoning, judgment, abstract thinking) and changes in memory and verbal fluency. Bradyphrenia (slowed thinking) is also seen in patients with PD. Hallucinations, delusions, and psychosis are common complications owing to medication toxicity.

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• Sleep disorders: Individuals with PD can experience excessive daytime sleepiness. At night, insomnia (disturbed sleep pattern) may occur. This includes problems in falling asleep, staying asleep, and good quality of sleep.

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• Depression and Anxiety: These are common symptoms in patients with PD. A significant number of patients develop depression and anxiety due to the disease course.

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• Constipation and Urinary Incontinence: Constipation is a common problem for most patients and typically occurs early in PD. Urinary incontinence (loss of bladder control) occurs with associated symptoms of urinary frequency, urgency and nocturia (excessive nighttime urination).

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Diagnosing Parkinson's disease involves a thorough evaluation of the person's medical history, physical examination, and assessment of symptoms. There is currently no cure for Parkinson's disease, but various treatment options are available to manage symptoms and improve quality of life. These may include medications to increase dopamine levels in the brain, physical therapy to improve mobility and balance, occupational therapy to assist with daily activities, speech therapy to address speech and swallowing difficulties, and lifestyle modifications. Additionally, ongoing research is being conducted to develop new therapies and approaches to better manage Parkinson's disease.

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What causes Parkinson's disease?

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The exact cause of Parkinson's disease is not fully understood, but a combination of genetic and environmental factors is believed to contribute to its development. Some potential factors that may increase the risk of Parkinson's disease include:

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1. Genetic factors: Certain genetic mutations and variations are associated with an increased risk of developing Parkinson's disease. However, it is important to note that most cases of Parkinson's disease are not directly inherited.
2. Environmental factors: Exposure to certain environmental toxins, such as pesticides and herbicides, as well as certain industrial chemicals, may increase the risk of Parkinson's disease. However, the exact link between these factors and the disease is still under investigation.
3. Age: Parkinson's disease typically develops in people over the age of 60, although it can occur earlier in some cases known as early onset PD (patient is less than 40 years of age), young-onset PD (between 21 to 40 years of age) and juvenile-onset PD (less than 21 years of age).

How can physical therapy help? 

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Physical therapy plays a crucial role in the management of Parkinson's disease (PD) by addressing the movement-related symptoms and improving functional abilities. Here's how physical therapy can help individuals with Parkinson's disease:

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1. Balance and coordination training:  Physical therapists can design exercise programs tailored to the individual's needs, focusing on improving balance, and coordination. This type of training includes a variety of activities that alter task demands and expose the patient to varying environmental conditions. Emphasizing practice of dynamic stability tasks (e.g. weight shifts, alternating unilateral weight bearing, reaching, rotation and so forth). 
2. Flexibility exercises: The purpose of flexibility exercises (stretching) is to improve range of motion and physical function of an individual. Initially, a combination of passive and active range of motion exercises are utilized and later on will progress to manual stretching and joint mobilization to reduce the tightness of the joints and muscles.
3. Resistance/Strength training: This type training is indicated for patients with PD who demonstrate primary muscle weakness. It involves the use of resistance machines, free weights, elastic resistance bands, or manual resistance. Strength training has been shown to improve muscle force, bradykinesia, and quality of life in patients with the said condition. 
4. Locomotor training: The locomotor training goals focus on reducing primary gait impairments, which typically include slowed speed, decreased stride length and shuffling (festinating) gait pattern. Goals also focus on increasing the patient’s ability to safely perform functional mobility activities and prevent falls. Physical therapists provide safe strategies to enhance upright alignment and gait patterns of patients with PD. This type of training also includes task-specific training designed to promote full participation in social roles. 
5. Posture and alignment: Parkinson's disease can lead to stooped posture and impaired alignment. Physical therapists can address these issues by providing exercises and techniques to improve posture, alignment, and body mechanics. This can help prevent musculoskeletal problems, reduce discomfort, and improve overall function. In some cases, spinal bracing is prescribed as an adjunct to therapy for patients with postural deformities.
6. Assistive devices and adaptations: Physical therapists can assess the need for assistive devices, such as canes or walkers, and provide recommendations on their appropriate use. They can also suggest environmental modifications and assistive technologies to enhance safety, promote mobility and independence in daily activities.
7. LSVT BIG and other specialized programs: LSVT BIG (Lee Silverman Voice Treatment) is a specific physical therapy program designed for individuals with Parkinson's disease. It focuses on large-amplitude, high-intensity exercises to improve movement quality and amplitude. Other specialized programs, such as PWR (Parkinson Wellness Recovery), also aim to improve functional mobility and quality of life through targeted exercises.
8. Fall prevention and safety: Physical therapists can assess fall risk and develop strategies to prevent falls. They can provide education on fall prevention techniques, such as improving home safety, practicing proper body mechanics, and teaching strategies to manage balance disturbances.
9. Aerobic exercises: Aerobic conditioning exercises are also an important component of the rehabilitation program. It has been shown to be safe and effective for patients with PD in improving aerobic capacity. Training modes may include leg and arm ergometry and walking. The duration, mode and intensity of the exercise may vary depending on the specific abilities of the patient.
10. Functional training: An exercise program should be based on focused practice of functional skills. The overall emphasis is on improving functional mobility with specific emphasis on improving mobility of the head, trunk, hips and shoulders. It includes bed mobility skills (e.g. rolling, bridging, lying to sitting transitions), sitting, sit-to-stand and standing activities. Progression to more difficult activities is gradual.
11. Breathing exercises: Respiratory dysfunctions in patients with PD are medication complications and are linked to a high rate of disability and mortality. It is critical that the prevention and treatment of these dysfunctions take priority. Components include diaphragmatic breathing, air-shifting techniques and exercises that recruit neck, shoulder and trunk muscles to improve chest wall mobility and lung capacity.
12. Education and self-management: Physical therapists can provide education about Parkinson's disease, its symptoms, as well as the role and importance of the rehabilitation program in managing the condition.  They also provide strategies for self-management and  teach individuals techniques to conserve energy, activity pacing, manage fatigue, and optimize daily routines. They may also provide guidance on exercise programs to be continued at home.

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It's important for individuals with Parkinson's disease to work closely with a physical therapist who has experience in treating Parkinson's and is familiar with the unique challenges of the condition. Regular and ongoing physical therapy can help individuals with Parkinson's disease maintain or improve their physical function, enhance their quality of life, and manage the impact of the disease on their daily activities.

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