1. Parkinson’s Disease
HESS 509
CHAPTER T W E N Y
NINE
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.
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.
Approximately 20% of PD patients have a family history of PD.

2. Parkinson’s Disease
HESS 509
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
CHAPTER T W E N Y
NINE

3. Video – Basic Pathophysiology of /and PD signs/symptoms
Parkinson’s Disease
HESS 509
Video – Basic Pathophysiology of /and PD signs/symptoms
CHAPTER T W E N Y
NINE
Video – Parkinson’s Gait Demonstration

4. Parkinson’s Disease
HESS 509
CHAPTER T W E N Y
NINE
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.
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%.

5. Basic Pathophysiology
Parkinson’s Disease
HESS 509
Basic Pathophysiology
CHAPTER T W E N Y
NINE
The following are the symptoms (VIDEO) caused by the loss of dopamine:
Resting and action tremors
Rigidity
Bradykinesia
Standing kyphosis with flexed extremities
Start hesitation with festinating gait
Dynamic postural instability
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

6. Basic Pathophysiology
Parkinson’s Disease
HESS 509
Basic Pathophysiology
CHAPTER T W E N Y
NINE
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).
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.

7. Management and Medications
Parkinson’s Disease
HESS 509
CHAPTER T W E N Y
NINE
Management and Medications
PD is clinically classified in a number of categories related to the gross features of the person’s condition:
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 )
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.

8. Parkinson’s Disease Chart only is FYI
HESS 509
Chart only is FYI
CHAPTER T W E N Y
NINE
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.

9. Management and Medications
Parkinson’s Disease
HESS 509
CHAPTER T W E N Y
NINE
Management and Medications
Chart only is FYI
Anti-Parkinson medications have both peripheral and central side effects; the following are the most common (see also table 29.2):
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

10. Effects on the Exercise Response
Parkinson’s Disease
HESS 509
CHAPTER T W E N Y
NINE
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.
The motor control abnormalities adversely affect many aspects of movement and result in poor physical functioning:
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
In addition to these motor control difficulties, autonomic nervous system dysfunction is common in Parkinson’s disease.
This dysfunction can cause problems with thermal regulation, and altered heart rate and blood pressure responses with postural changes and during physical activity.

11. Effects of Exercise Training
Parkinson’s Disease
HESS 509
Effects of Exercise Training
CHAPTER T W E N Y
NINE
Aerobic training can improve function, can fail to affect function, or can reduce function in individuals with Parkinson’s.
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

12. Effects of Exercise Training
Parkinson’s Disease
HESS 509
CHAPTER T W E N Y
NINE
Effects of Exercise Training
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 .
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.
Recommendations for Exercise Testing
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

13. Recommendations for Exercise Testing
Parkinson’s Disease
HESS 509
CHAPTER T W E N Y
NINE
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.
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.
Evaluations of exercise assessment include :
Pull test
Timed tandem stand and 360° turn
Functional reach or chair sit and reach
Reaction time

14. Recommendations for Exercise Testing
Parkinson’s Disease
HESS 509
CHAPTER T W E N Y
NINE
Recommendations for Exercise Testing
Gait and physical functioning should be evaluated to determine competency with ADLs; assessment can include these measures:
Gait speed
Timed walk
Walking cadence and step length
Sit to stand
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

15. Recommendations for Exercise Testing
Parkinson’s Disease
HESS 509
CHAPTER T W E N Y
NINE
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)

16. Recommendations for Exercise Programming
Parkinson’s Disease
HESS 509
Recommendations for Exercise Programming
CHAPTER T W E N Y
NINE
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
strength and flexibility,
gait and balance,
physical functioning (sit to stand and transfer exercises), and
orofacial and manual dexterity (speech and occupational therapy).

17. Recommendations for Exercise Programming
Parkinson’s Disease
HESS 509
Recommendations for Exercise Programming
CHAPTER T W E N Y
NINE
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.

18. Recommendations for Exercise Programming
Parkinson’s Disease
HESS 509
CHAPTER T W E N Y
NINE
Recommendations for Exercise Programming
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)

19. Recommendations for Exercise Programming
Parkinson’s Disease
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.

20. Recommendations for Exercise Programming
Parkinson’s Disease
HESS 509
CHAPTER T W E N Y
NINE
Recommendations for Exercise Programming
Some desired outcomes in PD Patients :
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
Additional Resources:
National Parkinson Foundation
Parkinson's Disease Foundation
The Michael J. Fox Foundation
END