Assessment, Evaluation and

Treatment/Management of
Parkinson’s Disease
P R OF E SS OR M AT T H E W O. B . OL AOGU N .
Objectives .
Appraise the historical medical background of [PD].
Clinical diagnosis of Parkinson’s disease [PD]
Review of the Pathophysiology and Pathokinesiology of PD
List the Motor symptoms and non-motor symptoms of PD
Overview of Multidisciplinary rehabilitation of PD
Updates on Neurorehabilitation of PD
Background
•Parkinson’s disease (PD) is the second most common neurodegenerative disease in the
world after Alzheimer’s dx, and in addition to the classical motor signs, such as
bradykinesia, rigidity, and tremor, this disorder causes cognitive and mood changes (1)
•Parkinson’s Disease (PD) poses significant health burden worldwide with increasing
ageing population (Dotchin et al, 2007, Kowal et al, 2013, Tysnes and Storstein, 2017)
•Though not life-threatening, increase in mortality in those with PD duration for 10years
and above have been reported (Diem-Zangerl et al,2009).
•PD is a leading cause of neurological disability globally affecting over 10million people.
•This figure have been projected to double by year 2030 (De-Celis et al, 2015)
Background continued
Characterized by impairments of motor, cognitive and behavioural functions.
Caused by selective degeneration of dopamine-producing neurons in the
substantial nigra of the basal ganglia.
Recent discovery suggests that dysfunction in the neuron synapses – the
tiny gaps across which a neuron can send an impulse to another neuron-
leads to the deficits in dopamine and precedes the neurodegeneration
(Maria Paul, 2023}
PD predominantly affects 1% of 60yrs and above, 4% of 80yrs and above
and has
Higher prevalence in males and Caucasians (Delil et al, 2005)
Background
Gait and balance impairments- movement disorders - most
significant consequences and reason for referral for physiotherapy
Markedly reducing function and QoL (Wood et al, 2002).
Management of PD is multidisciplinaryinterdisciplinary
Pharmacologic and non-pharmacological interventions
Physical therapy is an important component of non-
pharmacological management
Parkinsonism
What of Parkinsonism?
Parkinsonism is the collective term for a group of
conditions that includes PD (about 78%) as well as several
other degenerative brain disorders with symptoms of
tremors, slow movement and stiffness.
Parkinson’s disease worsens with time. Other disorders in
Parkinsonism are non-progressive.
Focus of this lecture is Parkinson’s disease.
Motor Symptoms
Resting tremor
Bradikinesia
Rigidity
Postural instability

Asides the above there are PreClinical Symptoms

Preclinical Symptoms
Olfactory dysfunction
Sleep disturbances
Depression
Anxiety
Apathy and
Constipation
Pathophysiology
Neurochemically, there is an imbalance in the doperminergic
pathways which connects the substantial nigra to the striatum.
Death of the cells of these regions leads to a loss in the production
of dopamine.
Presence of intracytoplasmic inclusions called lewy bodies ( Lang &
Obeso, 2004).
When dopamine is decreased and acetylcholine is increased, the
excessive excitatory output results in a generalized activation of
skeletomotor and fusimotor systems by corticospinal, reticulospinal
and rubrospinal pathways.
Pathophysiology of Parkinson’s disease. Copyright approved under Creative Commons Attribution 4.0 International.
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Pathophysiology of Parkinson’s disease. Copyright approved under Creative Commons Attribution 4.0 International.
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With reference to the illustration in Fiure 1,two separate
pathways originating from the striatum and reaching the
thalamus explain that. The direct path (2) leads straightly
from the striatum to the thalamus, by passing through the
medial globus pallidus or the substantia nigra reticularis,
while in the indirect pathway (3) additionally the lateral
globus pallidus and the glutamatergic (shown in doubled
red arrows) subthalamic nucleus are connected in series
(Kammerer et al., 2010)
Pathokisesiology
The lesion of the basal ganglia therefore affects
motor control and function bilaterally. The ambulant
patient presents the pathologic gait deviation known
as the festinating (Parkinsonian) gait with the
following characteristics. The patient’s trunk is flexed
forward, gait is slow and shuffling, the steps are
rapid, there are difficulties with stops and turns, and
falls are very frequent.
Definition of Terms
Bradykinesia is the generalized slowness of movement as
the individual struggles, particularly when starting a
movement. It is a classic and most debilitating symptom in
almost every person with PD, making its presence essential
for diagnosis.
Definition of Terms

Akinesia is the loss of spontaneous, voluntary muscle movement

commonly associated with PD. However, it can be experienced as a
symptom of other medical conditions, such as hypothyroidism and
fetal akinesia deformation sequence.
Hypokinesia is when a person's movements are not as wide-ranging
as they usually should be. It is considered part of bradykinesia — a
condition where a person's movements are very slow. Bradykinesia
can also include akinesia, where there is no movement. In general,
hypokinesia, bradykinesia, and akinesia can be grouped under the
umbrella term "bradykinesia."
Bradykinesia is the generalized slowness of movement as
the individual struggles, particularly when starting a
movement. It is a classic and most debilitating symptom in
almost every person with PD, making its presence essential
for diagnosis.
Tremor is a neurological condition that includes shaking or trembling
movements in one or more body parts, particularly in the hands, arms,
legs, head, vocal cords, and torso.
Rigidity is the increased resistance to passive movement about a joint
that usually starts on one side and later spreads to the other. Rigidity is
similar to spasticity since both conditions show increased resistance to
passive movement. However, rigidity is not direction-dependent, which
means there is the same amount of resistance in the affected limb's
extension and flexion. In addition, rigidity is not velocity-dependent,
and the tone usually does not vary with the speed of passive motion.
Freezing of gait, (FOG) is a brief, episodic absence or
significant reduction of forward progression of the feet
despite the intention to walk. The condition is one of the
most debilitating motor symptoms in patients with PD, as it
often leads to falls and a loss of independence.
Motor imagery is the mental performance of a movement
without any overt movement or peripheral (muscle)
activation.
Neuroplasticity is the brain’s ability to adapt and change
throughout life and is a fundamental aspect of learning,
remembering, and recovering from brain injuries. Neuroplasticity
is the capacity of neural networks in the brain to change through
growth and reorganization, which includes the formation of new
neural connections, the strengthening of existing ones, and the
pruning of less-used connections. It is essential for learning new
information, adapting to new experiences, and recovering from
injuries (Psychology Today, n.d.).
*includes depression, anxiety, fatigue, sleep problems, and cognitive ability and personality changes
Diagnosis
1. Diagnosis is on the basis of history and Clinical examination
2. Major symptoms are bradykinesia and any other
3. EEG, CAT [Computerized Axial Tomography] Scan, MRI can aid
in the differential diagnosis to rule out other conditions
4. Dopamine transporter Scan [Abnormal in PD, normal in other
conditions…
5. An estimate of the stage and severity of the disease using
Hoehn and Yarh Scale
Management
Multidisciplinary
• Includes co-ordination of pharmacological and non-
pharmacological treatments ( Cutson et al, 1995; Giroux,
2007).
• Involving Neurologists, Physical Therapists, Nurses,
Medical Social workers, Occupational Therapists, Speech
and Language therapists, Psychiatrists,
Neuropsychologists, Neurosurgeon.
Management.- Physiotherapy
Integral component of multidisciplinary mgt
Effective non-pharmacological Rx with positive
effects on mobility and ADL
Most common exercise mode used in the mnx is
aerobic exs in various standing and sitting positions.
Assessment
1. Demographic details
2. History taking including history of present complaint, onset,
progression intervention sought, medicine taken, hx of other
medical conditions, family and social history.
3. Physical examination: Observe tremor at rest, facial
expression posture, assess gait initiation pattern, ability to
stand witout assistance, ability to turn arround, mental
function [cognition], asseess muscular rigidity, presence of
freezing.
Goals
1. To stimulate patient’s safety and independence in
performance of activities with emphasis on transfers, body
posture, balance, gait, reaching and grasping.
2. To preserve or improve physical capacity
3. Toprevent falling
4. To prevent pressure sores
5. To stimulate insight into impairment and functional
limitation
Goals continued
1. To teach compensatory strategy
2. To prevent or minimise the development of
secondary impairments
3. To assist patient and family in psychological
adjustment
4. To teach energy conservation techniques
5. To promote functional range of motion
Means
1. Sensorymotor integration training
2. Balance exercises
3. Strengthening exercises
4. Range of motion exercises
5. Step training
6. Treadmill exercises
7. Gait training
8. Use of walking aids
Exercise prescription
INTENSITY: Low intensity- 20%-40% Hrmax (early stages of Mgt}
Frequency: 3 - 5 times/week)
Time: 20-39 minutes (short sessions at early stages). This can
extend to 45 minutes as cardiovascular condtioning improves,
Mode uf exercises: Deep breathing exs, Relaxation Exs, Range of
Motion Exs, Aerobis- Bike ergometer, Treadmill, Musical fherapy
.
Outcome Measures
Mini Mental State Examination (MMSE) (Healthdirect Australia,
2022)
Hoehn and Yahr Scale (Hoehn and Yahr, 1967.
BTS G-Walk Device (BTS Bioengineering S.P.A. Milan, Italy)
Level of cognition
Parkinson’s Activity Scale (Korpan SM et. al., 2014)
Ten-meter walk test.
Freezing of Gait Questionnaire (Shirley Ryan AbilityLab, 2012)
Outcome Measure Continued
Berg Balance Scale (Berg, 1989)
Functional Reach Test (Dunca PW et al, 1990)
Borg’s Perceived Exertion Scale (Borg, G. 1998).
PDQ-39 questionnaire.
Exercise Techniques
Mobilty Exercises:: This should be based on functonal
movement patterns that engage several body
segments
Movement should be rhythymic, reciprocal and
progress to full range of motion.
Begining first in dependent position and progress to
more upright supported position
The use of verbal, auditory and tactile stimulation
promote sensory reinforcement and help increase patient
awareness of movement.
Verbal commands, music, clapping, marching,
metronome, mirror and floor markings,… are examples of
Relaxation exercises
Rolling exercises
Callisthenics
Virtual Reality Gaming
(VRG XBOX 360 SETUP)
Methodology (XBOX 360)
The MiniMental State
Examination (MMSE)
Test was developed in 1975 as a screening tool for cognitive
impairment in community-dwelling geriatric, hospitalized and
industrialized adults (Medlink Neurology) (see Picture 1). Consisting
of 11 questions, MMSE assesses six mental abilities: i) Orientation to
time and space, ii) Attention/Concentration, iii) Short time memory
(recall), iv) Visuospatial abilities and vi) Ability to understand and
follow instructions. Taking about 5 t0 10 minutes to complete, the
MMSE possible maximum score is 30. A person with a score of 25 or
higher is considered normal.
MMSE Continued.
A score below 25 indicates possible cognitive impairment in the
person. In other words a score of 24 and bellow suggests an
abnormality (Healthdirect Australia, 2022). Although MMSE has been
extensively investigated and used in clinical practice and research it
should not replace a comprehensive clinical mental status
assessment. According to Kurlowicz and Wallace, (1999) Persons
with auditory and visual impairment, intubation, low English literacy
or other communication disorders may perform poorly on the MMSE
test even though they may be cognitively intact.
Modified Hoehn and Yahr
Scale (Lansen et.al, i983)
1.0: Unilateral Involvement only
1.5: Unilateral and axial involvement
2.0: Bilateral involvement without impairment of balance
2.5: Mild bilateral disease with recovery on pull test
3.0: Mild to moderate bilateral disease; some postural instability; physical
independent
4.0: Severe disability; still able to walk or stand unassisted
5.0 Wheel chair bound
 Level of Cognition Scale
• There are six levels of cognitive learning according to the revised version of Blooms Taxonomy (Central
New Mexico Community College, (2023)), Each level is conceptually different. They are:
• Knowledge. Remembering information- listing, reciting, identifying, recognizing and matching.
• Comprehension. Explaining the meaning of information as in describing, giving original examples,
interpreting and discussing
• Application. Using abstractions in concrete situations – predicting, calculating, illustrating and using..
• Analysis. Breaking down a whole into component parts as in classifying/categorizing, illustrating even
with diagrams
• Synthesis. Putting parts together to form a new and integrated whole as in designing, formulating,
modifying..
• Evaluation. Determining, judging, comparing, grading and evaluating.
However assessing cognition level of patients
with PD with the concept above may be
clinically cumbersome and may, therefore, be
obviated if MMSE is used.
Functional Reach Test (FRT)
Dunca PW et al, 1990) is a reliable clinical outcome measure and
assessment tool for ascertaining dynamic balance in one simple task.
The FRT is performed with the patient/participant in standing. The
outcome is the measure of the difference, in centimetres, between
arm’s length with stretched arm at 90% shoulder flexion and
maximal forward reach, using a fixed base support. The test uses a
centimetre measuring device against a wall at (the) shoulder height.
See Picture .
Scores less than 15 or 18 cm indicate limited functional balance.
Adequate functional balance can reach 25 cm or more
Functional Reach Test
The Pull Test
The examiner stands behind the patient and
By pulling on their shoulder tries to make them fall
backwards
If the patients are able to correct their centre of
gravity/restore balace in just one or two steps the test is
negative for balance abnormalities.
The test is positive if patient are unable to restore balance
after two steps
Equipment/Instruments

Microsoft Kinect Xbox 360 game console

BTS G-Walk device/Walk Way for gait
assessment
Instrumented Treadmill Device
42 inch display monitor screen
Equipment/Instrument
continued
Wooden balance board
Electronic sphygmomanometer
Weighing scale, stadiometer
PDQ-39, MMSE, Borg scale, Berg balance scale,
exercise readiness
MEDICAL MANAGEMENT
Levodopa combined with carbidopa (Sinemet)
benserazide (Madopar), Amantadine(Symmetrel),
Biperiden ( Akineton).
Drug is indicated if disability is severe, or there is failure
to respond to simple therapy.
Surgery indicated in patients with early severe disease
resistant to drugs.
(XBOX 360)
(BTS G-WALK DEVICE)
CAGBT: Conventional Activity-based gait and
balance training
Participants had 5 to 10minutes warm up
exercise:
Breathing in and out, arm curls, leg raise, sit and
reach, hip rotation
Main exercise : Treadmill : participant step on the platform
with a protective strap around the abdomen. The machine
started at a baseline speed of 0.5kmph after which it was
gradually increased according to patient’s tolerance until
the intensity of 50 to 65% of HRmax was achieved
monitored through a pulse oximeter. This exercise
continued for 25minutes before the speed was gradually
reduced and participant came down
VRG
River rush game: participant’s image stands on a raft and tries to pick up the adventure
pins scattered through the winding rapids while trying to steer the raft. (this game
trains balance).

Bubble game: participant follow the image on the screen to direct a bubble by shifting
their weight right to left until bubble reaches the end of the river. (Balance training).

Tight rope tension: this engage the participant in walking while attempting to cross a
tight rope making them bend and extend their knees before jumping over the obstacle
(helps gait training)
VRG
Each of the games lasted 3 to 5minutes and were repeated twice for each
session of treatment.
Intensity of the training were set within 50 to 65%Hrmax
Participants were asked to indicate their level of exertion on the Borg’s scale
placed directly beside the display monitor.

Cool down exercise: deep breathing in and out, arm curls, back extension,
flexion, sit and reach (10 reps).
Virtual Reality Gaming and Activity-based gait and balance training led to
significant improvements in balance, step length, stride length, gait velocity,
cadence and quality of life of patients with Parkinson’s disease.
References
De Celis Alonso B, Hidalgo-Tobon SS, Menedez-Gonzalez M, Salas-Pacheco J and Arias-Carrion O
(2015). Magnetic Resonnace Techniques applied to the Diagnosis of Parkinsons’s disease.
Frontiers in Neurology: 6;146.
Delil S, Benbir G, Apaydin H, Ozekmkci S, Erginoz E (2005). Parkinson hastansnin demografik ve
kinik ozellikleri. Turk Noroloji Dergisi, 11:499-505.
Diem-Zangerl A, Seppi K, Wenning GK, Trinka E, Ransmayr G, Oberaigner W and Poewe W
(2009). Mortality in Parkinson’s disease: A 20year follow-up study. Movement Disorder: 24(6):
819-25.
References
Dockx K, Bekkers EM, Van der Bergh V, Ginis P, Rochester L and Hausdorff JM (2016). Virtual
Reality for Rehabilitation in Parkinson’s disease. Cochrane database systematic review.
Dotchin CL, Msuya O and Walker RW (2007). The challenge of Parkinson’s disease management
in Africa (2007). Age Ageing, 36:122-7.
Frazzitta G, Maestri R, Uccellini D, Bertoti G and Abelli P (2009). Rehabilitation treatment of gait
in patients with Parkinson’s disease with freezing; a comparison between two physical therapy
protocols using visual and auditory cues wit or without treadmill training. Movement Disorders,
24:1139-1143.
REFERENCES AND NOTES
1
W. Poewe, K. Seppi, C. M. Tanner, G. M. Halliday, P. Brundin, J. Volkmann, A.-E. Schrag, A. E. Lang,
Parkinson disease. Nat. Rev. Dis. Primers 3, 17013 (2017).
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