1. The
Patient with
Parkinson’s
Disease: Exam
ination
and
M
anagem
ent
Darcy Jam
es, SPT

2. overview
Introduction to Parkinson’s Disease
 Etiology
 Cardinal signs
Examination procedure
Physical therapy interventions and management

3. PD: an introduction
Second most prevalent neurodegenerative disorder
 Impacts approximately 1.5 million in the United States
Differential diagnosis
 Idiopathic PD or primary PD verse parkinsonism or parkinsonian features
In general, all individuals have a dysfunction in the dopamine pathways
of the basal ganglia
Underlying cause is unknown
(Kegelmeyer, 2014)

4. The role of the basal ganglia and dopamine
Located in the midbrain and includes substantia nigra, globus pallidus,
and striatum
Responsible for a variety of functions including voluntary motor control,
procedural learning, motivation, and executive function
Dopamine has many functions, one being voluntary movement and is
present in the midbrain
Lack of dopamine in the basal ganglia impacts the motor pathways
leading to symptoms such as bradykinesia and postural instability
 Inhibition of motor systems
(Kegelmeyer, 2014)

5. Cardinal motor symptoms of PD
Diagnosis of PD is based on the presence of at least two of the four
cardinal motor signs:
 Bradykinesia
 Resting tremor
 Rigidity
 Postural instability
(Kegelmeyer, 2014)

6. bradykinesia
Defined as a slowness of movement
Other terms associated include hypokinesia and akinesia
 Hypokinesia refers to small movements, believed to be one of the primary causes of
reduced walking velocity due to reduction in step length
 Akinesia refers to lack of movement, typically associated with the inability to initiate
movement or “freezing”
Causes prolonged time to complete ADLs and may impair reflexive
movements
Typical parkinsonian gait pattern is described as shuffling gait
(Kegelmeyer, 2014)

7. Resting tremor
Noted at rest but diminishes when the limb is moving
“Pill rolling” tremor
 Flexion and extension of the fingers in connection with adduction and abduction of
the thumb
 Usually appears unilaterally but may become bilateral
(Kegelmeyer, 2014)

8. Rigidity
Increased stiffness of the muscles, which is not speed dependent
Affects proximal musculature first and eventually spreads to the
muscles of the face and extremity
Cogwheel verse lead pipe rigidity
 Cogwheel: jerky, ratchet-like resistance to passive movement as muscles alternately
tense and relax
 Lead pipe: constant uniform resistance to passive movement
Can lead to muscle shortening, loss of motion, slowness, and fatigue
(Kegelmeyer, 2014)

9. Postural instability
Impaired balance and balance reactions due to damage to basal ganglia
pathways
Difficulty recovering balance
Respond to inability with abnormal muscle co-activation patterns
Exhibit difficulty with feed-forward postural control
(Kegelmeyer, 2014)

10. Autonomic problems
Damage to the autonomic nervous system leads to problems involving
the major organ systems including cardiovascular, gastrointestinal,
and urogenital systems
Orthostatic hypotension is the most noticeable change to the
cardiovascular system
 Drop in systolic blood pressure > 20 mm Hg or drop in diastolic blood pressure > 10
mm Hg that occurs within 3 minutes of either standing or head-up tilt to at least 60
degrees
 Can result in dizziness and falls
(Kegelmeyer, 2014)

11. Additional associated symptoms
Dual task inability
Impaired dexterity and coordination
Fatigue
Muscle aches or cramps
Feelings of fear and anxiety
(Kegelmeyer, 2014)

12. Hoehn and Yahr classification
It is also limited by its focus on issues of unilateral versus bilateral disease and the
presence or absence of postural reflex impairment, thereby leaving other specific
aspects of motor deficit unassessed. Also it does not provide any information concern-
ing nonmotor aspects of PD. A modified version of HY is sometimes used.
Hoehn and Yahr Scale Modified Hoehn and Yahr Scale
1: Only unilateral involvement, usually with
minimal or no functional disability
2: Bilateral or midline involvement without
impairment of balance
3: Bilateral disease: mild to moderate
disability with impaired postural re flexes;
physically independent
4: Severely disabling disease; still able to
walk or stand unassisted
5: Confinement to bed or wheelchair unless
aided
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 reco very on
pull test
3.0: Mild to moderate bilateral disease; some
postural instability; physically independent
4.0: Severe disability; still able to walk or stand
unassisted
5.0: Wheelchair bound or bedridden unless
aided
References
1. Hoehn MM, Yahr MD. Parkinsonism: onset, progression, and mortality. Neurology. 1967;

13. Examination
History
Body structure and function
Neurologic system
Musculoskeletal system
Gait assessment
Falls screening
Balance
Function
Participation measures
(Kegelmeyer, 2014)

14. Neurologic system
Every examination should include routine neurologic tests such as:
 Proprioception, sensation, reflexes, and tone
MDS-UPDRS Scales for the clinician and patient self-report to include
information on impairments specific to PD
 Bradykinesia: finger/toe tapping test
 Balance: pull test for postural instability
 Tremor: described in terms of location, amplitude, and consistency
 Dyskinesia: present or not present
 Freezing: rapid-360 degree turn, observe gait in a confined space
 Movement scale: repetitive finger-to-finger movements
(Kegelmeyer, 2014)

15. Musculoskeletal system
Muscle rigidity and postural changes can make people with PD susceptible
to muscle shortening and decreased ROM leading to contractures
Specific muscle groups prone to shortening
 Pectoralis muscles
 Iliopsoas
 Hamstrings
 Gastrocnemius
Scoliosis should be assessed
Trunk rotation should be assessed as it is the key to many functional
activities such as walking with long strides and reaching
(Kegelmeyer, 2014)

16. Gait assessment
Gait speed can be correlated with both function and health outcomes
Slowing of gait has been shown to correlate to increased disability in
ADLs and increased fall risk
For valid measurements, speed should be measured over the longest
distance feasible and include sufficient space for acceleration and
deceleration
 10 meter walk test
(Kegelmeyer, 2014)

17. Gait assessment
Many falls occur in situations requiring a backward step, procedures for
testing backwards walking have been established
 Backwards walking velocity < 0.60 m/s was indicative of high fall risk
 10 meter walk test
Tinetti Mobility Test
 Made up of two scales, balance and gait
 Mobility portion can be used to examine gait and has been found to have a good
correlation with gait speed
6 Minute Walk Test
 Most commonly used measure of functional walking ability and endurance
 Studies have shown that the distance walked is less for those with PD than for
community dwelling elderly (PD = 392 m; elderly = 631 m)
(Kegelmeyer, 2014)

18. Fall screening
Critical for ensuring safety of patients
One of the best predictors for fall risk is fall history
 Individuals who have fallen are at risk for future falls
Balance Evaluation Systems Test (BESTest)
 Combines elements of tests such as the TUG and Berg Balance Scale
 Two shorter versions available as well which are both highly recommended for fall
screening (Mini BESTest)
(Kegelmeyer, 2014)

19. Fall screen comparison
TOOL CUT-OFF SCORE SENSITIVITY SPECIFICITY
TMT < 21 70% 70%
TUG 13.5 seconds 39% 87%
Mini-BESTest <20 86% 78%
Brief-BESTest <11 71% 87%
BBS <46 46% 41%
(Kegelmeyer, 2014)

20. Balance assessments
Berg Balance Scale is one of the most commonly used tests for assessing
balance
 Has been shown to have ceiling effect with people with PD, may not be appropriate for
some individuals with more subtle balance problems
Functional Gait Assessment
Mini-BESTest
Four-square step test
 Assesses coordination and balance while stepping forward, side-to-side, and backward
 Does not allow for the assessment of ability to reverse directions, step over an object,
and step sideways and backwards
 Can also be used to measure bradykinesia since it is timed
(Kegelmeyer, 2014)

21. Balance assessment
Impairments that are usually assessed include limits of stability,
postural response to perturbation, and both static and dynamic
balance
Functional reach test
 Provides indication of anticipatory balance responses
Static balance
 Single leg stance
 Romberg test
 Sharpened Romberg
(Kegelmeyer, 2014)

22. Functional assessment
Measures should be chosen based on the goals of the individual
Modified Physical Performance Test
 Examines mobility, upper extremity function, and a few ADLs
Timed chair rise
 Several varieties of the test
OPTIMAL
 Measures difficulty and self confidence in performing movements
(Kegelmeyer, 2014)

23. Participation measures
Several quality of life measures used in research studies
Will be necessary for clinicians to use participation measures because
with insurance changes insurers are now looking for therapists to
demonstrate that therapy is impacting participation
 Lead to better tracking of return to participation-level activities and improve
reimbursement
Parkinson’s Disease Questionnaire (PDQ-39)
Short Form Health Survey (SF-36)
(Kegelmeyer, 2014)

24. Management of Parkinson’s Disease

25. neuorplasticity
Changes that occur in the reorganization of the brain as a result of
experience
 In neurodegenerative diseases, the brain must constantly be reorganized due to loss of
neurons
Animal studies
 Demonstrated that exercise immediately after lesion is neuroprotective
 Treadmill training improves motor symptoms and neurochemical deficits
Fisher et al. (2008)
 Treadmill training in individuals improved walking function and corticomotor excitability
 Indicated that the pattern of activity in the brain was different after treadmill training
Physical therapy interventions are bringing both changes about function and
neuroplastic changes in the central nervous system
(Kegelmeyer, 2014)

26. Key components for Therapy Programs
Repetition
 Neuroplasticity relies on repetition
 Treadmill training verse over-ground walking
Cueing
 Found to influence the speed and amplitude of movement
 Studies have shown that self-given auditory cue is more effective than external cues
 Visual cues and benefits on gait
Useful of meaningful, functional activities
 Practice the specific task that an individual wants to improve
Exercises designed to specifically address individual impairments
 Address underlying impairments and specific functional activities
(Kegelmeyer, 2014)

27. Orthostatic hypotension
Significant safety issue because these can leads to episodes of falls
Education and exercise treatment approach
 Slow position changes
 Ankle pumps, lower extremity isometrics prior to standing
 Pause after standing
 Have something to grab onto when standing, if possible
(Kegelmeyer, 2014)

28. Range of motion/stretching
Primary deficit is rotation in all joints
Stretching should be initiated early in the disease and become part of
the daily routine
 Shoulder internal rotation/adduction, hip flexion with knee extension, hip extension,
and trunk extension
 Muscles are prone to contractures, causing the need for a flexibility program to be
initiated early in the disease course
(Kegelmeyer, 2014)

29. strength
Strength training needs to address muscle groups associated with
functional activity
Gross strength impairments are not common until later in the disease
process, but it is indicated early
Due to early postural changes, core strengthening may benefit as well
(Kegelmeyer, 2014)

30. balance
Most falls occur when an individual is turning or getting out of a chair,
activities which include stepping laterally and backward
 Backwards walking would be beneficial
Many functional activities require prolonged periods of time spent on a
single leg
 Single leg stance activities
Balance training incorporating the proprioceptive system
 Goal of decreasing visual reliance or teaching individuals to compensate for
proprioceptive deficits in the later stages
(Kegelmeyer, 2014)

31. mobility
Treadmill training has been shown to improve gait, walking confidence,
and quality of life
Advantages of treadmill training
 Preset pace of walking
 Consistent pace, repetition of stepping pattern
 Increased stride length and decreased variability in stride length
Studies have shown that treadmill training has decreased bradykinesia
and hypokinesia while promoting neuroplasticity
(Kegelmeyer, 2014)

32. Treadmill training recommendations
Conduct 3 sessions per week lasting 20-30 minutes
Based on pace retraining
 Start with comfortable walking speed and increased by 0.4 miles per hours after a
warm-up period
 Participant should be able to increase the pace with the goal of attaining a speed of
1.2 m/s
Conducted while the participant is at peak dose dopaminergic
medication
(Kegelmeyer, 2014)

33. Effect of physical exercise-movement
strategies programme on mobility, falls,
and quality of life in parkinson’s disease
Geogry, Barnsley, chellappa (2011)
Participants: 15 patients with idiopathic PD
Intervention: Participants attended weekly (first year) and biweekly (second year) 90-
minute standardized rehabilitation sessions
Sessions focused on improving cardiovascular fitness, strength, flexibility, balance,
posture, and gait pattern
Combination of two interventions: standardized mat/chair program and movement
strategy training to improve gait and reduce freezing and risk of falls
Outcome Measures: Tinetti, New Freezing of Gait Questionnaire, PDQ-39
Conclusion: Combination of regular exercise and movement strategy training has the
potential for reducing falls risk, and improving mobility, functional capacity, and quality
of life in people with PD.

34. The effects of an exercise program on fall risk
factors in people with parkinson’s disease: a
randomized controlled trial
Allen, et al. (2010)
Participants: 48 participants with idiopathic PD
Intervention: Participants were randomly allocated into a control or an exercise group
Exercise group: Participated in a 40-60 minute program of progressive lower limb
strengthening and balance exercises 3x/week for 6 months; attended a monthly exercise
class; cueing strategies to reduce freezing during gait
Outcome Measures: PD falls risk score, swaymeter, alternate step-test component of
BBS, Freeing of Gait Questionnaire, Falls Efficacy Scale-International questionnaire, PDQ-
39
Conclusion: People with PD are able to exericse at home which results in improvement of
freezing of gait, sit-to-stand time, overall falls risk, knee extensor muscle strength, fast
walking speed, and fear of falling. Greater supervision may improve results by
encouraging participants to exercise more often and at a higher intensity.

35. LVST BiG intervention
Based on the findings that hypokinesia movements are underlying
impairments leading to decreases in movement speed
Started initially as a voice treatment focusing on movement amplitude,
program developed based on same principles for movement
Focuses on need to practice large amplitude movements in order to
obtain long-term changes in movement size
Involves intensive therapy lasting 60 minutes, 4 days/week for 4 weeks
(Kegelmeyer, 2014)

36. Comparing exercise in parkinson’s
disease – the berlin big study
Ebersbach et al. (2010)
Participants: 60 patients with PD
Intervention: Participants were assigned to Nordic walking, BIG intervention, or home
program
BIG intervention: 16 1-hour session, 50% of exercises consist of standardized whole-
body movements with maximal amplitude, repetitive multidirectional movements, and
stretching; second half of exercises includes goal-directed ADLs with high-amplitude
movements
Walk group: 16 1-hour sessions consisting of a standardized protocol including warming
up, practicing Nordic walking, and finally a cool down as sessions were performed in a
local park with groups of 4-6 participants
Home: received 1-hour instruction of domestic training including stretching, and active
workouts for muscular power and posture
Outcome Measures: UPDRS-III score, PDQ-39, TUG, time to walk 10 meters
Conclusion: Training BIG led to improved motor performance and was found to be more
effective than Nordic walking and the home program.

37. Tango dancing
Used to capitalize on partnering to improve movement and the use of
muscle to set the pace and cue movement
Studies have demonstrated improvement in the BBS and UPDRS
demonstrating that tango dancing helps to improve functional
balance
(Kegelmeyer, 2014)

38. Randomized controlled trial of community-based
dancing to modify disease progression in
parkinson disease
Duncan & Earhart (2012)
Participants: 62 participants clinically defined with PD
Intervention: Participants were randomly assigned to the Tango or control group
Tango group: attended 2x weekly, 1-hour community based Argentine Tango classes for
12 months
Control group: no prescribed exercise and were instructed to go about their lives as
usual
Outcome Measures: MDS-UPDRS, MiniBESTest, Freezing of Gait Questionnaire, GAITrite,
Nine-Hole Peg Test
Conclusion: Long-term participation in Tango dancing benefits people with PD, which
may be attributed to the specific movements incorporated such as backwards walking,
physical and cognitive challenges, low level aerobic activity, and movements challenging
gait and balance while requiring high-level of multitasking.

39. Fall prevention
Multifactorial approach
 Environmental and intrinsic factors
Prescription of assistive device
 No research currently exists demonstrating that A.D.s actually prevent falls, but they
have looked at the impact on gait parameters
 Rollator walker has been shown to improve walking and safety, producing least
variability in all gait measurements
Falls diary
 Determine a pattern of falls
 Timing of medication? Time of day? Location of falls?
(Kegelmeyer, 2014)

40. recap
Parkinson’s Disease is the second most prevalent neurodegenerative
disease in the world
Important to encourage long-term planning for maintaining and improving
ability to participate in activities
Initial goal of physical therapy should be aimed at prevention of
associated problems
 Create a long-term fitness program
As disease progresses, the shift must focus on including more task-based
activities
Components of any program should include flexor stretching, balance
exercises individualized to the patient, practice with larger
movements, and use of repetition and functional practice

41. references
Allen, N., Canning, C., Sherrington, C., Lord, S., Latt, M., Close, J.,
O’Rourke, S., Muray, S., & Fung, V. (2010). The effects of an
exercise program on fall risk factors in people with Parkinson’s
Disease: A randomized controlled trial. Movement Disorders, 25(9),
1217-1225. doi: 10.1002/mds.23082.
Duncan, R. & Earhart, G. (2011). Randomized controlled trial of
community-based dancing to modify disease progression in
Parkinson Disease. Neurorehabilitation and Neural Repair, 26, 132.
doi: 10.1177/154596831142614.
Ebersbach, G., Ebersbach, A., Elder, D., Kaufhold, O., Kusch, M.,
Kupsch, A., & Wissel, J. (2010). Comparing exercise in Parkinson’s
Disease – The Berlin BIG study. Movement Disorders, 00 (00), 000-
000. doi: 10.1002/mds.23212.
Georgy, E., Barnsley, S., & Challeppa, R. (2011). Effect of physical
exercise-movement strategies programme on mobility, falls, and
quality of life in Parkinson’s disease. International Journal of
Therapy and Rehabilitation, 19(2), 88-96.
Kegelmeyer, D. (2014). Examination and management of the client with
Parkinson’s Disease. Western Schools.

42. questions