2. Introduction
Extrapyramidal system consists of basal
ganglia (caudate, putamen, and Globus
pallidus) and substantia nigra, sub thalamic
nucleus, red nucleus and the cerebellum.
3. extrapyramidal conditions
Movement disorders are referred to as
the CNS disorders characterized by either
diminished or excessive movements.
They are divided in two major categories.
4. extrapyramidal conditions
Hyperkinetic Movement disorders:
They refer to excessive, often repetitive,
involuntary movements that interfere with
the normal flow of motor function.
This category includes chorea, athetosis,
dystonia, myoclonus, tics and tremor.
5. extrapyramidal conditions
Hypokinetic Movement disorders:
These refers to diminished movement
causing limitations in normal motor
functions.
These are akinesia, hypokinesia (reduced
amplitude of movement), bradykinesia (slow
movement), and rigidity.
Parkinsonism is the primary hypokinetic
movement disorders.
7. Function of basal ganglia
The “basal ganglia” refers to a group of
subcortical nuclei responsible primarily
for motor control, as well as other roles such
as motor learning, executive functions and
behaviours, and emotions.
Basal ganglia receive input signals from
cortex & also return signal to cortex.
8. Controls automatic & associated movement
Red nucleus is center of righting reflex
Substantia nigra is center of co ordination
of skill movement
9. Associated function
Planning of multiple, parallel & sequential
patterns of movement that the mind must put
together to accomplish a purposeful task
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11. Athetosis
It describes the slow writhing movements
that predominantly affects distal limbs, neck
& head
It can be generalized or unilateral
Hypertonia or hypotonia may be present
It is related to chorea or dystonia
It results from excess co contraction of
antagonist
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12.
13.
14. Tics
They are quick, brief, stereotyped
repetitive movements
Commonly involve face, neck, shoulders
such as blinking, smacking & shrugging
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15.
16. Dystonia
Dystonia is a movement disorder that causes
the muscles to contract involuntarily. This can
cause repetitive or twisting movements. The
condition can affect one part of your body
(focal dystonia), two or more adjacent parts
(segmental dystonia), or all parts of your body
(general dystonia).
They are usually long standing disorders
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17.
18. Bradykinesia
Characterizes by inability to initiate a
movement or perform a purposeful movement
Due to decrease activation of the
supplementary motor cortex, pre-motor cortex
& motor cortex
Complex movements are more effected than the
simple ones
Sequential movement becomes more impaired
It is not due to rigidity or inability to relax
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19. Rigidity
It can be of two types
Lead pipe
Cog wheel
It is increase resistance to movement
throughout the range in both direction
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20. Tremor
Rhythmic and sinusoidal
There will be resting tremor which
decreases during movement
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21. Postural instability
It is one of the serious problem that leads
to increased episodes of falling
Due to deficits in processing of kinesthetic
& proprioceptive sensations
Also due to inflexibility & also interaction
with rigidity and bradykinesia
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22. Gait abnormalities
Festinating or short shuffling gait
Due to decrease equilibrium response:
chase of COG
Inability to step over obstacles & walk on
carpeted surface
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23. Hemiballismus
If there is a lesion in subthalamus or its
connection with the Globus pallidus, the
patient develops a wild swinging movement
of arm and leg of opposite side of the body
termed as hemiballisums.
It mostly improves with time.
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24.
25. Chorea
Involuntary rapid irregular & jerky movements
Involvement of the face, tongue and the limbs
Usually seen with athetosis (chorea athetosis)
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28. Parkinsonism
“Parkinsonism” is a general term used to
describe a group of central nervous system
disorders that shows similar movement
problems and occur due to pathology in
dopaminergic system of the substantia nigra.
They are classified as Primary Parkinsonism,
Secondary Parkinsonism, Parkinson’s plus
syndromes.
29. Classification
Primary Parkinsonism: Also known as Parkinson’s
disease. It is the most common type seen in the
patients. Aetiology is idiopathic.
Secondary Parkinsonism: It is associated with a
causative factor. The causes can be viral infection,
vascular, metabolic, etc.
Parkinson plus syndromes : They show similar
symptoms such as Parkinson’s disease, but these symptoms
are attributed to other neurodegenerative disease, such
as multiple system atrophy, progressive supranuclear
palsy, corticobasal degeneration & dementia with Lewy
bodies)
30. Parkinson’s disease
It is a Progressive degenerative disease of
the CNS affecting mainly basal ganglia
characterized by rigidity, tremor,
bradykinesia & postural instability
Also called primary or idiopathic parkinsonism
Also called paralysis agitans or shaking palsy
31. Epidemiology
Occurs in 1% of population older than 50
years of age & 2.6% of population by 85 years
Males are slightly at more risk than females
32. Pathophysiology
Degeneration of dopaminergic neurons that produce
dopamine
Dopamine is the main neurotransmitter of the
nigrostriatal pathway (substantia nigra to striatum).
Pathology of the Parkinson’s disease involves
reduction in dopamine due to degeneration of
dopaminergic neurons present in the substantia nigra.
As disease progress & neurons degenerate they
develop characteristic cytoplasmic inclusion bodies
called Lewy’s body
33. Dopamine also inhibits the corpus striatum
(stimulates release of acetyle choline)
In parkinson’s when dopaminergic cells are
degenerated there is no inhibition of corpus
striatum
Production of more acetyle choline increased
skeletal muscle activity rigidity & tremor
34. Clinical manifestations
Rigidity: lead pipe or cog wheel type
Akinesia/ Bradykinesia
Tremor: pill rolling or drum beating
Postural instability & imbalance
Musculoskeletal changes: kyphosis/ scoliosis, Fatigue
Gait: festinating, Loss of reciprocal arm swing
Dysphagia, sialorrhoea, hypokinetic dysarthria,
mutism
35. Mask like face
Akathesia (extreme motor restlessness)
Visual & sensory: blurring of vision, paraesthesia, pain
Bradyphrenia (disorder of intellectual dysfunction) &
Dementia
Autonomic dysfunction
Cardiopulmonary dysfunction
Micrographia
36. Diagnosis
It is made on the basis of clinical findings & history
Handwriting samples, speech analysis & physical
analysis are use to detect early manifestations of the
disease
There is no definite test or group of test to diagnose
PD
37. Hoen & yahr classification of disability
Stage I – minimal or absent, unilateral if present
Stage II – minimal bilateral or midline involvement.
Balance not impaired
Stage III- impaired righting reflex , unsteadiness
while turning or raising from chair. Some activities are
restricted but patient can live independently & continue
some forms of employment
Stage IV – all symptoms present & severe. Standing &
walking possible only with assistance
Stage V – confined to bed or wheelchair
38.
39.
40. PT assessment
History – gradual onset of signs & symptoms, initial
difficulty in fine motor movement & presence of
resting tremor
Cognitive asst – is assessed by MMSE.
memory, attention, orientation, problem solving,
communication
Late stage dementia
Dysarthria & hypophonia
Micrographia
41. Pain asst – postural stress syndrome,
paraesthesia
Burning & Aching pains, numbness, tingling or
abnormal heat & cold sensations
Intense pain during “off” period
Visual function – impairment in acquity, peripheral
vision, tracking,
42. Cranial nerve integrity –
Dysphagia (swallowing difficulty) (IX & XI)
Dysarthria (slurred speech) (IX, XI, & XII)
Sialorrhea (excessive increase of saliva) due to ANS
dysfunction
Sensory integrity
May have impaired proprioceptive & kinaesthetic
sensation
43. Motor Function
Demonstrate increased resistance to passive
movements throughout ROM (leadpipe or cogwheel
rigidity)
Initiating or stopping movement difficulties
Bradykinesia, Resting tremor
Weakness due to deconditioning
44. Reflex integrity
Increased or normal DTR
Impaired, delayed, or absent equilibrium &
protective extension reactions
45. ROM & joint integrity
limited joint play movement due to rigidity
Posture
Universal flexed posture, scoliosis
Kyphosis with forward head
Asymmetry (leaning to one side)
46. Gait, Locomotion, and Balance
Impaired static or dynamic balance
festinating gait (rapid, small steps)
Shuffling gait (dragging feet)
Difficulty turning & changing directions
Initiating or stopping difficulties
Freezing at a doorway
Frequent falls & fear of falls
48. Fatigue:
It is very common.
The patients complains of “heaviness” and
“stiffness” of the limbs while moving due to
rigidity which increases energy expenditure and
induces fatigue.
“Fatigue severity scale” is used to assess fatigue.
50. Ventilation & respiration
Decreased tidal volume & vital capacity due to stooped
posture
Low voice volume due to decreased tidal volume
Impaired pulmonary responses to exercise
Impaired cough
51. Skin integrity – bruising, skin breakdown
Excessive sweating
Seborrhoea (a skin condition characterized by greasy
or dry, white, flaking scales over reddish patches)
Functional status –
Varies from mild functional difficulty to complete
dependence
Disease specific measure – unified PD rating
scale, PDQ- 39
52. PT management
The stages described in modified Hoehn-Yahr
can broadly help the physical therapists to
plan the goals of physiotherapy management.
53. PT management
In early phase – (stage 1-2.5)
Prevention of inactivity
Prevention of fear to fall or move
Preserving & improving physical activity
In the mid phase (stage 2.5-4)
Preserve & improve activities in 5 core areas
Transfer, body posture, reaching, grasping, balance &
gait
In the late phase (stage 5)
Preserve vital function& prevent pressure sores
54. Treatment strategies
Strategies to reduce rigidity
Large amplitude movements of extremities
and trunk along with rotational components
such as PNF pattern are found to be
beneficial.
56. Flexibility exercise
Active & passive ROM ex
PNF patterns of movement targeting till the
end range
Hold relax & contract relax
Passive positioning in lengthen position
ROM ex combined with rotational movement
Mechanical stretching ex
57. Mobility exercise
Focus on functional movement pattern
Bed mobility activities, weight shifting, UL
reaching exercise
Rocking chair to facilitate independent sit to
stand
Adequate strength training
Mobilization of facial muscles – massage,
stretching
58. Balance exercise
Weight shifting in both sitting & standing
Progress shifting with UL activities
Balance exercise on gym ball with induced
perturbations
Balance board exercise
Reaching exercise
59. Gait training
Goals to lengthen stride length, broaden BOS,
improve stepping, increase trunk movement &
arm swing
Marching in place emphasizing on high stepping
Reciprocal arm swing
Visual cue & brisk march music enhance gait
performance
60. Functional adaptation
Loose fitting cloths, Velcro closures can optimize
dressing
Stable & firm mattress can facilitate rolling &
ease of getting out
Chair with arm rest with help in sit to stand
Festinating gait will be alleviated with use of
heel or shoe wedge
Assistive aids will improve ambulation
61. Respiratory exercise
Respiratory exercise
DBE, & exercise that recruit neck, shoulder &
trunk muscles
Upper body resistance exercise may improve
respiratory efficiency
Exercise in unsupported sitting to improve
trunk stabilization
Improve trunk extension & prevent from
becoming kyphotic
62. Aerobic conditioning
Submaximal intensities (50- 70% ) are
indicated to improve CV response
Training modes include UL & LL ergometer,
walking
Regular exercise is recommended
63. Group & home exercise
Benefit from positive support & communication
among group
Select Pt with similar level of disability
Regular exercise is started but avoid over
exercise
Early morning calisthenics will help in reducing
morning stiffness
64. Patient & family education
Education about medications (purpose, dosage)
Assist in decision making & behavioral skills to
promote optimal self care
Caregivers should be advised not to give too
much of assistance & give room for
independent performance
Information is given regarding community
support groups
67. Definition
A group of neurodegenerative disease that
can affect the basal ganglia & produce
parkinson like syndrome with other
neurological disease
68. Examples
Striatonigral syndrome
Shy-dragger syndrome
Progressive supranuclear palsy
Olivopontine cerebellar atrophy
Corticobasal ganglionic degeneration
Others
Multi infarct vascular disease
Normal pressure hydrocephalus
Multi system atrophy
Multiple sclerosis
69. Early signs
Rigidity
Bradykinesia
Cognitive impairment
Other non extrapyramidal symptoms that
do not improve with dopamine agonist or
L-dopa