What is Parkinsonism? 

Parkinsonism or Parkinsonian syndrome group is of disorders which manifests as tremors, disturbances in voluntary movement (rigidity, bradykinesia or akinesia) and impairment in the balance and automatic reactions. 

This syndrome do occur in various conditions, of which Parkinson's disease is quite common. 

Parkinson's disease was observed by James Parkinson in the year 1817.

Etiology of Parkinsonism

IDIOPATHIC: The etiology is not understood. Example of this type of parkinsonism is Parkinson's disease, where there is degeneration of neurons in the substantia nigra and corpus striatum. It occurs usually in the late adult life, progress slowly, and kills the patient by 10-15 years after the onset. 

VASCULAR: Multi-infarct disease (atheroschlerotic parkinsonism).

INFECTION: Infection by various viruses, most commonly influenza virus may be causing parkinsonism like features. It is termed as encephalitis lethargica that causes focal insult to the brain matter. 

DUE TO TOXICITY: Certain toxic chemicals like manganese, carbon disulphide, carbon monoxide, cyanide exposed in various occupation can cause diffuse damage to the brain exhibiting parkinsonian syndromes. 

VARIOUS DRUGS: Phenothiazines, butyrophenones, tetrabenazine can cause Parkinsonism. 

Multiple system degeneration that occurs in conditions like Alzheimer disease shy-Drager syndrome, supranuclear ophthalmoplegia, Wilson's disease, etc, can cause parkinsonism. 

METABOLIC: Abnormal calcium metabolism can cause disposition of calcium in the basal ganglia causing parkinsonism.

TRAUMATIC: Multiple brain damage commonly encountered in boxers usually causes parkisnsonism. This types of parkinsonism are called as punch boxers syndrome. 

Pathology of Parkinsonism

Due to degeneration of neurons in the striatonigral pathway, there is deficiency in the level of dopamine. Dopamine is a neurotransmitter in the striatonigral pathway that inhibits the excitation of the cholinergic pathway, which has acetylcholine as the neurotransmitter. Thus decrease in the dopamine level, removes the inhibitory influence on the cholinergic pathway causing excessive excitation of the extrapyramidal system (reticulo and rubro), which causes increased tone in the agonist and antagonist. This gives rise to rigidity and bradykinesia. 
The exact tremors is not properly known. 

Clinical features of Parkinsonsim

Disturbances in the Voluntary Movement 
BRADYKINESIA : According to Jacksonian's principle, this is a negative feature of parkinsonism. It means slowing of movement with decrease in the amplitude and intensity of contraction. 
There is plenty of time lag between patients desire to act and the actual action produced. This is called as increased reaction time. 
There is also an increase in the movement time, which is the total time needed by the patient to complete a single sequence of movement. 
These disabilities are more pronounced while performing precision function involving distal parts of body. 
The exact mechanism that leads to bradykinesia is not known, but however, it is theoretically presumed that it could be because of difficulty of the the basal ganglia to integrate sensory information. 
EMG  studies have proved that there is a lot of time lapse before the actual recruitment of motor units and also the firing by motor units are not maintained after its initiation. 

RIGIDITY :This can be called positive features in parkinsonism. It is manifested as cocontraction of agonist and antagonist muscles due to an increase in the supraspinal influences on the normal spinal system causing increase tone in the agonist and antagonist. The patient usually complains of rigidity as a sensation of heaviness or stiffness of the limbs. 
Rigidity may involve all the body parts and may be symmetrically or asymmetrically distributed. It occurs in three forms:
Lead pipe: In this the resistance is constant and uniform. 
Cogwheel: In this the resistance is intermittent but uniform. 
Akinesia: It is an ability to initiate movement. It occurs due to severe rigidity. 

POSTURAL DISTURBANCES: The patient's ability to maintain both static and dynamic posture or balance is severely impaired due to combined influence of disturbance in vestibular, proprioception, visual and righting reactions. Also there is loss of protective reaction of upper limb extension during a fall causing a fear of injury to the patient. 

TREMORS: This is defined as involuntary oscillations of body parts at frequency ranging from 3.5-7Hz. It is one of the cardinal signs of parkinsonism and in many patients this is the first sign of disease. The tremor occur due to uninhibited activity of the basal ganglia cortico-thalamus circuit as a result of degeneration of the striatonigral pathway. The tremors seen in parkinsonism is resting tremors which is absent in sleep and increase with voluntary efforts or even emotional excitement. The tremor is typically the pin-rolling type observed in finger, tremors may also be occasionally seen in the lips and tongue. 

GAIT: Combination of movement and sequential movement task are grossly affected in parkinsonism. Thus, parkinsonism patient exhibits severe difficulty in walking. 

FACIAL ATTITUDE: Parkinsonism patient suffer from masked or expressionless face. The person appears to be continuously staring. There is constant frowning in majority of individuals. The skin appears shiny and greasy with increased salivation and drooling due to autonomic dysfunction. 

POSTURE: Stooped attitude with flexed trunk and limbs. 

SPEECH: Parkinsonism patient have slurred speech. Hand writing is micrographia (the size of the letter gradually becomes smaller and smaller). 

DYSPHAGIA: It may be seen in half percent of parkinsonian patients.

VISUAL DIFFICULTIES: Blurring of vision, decreased blinking that causes eye strain and carely diplopia. Glabellar tap reflex fails to habituate. Oculogyric crisis may occur sometimes. 

ASTHENIA: Generalized weakness may be seen, although, these are not due to direct involvement of lower motor neuron but mainly due to deconditioning and rigidity. 

REFLEXES: Deep tendon reflexes are not directly affected, but however, they may be difficult to elicit or may be reduced in amplitude due to rigidity. Plantar response is down going. 

SENSORY INVOLVEMENT: Inactivity and stiffness may cause generalized body pain in 50 percent of causes along with cramps and tight muscles. 

PSYCHOLOGICAL IMPAIRMENT: Dementia is very common in about 40 percent of parkinsonism patients. Depression, lack of motivation, over-dependency are other psychological manifestations noted in parkinsonism patients.
Perceptual deficits like difficulty in vertical perception, body scheme, body image disorder and topographical disorientation have been noted. 

SECONDARY COMPLICATIONS: Decrease in joint range and flexibility causing tightness and contracture. Contractures are seen in hip and knee flexors, hip abductors, trunk flexors, neck flexors, shoulder adductors, elbow flexors, wrist and finger flexors. Kyohotic deformity is common due to the patient's abnormal attitude. 

Muscle atrophy and weakness are secondary dysfunction. 

Cardiopulmonary changes: Deconditioning of the cardiovascular and respiratory system is common due to decreased activity and kyphotic posture that causes compression of the vital structure in the the thorax. 

Osteoporosis: Prolonged inactivity and poor diet intake causes osteoporosis. Moreover, frequent fall always increase the likelihood of a fracture. 

Edema: May occur in the distal parts of the foot due to venous pooling as a result of decreased pumping action of calf muscles. 

Skin infections like dermatitis can occur due to increased secretion by sweat and sebaceous glands. 

Management of Parkinsonism 

Unlike earlier days, today the role of a physiotherapist in managing a Parkinson's disease patient starts in the acute stages itself, mainly to maintain the musculoskeletal flexibility and to advice the patient to lead an active livestyle. This is essential to minimize deconditioning and to prevent psychological decline. 

The physiotherapy treatment methods should be directed towards achieving the main goal that is improving the functional performance in everyday life. 

In order to achieve this long-term goal various short-term goal has to be first achieved:
1- Maintaining or improving the rom at all joints. 
2- Preventing any contracture or deformity especially of the upper limb and trunk. 
3- Prevent any deconditioning of the muscles or cardiorespiratory system.
4- Encourage the patient to lead an active lifestyle. 
5- Improve the physical fitness of the patient. 
6- Prevent the influence of psychosocial factors like depression and over dependency on the patient. 

REDUCTION OF RIGIDITY: Rigidity has been found to reduce, to some extent, by generalized relaxation technique. Generalized relaxation can be obtained by vestibular stimulation that can be achieved by various rocking techniques. Rocking can be achieved by the use of adult vestibular ball, rocking or rotating chair, and cradle. Rhythmic initiation, which is a technique of PNF, can be used to reduce rigidity. This technique, which involves progression of exercise from passive to active without any increase in tone, has been found to be very effective in reducing rigidity of the trunk. 

Generalized relaxation techniques like Jacobson's technique of progressive relaxation, yogasana, transdental meditation, biofeedback, etc, can also be used. 

MAINTAINING THE FLEXIBILITY OF MUSCULOSKELETAL SYSTEM: Flexibility of the musculoskeletal systems can be maintained by encouraging the patient to lead an active life. 
However, passive exercise by the therapist or the relatives may be of help in maintaining or increasing flexibility. 
Passive exercise to the patient should be given at least 2-3 times in a day. 
As the patient has a predominantly flexed posture to the mobility exercises should involve plenty of extension activity. 
Passive stretching should be given for all shortened muscles. 
Sometimes braces may be used for prolonged stretching of tight muscles. 
PNF technique if hold relax or contract relax can be used to bring about lengthening of contracted muscles and thus increase the ROM of various joint. 
Apart from passive exercise, the patient should be encouraged to maintain joint mobility through active exercises and autostretching.
Calisthenics exercises in supine, sitting or standing posture is of great use to patients of parkinsonism. As there is an tendency in parkinsonism patient to develop overall flexed posture, this may be countered by various simple stretching programs like standing erect with arms in elevation against a wall or corner of the room, and the patient should try and stretch out his whole body. 
Also, the patient should be instructed to lie supine with a pillow under the upper thorax, which can play a significant role in stretching the upper limb and upper thoracic spine. 

BALANCE TRAINING: The balance training should always be begun from a low center of gravity level to higher center of gravity level. 
In sitting at the edge to the cot, the patient may be given perturbation to develop his static stability. 
Dynamic stability in sitting may be developed by weight shift, shifting from one end of the cot the other, and by incorporating various reaching out activities. 
Trunk rotation activities both in horizontal plane and in diagonal manner should be trained in the patient.
Sitting activities on an adult vestibular ball has also been found to be very effective in training the patient's balance. 
Once the patient is quite stable in sitting the therapist can progress to train him to achieve standing balance. 
In standing, the patient may be trained for weight shift from one limb to other, trunk rotation, and other bending and reaching out activities. 
One should always remember that training should be done in different sensory and environmental conditions and preferably in his house. 
The patient's anticipatory and automatic response should be trained.

COORDINATION EXERCISES: The various tests are used for testing coordination both in the upper limb and lower limb can be used as exercises for training coordination. Frenkel's exercises can also be used. 

BREATHING OR THORACIC EXPANSION EXERCISES: Diaphragmatic and segmental breathing exercises should be taught to improve the patient's vital capacity. Exercises like balloon blowing it incentive spirometry gives the patient visual feedback and is quite effective in improving the thoracic expansion. 

FUNCTIONAL REEDUCATION OR TRAINING: The patient should be trained for various activities like turning in the bed, lying to sitting, sitting to standing, walking straight, and walking around a chair or cot.
Turning around and sudden stopping imposes severe difficulty to a parkinsonism patient. This has to be trained once the patient masters the other challenges in walking. 
Gait cab be very well trained by use of visual cues in the form of foot markers in the floor. 
The patient learns to step over the lines quite comfortably as compared to wooden blocks. 
Once the patient is able to walk in the empty room quite comfortably then he should be trained to walk in the environment of the house. 
It us essential to keep track of the time taken by the patient to cover a particular distance and the speed of walking so that it could be compared later on to see the extent of improvement. 
Similarly other precision activities of daily living like eating, dressing, washing etc. should be trained by overcoming the bradykinesia. 

IMPROVING THE PHYSICAL FITNESS: Cardiovascular and respiratory conditioning can be achieved by involving the patient in various aerobic exercises like calisthenics, status cycling, swimming, etc. 
It has been shown that the parkinsonism individual who performed regular aerobic exercises produced higher percentage predicted maximum oxygen consumption values that those who were sedentary. 

IMPROVEMENT IN THE PSYCHOLOGICAL WELL-BEING: Once the patient learns to lead a relatively active functional life he will feel much more confident and independent the it will reduce depression or over dependency of the patient.