Parkinson's Disease : diagnosis and PT assessment

DIAGNOSIS:a diagnosis of PD can be made only if 2 or more cardinal features are present.
Exclusion of parkinson-plus syndromes is necessary and can be done by observing bilateral symmetry in the symptoms and no response to L-dopa. As these are the differentiating factors between the two.
MRI using chemical markers , PET scan and SPECT scan are done.

MEDICAL MANAGEMENT: there is no absolute cure for PD.
Neuroprotective  monoamine oxidase inhibitors(MAOs) like seligiline are administered to facilitate metabolism of intracerebral dopamine.
Seligiline also shows symptomatic relief .If given in combination with L-dopa ,dose can be lowered.

Symptomatic treatment:
1:levodopa-(L-dopa) is the mainstay for symptomatic treatment.It is a precursor of dopamine and is able to cross the blood brain barrier .It corrects the neurochemical imbalance by increasing the level of dopamine in basal ganglia.This drug is however metabolised to a great extent before reaching the brain so higher dosage has to be administered.But that can be changed if carbi-dopa is given along.Sinemet is the common levodopa/carbidopa combination.It reduces bradykinesia and rigidity.There is an initial 'honeymoon' phase where dramatic improvement is seen with the therapeutic window of 5-7 years before the optimal effect wears off.Wearing off phase shows worsening of symptoms. Deprenyl can be given with L-dopa to control it.

 2:Dopamine agonists-administered along with L-dopa so that lower doses can be administered with effectiveness .This is also known as  L-dopa sparing therapy.They reduce rigidity and bradykinesia.
eg.bromocriptine(parlodel),ropinirole(requip)

 3:Anticholinergic agents-given with L-dopa as an early therapy to reduce tremors and rigidity and to smooth motor fluctuations.
eg.benztropine(cogentin),ethoprppazine(parsidol).amantadine also has antiparkinson effects.


SURGICAL MANAGEMENT:
ablative surgery, deep brain stimulation and neural transplantation can be done.


 PHYSICAL THERAPY ASSESMENT: a PT should remember that a patient on L-dopa therapy may demonstrate fluctuations. Good results are obtained in the initial phase whereas results may worsen in the wearing-off phase.A comprehensive evaluation is required to determine the level of impairment of the functions:

1.Posture : posture is invariably affected . It can be graded using a pictorial grading method , on a scale of 1 to 4.
1=normal.
2=with head protruding.
3=head protruding ,with marked kyphotic thoracic spine,slight flexion at knees and elbows.
4=marked flexion of the trunk, elbows,hips and knees.

2.Balance: can be checked using Berg-balance scale , or, ask the patient to -
-sit unsupported for 1 minute
-stand unsupported  for 5 seconds
-stand on one leg and then the other for 5 seconds without an aid.

3.Gait : gait should be assessed by asking the patient to walk a fixed distance. All the parameters like step length, stride length, cadence, etc should be measured. Time taken to walk should also be recorded.

4.Functional assessment: difficulties to carry out essential movements should be assessed. eg, turning in bed ,  lying to sitting,  sit to stand, stand to walk  ,etc. the grading scale used is :
1-normal
2-completes a task with difficulty , but without help.
3-can complete a task with use of an aid , like pulling on the side of the bed.
4-unable to complete the task.

Hoehn and Yahr scale should be used to determine the severity of the disease.
This assessment is done in addition to the routine assessment for neurological conditions.