Parkinson's

 

Overview of the pathology

In Parkinson’s disease, there is not enough dopamine (neuro-transmitter) to keep balance with the acetylcholine. The result of this imbalance is the malfunction of nerve synapses, causing a lack of coordination of movements that often appear as a tremor, stiff muscles and joints, and/or difficulty moving. Currently there is no way to stop the loss of nerve cells that produce dopamine or to restore those that have already been lost. However, there are several methods, including drug therapy, which can help manage the slow decline in function that occurs with Parkinson’s disease.

Classification of Parkinson's

  • Age at onset (<40 (juvenile); between 40 and 70; >70)

  • Clinical symptoms (tremor predominant, akinetic-rigidity predominant, postural instability-gait difficulty predominant)

  • Mental status (dementia present/absent)

  • Clinical course (benign, progressive, malignant)

  • Disability

Symptoms

Primary Symptoms Rigidity is an increased tone or stiffness in the muscles. Unless it is temporarily eased by anti-Parkinson’s medication, rigidity is always present. However, it increases during movement. It is often responsible for a mask-like expression of the face. In some patients, rigidity leads to sensation of pain, especially in the arms and shoulders.

Tremor is the symptom the public most often identifies with Parkinson Disease, but in fact, up to 25% of patients experience very slight tremor or none at all. When it is present, the tremor may be worse on one side of the body. Besides affecting the limbs it sometimes involves the head, neck, face and jaw.

Bradykinesia means slowness of movement. This symptom is characterized by a delay in initiating movements, caused by the brains slowness in transmitting the necessary instructions to the appropriate parts of the body. When the instructions have been received, the body responds slowly in carrying them out.

Poor balance tends to affect people with Parkinson Diseases. This is particularly true when they move abruptly, causing a sudden change in the position of their bodies. Some patients experience repeated falls due to poor balance

Walking problems commonly include a decreased or non-existence arm swing; short, shuffling steps; difficulty in negotiating turns; and sudden freezing spells (inability to take the next step).

Secondary symptoms

  • Depression

  • Sleep disturbances

  • Stooped posture

  • Constipation

  • Dementia

  • Problems with speech

  • Breathing

  • Swallowing

  • Sexual function

Important to note that different patients experience different symptoms.

Treatment

Exercise For people with Parkinson’s, regular exercise and/or physical therapy are essential for maintaining and improving:

  • Mobility

  • Flexibility

  • Balance

  • Range of motion

  • Warding off many secondary symptoms

Suggestions before beginning exercise

  • Always check with your doctor before beginning any exercise program.

  • Exercise your face, jaws and voice whenever possible.

  • Begin and end exercise with stretching and bending and breathing exercises. Never overexert yourself and rest if you become tired.

  • Exercising in bed might be easier than on the floor or on an exercise mat.

  • Build your walking skills, even if you need to hold onto someone or something.

  • Take part in sports and hobbies, with your doctor’s approvals.

  • Try water exercises because they are easier on the joints. 

Parkinson's disease excercise programming 

 

MODESGOALSINTENSITY/FREQUENCY/
DURATION

Aerobics
• Leg and arm cycle ergometry
• RowingMaintain or improve work capacity• 60-80% peak HR 
• 3 days/week
• Up to 60 minutes/session

Endurance
Well supervised short walking bouts (20-30 meters)Increase work capacity• Speed dependant on individual
• 4-6 sessions/day

Strength
Weight machinesMaintain strength of arms, shoulders, legs and hips.• Use light weights.
• 1 set of 8-12 repetitions
• 3 sessions/week

Flexibility
StretchingIncrease or maintain range of motion1-3 sessions/week

Functional performance
• Daily living activities
• Postural changesMaintain capacity to maintain as many daily living activities as possible 

Support Groups These groups play an important role in the emotional well-being of patients and families. They provide a caring environment for asking questions about Parkinson’s, for laughing and crying and sharing stories and getting advice from sufferers, and for forging friendships with people who understand each other’s problems. Staying Active Parkinson’s disease seems to advance more slowly in people who remain involved in their pre-Parkinson’s activities, or who find new activities to amuse them and engage their interests. 

Special considerations

 

  • Aerobic power: Walking is a problem for individuals with balance deficits; however, some patients may be able to jog without risk of falling. Heart rate response: power levels may vary form day to day because of autonomic fluctuations.

  • Duration: should be increased slowly (every 3-4 weeks) and intensity and duration should receive equal priority.

  • Orthopaedic: Dyskinesia and dystonia (a state of abnormal (either hypo- or hyper) tonicity in any tissue) can aggravate problems such as degenerative joint disease. There is some evidence that exercise may reduce joint pain.

  • Cardiac: Use caution with any medication change.

  • Muscular: Supervised training is recommended to minimise muscular problems.

  • Metabolic: Observe for changes in medication dosages after 4-5 weeks of aerobic training.

  • Psychological: Mask-like face makes it difficult to interpret patient’s reaction or RPE.

  • Thermoregulatory: Sweating begins to occur with exercise conditioning.

  • Environment: Time of day for exercise and medication should be kept as constant as possible.

How our brain controls our movement

 
Many different areas within the brain are involved in a complex chain of decisions required for even the smallest muscular movement. For an action like walking, for example, the brain must gather all the information it needs about your body position. Then, the brain must add in what it knows about where you will be going. 

This information comes together in a central area of the brain, called the striatum, which controls many aspects of bodily motion. The striatum works with other areas of the brain including the substanta nigra, to send out the commands for balance and coordination. These commands go from the brain to the spinal cord through the networks to the muscles that will then do the movement. 

The entire nervous system is made up of individual units called nerve cells, which serve as a “communication network” in the body. 

For the nerve cells to communicate with each other chemical messengers called neurotransmitters are used. Neurotransmitters carry messages between nerve cells by crossing the space between cells, called synapse. 

Neurotransmitters allow the nervous system to communicate with the body’s muscles and translate thought into motion. Dopamine is crucial to human movement and is the transmitter that helps transmit messages to the stratium that both initiate and control your movement and balance. Dopamine ensures that the muscles work smoothly, under precise control, and without unwanted movement. 

When a dopamine message is needed, a nerve cell that produces dopamine gathers packets within itself filled with dopamine particles. These packets carrying the dopamine move to the end of the nerve cell, open a “window,” and release the dopamine particles into the synapse. The particles fit into special pockets on the outside of the neighbouring or receiving nerve cell. The receiving cell is now stimulated to send on the message, and then the process repeats itself. 

After the receiving cell has been stimulated to pass along the message, the pockets then release the dopamine back into the synapse. To fine-tune coordination of movement, these “used” dopamine particles, along with any excess dopamine that did not originally fit into a pocket on the receiving cell, are broken down by a chemical in the synapse called MAO-B. This is an important step in the precise control of muscle movement. Too much or too little dopamine can disrupt the normal balance between the dopamine system and another neurotransmitter system, and interfere with smooth, continuous movement. 

The other neurotransmitter system that works in conjunction with the dopamine system to produce smooth muscle movement uses a messenger called acetylcholine. Some of the nerve cells in the brain are specialized to use either dopamine or acetylcholine to send different messages, depending on what it is you want to do. 

To illustrate how the muscle control process works is as follows: two buckets – one for dopamine system and one for the acetylcholine system – balanced on either end of a seesaw. This depicts the situation at rest when the dopamine and acetylcholine systems are balanced. When you decide to move, your brain understands the movement you want to make and it sends out a balance of dopamine and acetylcholine messages to keep that movement smooth. 

With a person that has Parkinson Disease there is a decrease in amount of dopamine that is release and this causes the movement not to be smooth, or controlled.