Unified Parkinson Disease Rating Scale
Multiple different scales for PD have been developed for quantification of motor manifestations disability or both . Of these different scales, the UPDRS has gained the greatest acceptance as a tool for evaluation of interventions and as a clinical tool to follow patients . However, there are important limitations to this scale , and a new UPDRS is undergoing validation testing .
What Is Parkinsonian Gait
Parkinsonian gait is a defining feature of Parkinsons disease, especially in later stages. Its often considered to have a more negative impact on quality of life than other Parkinsons symptoms. People with Parkinsonian gait usually take small, shuffling steps. They might have difficulty picking up their feet.
Parkinsonian gait changes can be episodic or continuous. Episodic changes, such as freezing of gait, can come on suddenly and randomly. Continuous changes are changes in your gait that happen all the time while walking, such as walking more slowly than expected.
Treating Freezing Of Gait For People With Parkinsons
Freezing of gait episodes often occur when a person is under-medicated and can improve with increased amounts of their PD meds, usually carbidopa/levodopa. However, as mentioned earlier, the brain abnormalities that lead to freezing of gait are very complex, so giving more dopaminergic medication is only part of the solution. In fact, some people have what is referred to as ON freezing. This means that freezing of gait episodes occur even when other PD symptoms are well treated with their medication regimen.
Cueing, or the introduction of an external sensory stimulus to facilitate movement, has been identified as a way to break a freezing episode. Terry Ellis, PhD, PT, NCS, Director of the APDA National Rehabilitation Resource Center at Boston University, and Tami DeAngelis, PT, GCS, compiled this list of cues that can be used to get out of a freezing episode:
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Pharmacological Treatment Of Parkinson’s Disease
There is currently no proven disease-modifying or neuroprotective therapy for PD. A summary of previous neuroprotection trials is given in a recent review article. Current evidence-based treatment for PD is symptomatic and mainly based around dopaminergic replacement or modulation . The evidence base is summarised in recent guidelines from the National Institute for Health and Care Excellence and the International Parkinson and Movement Disorder Society. Levodopa, dopamine agonists and monoamine oxidase B inhibitors are all licensed for use as initial therapy in PD. Anticholinergics are no longer routinely used due to the risk of cognitive decompensation.
Pharmacological therapies currently used for initial and adjunctive treatment of motor symptoms in Parkinson’s disease
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Advanced Therapies For Parkinson’s Disease
When significant off-time or dyskinesia persists despite optimised oral treatment, advanced therapies should be considered. Apomorphine, a potent dopamine agonist given by continuous subcutaneous infusion, is the least invasive and most straightforward of these. Following on from extensive clinical experience, the recent double-blind TOLEDO study confirmed a significant reduction in off-time and improved on-time with apomorphine versus placebo.
Deep-brain stimulation involves surgical placement of electrodes into brain regions such as the subthalamic nucleus to improve motor fluctuations or refractory tremor. DBS is typically considered in patients without significant axial or neuropsychiatric problems. It improves motor function, off-time and QoL in patients with PD, and provides significant benefits over medical therapy even in patients with an average disease duration of 7 years. The benefits of DBS on motor function, fluctuations and activities of daily living have been demonstrated up to 10 years postoperatively, although axial features continue to progress. Infusion of levodopacarbidopa intestinal gel via jejunostomy has also been shown to improve off-time compared to oral levodopa, and is commissioned in specialist centres where other advanced therapies are ineffective or contraindicated. Further information on the decision-making process for advanced therapies is summarised in a dedicated review.
Limitations Of The Review
The methodological quality and reporting of the majority of trials was variable, and often inadequate. Of 39 trials, only 18 provided information on the randomisation method and only five used a central randomisation procedure to ensure concealment of treatment allocation. Blinded assessors were used in 24 studies, and only nine reported using intention to treat analysis. The lack of information in many reports may not necessarily indicate poor implementation within the trial, but without this information, the level of bias within each trial is difficult to assess. The need for further improvement in the methodological quality of trials in physiotherapy for Parkinsons disease was noted in another recent systematic review.70 Future trials therefore need to ensure that their designs fulfil the requirements of a methodologically sound, large randomised controlled trial, and that the reporting follows the CONSORT guidelines.71
Outcome reporting bias may have created a deceptively positive impression of the effectiveness of the studied interventions. Unfortunately, the proportion of outcomes that went unreported could not be assessed here, owing to a lack of information on trial protocol.
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Walking Aids To Help With Freezing Of Gait
Often freezing of gait cannot be overcome with medication adjustment and physical therapy, and a walking aid needs to be introduced for safety and walking support.
There are many types of walkers that are available for people with walking difficulties. Here is a simple guide:
- Basic walker this is usually just a metal frame without wheels
- Wheeled walker a metal frame with wheels. The wheels may be on two or four legs and the wheels may swivel or be fixed
- Rollator a walker with swivel wheels on all four legs and hand brakes. The brakes typically need to be engaged for the walker to stop. Often the rollator has a seat and a basket for convenience.
A common concern with all these walkers is that there either is no braking system or the braking system must be engaged in order for the walker to be stopped. Therefore, if a freeze occurs with the feet stuck to the floor, and the person is not fast enough to engage the brake, the walker will continue to move, potentially precipitating a fall.
Your physical therapist can help you determine the walking aid that is best-suited for your specific situation.
Clinical Motor Cardinal Signs
A-/hypo-/bradykinesia: These terms are defined, collectively, as slowed voluntary movement. Separately, akinesia indicates the absence of voluntary movement, while hypokinesia means smaller movements, and bradykinesia refers to slowness of movement. They usually determine any impairment in fine motor movements, facial expression , monotonic and hypophonic speech with a reduction of speed, and general motion amplitude. This can have an important impact in functional skills like arm swinging when walking, raising from a chair, handwriting, and general gesturing .
This cardinal sign is one of the best that emerges from its origin of dysfunction, which is cited in this chapter . It has been determined especially by a characteristic involving the movement programming of the cerebral cortex, in particular the supplementary motor area .
2. Rest tremor : this sign is usually asymmetric, consisting of alternate contractions of agonist and antagonist muscles, including flexors, extensors, pronators, and supinators of the wrists and arms, resulting in the pill rolling movement of the hand. It has a medium frequency and tends to disappear with action. The legs, lower jaw, or head may also be involved, resulting in an adduction-abduction movement of the lower limbs and yes-yes or no-no motion in the head .
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General Approach To Management
The primary goal in the management of PD is to treat the symptomatic motor and nonmotor features of the disorder, with the objective of improving the patients overall quality of life. Appropriate management requires an initial evaluation and diagnosis by a multidisciplinary team consisting of neurologists, primary care practitioners, nurses, physical therapists, social workers, and pharmacists., It is also important that the patient and his or her family have input into management decisions.
Effective management should include a combination of nonpharmacological and pharmacological strategies to maximize clinical outcomes. To date, therapies that slow the progression of PD or provide a neuroprotective effect have not been identified., Current research has focused on identifying biomarkers that may be useful in the diagnosis of early disease and on developing future disease-modifying interventions.,
What Are The Causes
In Parkinsons disease, nerve cells in a part of the brain called the basal ganglia start to die and produce less of a neurotransmitter called dopamine. The basal ganglia use dopamine to form connections between neurons. This means when theres less dopamine, there are fewer connections.
The basal ganglia are responsible for making sure your body movements are smooth. When there arent as many connections in this area of the brain, it cant do that job as well. This leads to Parkinsonian gait and the other movement symptoms of Parkinsons disease.
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Ten Tips To Put The Freeze On Freezing
While these methods can be helpful to get out of a freeze that is already underway, physical therapy techniques that incorporate these types of cueing strategies are utilized to reduce freezing of gait overall. Rhythmic auditory cueing is one such technique which utilizes rhythm and music to improve gait in PD and other neurologic diseases.
Think Big Exercises For Individuals With Parkinsons Disease
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Think BIG!Exercises for Individuals with Parkinsons Disease Betty MacNeill, PT, DPT January 2013 SED Meeting
Identify the symptoms of Parkinsons disease that benefit from exercise interventions Identify both traditional and non-traditional therapeutic models for managing the symptoms of PD Define and discuss the basic philosophy associated with the LSVT-BIG intervention model Identify and discuss the 4 fundamental treatment concepts of the LSVT-BIG model Describe the basic exercise protocols associated with LSVT-BIG and provide a rationale for each Develop confidence in applying some LSVT-BIG techniques and principles with selected patient populations Presentation Objectives
Pathophysiology/Etiology Pathophys: Loss of dopanergic cells in the substantianigra leads to a deficiency in dopamine for use by the communication pathways in the basal ganglia, which are critical to producing normal movement and postural control, and neural circuits to the frontal lobe, which are critical for mental processing, motor planning, and personality.
PARKINSONS DISEASEClassical Clinical Features = TRAP Tremor, resting Rigidity, cogwheel Akinesia, bradykinesia Postural Instability
Exercise Considerations Who should exercise? How much exercise? Which symptoms and/or movement challenges are affected by exercise ? Freezing? Tremors? Balance? Weakness? Endurance? Tightness?
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Assessment Of Symptomatic Effects
Ratings such as the UPDRS, either in its entirety or with motor subscale 3 alone, have been used to assess symptomatic benefit from therapeutic interventions. A critical factor in longitudinal studies is to try to control the variables in the temporal responses to individual doses of medication. Ideally, repeated ratings should be done at the same time of day, at the same time after the last dose of medication, and by the same rater. Other factors also may influence these ratings, such as diet, fatigue, or other potential stresses that may alter PD manifestations.
Progression Of Parkinson’s Disease
The disease progression of PD from diagnosis has been conceptualised into four stages . It is also important to recognise a prodromal phase in which non-motor symptoms, such as anosmia, constipation and rapid-eye-movement sleep behaviour disorder may predict the development of motor PD. Motor complications are more common as PD progresses, and typify transition to the complex phase. Many so-called axial symptoms of later stage PD, such as dysphagia, gait disturbance and falls, do not respond to levodopa, but may be helped by multidisciplinary team input. Dementia occurs in up to 80% of people with PD after 20 years disease duration. The rate of PD progression is heterogeneous and is generally more rapid in those with older age and more severe motor impairment at onset.
Stages of Parkinson’s disease. RBD = rapid eye movement sleep behaviour disorder.
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Is Surgery An Option
If medicine doesnât work well enough, your doctor may suggest deep brain stimulation . In DBS, your doctor implants electrodes deep in the brain. A device connected to them delivers electrical pulses. Those pulses can help control the tremors caused by Parkinson’s.
In the past, doctors sometimes used other operations to damage the brain in ways to help with movement symptoms. But they rarely use those surgeries now.
What Is Freezing Of Gait
Freezing of gait is an abnormal gait pattern that can accompany Parkinsons disease as well as other parkinsonian disorders in which there are sudden, short and temporary episodes of an inability to move the feet forward despite the intention to walk. In a sense, youre stuck. This results in the characteristic appearance of the feet making quick stepping movements in place. However, while the feet remain in place, the torso still has forward momentum which makes falls unfortunately common in the context of freezing of gait. For some, these episodes can simply be frustrating, annoying and perhaps embarrassing for others freezing of gait can become incredibly disabling and lead to injury.
Freezing of gait episodes tend to occur least often when walking on an unobstructed, straight path. Any deviation from that can induce freezing for example, when you first try to start walking, when you go to make a turn, or try to navigate around obstacles or through narrow spaces any of these can cause you to get stuck.
The particular triggers for one person may be different than for another. An episode is typically very brief, often lasting only 1-2 seconds, although they can last longer. Freezing of gait can be affected by anxiety, so if a person feels rushed , freezing may be particularly prominent.
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What Does It Look Like
Parkinsonian gait is one of several motor symptoms that are the hallmarks of Parkinsons disease, including slowness of movement and tremors. Motor symptoms in Parkinsons disease come from a lack of control over movements and difficulty initiating muscle movements.
The exact features of Parkinsonian gait can differ from person to person, but there are some very common features that most people have. These include:
- taking small, shuffling steps
- moving more slowly than expected for your age
- festinating, or when your strides become quicker and shorter than normal, which can make it look like youre hurrying
- taking jerky steps
- moving your arms less when walking
- falling frequently
- freezing of gait
People with Parkinsons disease can sometimes lose the ability to pick up their feet, which makes them stuck in place. Freezing of gait can be triggered by environmental factors, such as walking through a narrow doorway, changing directions, or walking through a crowd. It can also be triggered by emotions, especially anxiety or feeling rushed.
Freezing of gait can happen anytime. However, it often occurs when you stand up. You might find that youre unable to pick up your feet and start moving.
Update Of Latest Evidence
For our guideline , literature published until October 2003 was reviewed. We have repeated the literature search for all studies published until June 2006. Several papers have appeared since the publication of the guideline.- An analysis of these studies demonstrates that the level of evidence of the recommendations provided in our guideline is not altered by the results of these studies.
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