Neurodegenerative disorders and epilepsy
Parkinson’s disease
The basal ganglia are a group of structures within the cerebrum working in synchrony to aid in the initiation of voluntary movements and the smoothness of these movements by coordinating muscle activation. The basal ganglia contain dopamine, which assists in movement control. A deficit in dopamine causes difficulty with the initiation of movement and decreased ability to voluntarily activate muscles to perform tasks. Because bradykinesia impairs automatic movement initiation, treatment often starts with external cues and simple, blocked practice, then progresses to more complex, random practice schedules as motor learning improves.
Common impairments of Parkinson’s disease
- Resting tremor
- Impaired postural reflexes
- Cogwheel rigidity
- Bradykinesia
- Slowed reaction time
- Masked face
- Dysarthria
- Hypophonia (decreased speech volume)
- Contractures in the flexor and adductor muscles
- Postural deficits - rounded shoulders, kyphosis
- Gait deviations: difficulty initiating gait; short, shuffling steps with decreased step length, arm swing, and trunk rotation and a flexed posture at the trunk, hips, and knees; and festinating gait, in which the steps quicken and shorten involuntarily as the trunk leans forward
- Freezing of gait: a sudden, brief inability to take a step, most often when starting, turning, or approaching a doorway or narrow space; external cues help (see cueing strategies for Parkinson’s disease)
- Restrictive lung disease
- Visual impairment
- Dementia in later stages
Standardized tests for Parkinson’s disease
Hoehn & Yahr classification of disability
Stage 1
- Disability: Minimal or absent
- Extent of disability: Unilateral
Stage 2
- Disability: Minimal
- Extent of disability: Midline involvement and bilateral
Stage 3
- Disability: Impaired postural reflexes, unsteadiness when rising from a chair; continues to be independent and work
- Extent of disability: Midline involvement and bilateral
Stage 4
- Disability: Severe disability; still able to walk or stand unassisted but markedly incapacitated
- Extent of disability: Midline involvement and bilateral
Stage 5
- Disability: All symptoms present; confined to wheelchair or bed
- Extent of disability: Midline involvement and bilateral
Retropulsion pull test
Testing procedures
- The subject stands in a comfortable stance with eyes open (have feet shoulder width apart if they assume an unusually wide or narrow stance).
- The examiner stands behind the subject.
- The subject is instructed to do whatever it takes not to fall and is told that the examiner will catch them if they do fall.
- The examiner gives a sudden, brief backward pull to the shoulders with sufficient force to cause the subject to have to regain their balance.
- The subject should not know exactly when the pull is coming.
Interpretation of results - scoring is from 0 to 4
- 0 = recovers independently, may take 1 or 2 steps or an ankle reaction
- 1 = three steps or more backward, but recovers independently
- 2 = retropulsion, needs to be assisted to prevent a fall
- 3 = very unstable, tends to lose balance spontaneously
- 4 = unable to stand without assistance (UPDRS method)
Medication for Parkinson’s disease
- Levodopa
- Mechanism of action: relieves symptoms of Parkinson’s disease by turning levodopa into dopamine (due to a lack of dopamine in the basal ganglia)
- Side effects: mental confusion, hallucinations, postural hypotension, restlessness, abnormal movements
- On and off time: Levodopa should be given 1 hour before initiation of activity for optimal effects; medication will wear off, and symptoms will occur
- Anticholinergic medications
- Mechanism of action: decreases tremors by blocking acetylcholine receptors in the basal ganglia
- Side effects: dry mouth, urine retention, constipation
Huntington’s disease
Although genetic (autosomal dominant), symptoms typically do not present until the 30s or 40s.
Symptoms
- Involuntary writhing movements (choreic movements) at rest
- Muscle rigidity
- Poor balance
- Difficulty with swallowing/speaking
- Impaired executive function
- Decline in overall mental health
- Functional decline
Physical therapy considerations with Huntington’s disease
- Balance/gait exercise - using a weighted walker
- Postural stability
- Family education/training as needed
- No modalities indicated
Multiple sclerosis (MS)
Types of multiple sclerosis
- Relapsing-remitting
- Characterized by cycles of disease exacerbation followed by periods of remission; varied levels of disability
- Primary progressive
- Characterized by disease consistently being present without remission; permanent disability results
- Secondary progressive
- Characterized by disease beginning as cyclic relapse/remitting initially, followed by continuous progression of disease without remission; permanent disability results
- Progressive-relapsing
- Characterized by steadily progressive disease from onset with superimposed acute relapses; permanent disability results
Symptoms of multiple sclerosis - symptoms vary depending on the location of plaques
- Weakness
- Spasticity
- Hyperreflexia
- Impaired coordination
- Visual deficits
- Ataxia
- Vestibular dysfunction
- Dysarthria
- Paresthesia
- Lhermitte’s sign: electric shock-like symptoms resulting from neck flexion
Special considerations with multiple sclerosis
- Avoidance of precipitating factors:
- Stress
- Trauma
- Pregnancy
- Heat
- Hyperventilation
- Dehydration
- Increased exertion
Amyotrophic lateral sclerosis (ALS)
Cognition remains intact throughout disease progression. Death typically occurs 2-5 years after the onset of symptoms due to respiratory compromise.
Symptoms
- Asymmetrical weakness
- Facial weakness
- Difficulty with swallowing
- Hyperreflexia
- Spasticity
- Compromised cranial nerve integrity
Stages of ALS
Stage 1: early stage
- Mild weakness or stiffness in the hands, feet, or limbs, with difficulty in fine motor tasks (e.g., writing, buttoning)
Stage 2: middle severe
- Weakness spreads to other parts of the body, causing difficulty walking, speaking, or swallowing, and a need for assistance with daily activities
Stage 3: late stage severe
- Severe weakness and paralysis, difficulty breathing, and need for a wheelchair and ventilator
Stage 4: end stage
- Total paralysis; loss of cognitive function may occur in some cases, but this is rare
Medical management is the treatment of symptoms, as there is no cure for ALS. Motor function progressively diminishes until the individual becomes totally dependent for activities of daily living and mobility while on ventilator support. Physical therapy assists with the prescription of assistive devices and family education/training as appropriate.
Epilepsy
Symptoms
- Altered consciousness
- Convulsions
- Sensory phenomena (aura): heightened somatosensory, visual, auditory, or olfactory senses
- Autonomic phenomena: tachycardia, anxiety, diaphoresis
- Cognitive phenomena: inability to communicate, hallucinations
Classification of epilepsy
- Generalized
- Involves all areas of the brain
- Symptoms include loss of consciousness, rhythmic movements of extremities (convulsions), loss of bladder function, and alterations in breathing
- Lasting 1-5 minutes
- Absence
- Brief lapse of awareness with blank staring and no convulsions; symptoms are subtle, which increases the difficulty of diagnosing the condition
- Repetitive blinking or small movements may be present
- Lasts for seconds and can occur multiple times per day
- Brief lapse of awareness with blank staring and no convulsions; symptoms are subtle, which increases the difficulty of diagnosing the condition
- Partial or focal
- Only one part of the brain is involved, which causes symptoms to be focal
- Status epilepticus
- Prolonged seizures or a series of seizures with only brief moments of recovery
- Lasting 5 minutes or longer
Physical therapy and epilepsy
- To do if a seizure occurs
- Protect the airway
- Roll to sidelying
- Loosen restrictive clothes
- Remove harmful objects that may be nearby
- Do not restrain limbs
- Seek medical attention immediately at the conclusion of convulsions