Parkinson’s disease

PARKINSON’S PARKINSON’S DISEASEDISEASE

Parkinson’s DiseaseParkinson’s Disease

Parkinson’s disease , is named after Parkinson’s disease , is named after James Parkinson who in 1817 wrote a James Parkinson who in 1817 wrote a

classic “shaking palsy”a disease for which classic “shaking palsy”a disease for which the reason is still unknown . the reason is still unknown .

Definition :- Definition :- It is a chronic degenerative disorder that It is a chronic degenerative disorder that

primarily affects the neurons of the basal primarily affects the neurons of the basal ganglia.ganglia.

It is a syndrome that consists of slowing It is a syndrome that consists of slowing down in the initiation and execution of down in the initiation and execution of movement (brady kinesia), increased movement (brady kinesia), increased muscle tone (rigidity), tremor and impaired muscle tone (rigidity), tremor and impaired postural reflexes postural reflexes

The famous internationally known boxer The famous internationally known boxer

Mr. Mohammed Ali suffered from this Mr. Mohammed Ali suffered from this disease.disease.

incidence:incidence:

Occurs in the age group of 60s. Mostly men Occurs in the age group of 60s. Mostly men are affected than women. are affected than women.

Classifiation Classifiation

Post encephalitic parkinsonism , which Post encephalitic parkinsonism , which occured after the large epidemic of occured after the large epidemic of encephalitisin 1919.encephalitisin 1919.

Drug induced parkinsonism, occuring after Drug induced parkinsonism, occuring after long term use of phenothiazines .long term use of phenothiazines .

Toxin induced parkinsonism , Toxin induced parkinsonism , sometimesresulting from carbon sometimesresulting from carbon monoxide, mercury, or manganese monoxide, mercury, or manganese exposure.exposure.

Exposure to agricultural herbicides and Exposure to agricultural herbicides and pesticidespesticides

Trauma or injury to the midbrain. Trauma or injury to the midbrain.

Etiology Etiology HeredityHeredity Antipsychotic drugs (or neuroleptic agents)Antipsychotic drugs (or neuroleptic agents) Encephalitis infection in response to brain Encephalitis infection in response to brain

trauma, tumors, hydrocephalus or ischaemia trauma, tumors, hydrocephalus or ischaemia ArteriosclerosisArteriosclerosis Neurotoxins such as cyanide, manganese and Neurotoxins such as cyanide, manganese and

carbon monoxide carbon monoxide Drugs like reserpine (hydropress), meyhyl dopa Drugs like reserpine (hydropress), meyhyl dopa

(aldomet), haloperidol (haldol) and (aldomet), haloperidol (haldol) and phenothiazine (thorazine)phenothiazine (thorazine)

Pathophysiology Pathophysiology Antipsychotic drugs , encephalitis and other Antipsychotic drugs , encephalitis and other

causescauses

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Affects the substantia nigra Affects the substantia nigra

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Destuction of dopamine producing neurons Destuction of dopamine producing neurons within the basal gangliawithin the basal ganglia

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Reduces the amount of available straital Reduces the amount of available straital dopamine ( inhibitory effects )dopamine ( inhibitory effects )

There is increase in acetylcholine There is increase in acetylcholine (excitatory effects )(excitatory effects )

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Excitatory activity of Ach is inadequately Excitatory activity of Ach is inadequately balancedbalanced

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Difficulty in controlling and initiating Difficulty in controlling and initiating voluntary movements voluntary movements

Clinical manifestationsClinical manifestationsIn the beginning stagesIn the beginning stages • Mild tremor Mild tremor • Slight limp Slight limp • Decreased arm swingDecreased arm swingLaterLater• Shuffling, propulsive gait with arms flexed Shuffling, propulsive gait with arms flexed • Loss of postural reflexes Loss of postural reflexes • Slight change in speech patternSlight change in speech pattern

Classic clinical manifestations Classic clinical manifestations

1.Tremor1.TremorFirst sign affects hand writingFirst sign affects hand writingNon intentional, present at rest but usually Non intentional, present at rest but usually

not during sleepnot during sleepMovement of thumb across the palm gives Movement of thumb across the palm gives

a “pill rolling” charactera “pill rolling” characterTremor also seen in limbs, jaw, lips, lower Tremor also seen in limbs, jaw, lips, lower

facial muscles and head facial muscles and head

2. Rigidity 2. Rigidity • Increased resistance to passive motion Increased resistance to passive motion

when the limbs are moved through their when the limbs are moved through their range of motion range of motion

• Muscles feel stiff and required increased Muscles feel stiff and required increased effort to moveeffort to move

• Discomfort or pain may be percieved in Discomfort or pain may be percieved in muscle when rigidity is severe muscle when rigidity is severe

• ““Cog wheel” rigidity refer to rachet – like Cog wheel” rigidity refer to rachet – like rhythmic contractions of the muscle that rhythmic contractions of the muscle that occur when the limbs are passively occur when the limbs are passively stretched stretched

3. Bradykinesia (akinesia) 3. Bradykinesia (akinesia) • Slowness of active movement Slowness of active movement • Difficulty in initiating movement Difficulty in initiating movement • Often the most disabling symptom: Often the most disabling symptom:

interferes with ADK and predisposes interferes with ADK and predisposes patient to complication related to patient to complication related to constipation , circulatory stasis, skin constipation , circulatory stasis, skin breakdown and related complications of breakdown and related complications of immobility .immobility .

4.Postural instability4.Postural instability• i) Changes in gaiti) Changes in gait• Tendency to walk forward on the toes Tendency to walk forward on the toes

with small shuffling stepswith small shuffling steps• Once initiated, movement may accelerate Once initiated, movement may accelerate

almost to trotalmost to trot• Festination may occur, which propels the Festination may occur, which propels the

patient either forward or backward patient either forward or backward propulsively until falling is inevitable.propulsively until falling is inevitable.

ii) Changes in balanceii) Changes in balance• Stooped- over posture when erect Stooped- over posture when erect • Arms are semi flexed and do not swing Arms are semi flexed and do not swing

with walking with walking • Difficulty in maintaining balance and Difficulty in maintaining balance and

sitting erect sitting erect • Cannot ‘right’ or brace self to prevent Cannot ‘right’ or brace self to prevent

falling ,when balance is lost falling ,when balance is lost

Secondary manifestations Secondary manifestations 1)Facial appearance1)Facial appearance• ExpressionlessExpressionless• Eyes store straight aheadEyes store straight ahead• Blinking is much less frequent than normalBlinking is much less frequent than normal

2) Speech problems2) Speech problems• Low volumeLow volume• Slurred and muffledSlurred and muffled• MonotoneMonotone• Difficulty with starting speech and word finding Difficulty with starting speech and word finding

3) Visual problems3) Visual problems• Blurred visionBlurred vision• Impaired upward gazeImpaired upward gaze• Blepharospasm- involuntary prolonged Blepharospasm- involuntary prolonged

closing of the eyelids closing of the eyelids

4) Fine motor function 4) Fine motor function • Microphagia- handwriting progressively Microphagia- handwriting progressively

decreases in size decreases in size • Decreased manual dexterityDecreased manual dexterity• Clumsiness and decreased co-ordination Clumsiness and decreased co-ordination • Decreased capacity to complete ADL.Decreased capacity to complete ADL.• Freezing- sudden involuntary inability to Freezing- sudden involuntary inability to

initiate movement can occur during initiate movement can occur during movement or inactivitymovement or inactivity

5) Autonomic disturbances 5) Autonomic disturbances • Constipation- hypomotility and prolonged gastric Constipation- hypomotility and prolonged gastric

emptying emptying • Urinary frequency or hesitency Urinary frequency or hesitency • Orthoststic hypotension(dizziness, fainting and syncope)Orthoststic hypotension(dizziness, fainting and syncope)• Dysphagia( neuro muscular in co-ordination ) Dysphagia( neuro muscular in co-ordination ) • Drooling( results from decreased swallowing )Drooling( results from decreased swallowing )• Oily skin Oily skin • Excessive perspiration Excessive perspiration

6)Cognitive / behavioral6)Cognitive / behavioral• DepressionDepression• Slowed responsivenessSlowed responsiveness• Memory deficitMemory deficit• Visual-spacial deficitVisual-spacial deficit• Dementia Dementia

Pharmacological management Pharmacological management

Anti- cholinergicsAnti- cholinergicsAnti- histaminicsAnti- histaminicsDopaminergicsDopaminergicsDopamin agonists Dopamin agonists MAO inhibitors MAO inhibitors

Surgical treatmentSurgical treatment

ThalamotomyThalamotomyPallidotomyPallidotomyFetal tissue transplantation( no cases Fetal tissue transplantation( no cases

resulted in complete reversal of resulted in complete reversal of parkinsonian symptoms)parkinsonian symptoms)

Transplantation of genetically engineering Transplantation of genetically engineering cell lines or vector mediated gene cell lines or vector mediated gene transfection. transfection.