Parkinson’s Disease (PD)

OT Dude Academy’s Free NBCOT® Exam Prep Course Neurology Parkinson’s Disease (PD)

Overview

Parkinson’s Disease is a progressive disorder caused by a dysfunction or loss of dopamine-producing (dopaminergic) neurons in the brain (substantia nigra). Another hallmark of PD is the presence of Lewy bodies and cytoplasmic aggregations of the protein a-synuclein in neurons.1 2  PD is the second most common neurodegenerative disorder after Alzheimer’s disease. Dopamine helps with locomotion (coordinated movement), learning, working memory, cognition, and emotion. Dopamine biosynthesis also occurs outside the CNS and in the kidney, pancreas, lungs, and blood vessels.3  Decreased levels of dopamine is associated with difficulty with both voluntary and involuntary movements as well as nonmotor symptoms. Overall, the symptoms of PD can lead to a substantially decreased quality of life.4 

Cause

The cause is still unknown, but genetics and environmental factors likely play a role in the cause of PD. Less than 10% of cases of PD are due to genetic causes. Exposure to environmental factors such as pesticides, heavy metals, and repeated head injuries can cause an increased risk of PD. The main risk factor is age (over 50). PD can occur in younger people. Men have a higher risk of PD than women. PD seems to affect Caucasians more than African Americans or Asians. Most physicians diagnose Parkinson’s as idiopathic.5 

Symptoms

Insidious, progressive, asymmetric onset.1 6 7 8 

Early symptoms are subtle and occur gradually. People may experience mild tremors or difficulty with transfers. They may speak too softly or their handwriting is slow and small. The face may lack expression and animation or the limbs may not move normally. People often develop a Parkinsonian gait with a forward lean, small quick steps as if hurrying forward, and reduced arm swing. They may have trouble with initiating or continuing movement. Symptoms often begin on one side of the body or in one limb. As the disease progresses, both sides may be affected, but one side may be more severe.9 

Motor

  • Bradykinesia
  • Tremor
  • Cogwheel Rigidity
  • Postural instability
  • Impaired balance
  • Impaired coordination
  • Dystonia – involuntary and repetitive muscle movements in eyes, neck, trunk, and limbs; can be painful
  • “Freezing”

Non-motor

  • Vocal symptoms – changes in the voice; softer or start off strong and fade; monotone, or rapid and stuttering
  • Sense of smell – reduced sensitivity or loss of smell (anosmia)
  • Sleep disturbances; insomnia
  • Depression and anxiety
  • Pain
  • Psychosis – hallucinations and delusions
  • Fatigue -> depression and sleep disorders
  • Cognitive changes – thinking, word-finding, judgment
  • Weight loss
  • GI issues – constipation
  • Lightheadedness – contributes to fall risk; fainting or blackouts may occur
  • Urinary frequency and urgency, may be worse at night; slow urination or overfill of the bladder
  • Sexual concerns – decreased libido, impotence
  • Excessive sweating in the upper body
  • Personality changes – impulse control, hypersexuality
  • Vision – diminished movement in eyes, slow blinking leading to dry eyes.10 

Severity

Modified Hoehn and Yahr Scale11 12 

  • Stage 1 – initial stage with minor symptoms on one side of the body.
  • Stage 1.5 – Unilateral symptoms with initial axial difficulties.
  • Stage 2 – Bilateral symptoms. Slowness and speech problems. No balance impairments. Postural reflexes intact.
  • Stage 2.5 – Mild symptoms with slight retropulsion.
  • Stage 3 – Mild to severe symptoms. Postural and balance problems. Impaired gait, but still possible without assistance (physically independent).
  • Stage 4 – Severe symptoms. Some assistance is required. Impaired walking and standing, but possible without assistance.
  • Stage 5 – Final stage. Completely disabled. Walking or standing is not possible without assistance. Requires continuous care.

Management

  • Medications: levels of dopamine, brain chemicals, and nonmotor symptoms
    • Dopamine agonists that mimic dopamine
    • L-dopa, levodopa
    • Carbidopa – reduces side effects of levodopa, e.g., nausea vomiting, hypotension, restlessness
    • MAO-B inhibitors – slows down the enzyme that breaks down dopamine
    • Amantadine – reduces involuntary movements
    • Anticholinergics – reduces tremors and muscle rigidity
  • Deep brain stimulation – implantation of electrodes to a device implanted in the chest to stimulate the brain and stop movement-related symptoms13 
  • Thalamotomy (thalamus), Pallidotomy (globus pallidus – movement) 14 
  • Team: Physician, Physical, Speech, Psychosocial therapies, Nurse, Nutritionist, Social Worker, Sex Therapist

Outcome Measures

  • Home Assessment
  • Barthel Index
  • Parkinson’s Disease Rating Scale – Motor score15 
  • Canadian Occupational Performance Measure (COPM)
  • AMPS
  • Fatigue Severity Scale
  • Beck Depression Inventory
  • Activity Card Sort
  • Quality of Life – Visual Analogue Scale16 
  • Mini-Mental State Examination17 
  • Carer strain index
  • Trails B: driving18 

Occupational Therapy

Identify strategies to improve people’s ability to participate in valued activities and to fulfill their life roles in a client-centered manner. Use personal strengths, change the environment, and adapt the activity.19 

  1. Goal setting
  2. Activity analysis and access to services
  3. Enhance performance by improving skills, support performance by increasing knowledge and modifying the task, or change performance by modification of attitude and expectations15 
  4. Multisession, repetitive physical exercise to improve motor and sensory-erceptual performance skills.
  5. Use of auditory rhythmic external cues rather than visual, tactile, or other cues to help regulate walking.
  6. Use client-preferred external cues during ADLs for motor control.
  7. Incorporate complex and multimodal activities.20 
  • Education and coaching for clients and caregivers
  • Optimize daily structure and routine
  • Adapt the physical environment – removing obstacles, re-arranging furniture, improving lighting, optimizing heights of objects, providing external cues21 22 
  • Use compensatory strategies in activities, e.g., movement, cognitive, planning
  • Exercise and home exercise programs – virtual reality immersion, dual-tasking, aerobic and strength training23 
  • Motor Practice – cues and dual-task training, mental imagery24 
  • Movement strategy training – use of cueing, attention strategies, sequencing (frequency, timing) to reduce falls25 26 
    • Breaking down complex goal-directed movements in various environments27 
  • Fall prevention – functional, home, and community mobility
  • Handwriting – use of visual cues28 
  • Cognitive rehabilitation – planning, problem-solving, time management29 30 
  • Fine motor: hands and fingers exercises and activities
    • Use both hands in tasks
  • Assistive device and modifications
    • Use or adapt with larger handles for toothbrushes, hairbrushes, utensils, and writing tools
  • Communication interventions – education, strategies, cues, feedback, handwriting, mirror use, SLP referral31 32 
  • Energy conservation techniques for fatigue33 
  • Promotion of ADLs, IADLs
  • Promotion of leisure activities
  • Social participation34 
  • Lifestyle changes
  • Tai Chi, Hydrotherapy, Boxing35 36 37 38 39 
  • Dance – cognition, memory, attention, executive function40 
  • Driving – identifying at-risk drivers, caregiver interview18 
  • Coping and stress management
  • Relaxation techniques, Mindfulness41 
  • Cognitive Behavioral Therapy (CBT)
  • Addressing sexual problems – PLISSIT42 
    • Motor dysfunction may affect sexual activity
    • Nonmotor dysfunction may reduce desire and arousal, sleep disturbances
    • Achieving pleasure and satisfaction, reducing anxiety and concerns, decreasing relationship tension
    • Plan sexual activity when motor dysfunction is lowest
    • Don’t wait until bedtime.
    • Find alternative ways of expressing care.
    • Plan appropriate positions for intercourse.
    • Use lubricants to lessen the effects of motor dysfunction.
    • Massage may help in reaching an orgasm.
    • Use humor and communication
    • Emptying bowel and bladder before sexual activity
    • Referral to specialist
  • Pain management43 
    • Environmental control and assistive technologies
    • Antispasticity splint
  • PAMs – moist heat, stretching, gentle ROM
  • Group interventions and support groups44 

Additional Reading

Radder et al. – Physical therapy and occupational therapy in Parkinson’s disease

Sturkenboom et al. – Guidelines for Occupational Therapy in Parkinson’s Disease Rehabilitation

  1. Samii A, Nutt JG, Ransom BR. Parkinson’s disease. Lancet 2004;363:1783–93.[↩][↩]
  2. Parkinson’s Foundation. (n.d.). What is Parkinson’s? Retrieved from https://www.parkinson.org/understanding-parkinsons/what-is-parkinsons[↩]
  3. Drozak J, Bryła J. Dopamina–nie tylko neuroprzekaźnik [Dopamine: not just a neurotransmitter]. Postepy Hig Med Dosw (Online). 2005;59:405-20. Polish. PMID: 16106242.[↩]
  4. Lew, M. (2007). Overview of Parkinson’s disease. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 27(12P2), 155S-160S.[↩]
  5. American Parkinson Disease Association. (n.d.). Causes of Parkinson’s. Retrieved from https://www.apdaparkinson.org/what-is-parkinsons/causes/[↩]
  6. Nutt JG, Wooten GF. Clinical practice. Diagnosis and initial management of Parkinson’s disease. N Engl J Med 2005;353:1021–7.[↩]
  7. Rao S, Hofmann LA, Shakil A. Parkinson’s disease: diagnosis
    and treatment. Am Fam Physician 2006;74:2046–56.[↩]
  8. Weiner WJ. A differential diagnosis of parkinsonism. Rev Neurol Dis 2005;2:124–31.[↩]
  9. National Institute on Aging. (2017). Parkinson’s Disease. Retrieved from https://www.nia.nih.gov/health/parkinsons-disease[↩]
  10. American Parkinson Disease Association. (n.d.). Symptoms of Parkinson’s. Retrieved from https://www.apdaparkinson.org/what-is-parkinsons/symptoms/[↩]
  11. Keus SHJ, Hendriks HJM, Bloem BR, Bredero-Cohen AB, de Goede CJT, van Haaren M, et al. KNGF-richtlijn Ziekte van Parkinson. Amersfoort: Koninklijk Genootschap voor Fysiotherapie; 2004. Report No.: V-19/2004.[↩]
  12. Sanders Er. Parkinson handboek, een beknopte leidraad voor de praktijk. 2nd ed. Utrecht: Academic Pharmaceutical Productions BV; 2007.[↩]
  13. American Parkinson Disease Association. (n.d.). Treatment & Medication. Retrieved from https://www.apdaparkinson.org/what-is-parkinsons/treatment-medication/[↩]
  14. Schlesinger, I., Eran, A., Sinai, A., Erikh, I., Nassar, M., Goldsher, D., & Zaaroor, M. (2015). MRI-guided focused ultrasound thalamotomy for moderate-to-severe tremor in Parkinson’s disease. Parkinson’s disease, 2015.[↩]
  15. Dixon, L., Duncan, D., Johnson, P., Kirkby, L., O’Connell, H., Taylor, H., & Deane, K. H. (2007). Occupational therapy for patients with Parkinson’s disease. The Cochrane database of systematic reviews, 2007(3), CD002813. https://doi.org/10.1002/14651858.CD002813.pub2[↩][↩]
  16. Sturkenboom, I. H., Graff, M. J., Hendriks, J. C., Veenhuizen, Y., Munneke, M., Bloem, B. R., … & OTiP Study Group. (2014). Efficacy of occupational therapy for patients with Parkinson’s disease: a randomised controlled trial. The Lancet Neurology, 13(6), 557-566.[↩]
  17. Tiffany Chen, Peter Carley, Laura Cucinotta, Sheila Moran, Sara Tian, Linda Tickle-Degnen, Jessica Pickett; How People Living With Parkinson’s Disease Manage Daily Symptoms. Am J Occup Ther 2015;69(Supplement_1):6911505125. https://doi.org/10.5014/ajot.2015.69S1-PO5089[↩]
  18. Liliana Alvarez, Sherrilene Classen; Driving and Parkinson’s Disease: What Only Caregivers Can Tell Us. Am J Occup Ther 2016;70(4_Supplement_1):7011500005. https://doi.org/10.5014/ajot.2016.70S1-RP302A[↩][↩]
  19. Parkinson’s Foundation. (n.d.). Occupational Therapy. Retrieved from https://www.parkinson.org/Understanding-Parkinsons/Treatment/Occupational-Therapy[↩]
  20. American Occupational Therapy Association. (2014).Occupational therapy practice guidelines for adults with neurodegenerative diseases. Retrieved from https://www.guidelinecentral.com/summaries/occupational-therapy-practice-guidelines-for-adults-with-neurodegenerative-diseases/#section-society[↩]
  21. Sturkenboom IHWM, Thijssen MCE, Gons-van de Elsacker
    JJ, et al. Ergotherapie bij de ziekte van Parkinson, een
    richtlijn van Ergotherapie Nederland. Utrecht / Den Haag:
    Ergotherapie Nederland / Uitgeverij Lemma; 2008.
    English translation: Sturkenboom IHWM, Thijssen MCE,
    Gons-van Elsacker JJ et al. Guidelines for Occupational
    Therapy in Parkinson’s Disease Rehabilitation. Nijmegen,
    NL / Miami, Fl: ParkinsonNet/National Parkinson Foundation, 2011. Available at: http://www.parkinsonnet.nl/
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  22. Sturkenboom IHWM, Thijssen MCE, Gons-van Elsacker JJ, et al. Guidelines for occupational therapy in Parkinson’s disease rehabilitation. Nijmegen/Miami (FL): ParkinsonNet/NPF; 2011. Available at: http://parkinsonnet.info/guidelines.[↩]
  23. Radder, D. L., Sturkenboom, I. H., van Nimwegen, M., Keus, S. H., Bloem, B. R., & de Vries, N. M. (2017). Physical therapy and occupational therapy in Parkinson’s disease. International Journal of Neuroscience, 127(10), 930-943.[↩]
  24. Keus SHJ, Munneke M, Graziano M, et al. European Physiotherapy Guideline for Parkinson’s [↩]
  25. Rochester L, Hetherington V, Jones D, et al. The effect of external rhythmic cues (auditory and visual) on walking during a functional task in homes of people with Parkinson’s disease. Arch Phys Med Rehabil 2005 May;86 (5):999–1006.[↩]
  26. Kadivar Z1, Corcos DM, Foto J, et al. Effect of step training and rhythmic auditory stimulation on functional performance in Parkinson patients. Neurorehabil Neural Repair 2011;25(7):626–35.[↩]
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  28. Nackaerts E, Nieuwboer A, Broeder S, et al. Opposite Effects of visual cueing during writing-like movements of different amplitudes in Parkinson’s disease. Neurorehabil Neural Repair 2016;30(5):431–9.[↩]
  29. Sturkenboom IHWM, Thijssen MCE, Gons-van de Elsacker
    JJ, et al. Ergotherapie bij de ziekte van Parkinson, een
    richtlijn van Ergotherapie Nederland. Utrecht / Den Haag:
    Ergotherapie Nederland / Uitgeverij Lemma; 2008.
    English translation: Sturkenboom IHWM, Thijssen MCE,
    Gons-van Elsacker JJ et al. Guidelines for Occupational
    Therapy in Parkinson’s Disease Rehabilitation. Nijmegen,
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    parkinson/behandelrichtlijnen[↩]
  30. Ma HI, Trombly CA, Tickle-Degnen L, et al. Effect of one single auditory cue on movement kinematics in patients with Parkinson’s disease. Am J Phys Med Rehabil 2004;83(7):530–6.[↩]
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  34. Linda Tickle-Degnen, Shih-yu Lur, Jessica Pickett; Experience of Parkinson’s Disease Symptoms During Daily Life Activities. Am J Occup Ther 2015;69(Supplement_1):6911505111. https://doi.org/10.5014/ajot.2015.69S1-PO3087[↩]
  35. Lee MS, Ernst E. Systematic reviews of t’ai chi: an overview. Br J Sports Med 2012;46(10):713–8.[↩]
  36. Ni X, Liu S, Lu F, et al. Efficacy and safety of Tai Chi for Parkinson’s disease: a systematic review and meta-analysis of randomized controlled trials. PLoS One 2014 Jun;9(6):e99377[↩]
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  38. Volpe D, Giantin MG, Maestri R, et al. Comparing the
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  39. Combs SA, Diehl MD, Staples WH, et al. Boxing training for
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  40. Amruta Ulman, Nancy Baker, Jinali Thakker, Harshada Agawane, Saloni Solanki, Linda Tickle-Degnen; Dance, Cognitive Outcomes and Parkinson’s Disease (PD)—A Scoping Review. Am J Occup Ther 2020;74(4_Supplement_1):7411515354. https://doi.org/10.5014/ajot.2020.74S1-PO1720[↩]
  41. Pickut, B. A., Van Hecke, W., Kerckhofs, E., Mariën, P., Vanneste, S., Cras, P., & Parizel, P. M. (2013). Mindfulness based intervention in Parkinson’s disease leads to structural brain changes on MRI: a randomized controlled longitudinal trial. Clinical neurology and neurosurgery, 115(12), 2419-2425.[↩]
  42. Bronner, G., & Korczyn, A. D. (2018). The role of sex therapy in the management of patients with Parkinson’s disease. Movement disorders clinical practice, 5(1), 6-13.[↩]
  43. Cooper, C. (2007). Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity. St. Louis, MO: Mosby/Elsevier.[↩]
  44. Artigas, N. R., Striebel, V. L. W., Hilbig, A., & Rieder, C. R. D. M. (2015). Evaluation of quality of life and psychological aspects of Parkinson’s disease patients who participate in a support group. Dementia & neuropsychologia, 9, 295-300.[↩]
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