PARKINSONS DISEASE

DEFINITION It is a slow progressive neurologic movement disorder that eventually leads to disability Parkinsonism is a syndrome that consists of a slowing down in the initiation and execution of movement (bradsykinesia), increased muscle tonus (rigidity), tremor and impaired postural reflexes. INCIDENCE The average age of patient with parkinsons disease is 65 years.

ETIOLOGY Encephalitis lethargica or type A encephalitis(

postencephalitic parkinsonism) Parkinsonism like symptoms have occurred after intoxication with a variety of chemicals including carbonmonoxide and maganese (among copper mines) and an analogue of meperidine Drug induced parkinsonism can follow reseprine, methyl dopa, haloperidol, and phenothiazine therapy Little evidence by atherosclerosis (atherosclerotic parkinsonism)

PATHOPHYSIOLOGY
Associated with increased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain
Destruction of dopaminergic neuronal cells in the substantia nigra in the basal ganglia

Depletion of dopaminergic stores

Degeneration of the dopaminergic nigrostriatal pathway Imbalance of excitatory (acetylcholine) and inhibiting (dopamine) Neurotransmitters in the corpus striatum

Impairment of extrapyramidal tracts controlling complex body movements

Tremors

Rigidity

Bradykinesia

CLINICAL FEATURES
the onset is gratual and insidious Bigining stage :mild tremor , slight limb or a decreased

armswing LATER:shuffling propulsive gait with arms fixed and loss of postural reflexes. Some patient changes in speech pattern. Classic triad or cardinal signs Tremor, rigidity and bradykinesia(slow or retarded movement) Tremor: often first sign.this can affect handwriting . It is more prominent at rest and is agrevated by emotional stress or increased concentration. Hand tremor is described as pill rolliing because the thumb and fore finger appear to move in a rotatary fashion as if rolling a pill coin or small object Tremor can involve the diaphragm ,tongue, lips, and jaw rarely shaking of the head.

Regidity:second sign is the increased resistence to passive motion when the limbs are moved through their ROM. Parkinsonism rigidity is typified by a jerky quality, as if there were intermittent catches in the movement of a cog wheel, when the joint is Moved.This is called cogwheel rigidity. Bradykinesia: particularly evident in the loss of autonomic movements , which is secondary to the physical and chmical alteration of the basal ganglia and related structures in the extrapyremidal portion of the CNS. Automatic movements are involuntary and occurs subconsciously. They include blinking of the eyelids, swinging of the arms while walking,swallowing of saliva, Stooped posture , marked facies (dead pan expression), drooling of saliva and suffling gait Freezing phenomenon is a transient inability to perform active movement.

COMPLICATION
Dysphagia Severe cases leading to malnutrition or aspiration Pneumonia, UTI, and skin breakdown. Mobility is greatly decreased The gait slows and training is especially difficult The gait usually consists of rapid short, suffling ministeps.old man image with the head and trunk bent forward and legs constantly flexed. Lack of mobility may leads to constibation , ankle edema and contractures. Orthostatic hypotension along with loss of postural reflexes may result in falls or other injury Seborrhea (increased oily secretion of the sebaceous glands of the skin) , dandruff, excessive sweating, conjunctivitis, difficulty in reading , insomnia, incontinence and depression.

DIAGNOSTIC TEST: History, physical and neurological examination Positive response towards anti Parkinson drugs MEDICAL MANAGEMENT Levodopa with carbidopa(sinemet)is often the first drug to be used. Levodopa is a precussor of dopamine and can cross the blood brain barrier.it is converted to dopamine in the basal ganglia. Anticholinergics: eg.procyclidine biperiden are effective in controlling tremor and rigidity. Dopamine agonist: bromocriptine are dopamine receptor agonist Monamine oxidase inhibitors: eg. Seligiline(eldepryl) Inhibit the dopamine breakdown and is thought to slow the progression of the disease. Antidepressants :alleviates depression that is common in PD Antihistamins: diphenhydramine hydrochloride(benadryl) have mild anticholinergic and sedative effects and may

SURGICAL MANAGEMENT
Thalomotomyand palidotomy Is done to interept the nerve pathways and thereby alleviate tremor or rigidity. Thalomotomy: a stereotactic electrical stimulator destroys of the ventrolateral portion of the thalamus in an attempt to reduce trmor. Pallidotomy: involves destroying part of the ventral aspect of the medial globus pallidus of the basal ganglia are destroyed through electrical stimulation in patient with adsvanced disease. Transplantation of adrenal tissue in to the caudate nucleus in an attempt to provide viable dopamine producing cells to the brain. Deep brain stimulation: pacemaker like brain implants helps in relieving tremors.