Parkinson’s Disease

and Parkinsonism

By Naima Farooq
Parkinson’s Disease Stats

• First desribed by James Parkinson in

1817
• Affects ~1 million in the U.S.
• Onset typically between 50-60 years of
age, and slowly progresses with age
• Average onset is 62.4 years of age
 Background
• Parkinson’s disease is a disorder that
affects nerve cells in the part of the brain
controlling muscle movement
• Disease is progressive – signs/symptoms
worsen over time
• Eventually is disabling, but progresses
gradually
• Believed to be caused by genetics,
environmental factors or a combination of
the two
• Idiopathic or unknown etiology
• The exact cause of Parkinson's disease
is unknown, although research points to
a combination of genetic and
environmental factors.
• If a continuum existed, with exclusively
genetic causes at one end and
exclusively environmental causes at the
other, different Parkinson's patients
would likely fall at many different places
along that continuum.
 Neurological Basis
• “Neurodegenerative Disease” : caused by
degeneration (dysfunction and death) of neurons
within the brain
• NORMAL BRAIN FUNCTION – Basal Ganglia
• Cells in substantia nigra produce/release dopamine
• Dopamine released by SN neurons lands on neurons
of other brain centers, controlling their firing
• Main targets are caudate nucleus and putamen
(striatum)
• This basal ganglia pathway is involved in regulation of
movement
• The basal ganglia are a group of nuclei
situated deep and centrally at the base of
the forebrain.
• They have robust connections with the
cerebral cortex and thalamus in addition
to other areas of the brain.
• Their vast system of communication
allows them involvement with a variety of
functions, including automatic and
voluntary motor control, procedural
learning relating to routine behaviors and
emotional functions.
• The association with other cortical areas
ensures smoothly orchestrated movement
control and motor behavior.

• The striatum, composed of the caudate and

putamen, is the largest nuclear complex of
the basal ganglia. The striatum receives
excitatory input from several areas of the
cerebral cortex, as well as inhibitory and
excitatory input from the dopaminergic
cells of the substantia nigra pars compacta
(SNc). These cortical and nigral inputs are
received by the spiny projection neurons,
• Today, we understand Parkinson's disease to be
a disorder of the central nervous system that
results from the loss of cells in various parts of
the brain, including a region called the
substantia nigra.
• The substantia nigra cells produce dopamine, a
chemical messenger responsible for
transmitting signals within the brain that allow
for coordination of movement.
• Loss of dopamine causes neurons to fire
without normal control, leaving patients less
able to direct or control their movement.
Parkinson's disease is one of several diseases
categorized by clinicians as movement
disorders.
(https://www.michaeljfox.org/understanding-
parkinsons)
 Neurological Basis

• PARKINSON’S BRAIN FUNCTION–

Basal Ganglia
• Cells of substantia nigra degenerate
• These cells can no longer produce adequate
amounts of dopamine
• Neurons of striatum, etc. are no longer well
regulated, thus do not behave in normal manner
• Results in loss of control of movements – leads to
symptoms characteristic of Parkinson’s disease
• In Parkinson disease, degeneration of
the basal ganglia, along with damage to
the dopamine-producing cells of the
substantia nigra, hampers the proper
functioning of the nerve pathway that
controls movements of the muscles.
• The muscles become excessively tense,
a condition that gives rise to tremor and
a rigid joint action. The movements of
the body also begin to slow down
because of this malfunction.
 Characteristic Symptoms
• MOTOR • NONMOTOR
• tremor • diminished sense
• bradykinesia of smell
• rigidity/freezing in • low voice volume
place • foot cramps
• lack of facial • sleep disturbance
expression
• depression
• postural instability
• constipation
• stooped, shuffling gait
• drooling
Typically, symptoms begin on one side of the body and migrate over time to
the other side.
DIGNOSIS
•There is no objective test (such as a blood test, brain scan or
EEG) to make a definitive diagnosis of Parkinson's disease.
•Instead, a doctor takes a careful medical history and
performs a thorough neurological examination, looking in
particular for two or more of the cardinal signs to be present.
Frequently, the doctor will also look for responsiveness to
Parkinson's disease medications as further evidence that
Parkinson's is the correct diagnosis.
•In 2011, the Food and Drug Administration (FDA) approved
a specialized imaging technique called DaTscan that allows
doctors to capture detailed pictures of the dopamine system
in your brain. It is the first FDA-approved diagnostic imaging
technique for the assessment of movement disorders such as
Parkinson's disease. DaTscan alone can't diagnose
Parkinson's disease by itself, but it can help confirm a
physician's clinical diagnosis -- something that has never
been possible before.
 Conventional Treatments:
Medication
• LEVODOPA (L-DOPA)
• precursor to dopamine, converted to
dopamine by nerve cells in the brain
• Treatment with dopamine not possible,
because dopamine can’t cross blood-brain
barrier
• Generally combined with carbidopa (Sinemet)
– helps levodopa get to the brain
 ROLE OF SPEECH
PATHOLOGIST
•Speech-language pathology domains in
Parkinson’s disease
•With respect to Parkinson’s disease, speech-
language pathology focuses on three domains:
• – difficulty with speech
• – difficulty with chewing and swallowing:
dysphagia, choking and slow chewing and
swallowing
• – difficulty with controlling saliva: drooling
or dribbling of saliva
SPEECH PROBLEMS
•About 75% of people with PD experience changes
in speech and voice at some time during the course
of the disease. These changes usually come on
gradually and can vary from moderate to severe.
How Do I Know if I Have Problems with Speech
and Communication? This self-test can help you determine if
you have a communication problem. Think about the following
statements, and place a check mark next to the ones that apply to you.
❏ I am often asked to repeat a statement.
❏ People look slightly confused or as if they are trying hard to listen when I
speak.
❏ My care partner says that I sometimes slur or mumble words.
❏ My care partner asks that I speak louder.
❏ I feel that my care partner is ignoring me or may need a hearing aid.
❏ I do not attend social gatherings as often as before.
❏ I notice that I often stop trying to communicate in a group where others
seem to talk over me.
❏ I feel like people do not listen to me anymore
❏ I feel like people think that I don’t have anything interesting to say.
❏ I try to avoid the telephone.
❏ I need to clear my throat often.
❏ I cannot complete a conversation without feeling frustrated about my
inability to communicate what I have to say. If you checked any of these
Care Partner Speech and Communication Survey
If you are a care partner, family member or friend who has
regular contact with a person with PD, complete this
questionnaire. Check the statements that are true for your
family member or friend.
•I have difficulty hearing when s/he speaks.
•I have difficulty understanding his or her speech.
•S/he does not talk as much as in the past.
•S/he does not attend social functions as frequently as in the past.
•S/he often asks me to make phone calls or order from a menu for him or
her.
•S/he clears his or her throat often.
•S/he often sounds as if s/he is running out of breath when speaking.
•S/he suspects that I need a hearing aid.
•S/he thinks I ignore what s/he has to say.
If you checked more than one box, your family member or friend probably
has problems with speech and communicating.
Perceptually, speech and voice
in people with PD are
characterized by
• reduced loudness,
• monopitch,
• monoloudness,
• reduced stress,
• breathy,
• hoarse voice quality,
• imprecise articulation,
• short rushes of speech,
• and hesitant and
dysfluent speech
• Collectively, these
speech symptoms are
called hypokinetic
dysarthria
• Voice problems are
typically the first to
occur, with other
problems, such as
prosody, articulation
and fluency, gradually
appearing as the
speech disorder
progresses
TREATMENT
Lee slivervoice treatment
 One therapy, that has proven effective in treating patients
with neurological disorders, specifically Parkinson’s Disease,
is the Lee Silverman Voice Treatment (LSVT®).
Based upon nearly 15 years of research data, this
treatment offers the opportunity to consistently improve
speech and voice production in individuals with neurological
disorders and significantly improve their quality of life.
(https://www.rainbowrehab.com/RainbowVisions/article_dow
nloads/articles/Art-THPY-LSVT.pdf)
 LSVT is the first and only documented efficacious speech
treatment for individuals with Parkinson’s disease – over 400
have been treated and included in efficacy research studies.
Ninety percent of patients studied showed improvements in
vocal intensity from pre- to post-treatment. Approximately
80 percent maintained improvements in volume for 12-24
months post-treatment.
Learn appropriate breathing techniques
•As breath is the energy behind your voice , weak
breath support weak voice
•Figure out where your diaphragm is below your
lungs, when you breath your torso comes out
LSVT Sustained phonation\say a
In front of mirror or recording
•Open your mouth nice and big say loud and long as you
can
•Great strengthener, forces your vocal folds stay together
in a phonation position and work in muscles
Highest and lowest pitch
Start at a normal pitch and then glide as high as you can
and then as low as you can
Rationale
With Pd because of the stiffness of muscles, the range of
your muscle starts to get narrow and as you get
monotone.
Good exercise to increase your range super high and
super low.
To improve Vocal Quality
Relaxation exercises
•Yawn sigh (reduce the strain) 5 times
Expressive phase
Facial muscles are stiffening
List of expressive words e.g. wow!
Exaggerate the expression
Take ten sentences or phrases that u use every day /
name of people family members practices these
activities
•Good breath support
•Loud voice with
•good quality
https://www.parkinsons.va.gov/NorthWest/Documents/Pt_ed_handout
s/Handout_Swallowing_and_PD_2-8-13.pdf
Use it or loss it
Inactivity may accelerate deficit
Continuous activity may slow disease progression
http://www.parkinson.org/sites/default/files/Swallow
%20%26%20Dental.pdf
Saliva management
Saliva is necessary for digestion. It lubricates the throat to
make swallowing easier and contains chemicals that break
down food.
Some people with Parkinson’s develop problems controlling
their saliva, which can lead to drooling or dribbling. The
medical term for this is sialorrhea. Research shows that
this can affect more than half of people with Parkinson’s.
• When you have Parkinson’s the natural tendency
to swallow slows down. If you swallow less, saliva
can pool in your mouth and, instead of being
swallowed, it can overflow from the corners of
your mouth
PARKINSONISM
Also called atypical Parkinson's disease
Parkinsonism is an umbrella term for patients who have
sign and symptoms suggesting that they have got
• stiffness in the limbs the limbs that we call rigidity
• Bradykinesia- slowness of moment
• Shaking or tremors particularly in the hands
• That combination of signs and symptoms that we call
parkinsonism
Causes
Lot of different causes for that
• Parkinson disease is one of the common cause of the
combination of these symptoms.
But there are other causes
• Certain medication that block dopamine in the brain.
• Vascular diseases, or blockage of blood vessels in the
brain e.g. after stroke
• Combination of other rare degenerative disease
• Corticobasal degeneration
• Dementia with Lewy bodies
• Multiple system atrophy
• Progressive supranuclear palsy
Differences
• Tend to progress more rapidly then pd.
• Present with additional symptoms such as early
falling, dementia, hallucinations
• Not responding to PD drugs levodopa therapy.
• Examples
• Example 1LBD ( earliest sign memory loss )
• Early retirement no longer manages his meetings
and other task other wise multitask
• 5 years ago dignosed with dementia
• 3 years ago diagnosed with PD because of
stiffness in limbs and slowness
• Did not response well to medication
• Currently hallucinations
• Physically looks like he had mild pd walks talks
and sustain conversation.
• Example 2 PSP
• At the age of 60 started falling backwards
• Year ago start having double vision
• Six months ago diagnosed with pd but does not
respond well to medication
• Now cannot stand up without falling
• Example 3 FTD ( earliest symptom b change)
• Year ago 57 started embarrassing his wife by saying
odd things at party saying inappropriate things.
• When his brother died suddenly he didn’t seem to
care which was quite disturbing for the family.
• About 6 months ago noted tremor in right hand
( diagnosed with pd) but didn’t response well to
medicine L
• Friends donot like to talk to him any more / became
unfriendly and unappropriated
• Currently his wife has to tell him when to bath, eat
etc
• Extravagant vs lack of motivation
Example 4 MAS ( multiple system Atrophy) early S
Fainting
•Age 52 started having dizziness
•see urologist for bladder control issues
•1 year ago started fainting and Due to rigidity and
stiffness diagnosed with PD
•Now on wheel chair due to extreme low BP
•Intellect was completely intact( fully functioning in
this regard).
•L do not work .
•Prognosis poor
 Sources
• Aminoff, M. (2003). Parkinson Primer: Overview of Parkinson’s Disease.
Retrieved November 16, 2005, from
http://www.parkinson.org/site/pp.asp?c=9dJFJLPNB&b=71354.
• This source provided me with the most of the background information necessary
in explaining the foundation of the disease. This source was especially helpful in
determining the characteristic symptoms of the disorder as well as statistics.
• Freed, C.R., Green, P.E., Breeze, R.E., Tsai, W., DuMouchel, W., Kao, R.,
Dillon, S., et al. (1994). Transplantation of Embryonic Dopamine
Neurons for Severe Parkinson’s Disease. New England Journal of
Medicine, 344, (7), 710-719.
• This source played a large part in writing the actual paper. In this article was
information on the background of stem cells, implications in stem cell research,
and most beneficial, the actual experimental procedure itself.
• Lieberman, A. (2004). What is Parkinson’s Disease? Retrieved November
14, 2005, from http://www.pdcaregiver.org/WhatIsParkinsons.html.
• This source didn’t help much background information on the disease, but did help
in providing an comprehendable version of the substantia nigra and its role in
development of Parkinson’s disease. Also beneficial were the figures associated
with this source.
• Dr Georgia lea lectures.