• Parkinson's disease is a progressive nervous system
disorder that affects movement. Symptoms start
gradually, sometimes starting with a barely
noticeable tremor in just one hand. Tremors are
common, but the disorder also commonly causes
stiffness or slowing of movement.
3. Parkinson’s disease (PD)
• Parkinson’s disease (PD) is a
characterized by slowness in
the initiation and execution
of movement (bradykinesia),
increased muscle tone
(rigidity), tremor at rest, and
• Exact cause is unknown
• Family History: Having one or more
close relatives with the disease
increase the rise of getting.
• Advancing age : Above 60 years
• Sex: male are more likely to get
• Low Estrogen Level: most
menopausal women who don’t use
hormone replacement therapy are
more risk of getting the disease.
• Medications like
• Agricultural work: exposure to
environmental toxin such as
• Head injury.
Tremor, rigidity and Akinesia
Loss of motor control
Impaired extra pyramidal tract controlling
Disrupts the normal balance between Dopamine (DA)
and acetylcholine (ACh) in the basal ganglia.
Degeneration of the Dopamine-producing neurons in
the substantia nigra of the midbrain
7. CLINICAL MANIFESTATIONS
• Rigidity:- Defined as increased
resistance to passive motion.
– Cogwheel rigidity: jerky, ratchet
like resistance to passive
movement and muscles
alternately tense and relax.
• Tremor:- It is an involuntary
oscillation of body part.
– Parkinsonian tremor is described
as resting tremor, as it is typically
present at rest and disappears
with voluntary movement.
Manifests as pill-rolling tremor
8. • Akinesia:- absence of movement.
– Moments of freezing may occur and are
characterized by a sudden break or block in
– Hypokinesia: reduced amplitude of the movement
• Postural Instability
– Postural instability is common. Patients may
describe being unable to stop themselves from
going forward (propulsion) or backward
9. • Hypomimia
• Drooling of saliva
• Low volume speech.
• Dysarthria .
• Problem with swallowing
and Involuntary flow of
• Longer time to complete a
• Stiff face in advanced PD.
• Altered cognitive function
– Dementia .
• Disorder of intellectual
• These include motor symptoms
– Depression, hallucinations, psychosis
– Aspiration – pneumonia
– Orthostatic hypotension
– Risk for fall
• Diagnosis is based on the clinical features .
• CT scan or MRI of head to rule out
• PET-scan to evaluate levodopa uptake and
conversion to Dopamine in the corpus
12. ANTI-PARKINSONISM MEDICATIONS
• LEVEDOPA (L-Dopa): it is the most effective
agents and the mainstay of treatment, for
controlling the symptoms.
• SINEMET: it is made up of Levodopa and
carbidopa. Levodopa enters the brain and is
converted to Dopamine while carbidopa increase
its effectiveness and prevents the side effects of
levodopa such as nausea, vomiting.
13. • DOPAMINE RECEPTOR AGONISTS:
– This are the drugs that activate or stimulate the
– Ergot derivatives : bromocriptine or pergolite.
– Non-ergot derivatives: ropinirole, pramipexole
• MONOAMINE OXIDIZED INHIBITORS:
– It blocks the breakdown of dopamine , and are used
primarily to treat motors fluctuation associated with
levodopa treatment most commonly drugs used are
Seligiline and Rosagiline.
14. DRUG MECHANISM OF ACTION
levodopa (L-clopa) levodopa/carbidopa
Converted to dopamine in basal ganglia
Dopamine Receptor Agonists
Stimulate dopamine receptors
Binds NMDA type glutamate receptors, increase dopamine release and
blocks dopamine reuptake
Apomorphine Stimulates postsynaptic dopamine receptors
Block cholinergic receptors, thus helping to balance cholinergic and
Diphenhydramine Has anticholinergic effect
Monoamine Oxidase Inhibitors
Block breakdown of dopamine
Catechol O-Methyltransferase (COMT) inhibitors
Block COMT and slow the breakdown of levodopa, thus prolonging the
action of levodopa
Surgery is optional only when medicine doesn't
make the symptoms better.
• Thalatomy - is a surgical procedure in which an
opening is made into the thalamus to improve the
overall brain function.
• Deep brain stimulation – pulse generator, high
frequency electrical impulses to the thalamus and
block the nerve pathway to control tremors
16. Deep Brain Stimulation
• Deep brain stimulation
(DBS) can be used to
treat tremors and
Electrodes are surgically
placed in the brain and
connected to a
(pacemaker device) in
• A combined approach of physical therapy and
pharmacological intervention plays a key role in
management of the patient.
• Physical therapist should be fully aware of the medications
the patient is taking and its potential adverse effects.
• Optimal performance can be expected at peak dosage (on-
state) whereas worsening performance is associated with
end of dose cycle.
– Exercise training
– Strength training
– Balance training
– Correcting eating impairments.
– Verbal skills practiced with breath control.
18. NURSING MANAGEMENT
• Nursing Assessment:
• Obtain a history of symptoms and their effect on
functioning, mobility, feeding, communication, and
• Assess cranial nerves, cerebellar function (co-
ordination) and motor function.
• Observe gait and performance of activities.
• Assess speech for clarity and space.
• Assess for sign of depression .
• Assess family supports and access to social service.
19. NURSING ASSESSMENT
• Blank (masked) facial expression, slow and monotonous speech, infrequent
• Seborrhea, dandruff; ankle Oedema
• Postural hypotension
• Tremor at rest, first in hands (pill rolling), later in legs, arms, face, and tongue.
Aggravation of tremor with anxiety, absence in sleep. Poor coordination,
cognitive impairment and dementia, impaired postural reflexes
• Cogwheel rigidity, dysarthria, bradykinesia, contractures, stooped posture,
Possible Diagnostic Findings
• No specific tests. Diagnosis based on history and physical findings and ruling
out of other diseases
20. NURSING DIAGNOSIS
• Impaired physical mobility related to Bradykinesia, rigidity and
• Imbalance nutrition less than body requirement related to motor
difficulties with feeding, chewing and swallowing
• Impaired verbal communication related to decreased speech volume
• Constipation related to diminished motor function and inactivity
• Ineffective coping related to physical limitation and loss of
• Risk for fall-related injury
• Impaired sleep pattern