Parkinson Disease and parkinsonian syndrome are caused by alteration of the functions of two basal ganglion regions – nigral substance and striatum body – given that they contain practically the total human encephalon dopamine, (being this the chemical substance in charge of the electric message transportation). When dopamine concentration suffers a reduction synapses decreases, decreasing thus the neuronal influence of the nigral substance to the pallid balloon through the track uniting them, then producing the Parkinsonism signs and symptoms.
The cause of degeneration of the nigral substance and striatum body is unknown, what we do know is that it is a gradual process and its duration between onset and death is from 10 to 15 years.
Certain toxic or infectious agents can also cause this affliction. It usually occurs in patients between 40 and 70 years old, with no preference for any gender, race or weather.

PARKINSON AND PARKINSONIAN SYNDROME

Parkinson disease and parkinsonian syndrome comprise a range of typical disorders due to the tremor and alteration of voluntary movement, posture and balance.
The parkinsonian syndrome is a group of alterations in which signs and symptoms characteristic of Parkinsonism are developed, but in a secondary basis to other neurological illness (such as lethargic encephalitis, Alzheimer’s disease, due to prolonged consumption of certain medicines, etc.). Thus while Parkinson disease is primary degenerative disorder which appears in the second half of people’s lifespan, following a progressive course; parkinsonian syndrome has a natural history which is cause dependent. The term Parkinsonism is used to describe the signs and symptoms regardless the cause of the pathological status.

Clinical Features

A patient with Parkinsonism can appear with characteristic tremor. Diagnosis is then easily established, though it is important no to label as “parkinsonism” other types of tremor.
Common symptoms at presentation are slowness in walking and balance alteration with occasional falls or difficulty in performing fine-finger movements such as those used while dressing or shaving. Pain is a usual complaint at presentation.
The passage from different decubitus to a sitting position or from the latter to bipedestation is made with much difficulty given that the patient moves in blocks, not with the natural segmented sequence. As regards intellect, it is unaffected as well as its sensibility.
Early symptoms of the disease can include specific movement difficulty such as those made while writing, turning in bed or rising from a low chair; excessive skin fatness or unusual tendency to constipation, and incapacity to raise the voice or cough efficiently. All the symptoms tend to worsen disproportionately when the patient is under pressure, so they tend to avoid social engagements and to reduce the amount of work they do.

SIGNS
Posture

Usually the patient shows some alteration. When standing there is a slight flexion in all joints causing the “apelike posture” with knees and hips mildly flexed, rounded shoulders and head forward with arms curved through the body. When sitting, the patient often slides to the sides.
Abnormal posture may be corrected voluntarily, though only temporarily and with considerate effort and concentration.
Balance
When standing, they usually have the characteristic tendency to fall forward.
They are not able to perform compensatory rapid movements to regain balance and are easily knocked down.
When walking they have difficulties in deriving their gravity centre from one foot to the other, so that their steps become short and slow.
They also have specific difficulties to turn or initiate walking movements (bradycinesia).

Learned and voluntary movements
Magnitude and speed of movements is reduced (acinesia).
As mentioned above walking pace is slower, with shorter steps. Speech becomes slower and softer. Handwriting tends to shrink (micrography) and become untidy. Food cutting, buttoning or tying of laces can become impossible, as well as those activities involving repetitive movements such as whipping or brushing.
However, movements complexly coordinated, such as driving, cooking, house cleaning or machine writing may be relatively unaffected particularly when they are being carried out.

Automatic movements
These are specifically reduced and/or lost in Parkinson Disease.
The patient rarely blinks; his/her face appears with no expression. Hand movements and the swinging associated with walking are absent.
Automatic saliva swallowing is also altered so that very frequently they present with an involuntary continuous dribbling.
Cough as a reflex answer to an external agent can be deficient, thus presenting the risk of respiratory infection.
Rigidity
Muscular tone is increased presenting resistance during passive movement in the whole length of said movement.
Two types of parkinsonian rigidity are described: "lead tube” when resistance is uniform or plastic; and “cogged wheel” when it is intermittent.
It may be asymmetrical or even unilateral. It may affect occasionally only a group of muscles to a significant degree such as the neck muscles.
In this way, rigidity contributes to poor movements and is in part responsible for muscular pain.
Tremor
The tremor is usually asymmetrical or unilateral. It involves an alternate contraction of opposed muscular groups producing a rhythmic movement of about 4 to 6 cycles per second. It is commonly maximum at periphery and it affects more the arms than the legs.
It is more a feeling of discomfort for the patient than a disability, given that it appears at complete rest and it diminishes or disappears with voluntary movement.
Awareness or self-anxiety increases the tremor, so that the disturbance on any social occasion can become unendurable.
Although the already mentioned manifestations may not imply inability in themselves, they have a disabling effect for the patient when carrying out many of the everyday activities.
Haehn and Yahr used the following scale as a means to record the degree of disability and the speed of its evolution:

Given that this gradation scale is not operationally defined, Webster design a more detailed gradation scale in order to summarize the results of the assessment in ten gradation areas. In each area, the aspects are sequenced in a progression typical of the disability, allowing a general quantitative gradation. Said scale is the following:

GRADATION SCALE FOR PARKINSON DISEASE

Hand Bradycinesia
0.- Not affected
1.- Appreciable slowness in prone supination manifested by initial difficulty to handle tools, button up clothes and hand writing.
2.- Slight slowness in prone supination, in one or both sides, manifested by moderate alteration of the manual function; handwriting is disturbed and there is micrography.
3.- Extreme slowness in prone supination; the patient is unable to write or button up clothes; there is a marked difficulty in handling utensils.

Rigidity
0.- Not detectable.
1.- Rigidity detectable in neck and shoulders.
2.- Slight rigidity in neck and shoulders. Rigidity at rest is positive when the patient is without medication.
3.- Severe neck and shoulder rigidity. Rigidity at rest cannot be corrected with medication.

Posture
0.- Normal posture
1.- Head bends forward less than ten centimetres.
2.- Arm flexion begins. Head bends forward more than fifteen centimetres.
3.- Apelike posture begins. Head bends forward more than fifteen centimetres. One or both hands raised higher than the waist line. Knee flexion begins.

Superior extremity swinging
0.- Arms swing normally.
1.- The amount of arm swinging is definitely reduced.
2.- One arm does not swing.
3.- Both arms do not swing.

Walking
0.- Walks well, steps between 45 to 75 centimetres. Turns with no effort.
1.- Shortened walk with steps between 30 to 45 centimetres. Begins to tap with one heel. Turning is slow, requiring several steps.
2.- Moderately shortened steps (between 15 to 30 centimetres). Both heels begin to tap the floor with force.
3.- Beginning of dragging of feet while walking , with steps shorter than 15 centimetres. Walks on her/his toes and turns very slowly.

Tremor
0.- No tremor is detectable.
1.- Less than 2.5 centimetres of amplitude in the tremor movement observed in the limbs or head at rest or in any hand while walking or during the “finger to nose” test.
2.- The maximum amplitude of the tremor is no larger than 10 centimetres. Tremor is intense, though not permanent and the patient keeps certain control of her/his hands.
3.- The amplitude of the tremor is larger than 10 centimetres. Tremor is intense and permanent. The patient is unable to get rid of the tremor while s/he is awake. It is impossible for her/him to write or eat by her/himself.

Facies
0.- Normal. Complete animation, There is no fixed facies.
1.- Noticeable immobility. Mouth remains closed. Anxiety or depression features begin.
2.- Slight immobility. Emotions are shown at an averagely increased threshold. Lips are separate part of the time. Moderate appearance of anxiety or depression. Dribbling may be intense.

Seborrhea
0.- None present.
1.- Increased perspiration, secretion is still abundant.
2.- There is evident fat increase. Secretion is much thicker.
3.- Marked seborrhoea, the whole face and head are covered with thick secretion.

Self-attention
0.- Not altered.
1.- Self-attention is present, but speed in dressing is definitely diminished. Still able to live by her/himself.
2.- Assistce is needed in certain areas, such as turning in bed, rising from chairs, etc. Very slow in performing most activities, though s/he can handle them taking a lot of time.
3.- Permanently disabled. Unable to dress, feed or walk by her/himself.

Then the total gradation is established and the interpretation is as follows:
0 – There is no affection.
1 - 10: Early disease.
11 -20: Slight disability.
21 -30: Severe disability.

EVALUATION

Evaluation is designed to obtain a general impression of the patient’s clinical status, her/his social circumstances and a detailed description of her/his physical problems.
The evaluation begins with the complete examination of the manifestations of the present symptoms. The degree of commitment and the effect on the functional activities are recorded.

General Information
It is important to consider the complete medical history in order to determine whether there are other factors concomitant with Parkinson Disease that affect the patient’s general health and mobility, e.g.: arthritis or hemiplegia.
The history of the disease must be considered, as well as its duration, physical signs and symptoms. Among them tremor, rigidity, pain and all the abovementioned are included.
The patient’s medications and their dosages must be taken into consideration, given that they may cause alterations in the performance of her/his activities. A complete social history is needed in order to ascertain if the patient is working or retired, what kind of work s/he does, which are her/his pastimes and how s/he spends her/his day. It is also relevant to determine whether the patient lives alone, any service s/he may receive, such as home delivered food.

Physiotherapeutic evaluation
The patient’s posture, balance and functional performance are taken into account. The functional performance of many patients is modified during the day, so it is important to register the time in which the evaluation takes place and the time since the intake of the last medication dose.

Posture
Given that posture is invariably affected, it must be evaluated using a scale from 1 to 4. Gradation in graphics is the easiest method that can be employed (Table 1). Similar gradations may be used in a sitting or lying position in case it is relevant for the individual.

BALANCE
In order to test the balance reaction, the patient is requested to:
1.- Be seated with no support for a minute.
2.- Remain standing with no assistance for five seconds.
3.- Remain standing on one foot and then on the other with no assistance for five seconds.
The aim of this is to observe tolerance and features of the patient's balance.

FUNCTIONAL EVALUATION
Common difficulties such as turning in bed, to sit from a lying position and to stand up from a sitting position must all be timed and graduated. The gradation scaled used is the following:
1.- Normal.
2.- Can perform a task with some difficulty but with no assistance.
3.- Can perform a task with assistance, such as pulling from the side of the bed.
4.- Unable to perform a task.
When appropriate, the same gradation and times evaluation can be used to record the performance of other functional difficulties.
Walking must be evaluated allowing the patient to walk a fixed distance, recording the number of steps and the time used in covering said distance. The quality of heel tapping must be observed. It can be divided into the following three categories:
1.- heel-toes,
2.- flat foot and
3.- toes-heel.
Film recording of walking patterns is also part of the evaluation in order to measure improvements or deteriorations.
In addition, the patient’s ambulatory posture must be observed and whether s/he has any difficulty in initiating the movement. Any assistance used for walking must be noticed.
Finger skills can be evaluated allowing a maximum of three minutes for the patient to do up three buttons of a shirt. The number of buttons and the time used will be noted.

Additional Evaluations
These evaluations aim at taking account of the following:
ß Articular passive movement arc: the presence of contractures can be detected.
ß Articular active movement arc: the movement characteristics can be determined.
ß Tremor and rigidity presence and characteristics. Tremor is observed and the maximum distance of the tremor course is calculated combined in both directions. Neck rigidity is studied by means of the passive flexion, extension and rotation.
ß Pain or other discomfort is present.
ß Functional activities: personal cares, everyday activities, communication, coordination, strength, reach, pressure.
ß Work position and potential.
ß Non vocational interests and abilities.
ß Emotional status.
ß Self-attention.
ß Situation at home, lifestyle, social interests and responsibilities.
ß Speech: evaluated while having normal conversations.
ß Verbal learning test: used to check immediate memory magnitude, learning and late evocation of the verbal material. It consists of a list of fifteen words read to the patient who must repeat at intervals during the evolution.
ß Verbal comprehension test: used to check the patient’s comprehension of verbal instructions. It consists of providing groups of instructions of increasing complexity for the patient to follow.
ß Seborrhea: asking about the frequency with which the patient washes her/his hair can reveal the presence of too much fat.
ß Facies: observations are done during conversation and at rest.

Standardized evaluations
ß Master copy of Evaluation Areas, Components and Occupational execution contexts.
ß Physical Red Cross Scale.
ß Mental Red Cross Scale.
ß Balance and Walking Tinetti’s Scale.
ß Geriatric Depression Scale summarized.
At the end of the therapeutic evaluation the severity of the patient’s disease should be oldclassified using Haehn and Yahr Scale and treatment objectives should be enumerated.

TREATMENT OBJECTIVES
Once the evaluation is finished, it is the time to consider the objectives that should result realistic in reference to the patient’s situation, the stage in which the disease is and its individual characteristics, not neglecting each person’s interests.
Given that this is a disabling disease, the general objectives are:
ß To improve and keep independence in occupational areas during the longest possible time.
ß To improve the quality of life and personal well-being.
ß To keep residual abilities.
ß To improve the feeling of competition and self-esteem.
ß To improve communication and cognitive abilities.
ß To provide family advice.
In order to achieve these objectives it is necessary to set up specific objectives such as the following:
ß To improve coordination and motor abilities.
ß To increase motivation and improve the state of mind.
ß To correct the generalized attitude of flexion.
ß To correct block movements.
ß To lessen rigidity.
ß To teach relaxation techniques.
ß To foster functional use of the relearned abilities.
ß To prevent deformities, articular retractions, posture disorders, etc.
ß To keep or improve articular trajectories.
ß To supply the adequate technical assistance and environment modifications.

TREATMENT

The treatment for Parkinson Disease may be pharmacological, physiotherapeutic, Occupational Therapeutic, language therapeutic and/or surgical. The objective of the treatment is to reduce the speed of progression of the disease, to control the symptoms and secondary effects derived from the medicines used to counteract it.
Medicines:
Amantadine may help patients with minor symptoms but without disability.
Anticholinergics: they are useful for alleviating tremor and rigidity, initiating its administrations with small doses that will be increased gradually until results are obtained or until secondary effects are greater than the benefits.
Levodopa: this medicine improves the whole symptomatology of Parkinsonism, including bradycinesia. But it does not stop the evolution of the pain. The way the organism behaves is with the transformation of this medicine into dopamine at intake.
Bromocriptine: this medicine works directly at the dopamine receptors and produces less secondary effects than levodopa. It is usually reserved for those patients that have become levodopa resistant.

Surgical Treatment
Thalamotomy is recommended for relatively young patients with tremor and rigidity predominantly unilateral not responding to the pharmacological treatment and with no evidence of diffuse vascular disease.
Given that Parkinson Disease is a progressive illness, any treatment must be concerned with helping the patient achieve her/his optimal physical potential, thus allowing her/his quality of life to improve at that moment. Even when the difficulties and objectives will vary permanently in the progression of the disease, it is essential to prolong the patient’s functional independence.

Julieta Cairo