PARKINSON’S DISEASE

AND
MULTIPLE SCLEROSIS
Grace Blankenhagen, SPT
 Parkinson’s Disease Vs. Multiple
Sclerosis
◦ Parkinson’s Disease is a neurodegenerative disease resulting in degeneration of the CNS1
◦ Other conditions like this include Huntington’s Disease, Alzheimer’s Disease, Spinal Muscluar
Atrophy2

◦ Multiple Sclerosis is an autoimmune disease resulting in degeneration of the CNS3

◦ Other conditions like this include: transverse myelitis, neuromyelitis optica, Acute Disseminated
Encephalomyelitis4
Parkinson’s Disease- Pathophysiology1
◦ Degeneration of basal ganglia’s dopamine neurons and areas that produce dopamine
◦ Substantia nigra
◦ Pars compactus
◦ Substantia nigra degenerates before motor symptoms surface
◦ 30-60%
◦ Pigment neurons degenerate and cause color change in SN
◦ Neuron degeneration ensues
◦ Lewy bodies develop
Parkinson’s Disease- Clinical
Presentation1
◦ Rigidity* ◦ Postural instability
◦ Cogwheel vs. lead pipe ◦ Especially anticipatory reactions
◦ Bradykinesia* ◦ Weakness of antigravity muscles
◦ Insufficient recruitment of muscle ◦ High fall risk
force during motion initiation ◦ More common in middle stages
◦ Freezing: Sudden stop in motion ◦ Paresthesias
◦ Tremor* ◦ Loss in sense of smell
◦ Resting tremor most common
◦ Dysphagia
◦ Postural: against gravity tremor in
head/trunk
◦ Action/Intention Tremor: occurs with
motion
*hallmark signs of PD
Parkinson’s Disease- Associated
Symptoms1
◦ Strength loss
◦ Delayed and under-recruitment
◦ Poor motor planning and dual tasking
◦ Gait disturbances
◦ Hypokinetic dysarthria
◦ Low voice volume and hoarseness
◦ Monotone
◦ Distorted articulation
◦ Uncontrolled speech rate
◦ Cognitive dysfunction
◦ Dementia and slowed thinking
◦ Depression and anxiety
◦ Autonomic dysfunction
◦ Sleep disorders
◦ Daytime sleepiness
◦ Insomnia
◦ Active, vivid dreaming
 Parkinson’s Disease- Staging1
◦ Hoehn-Yahr Classification of Disability

◦ Stage 1: unilateral, minimal symptoms

◦ Stage 2: Minimal bilateral involvement, no balance concerns
◦ Stage 3: Impaired balance with turning, righting reflexes impaired, grossly
independent
◦ Stage 4: Systemic involvement, requires assistance with mobility
◦ Stage 5: Bedridden or wheelchair ridden
Parkinson’s Disease- Current
Research
◦ People with Parkinson’s who exercise at least 2.5 hours per week have a higher quality
of life and improved mobility6

◦ General exercise is beneficial, however physical therapy allows for long term
maintenance of gains (HY II)7

◦ Consistent exercise demonstrates improvement in gait cadence both on- and off-
medication8

◦ Treadmill training improves mood, cognitive function9

Multiple Sclerosis- Pathophysiology3
◦ Immune response
◦ T cells, CD4+ cells, helper T cells, B cells
◦ Cross blood-brain barrier
◦ Activate auto-antigens
◦ Results in cytotoxic effects within the CNS
◦ Macrophages phagocytize the myelin sheaths
◦ Results in slowed nerve conduction, neural fatigue, and eventual conduction blocks
◦ Following…
◦ Acute inflammatory event with edema and monocytes, macrophages, and microglia
◦ Results in a mass effect
◦ Abnormal increase in pressure
◦ Inflammation subsides and restores some conductivity to nerve
Multiple Sclerosis- Pathophysiology3
◦ Oligodendrocytes are spared in initial attacks
◦ Allows for some remyelination
◦ Demyelinated nerves eventually undergo gliosis
◦ Plaque formation due to proliferation of fibrous astrocytes
◦ Leads to axon degeneration
◦ Most commonly affects white matter initially, and then progresses to gray matter
◦ Optic nerves
◦ Periventricular white matter
◦ Corticospinal tracts and posterior white columns of spinal cord
◦ Cerebellar peduncles
Multiple Sclerosis Subtypes3
◦ Relapsing-Remitting
◦ Most common
◦ “Attacks” of neurological symptoms with full/partial recovery
◦ Secondary-Progressive
◦ Begins as relapsing-remitting
◦ Decline in function with or without attacks
◦ Primary-Progressive
◦ Steady functional decline with no attacks
◦ Later onset in life (>40 years old)
◦ Progressive-Relapsing
◦ Most rare
◦ Steady functional decline with attacks
Multiple Sclerosis- Signs/Symptoms
◦ Initial symptoms3,10:
◦ Diplopia
◦ Paresthesias
◦ Weakness
◦ Fatigue
◦ Pain
◦ Difficulty walking
◦ Onset can occur quickly or slowly
Multiple Sclerosis- Common
Complaints3
◦ Sensation changes ◦ Fatigue
◦ Pain ◦ Coordination/balance
◦ Shooting, sharp, shocking, burning ◦ Speech/swallowing
◦ Hypersensitive
◦ Cognitive deficits
◦ Visual disturbances
◦ Depression
◦ Motor
◦ Upper motor neuron symptoms ◦ Emotional changes
◦ Weakness ◦ Bladder/bowel
◦ Slow, stiff, weak ◦ Sexual dysfunction
◦ Spasticity
◦ Fluoxetine, sertraline, paroxetine can
exacerbate spasticity
Multiple Sclerosis- Current Research
◦ High intensity training for cardiovascular and resistance training is beneficial for
improving muscle strength and contractility, endurance capacity, and body
composition11

◦ Cognitive processing speed improves with progressive treadmill walking program12

◦ Endurance training + resistance training improves mobility, balance, strength,

endurance, and coordination within tolerable levels10

◦ Limited Vitamin D and sun exposure in childhood could increase chances of being
diagnosed with MS and further lead to increase chance of relapse13,14
Conclusions…
◦ Exercise improves quality of life for people diagnosed with MS and PD
◦ Treadmill training for extended periods of time is beneficial for mobility and cognition
◦ Interval training is beneficial for larger gains in cardiorespiratory fitness and strength

◦ Side note…
◦ People appreciate when you focus on their impairments related to pain, but keep the disease
in the back of your mind
References
1. O’Sullivan SB, Bezkor EW. Parkinson’s Disease. In: O’Sullivan SB, Schmitz TJ, Fulk GD, ed. Physical Rehabilitation. 6th ed. Philadelphia, PA: F.A. Davis Company; 2014; 807-844.
2. What is neurodegenerative disease? Joint Programme-Neurodegenerative Disease Research website. http://www.neurodegenerationresearch.eu/about/what/. Updated
2017. Accessed March 11, 2018.
3. O’Sullivan SB, Schreyer RJ. Multiple Sclerosis. In: O’Sullivan SB, Schmitz TJ, Fulk GD, ed. Physical Rehabilitation. 6th ed. Philadelphia, PA: F.A. Davis Company; 2014; 721-755.
4. Related Conditions. National MS Society website. https://www.nationalmssociety.org/What-is-MS/Related-Conditions. Accessed March 11, 2018.
5. Lewy Body Dementia. Lewy Body Dementia Association website. https://www.lbda.org/category/3437/what-is-lbd.htm. Updated 2016. Accessed March 10, 2018.
6. Rafferty MR, Schmidt PN, Luo ST, et al. Regular exercise, quality of life, and mobility in Parkinson’s disease: A longitudinal analysis of National Parkinson’s Foundation quality
improvement initiative data. J Parkinsons Dis. 2017;7(1):193-202. doi: 10.3233/JPD-160912.
7. Dipasquale S, Meroni R, Sasanelli F, et al. Physical therapy versus a general exercise programme in patients with Hoehn Yahr stage II Parkinson’s disease: A randomized
controlled trial. J Parkinsons Dis. 2017;7(1):203-210. doi: 10.3233/JPD-161015.
8. Rafferty MR, Prodoehl J, Robichaud JA, et al. Effects of 2 years of exercise on gait impairment in people with Parkinson disease: The PRET-PD randomized trial. J Neuro Phys
Ther. 2017; 41(1): 21-30. doi: 10.1097/NPT. 0000000000000163.
9. Picelli A, Varalta V, Melotti C, et al. Effects of treadmill training on cognitive and motor features of patients with mild to moderate Parkinson’s disease: A pilot, single blind,
randomized controlled trial. Funct Neurol. 2016;31(1): 25-31.
10. Charron S, McKay KA, Tremlett H. Physical activity and disability outcomes in multiple scleroisis: A systematic review (2011-2016). Mult Scler Relat Disord. 2018;20:169-177. doi:
10.1016/j.msard.2018.01.021.
11. Wens I, Dalgas U, Vandenabeele F, et al. High intensity exercise in multiple sclerosis: Effects on muscle contractile characteristics and exercise capacity, a randomised
control trial. PLoS One. 2015; 10(9). doi: 10.1371/journal.pone.0133697.
12. Sandroff BM, Wylie GR, Sutton BP, Johnson CL, DeLuca J, motl RW. Treadmill walking exercise training and brain function in multiple sclerosis: Preliminary evidence setting the
stage for a network-based approach to rehabilitation. Mult Scler J Exp Transl Clin. 2018;4(1). doi: 10.1177/2055217318760641.
13. Simpson Jr S, van der Mei I, Lucas RM, et al. Sun exposure across life course significantly modulates early multiple sclerosis clinical course. Front Neurol. 2018;9. doi:
10.3389/fneur.2018.00016.
14. Tremlett h, Zhu F, Ascherio A, Munger KL. Sun exposure over the life course and associations with multiple sclerosis. Neurology. 2018. doi: 10.1212/WNL.0000000000005257.
QUESTIONS?