Pt neuro degenerative disease of the brain especially affecting Substantia nigra

> maximal when the limb is at rest, and decreased

with voluntary movement.

> stiffness; increased muscle tone. In combination

> respectively, slowness or absence of movement. > failure of postural reflexes, whi leads to impaired balance.

Shuffling Stooped, forward-flexed posture Festination Gait freezing Dystonia

Drooling Dysphagia

Mood disturbances depression Cognitive disturbances slowed reaction Short term memory loss Sleep disturbances - insomnia

Visual problems. Dizziness. Loss of smell.

Urinary incontinence Weight loss Altered sexual function Nocturia

Based on history and clinical examination a diagnosis of Parkinson's disease is made if two of the four cardinal features are present. INVESTIGATION CT ( computerized tomography scan ) MRI ( magnetic resonance imaging )

NAME : Madam M AGE : 45 years old SEX : Female OCCUPATION : Journalist DATE OF ADMISSION : 8/Feb/2011 DATE OF ASSESSMENT : 1/Sept/2011 DOCTOR DIAGNOSIS : Parkinson disease DOCTOR MANAGEMENT : Conservative 1. Medication 2. Referred physio

CHIEF COMPLAINT : Pt complaint mild shaking Rt side of hand occur, sometimes disturbed pt writing & eating.

: Difficulty to initiate walking

: Difficulty to do ADL

PRESENT HISTORY : Patient fall down while go to toilet because of headache. : Her daughter send her to the Hospital because bleeding at knee but fracture non seen. : Have admitted at Hospital 1 week because on the same time she had hypertension. PAST HISTORY : NIL

MEDICATION : Aspirin : Madopar FAMILY HISTORY : Her mother had Parkinson disease. PERSONAL HISTORY : Non smoking and alcoholic .

BUILT OF PATIENT : Mesomorphic (medium ) POSTURE : Stooped posture GAIT : Shuffling gait

LOCAL
DOMINANT HAND : Rt side DEFORMITY : Nil SWELLING : Nil SKIN COLOR : Normal

MUSCLE TONE : Normal TENDERNESS : NIL TREMORS : Present (Rt side UL ) EDEMA : NIL

HIGHER MENTAL FUNCTION ORIENTATION ( NAME, PLACE, TIME ) Intact MEMORY : Short term memory Intact : Long term memory Absent

BEHAVIOUR Intact INTELLIGENCE Intact

NAME Olfactory

RESULT - intact - Pt can identify a smell such as coffee, fragrance & more - intact - Pt can see superior & inferior with a finger moving - intact - Pt can able to see side by side - intact - Pt can able to move her eyes until nose - intact - Pt can able to feel when the therapist touch

Optic Occulomotor Trochlear Trigeminal

Abducens

- intact - Pt can able to follow when hand movement done by therapist

Facial Vestibulocochlear

- intact - Pt can smile, sad - intact - Pt can able to hear the sound

Glossophalangeal

- intact -Pt can able to up & down the tongue with rolling it
- intact - Pt can able to say ARGHHH - impaired - Pt unable elevate the shoulder - impaired - Pt unable to move side by side her tongue

Vagus Accessory

Hypoglossal

Full ROM for upper limb active & passive Full ROM for hip & knee joint active & passive
ANKLE ACTIVE RIGHT ACTIVE LEFT PASSIVE RIGHT PASSIVE LEFT

DORSIFLEXION

15

10

20

15

PLANTARFLEXION
INVERSION EVERSION

30
13 13

30
13 13

35
15 15

45
15 15

RIGHT UPPER LIMB LOWER LIMB ( HIP & KNEE ) ANKLE 4/5 4/5 4/5

LEFT 4/5 4/5 4/5

Superficial sensation

TOUCH apply light touch using sponge Result : intact ( grade 2 )

PAIN using disposable needle Result : intact ( grade 2 ) TEMPERATURE give the patient object with different temperature ( warmth or cold ) 0 no sensation 1 absent 2 normal

DEEP SENSATION
VIBRATION SENSE Poor

POSITION SENSE Good

CORTICOL SENSATION STEREOGNOSIS Fair BARGNOSIS Poor GRAPHESTHIA - Fair 2 POINT DISCRIMINATION Poor

COORDINATION
EQUILIBRIUM Walking in straight line Fair ( Pt can able to walking without helping ) Marching in the same spot Good ( Pt can able to do marching by her self ) Walking in the sideways Fair ( Pt can able to walking in a side way without helping ) Walking in the circle Fair ( Pt can able to move & doing circle without helping )

NON EQUILIBRIUM
Finger to nose Fair
Finger to finger Fair

Finger to opposition Fair

Heel to shin Good

SITTING : intact STANDING : absent

SITTING : intact STANDING : absent

ACTIVITIES Ambulation Bed Mobility Dressing Eating Toileting Combing Climbing Stair

GRADE 4 6 6 3 3 3 3

Postural problem due to pathological changes Walking problem due to loss of balance or coordination Difficulty in ADL activities

SHORT TERM GOAL To improved balance To improved posture To improve gait Increase muscle power LONG TERM GOAL To improve ADL activities

RESPIRATORY EXERCISES Purse lip breathing exercises FLEXIBILITY EXERCISES Passive ROM Active ROM GAIT EXERCISES Parallel bar POSTURE EXERCISES Mirror feedback

BALANCE ACTIVITIES Gymnastic ball Marching

Ask patient to sit with correct posture, with minimal assistance Gait training