Parkinson’s disease: from the first symptoms to diagnosis and therapy

Parkinson’s disease symptoms are very diverse. They begin with trembling of the hands and extend to complete blockage or the complete freezing of body parts. Parkinson’s disease is therefore also known colloquially as shaking paralysis. The neurodegenerative disease progresses very slowly and usually appears after the age of 50. What are the early symptoms? How does the disease progress? And what therapies are available? – You can find out all about this in this blog post.

The development of Parkinson’s disease – what happens in the body?

When suffering from idiopathic Parkinson’s (without discernible cause), the dopamine-producing nerve cells in the mesencephalon (substantia nigra) slowly die. The reason for this is still unknown. The falling dopamine level in the brain results in impaired communication between nerve cells and an imbalance of neurotransmitters. The body can compensate for this deficiency sufficiently for quite some time so that it goes unnoticed by the patient. The first typical symptoms occur once approximately 60 % of dopamine-producing nerve cells have died. It is hypothesized that this causes the shaking (tremor) that is so typical for Parkinson’s disease.

Does Parkinson’s start in the intestines?

It is becoming more evident that the nervous system in the abdomen is closely linked to the brain. Animal studies were able to show that incorrectly shaped proteins (alpha-synucleins) form in the digestive tract and can spread along the vagus nerve into the brain. Whether Parkinson’s actually starts in the digestive tract and the consequences for treatment options remain open at this time.

How is Parkinson’s disease diagnosed?

Parkinson’s disease is often diagnosed based on its typical symptoms. The severity of the disease is assessed based on the Hoehn and Yahr Scale, amongst others. It records the disruption of movements. The Unified Parkinson’s Disease Rating Scale (UPDRS) is another standardized tool for recording clinical symptoms.

Physicians and therapists may perform additional active and passive movement tests to get a clearer picture of the disease presentation and progression:

• Quick movements like screwing in a lightbulb are no longer possible (dysdiadochokinesis).
• Passive movement, such as of the elbow joint, results in the cogwheel phenomenon, i.e. the relaxation of muscles in short bursts.
• Tests to check balance and posture stability are also performed (Berg Balance Scale, Timed Up and Go Test).

Imaging technology such as CT or MRI can be used to exclude other diseases with similar symptoms.

If Parkinson’s is suspected but not confirmed, specific medication can be used to clarify the diagnosis. If the symptoms improve with medication, the patient likely has Parkinson’s. If no change is observed, there may be other causes for the Parkinson’s-like symptoms (secondary or atypical Parkinson’s syndrome).

Sources:

Parkinson Disease, 2020

Physiotherapy in Parkinson’s Disease: A Meta-Analysis of Present Treatment Modalities, 2020

In vivo distribution of α-synuclein in multiple tissues and biofluids in Parkinson disease, 2020

Deep Brain Stimulation in Parkinson’s Disease, 2019

Initiation of Parkinson’s disease from gut to brain by δ-secretase, 2019

Chronic stress-induced gut dysfunction exacerbates Parkinson’s disease phenotype and pathology in a rotenone-induced mouse model of Parkinson’s disease, 2018

Motor assessment in Parkinson’s disease, 2017

Aphasia is a speech disorder. It is caused by damage to the brain or the brain areas which are responsible for speech control, speech comprehension, and non-verbal aspects of speech.

Aphasia mostly occurs following non-progressive cerebral damage, as with a stroke. An acute new speech disorder is one of the main symptoms (FAST principle) for a stroke.

Types of aphasia

Broca aphasia (expressive aphasia)

Broca aphasia mainly affects the ability to produce speech. Aphasia patients often speak very slowly, seem to take a long time to order their thoughts, or seem unable to find the right words. Any communication takes place in “telegraphic speech”: Affected patients speak in sentences containing only one or two words, often with grammatical errors. Also articulation of words (dysarthria) reading and writing are affected.

Speech comprehension is often not or only partially affected.

Many of those who are affected are impatient with the inability to express themselves or with the long-time communication needs. This can reduce verbal communication even more.

Wernicke aphasia (sensory aphasia)

Patients with Wernicke aphasia often talk a lot and use words incorrectly. They do not realize that their speech lacks coherence and meaning.

Patients also struggle to understand others, to read, and to write. Sometimes, this means verbal communication is impossible. Non-verbal communication is possible to a certain extent.

Affected patients often respond to their surroundings with severe incomprehension. They cannot understand why the person they are talking to cannot understand them.

Amnesic aphasia

Amnesic aphasia mainly affects the ability to find the rights words. Speech comprehension, reading, and writing are usually only moderately affected. Communication with the patient is reasonably easy.

Global aphasia

Severe strokes affecting the middle cerebral artery (Arteria Cerebri Media) can cause both expressive and sensory aphasia, resulting in a complete loss of both the ability to speak and to understand speech. Affected patients use many automatisms, repeat phrases over and over, or speak little to not at all. Reading, writing, and body language are also affected.

This makes communicating with stroke survivors affected by global aphasia extremely difficult and requires patience and empathy from those involved.

Diagnosis of Aphasia

Speech disorders often occur in connection with a stroke. If there is no obvious cause for a speech disorder, it is necessary to exclude other possible reasons (deafness, etc.).

Parameters for diagnosing speech disorders

• Spontaneous speech: How many words are used? How fluent is the speech? Does the patient hesitate?
• Repetition: Is the patient able to repeat complex grammatical structures?
• Comprehension: Does the patient identify the named objects? Are they able to follow simple or complex instructions? Is the patient able to answer simple or complex yes-or-no questions?
• Naming objects: Patients often paraphrase (using phrases such as “the thing you use to tell the time” instead of “clock”).
• Reading and writing: The abilities to understand written words, to spell correctly, and to write from dictation are assessed.

Standardized aphasia tests are carried out to diagnose aphasia.

How to better communicate with aphasia patients

SPEAKING

1. Create a calm environment.
2. Speak calmly, not too fast, but normally and at a normal volume.
3. Use short sentences. Small pauses between sentences can help the other person to understand you better.
4. Use more non-verbal signals. In addition to tone, facial expressions, and body language, writing and images can help affected patients follow to the conversation.
5. If the other person does not immediately understand you, try rewording.
6. Where possible, use yes-no questions instead of open questions.
7. Have one-on-one conversations, as patients with aphasia find personal conversations easier than group discussions.

UNDERSTANDING

1. Listening means waiting: The patient needs more time to say something.
2. Listen with your heart: Try to understand what the patient is trying to tell you.
3. Listen beyond the language: Do not interrupt or correct all the time. Just wait, the meaning often becomes clear.
4. Let the situation speak: Thinking ahead and carefully observing the situation will help you to understand.
5. Try and decipher the meaning of a statement together with the patient. Be aware of non-verbal communication.
6. In the case of perseverating repetitions interrupt and distract.
7. Don’t give up! Use the key phrase: “We’ll figure it out together – start again!”
8. Hyperfocusing does not work! If needed, use the key phrase: “Maybe you can tell me later.”

Sources:

Lutz, L. (2011). Das Schweigen verstehen, Über Aphasie. Springer-Verlag Berlin Heidelberg

Efficacy of Intensive Aphasia Therapy in Patients with Chronic Stroke: A Randomised Controlled Trial, 2018

Aphasia Recovery: When, How and Who to Treat?, 2018

Screening tests for aphasia in patients with stroke: a systematic review, 2017

Multiple Sclerosis – How the autoimmune disease turns life upside down

Repeatedly twisting an ankle, tingling or numbness in one arm or leg, great fatigue throughout the day or blurred vision can be symptoms of multiple sclerosis (MS).

Multiple sclerosis (Encephalomyelitis disseminata) is one of the most common neurological disorders. The typical age of onset is between 20 and 40 years old. An MS diagnosis raises many questions for patients as well as for their relatives. This article tries to provide some answers.

Causes of MS

MS is a chronic inflammatory autoimmune disease. The immune system attacks the body’s own cells in the patient’s brain and spinal cord.

Despite worldwide research, the causes of MS are not yet clear. Classical MS theory assumes that three factors cause the condition to manifest:

• Genetic predisposition: Approximately 15% of MS patients have immediate or extended family members who were also diagnosed with MS
• Environmental influences in childhood: Viral infections (e.g. Epstein-Barr virus) or vitamin D deficiency
• Trigger event in adulthood: It is not yet absolutely clear what such a trigger event might be. In most cases, emotional stress precedes the first acute episode of the disease.

There is a consensus in the scientific community that complex interactions of environmental, genetic, and epigenetic factors are the probable cause for onset of the disease.

What are the symptoms of MS?

The symptoms are varied and manifest differently in each patient. This is why MS is also called the “disease of a thousand faces”.

There are different types of MS. In most cases (85–90%), the disease is intermittent-relapsing.

Neurological symptoms appear relatively suddenly, subside over several weeks, and often regress completely.

MS is not always diagnosed immediately. A diagnosis may take years.

As the disease progresses, symptoms may not regress completely after an acute episode, leaving residual impairments. The condition can become chronic, and symptoms may gradually worsen over time.

In rare cases (10–15%), the disease progresses from onset. This form has no distinct acute episodes.

The symptoms vary depending on the areas of the brain and/or spinal cord affected by inflammatory lesions. Some possible symptoms include:

• Optic neuritis (inflammation of the optic nerve) – Common first symptom; deterioration of vision, usually in one eye; foggy or hazy vision; pain may occur.
• Paresthesia Common first symptom; sensory impairments such as tingling, tightness around joints, numbness; often described as a sock-like or glove-like sensation; difficulty sensing temperature.
• Ocular motility disorder – e.g. double vision; nystagmus (uncontrolled horizontal or vertical eye movements).
• Paresis (weakness) / plegia (paralysis) – Initial mild weakness, such as “tiredness” in an arm or leg; frequent ankle twisting or joint stiffness; paralysis is rare in early stages.
• Coordination Problems– Often develop during the disease course; e.g. vertigo, loss of balance, tremors.
• Vegetative dysfunction – Changes in bladder function, frequent urinary tract infections, sexual dysfunction, altered sweating.
• Psychophysical symptoms – Fatigue (abnormal fatigability), marked exhaustion that improves with rest.
• Psychological changes – Cognitive impairment, such as reduced attention or cognitive performance; depression.

MS has many faces:

• Appoximately1/3 of patients with MS experience no significant impairment throughout their life.
• Approximately 1/3 of patients with MS experience limitations that interfere with everyday activities. Living a normal life is mostly possible (e.g.: professional occupation, family planning).
• Approximately 1/3 of patients with MS experience significant impairments (e.g.: inability to work, loss of ability to walk).

Author: Saskia Wibner

Sources:

Wiendl, H., Korsukewitz, C. & Kieseier, B. (2021). Multiple Sklerose: Klinik, Diagnostik und Therapie. 2. Erweiterte Auflage. Kohlhammer Verlag

Hansen, S., Wettinger, L. & Keune, P. (2021). Multiple Sklerose. Hogrefe Verlag.

Epigenetic aspects of multiple sclerosis and future therapeutic options (2021)

Multiple Sclerosis Epidemiologic, Clinical, and Therapeutic Aspects (2017)

Differential diagnosis of multiple sclerosis and other inflammatory CNS diseases (2019)

Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews (2019)

Sensor-based technology for upper limb rehabilitation in patients with multiple sclerosis: A randomized controlled trial (2020)

Neuroplasticity – How learning and rehabilitation work

The human nervous system consists of the central nervous system and the peripheral nervous system. The brain and spinal cord form the central nervous system. As “conductors,” the nervous system orchestrates everything happening in the human body.

How our brain, spinal cord, and body communicate

The peripheral nervous system extends throughout our bodies like a network. It acts as a “scout” and reports external information to the spinal cord and on to the brain. Simultaneously, it forwards instructions from the brain through the spinal cord to the arms, legs, and other parts of the body. The nervous system and the body are in constant communication, using electrical signals.

The following are examples of how the central and the peripheral nervous systems work together:

• Our skin contains cells that are part of the peripheral nervous system. They send information via the spinal cord to the brain, such as the ambient temperature. When the brain receives the information “it’s hot,” it activates the sweat glands to cool the body down. When it gets the information “it’s cold”, it triggers muscle contractions to heat the body through shivering.
• Our nose is also part of the peripheral nervous system, detecting smells. The brain identifies the smell and reacts accordingly. Based on previous experiences, the smell of fresh cake stimulates our appetite.

Brain plasticity or how we learn

Imagine our brain and spinal cord like a network of roads – some are used all the time, and some are hardly used at all. Motorways form the busiest roads. Routes seldom used fall into disrepair and become narrow paths with a cracked surface.

After a neurological injury, we need to start using the narrow paths more often to turn these into motorways. Slowly but steadily, the human brain and spinal cord start to improve these paths and create new motorways.

In neuroscience, the term “plasticity” refers to the brain’s and spinal cord’s ability to modify its cells’ architecture, structure, and function. The brain and spinal cord are adaptable like plastic. Hence the term “neuroplasticity”.

Do you remember what it was like to drive a car for the very first time? Placing the clutch, selecting a gear, looking over your shoulder to keep an eye on traffic – all of that can be very overwhelming. After gaining experience over time, driving happens virtually automatically. This is neuroplasticity at work!

How the brain and spinal cord change

Neurogenesis – continuous formation of new nerve cells (no matter the age!)

New synapses – new experiences create new nerve cell connections

Enhanced synapses – frequent repetition and practice strengthen nerve cell connections

Weakened synapses – unused connections become weaker or even inactive

Author: Michaela Partel

Sources:

Annunciato, N. (2021). Training: Plastizität des Nervensystems. Vienna: Physiozentrum für Weiterbildung

De Gruyter, W. (2017). Pschyrembel. Klinisches Wörterbuch. 267th edition Berlin / Boston

Nowak, D. (2011). Handfunktionsstörungen in der Neurologie. Würzburg: Springer Verlag

Principles of Experience-Dependent Neural Plasticity: Implications for Rehabilitation After Brain Damage, 2008

De Marées, H. (2003). Sportphysiologie. Köln: Sportverlag Strauss

Increased Cortical Representation of the Fingers of the Left Hand in String Players, 1995

Patient Motivation: The role of health data in physical and occupational therapy

Patients often experience multiple side effects as a result of a stroke or traumatic brain injury (TBI). In addition to the physical limitations, the health event can alter a patient´s life forever.

That realization can be hard to accept. Not surprisingly, many post-stroke patients struggle emotionally with problems like low self-esteem and lack of hope. They can also feel lethargic and unmotivated. A very high percentage of stroke survivors faces mental health crises, like depression and anxiety.

With these barriers in mind, how can physical and occupational therapists motivate their patients to keep moving forward in their recovery?

Health Data is the answer

Data is increasingly becoming the heart of everything we do — and healthcare is no different. Objective data from rehabilitation technology can help doctors and therapists to adapt the therapies according to the patients progress.

Numbers foster motivation and can generate hope in patients. By seeing daily or weekly improvements, patients tend to perform more exercise repetitions and exert more effort.

All Tyromotion devices include TyroS, a sophisticated therapeutic software developed by and together with therapists. TyroS uses gamification and data to help patients in the following ways:

1. Make Therapy Fun and Engaging

Games like Pac-Man and Asteroids have remained popular for a reason. Gaming harnesses our intrinsic desire to perform and reach higher goals. Competition, even with oneself, can be a critical motivator, and it fits perfectly into the rehabilitation environment.

Gamification of therapy takes otherwise dull and mundane tasks and makes them fun and engaging. For instance, patients are encouraged when they receive positive feedback or when they beat their own high score.

In addition to the instant feedback of gaming, therapists can share a more global picture of progress. Daily, weekly or monthly analytic reports help patients further visualize their achievements.

Since advanced rehabilitation technology is software-based, grading treatment plans is simple. Therapists can start with easier exercises and develop personalized programs based on patient ability and progress.

These devices also allow patients to move through therapy at their own speed. When a patient is ready, the therapist can increase the difficulty of each task to fit the client’s individual needs. Grading can also help the therapists to ‘push’ patients on by increasing the difficulty.

3. Relearn Activities of Daily Live (ADLs)

Sensor-based technology is helping patients of varying impairments relearn the so-called activities of daily living like dressing or feeding. Tyromotion’s sensor-enabled devices, including Pablo , Pablo Lower Extremity and Tymo, provide meaningful data that measures:

• Overall movement
• Limb flexion and extension
• Exerted force
• Gait parameters
• Asymmetries in gait patterns
• Stability and coordination

Neurological events such as stroke or traumatic brain injury can take away a great deal from the affected person. Data and gamification can help to increase motivation and redirect focus in a positive way.

Progress, whether slow and steady or rapid, is a step forward in recovery. Data offers objective markers that can provide hope and inspiration to patients as well as ultimately lead to better outcomes.

Sources:

Emotional & Behavioral Effects of Stroke

Design strategies to improve patient motivation during robot-aided rehabilitation (2007)

Advanced Rehabilitation Technology offers Hope to pediatric Patients

Over the past decade, the rehabilitation sector has made great strides in incorporating advanced technologies into the pediatric rehab environment. This includes designing adjustable devices to offer the benefits of advanced rehabilitation technology to even the smallest of patients.

The Role of Fun in pediatric Rehabilitation

Modern therapy devices allow children to train in a playful way. Therapy programs look and feel a lot like computer or console games. All of a sudden, therapy isn´t that frightening anymore. These devices prove that fun and monotonous therapy tasks can be combined.

Modern rehabilitation devices encourage a children’s natural play instincts. They practice necessary movements and have fun in therapy. Motivation increases. The children want to get better and better. Beating their own high score becomes the goal. The improvements children may see after physical or occupational therapy can instill a sense of self-confidence and foster independence.

The next few years will bring further progress in the rehabilitation of children and adolescents. This gives hope to young patients and parents.

Sources:

Effects of interactive robot-enhanced hand rehabilitation in treatment of paediatric hand-burns: A randomized, controlled trial with 3-months follow-up (2020)

Devices and Protocols for Upper Limb Robot-Assisted Rehabilitation of Children with Neuromotor Disorders (2019)

The effect of interactive computer play on balance and functional abilities in children with moderate cerebral palsy: a pilot randomized study (2019)

Hand Robotic Therapy in Children with Hemiparesis: A Pilot Study (2017)

Does Interactive Hand Rehabilitation Experiences an Improvement of Upper Limb Function in Hemiplegic Children? A Double Blind Randomized Controlled Trial (2016)

Shoulder and hand pain after a stroke: Prevention of pain syndromes

Paralysis is a common symptom after a stroke, especially of the upper limb. In addition, sensory disorders and depression can lead to inattention to the affected arm or hand.

It is not uncommon for stroke survivors to lie on their paralyzed arm or for the affected fingers to get caught in the spokes of the wheelchair. The resulting injuries can lead to severe pain and significantly delay the rehabilitation process.

Pain syndromes in the hand or shoulder after a stroke

When pain symptoms begin, for example in the shoulder, the pain is usually localized to one area of the shoulder joint. If not addressed in a timely manner, it can become a severe, generalized pain.

The paralyzed hand is particularly at risk of developing permanent limitations in mobility due to pain symptoms. Here, the typical signs of inflammation such as swelling, redness and heat are initially evident. To prevent pain, the hand is moved even less and the limitation in mobility increases. A vicious cycle begins.

If pain is already occurring in the wrist or shoulder, affected patients should consult medical advice. Medications can help to disrupt the pain process.

How to prevent pain in the hand and shoulder after stroke

To prevent pain symptoms, correct positioning of the arm or hand affected by paralysis should be started as early as possible.

The correct positioning in the wheelchair:

• Even for short distances, use a wheelchair table or arm support upon which the affected arm or hand can be rested.
• Provide a soft support surface (e.g. a towel).
• Place the affected hand palm down on the table.
• Some individuals find that a rolled-up towel or soft stuffed animal in the affected hand to be comfortable. If the fist involuntarily closes tightly around the fabric, it might be better to choose another object or talk to your therapist about suitable support materials, like splints.
• Make sure to sit up straight. This ensures a physiological joint position in the shoulder joint.
• The affected hand should be positioned in the patient’s field of vision.

If you are a wheelchair user, avoid long periods of poor sitting posture as best as possible. Be cognizant of positions that put your shoulder at risk of becoming painful.

The correct positioning while lying:

Even when lying down, care must be taken to ensure that neither the hand nor arm is trapped.

• Stretch the arm at a 90-degree angle at the side of the body.
• The wrist should be elevated to approximately the same level as the heart to prevent blockages in the arm and ensure lymphatic return.
• A pad under the arm can be helpful.

Particular care in the event of neglect

Preventive measures are more difficult when patients suffer from “neglect” as a result of a stroke. Patients with neglect ignore the affected half of the body or one half of the room. This increases the risk of injury.

If, for example, the patient sits on the neglected handtrapping it, the patient may perceive pain, but may not localize it or react to it. The hand can remain trapped for hours. This can lead to inflammation with severe swelling.

These patients in particular are dependent on support from relatives, caregivers, and therapists. Care must be taken to ensure that the positioning is closely monitored.

Neuropathic pain

Neuropathic pain is a nerve pain that occurs even without visible reason. The cause of this pain is associated with damage to the nerve tissue in certain parts of the brain or spinal cord. This pain is often described by patients as burning, stabbing, and shooting, but can also present as dull and pressing. It is usually excruciating pain.

If a diagnosis of neuropathic pain is made, medication is started early. Successful treatment requires interdisciplinary cooperation between doctors, therapists, and psychologists.

Injury-related pain in the upper limb after a stroke is not inevitable. Stroke patients, caregivers, and therapists should be particularly careful with the affected arm or hand in the initial period following the stroke.

Author: Hannes Aftenberger

Sources:

Diagnostik und Therapie komplexer regionaler Schmerzsyndrome (CRPS) (2018)

Kumar, P. (2019). Hemiplegic shoulder pain in people with stroke: Present and the future. Pain Management, 9(2), 107–110. https://doi.org/10.2217/pmt-2018-0075

How Advanced Rehabilitation Technology helps Spinal Cord and Brain Injury Patients

After a Spinal Cord Injury (SCI) or Traumatic Brain Injury (TBI) devasting long-term dysfunctions may occur. Physical, emotional and financial hardships may follow. Patients are often overwhelmed by the new life situation.

Advanced Rehabilitation Technology-based devices provide patients new hope during recovery. High intensity, large numbers of repetition and a game-based approach change occupational and physical therapy settings as we know it today rapidly.

Robotics, sensors, virtual reality, and gamification allow a patient’s attention to divert away from the stress and anxiety of their health problems.

Adjustable devices offer real-time feedback to the therapist and the patient. Data from each device can be analyzed to determine when to increase the difficulty of the exercises and to challenge patients to reach higher goals.

Read on to learn more about how advanced rehabilitation devices can help SCI or TBI patients.

Assessing and Building Life Skills after Spinal Cord Injury or TBI

Technology-based therapeutic devices can be used to assess and help reduce:

• Deficits in vestibular function and balance
• Impairments of executive dysfunction and memory
• Abnormalities in cognition and attention issues
• Difficulties with motor skills needed to live independently

Advanced rehabilitation technology can inspire patients with spinal cord and traumatic brain injury to persevere. From gait and balance therapy to upper and lower extremity exercises, technology-based devices push the limits of what is possible.

Sources:

Clinical Practice Guideline to improve Locomotor Function following chronic Stroke, incomplete Spinal Cord Injury, and Brain Injury (2020)

Virtual Reality Neurorehabilitation for Mobility in Spinal Cord Injury: A Structured Review (2019)

Report to Congress: Traumatic Brain Injury in the United States (1999)

Virtual Reality for Traumatic Brain Injury (2018)

Virtual Reality Neurorehabilitation for Mobility in Spinal Cord Injury: A Structured Review (2019)