PARKINSON’S DISEASE

 

PARKINSONISM

Progressive neurological disorder of muscle movement as a clinical syndrome consist of 4 cardinal features

§  Slowness of movement ( Bradykinesia )

§  Increased tone/ stiffness ( Rigidity )

§  Tremor

§  loss of postural reflexes

Most common parkinsonism is idiopathic (no known cause ) Parkinson's disease

PARKINSON’S DISEASE

• Parkinson's disease is a slowly progressive degenerative disease of nervous system associated with destruction of brain cells , which produce dopamine.

EPIDEMIOLOGY

• PD accounts for more than 80% of all parkinsonism.
• The prevalence shows a gradual increase after the age of 50 yrs and a steeper increase after age 60 yrs.
• Disease onset before age of 30 suggest a hereditary form of parkinsonism.

PATHO-PHYSIOLOGY

• Dopamine and acetylecholine are present in corpus striatum.
• Due to some unknown cause,
• There will be degeneration of dopaminergic neurons.
• Cause imbalance between dopamine and acetylcholine.

Cause for dopamine depletion is not found , so idiopathic Parkinson's disease

CAUSES

• Parkinson's disease occurs due to lack of dopamine.
• Caused by the damage of basal ganglia.
• It is mostly due to the destruction of substantia nigra and the nigrostriatal pathway, which has dopaminergic fibers.

Cause of idiopathic parkinsons disease ;

• Cigarette smoking
• Coffee drinking
• MPTP (methylphenyltetrahydropyridine)
• Pesticides/herbicides
• Heavy metal (iron, manganese)
• Hydrocarbon solvents
• Diet
• Genetic factors

CLASSICAL CLINICAL FEATURES

·         Resting Tremor

·         Cogwheel Rigidity

·         Bradykinesia

·         Postural Instability

Other clinical Features

·         Masked face expression

·         Dysphagia

·         Dysphonia

·         Akinesia

·         Hypokinesia

·         Dementia

·         Urinary retention

·         Constipation

DIAGNOSIS

• Parkinson's disease remains a clinical diagnosis.
• Routine laboratories are not helpful
• CT , MRI

TREATMENT

• 6 type of medications are available for symptomatic treatment; (help you manage problems with walking, movement and tremor)
• Anticholinergics
• Amanatide
• L-dopa
• Monoamineoxidase inhibitors
• Catechol-o-methyltransferace inhibitors
• Dopamine agonists

OTHER MEDICINES

• Dopamine promoter

Stimulates dopamine receptors in the brain.

• Antidepressant

Prevents or relieves depression and elevates mood.

• Cognition-enhancing medication

Improves mental function, lowers blood pressure and may balance mood.

• Anti-Tremor

Helps control tremor, shaking and unsteadiness.

SELF-CARE

• Physical exercise

Aerobic activity for 20–30 minutes 5 days a week

SURGICAL TREATMENT

• Deep brain stimulation

Deep brain stimulation involves implanting an electrode deep within your brain. The amount of stimulation delivered by the electrode is controlled by a pacemaker-like device placed under the skin in your chest. A wire that travels under your skin connects the device to the electrode.

• Implantation of cellular sourses of dopamine
• Degenerative process like ; gene therapy as well as cellular transplantation
• some of the symptoms of Parkinson's disease such as tremor are abolished by surgical destruction of basal ganglia or thalamic nuclei.

DIFFERENTIAL DIAGNOSIS

• Drug induced parkinsonism
• Parkinson plus syndrome

INSOMNIA

 

Insomnia is inadequate or poor quality of sleep because of difficulty in falling asleep, difficulty in maintaining sleep or waking too early in the morning

It is the most common sleep disorder in elderly.

Chronic Insomnia can lead to severe fatigue, anxiety, depression and lack of concentration.

Insomnia comes under Vata nanatmaja vikara and called as Anidra or Nidranasa in Ayurveda.

Is more common in persons aged more than 65 years and mainly in women than men

TYPES

·         Transient insomnia- lasting from a night to a week and is usually caused  by  traveling or sleeping in an unusual environment.

·         Short term Insomnia- lasts about two to three weeks and is usually attributed to emotional factors such as worry or stress.

·         Chronic Insomnia- occurs most nights and lasts a month or more

ETIOLOGY

• caused by stress Or life style changes
• medical or psychological condition
• About half of Insomnia cases have no identifiable cause.

Ayurveda believes that usually it is the vitiated vata which disturbs the natural body physiology and results in various types of sleep disturbances.  In Ayurveda  causes of  insomnias are pointed out by Caraka. REFER (Ca.su 21/55-57)

FACTORS AFFECTING SLEEP PATTERN

·    Smoking,  caffeine, alcohol

·     Disruption of circadian rhythms; such as shift work, change in work schedule.

·    Uncomfortable and unusual sleeping environment.

·    Psychiatric and neurological conditions

·     Biological factors- By advancement of aging

·     Sleep disordered breathing-sleep apnea

·      Chronic medical illness

·          Excessive computer work or watching T.V.

PATHOGENESIS

Sleep disorders are associated with an impairment of melatonin production. Melatonin produced by the pineal gland at night, plays a role in regulation of sleep-wake cycle and diminished-melatonin Secretion may cause insomnia.

CLINICAL FEATURES

·         Not feeling refreshed
·         Inability to sleep 
·         Drowsiness ,iritability
·     Difficulty in concentrating
·         Impaired ability to perform normal activities
·         Body-ache and heaviness of the body

INVESTIGATIONS

·         Polysomnography

·          Multiple sleep latency test (MSLT)

·         Thyroid function test

·         EEG

MANAGEMENT

Prevention :

·      Daily time table and proper sleeping environment.

·         Application of  ointment to the eyes (like ghee)

·         Head massage, comfortable bed, home and proper time.

·       Decrease use of  coffee and tea, especially in the late evening hours and avoiding alcohol

·         Taking a light and timely dinner, avoiding late night awakening.

·         Following an exercise schedule to reduce stress and help bring sound sleep.

 Medical management :

 Avoidance of aetiological factors

chronic medical illness should be treated first and smoking, excessive consumption of caffeine, alcohol, excessive computer work or T.V, watching should be avoided.

Pancakama procedures followed by Samana chikitsa

·         virecana with Eranda taila

·         Abhyanga , Padabhyanga

·         Siroabhyanga with medicated oils.

·         Sirodhara with medicated liquids (milk/water/oils(Narayana taila)  

·         Picu with Candanabala taila/ Himasagara taila

·         Takradhara

Drug therapy :

·         Single drugs : Asvagandha curna, Jatamansi curna, Bramhi  , Mandakaparni are effective in the management of insomnia.

·         Compound Formulations : Asvagandharista ,Sarasvatarista, Bramhi vați

Yogic Practices :

·         Practice of Pranayama and meditation

·         Suryanamaskara, Tadasana, Matsyasana, Makrasana, Bhujangasana, Padmasana, Pascimottanasana and Svasana

       Counseling : Advice the patient to;

·         Drink Warm milk.before going to bed

·         Do some light physical activities before going to bed

·         Take warm bath before bedtime

·         Sleep on comfortable bed

·         Use the bed and bedroom only for sleep

·         Maintain a regular sleep /wake up schedule

·         Practice yoga and meditation

·         Avoid stressful conditions

OSTEOARTHRITIS

DEFNITION

OA is a degenerative disease of synovial joints characterised by focal loss of articular hyaline cartilage with proliferation of new bone and remodeling of joint contour

 It is (inflammation) is a misnomer and there is no inflammation here and is a degenerative disease

·         occurs mainly in weight bearing joints like knee, hip

·         occurs mainly in age >65 yrs

·         more common in women

·         increased risk for those with family history

Main clinical features

Ø  pain

Ø  morning stiffness <30 mins

Ø  restricted functionality

ETIOLOGY

Ø  PRIMARY / IDIOPATHIC: When there is no obvious predisposing factor. Common form of OA.

o   Cause –Unknown

§  Common-in elders where there is no previous pathology. Its mainly due to wear and tear changes occuring in old ages mainly in weight bearing joints.

Ø  SECONDARY: When degenerative joint changes occur in response to a recognizable local or systemic factor.

Secondary OA  is due to  predisposing cause such as:

1.Injury to the joint

2.Previous infection

3.RA

4.CDH

5.Deformity

6.Obesity

7.hyperthyriodism

Primary OA ; more common than secondary OA

CLINICAL FEATURES OF OSTEOARTHRITIS

OA  can occur in any joint. commonly seen in hip and knee joint

one or few joints usually involved

Ø  PAIN - increase during movement

Ø  STIFFNESS -

•  Morning stiffness less than 30 minutes
• Stiffness also after prolonged period of inactivity

Ø  SWELLING - of affected joint

Ø  DEFORMITY -  genu varum in case of knee OA

Ø  CREPITUS - grating sensation on moving a joint

Ø  LOSS OF RANGE OF MOTION - due to osteophyte formation ,capsular thickening

RISK FACTORS

Ø  Age :  Age is the most potent risk factor for OA  OA is rare in under age 40  OA occurs in more than 50% of persons over age 70

Ø  Gender :  In general, arthritis occurs more frequently in women than in men. Before age 45, OA occurs more frequently in men; after age 45, OA is more common in women. OA of the hand is particularly common among women.

Ø  Hereditary Gene defect : A defect in one of the genes responsible for the cartilage component collagen can cause deterioration of cartilage.

Ø  Joint’s Abnormalities :  People with joints that move or fit together incorrectly, such as bow legs, a dislocated hip, or double- jointedness, are more likely to develop OA in those joints.

Ø  Obesity : Being overweight during midlife or the later years is among the strongest risk factors for OA of the knee

Ø  Joint overuse or injury  : Traumatic injury (ex. Ligament or meniscal tears) to the knee or hip increases your risk for developing OA in these joints. Joints that are used repeatedly in certain jobs may be more likely to develop OA because of injury or overuse

XRAY FINDINGS

Ø  JOINT SPACE NARROWING

Ø  OSTEOPHYTE FORMATION

Ø  SUBCHONDRAL SCLEROSIS

Ø  LOOSE BODIES WITHIN JOINTS

Ø  CYST FORMATION IN CORTICAL BONE

LAB FINDINGS

Ø  ESR, CRP - normal

Ø  RA factor, anti CCP – negative

TREATMENT PRINCIPLES

EDUCATION

Ø  Nonsystemic nature of disease

Ø  Prevent overloading of joint. Obesity!!

Ø  Appropriate use of treatment modalities

·         Importance of exercise program

·         Aids, apliances, braces

·         Medial treatments

·         Surgical treatment

EXERCISE

Ø  Important for cartilage nutrition

Ø  Some evidence that lack of exercise leads to progression of OA

Ø  Encourage full range low impact movements eg swimming, cycling

Ø  Avoid ;  

§  Prolonged loading

§  Activities that cause pain

§  Contact sports

§  High impact sports eg running

Quadriceps exercises for knee OA

Quadriceps exercises are of proven value for pain relief and improving function, and everyone with knee OA should be taught the correct techniques and encouraged to make these exercises a lifetime habit.

Use of trans cutaneous electrical  nerve stimulation

TENS as an adjunct to other therapy for pain relief at the knee joint .The use of acupuncture, TENS and other local techniques to aid pain relief in difficult cases of OA is often worthwhile.

AIDS AND APPLIANCES

Ø  Braces / splints

Ø  Special shoes/insoles

Ø  Mobility aids

Ø  Aids: dressing, reaching, tap openers, kitchen aids

Ø  Taping of patella in patello femoral OA

Use of a cane, stick or other walking aid. This patient ,who has hip OA, has found that she can reduce the pain in her damaged left hip by leaning on the stick in the right hand as she walks. The reduction in loading can be huge, and the effect on symptoms and confidence with walking very beneficial.

The use of shoes and insoles to reduce impact loading on lower limb joints. Modern sports shoes (‘trainers’)often have appropriate insoles. Alternatively, special heel or shoe insoles of sorbithane or viscoelastic  materials can be used. They may help relieve pain as well as reducing the peak impact load on the joints during walking.

MEDICAL TREATMENT

Ø  Simple analgesics: paracetamol , low dose ibuprofen

Ø  NSAID’s/Coxibs PRN regular

Ø  Intra-articular corticosteroids

Ø  Topical treatment  eg :  NSAID creams, capsaicin

Ø  ‘Chondroprotective agents’

SURGICAL TREATMENT  : Joint replacement surgery

BAMS SHALYATANTRA PREVIOUS YEAR QUESTION PAPER

BAMS SHALYATANTRA PREVIOUS YEAR QUESTION PAPER

PAPER 2 (2012 SCHEME)

10 marks

Explain the nidana, lakshana and chikitsa of anthravridhi (inguinal hernia)

Discuss the aetiopathogenesis, classification, clinical features and management of

carcinoma of brest

Explain fracture management and its complications

Describe clinical features, diagnosis and management of mootravridhi

Explain in detail about classification of Asthi Bhagna and its management.

Discuss the aetiopathogenesis, classification and management of Bhagandara.

Mention the Nidana, Samprapthi, Prakara and Lakshanas of Arsas and describe its

management briefly.

Define hernia and explain its classification, complications and management

Define Bhagandara. Classify it according to ancient and modern view along recent

advances.

Discuss the aetiopathogenesis, classification, clinical features and management of

Antra Vridhi.

Describe Kanda bhagna and management.

Define Hernia. Write its classification, complications and management.

 

5 marks

Pleehodara

Liver abscess

Mutravrudhi(Hydrocele)

Benign prostatic hypertrophy

Management of peptic ulcer

Murphy’s syndrome and Murphy’s sign

Umbilical hernia

Sandhimoksha types

Pancreatitis

Gudabhramsa

Dislocation of shoulder joint

Describe injury to brain

Fibro adenoma of breast

Lakshana and chikitsa of chidrodara

Liver abscess

Differential diagnosis of bleeding per rectum

Chaturvidha chikitsa of arshas

Treatment of bhagandara

Cholecystitis

Paraphimosis

Describe osteomyelitis.

Describe parinama soola and its management.

Describe the causes and management of esophageal varices.

Explain Jalodra and management.

Mention symptoms and management of Crohn’s disease.

Explain liver abscess and management.

Describe classification of renal calculi.

Describe benign prostate hypertrophy.

Explain ‘pleehodara’.

Describe diagnosis and management of femoral hernia.

Describe fibroadenoma of breast

Hydatid cyst.

Explain Gudabhramsha and its management.

Treatment of Ca of esophagus.

Explain the chikitsa of Parikarthika.

Shoulder joint dislocation and its management.

Explain about Siraja Granthi and its treatment.

Urethral stricture.

Classify cyst and mention its management.

Appendicular abscess and its management

Describe “Guda bhramsha”.

Explain Nidana, Samprapthi, lakshana and Chikitsa of ‘Parinama soola’.

Describe etiopathogenesis of acute pancreatitis along with management.

The clinical features of obstruction of large gut.

Rudhapada Kamala.

What is hydatid cyst and describe its etiopathogenesis.

The etiopathogenesis of urinary calculus from ancient and modern view.

Define femoral hernia and mention its surgical management.

Complications of appendicitis and their management in detail.

Classification of hemorrhoids (Arsha).

Majja paripaka (Osteomyelitis)

Hodgkin’s lymphoma

Congenital abnormalities of kidney

Colle’s fracture and its management.

Arsha’s and its various treatment modalities.

Causes of splenomegali

Classified head injuries and describe its complication.

Explain the surgical treatment of hydrocele

Gudaja arbuda

Explain Achalasiacardia and its management

 

3 marks

Clavicle fracture

Pleural abscess

Congenital pyloric stenosis

Sannirudhaguda

Parivarthika (Paraphimosis)

Ulcerative colitis

Shataponaka bhagandara

Cerebral contusion

Oesophagitis

Renal injury

Explain Pott’s disease

Benign prostatic hypertrophy

Paralytic ileus

Describe fracture of patella

Incisions in appendicectomy

Renal function test

Incisional hernia

Esophageal varices

Tortion of testis

Gulgulu panchapala choornam

Management of hydrocele.

Niruddha Prakasa (phimosis).

Hematuria.

Chronic pancreatitis.

Murivenna

Mooshika thailam

Retention of urine

Urethral stricture.

Gudabhramsa

Umbilical hernia.

Gulgulu panchapala churnam.

Describe ‘Nirudha prakasha’.

Explain Sharkararbuda.

Rupture of spleen and its treatment.

Explain ‘Mootra vridhi’.

Ano - rectal abscess.

Describe Gulma Upadrava.

Explain the indications for colostomy.

Causes for acalculous cholecystitis

The role of PSA in the diagnosis of prostatic pathologies.

Hydrocele

Phimosis

Parikartika

Asthi vidradhi

Fracture of femur neck

Musthadi marma kashayam

Pilonidal sinus

Pourusha grandhi sopham

Murivenna

Vasectomy

Charcoat’s tried

Inter vertebral disc prolapse

Indication of ESWL

Omentocele

Pseudo pancreatic cyst

Circumcision

Mutraghata

Shataponaka bhagandara

Pyloric stenosis

Oesophagial varices.