Basal Ganglia and Parkinson's Flashcards
What is the role of the basal ganglia?
act as a ‘way station’ by taking information, integrating it for complex modulation of motor behaviors and projecting back out to cortex for motor output
What neurotransmitter is produced in the substantia nigra?
Dopamine
What are the two main feedback systems for refining motor system output?
basal ganglia and cerebellum
What does the motor loop link and what is it’s role?
links the putamen, globus pallidus, and ventral lateral thalamic nucleus to the motor and premotor cortex
roles: movement selection and action, regulating muscle contraction, force, multi-joint movements, and sequencing
What does the basal ganglia motor circuit regulate?
- muscle contraction
- muscle force
- multi-joint movements
- sequencing of movements
True or False: the basal ganglia works directly with lower motor nuerons
False, there is no direct output to LMNs so basal ganglia works through 3 routes, the motor thalamus, pedunculopontine nucleus, and midbrain locomotor region
What disorder stems from excessive inhibition of the basal ganglia. (hypokinetic disorders)
What disorder stems from inadequate inhibition of the basal ganglia. (hyperkinetic disorders)
Parkinson’s
huntington’s disease, dystonia, tourette’s disorder, dyskinetic cerebral palsy
What is Parkinson’s Disease?
What is the result of Parkinson’s?
What are the common populations that are affected by Parkinson’s?
nuerodegenerative disorder of subcortical gray matter in the basal ganglia
Dopamine loss in PD=lose inhibitory control of indirect loop and excitatory control over direct loop=decreased movement
Most common in Caucasian males and the mean age of onset is in the early 60’s
What are the cardinal signs of Parkinson’s?
What other common movement symptoms are common?
TRAP:
- Tremor (resting)-diminshes with effort, increases w/ stress and fatigue
- Rigidity-not velocity dependant, commin in trunk, extremities and neck
- Akinesia/bradykinesia-correlates best with severity of loss of dopamine
- Postural instability-not common in early diagnosis
festinating gait freezing soft speech masked face dysphagia
What are common non-movement related symptoms for Parkinson’s?
-anosmia
-anxiety
-apathy
-bone health
-breathing difficulty
-cognitive changes
-nausea
-dysautonomia
-fatigue
hallucinations
-sleep disorders
-pain
True or False: The Rizzo diagnostic test for Parkinson’s is considered the gold standard for diagnosis.
False, there is no diagnostic test for Parkinson’s disease, the real gold standard is a neuropathological exam at autopsy as there is no biological marker that confirms the diagnosis of PD
diagnosis of PD is based on a clinical examination
What are the supportive criteria for diagnosing PD?
- clear and dramatic response to dopamine therapy
- levodopa-induced dyskinesia
- resting tremor of a limb
- diagnostic testing such as loss of olfaction and abnormal cardiac MIBG scintigraphy
What are the 9 absolute exclusions for diagnosing PD?
Negative Criteria
- unequivocal cerebellar abnormalities
- downward vertical supranuclear gaze palsy
- frontotemporal dementia
- parkisonism restricted to lower limbs over 3 years
- treatment with dopamine receptor blocker
- absence of response to levodopa
- unequivocal cortical sensory loss
- normal functional nueroimaging of dopaminergic system
- documentation of alternative condition known to produce parkisonism
What is the prognosis for Parkinson’s?
What are the progressive signs of PD?
It is a progressive disease for which there is no cure
- shift from unilateral to bilateral involvement
- increasing rigidity and postural flexion
- increasingly limited mobility and increasing need for assistance
- eventually w/c and/or bed-bound
- cause of death is usually pnuemonia
What are the stages for the Modified Hoehn and Yahr Scale?
Stage 1: unilateral symptoms-tremor, stiffness, slowed movement
Stage 1.5: unilateral symptoms plus axial involvement-postural problems
Stage 2: mild bilateral involvement and minor sxs: swallow, talk and decreased facial expression
Stage 2.5: bilateral involvement, recovers on pull test
Stage 3: bilateral involvement worsened. postural instability noticed. person is still independent
Stage 4: Severe disability, able to walk or stand unassisted but will need help with ADLs
Stage 5: person is confined to w/c or bed; needs total assistance
What are common early presentation for Parkinson’s?
- tremor
- micrographia
- slowness with ADL’s
- voice changes
- difficulty maneuvering in bed
- lack of arm swing with gait
- dragging the foot with walking
What is the primary objective for medical management for PD?
maximize control over the ‘target’ signs and symptoms by selecting appropriate drugs for each symptom
needs medical supervision as the response from patient for each drug may change over time and need to be managed
What are the advantages for levodopa/carbidopa medications for PD?
most effect for PD; prolongs capacity to perform iADLs
What are the advantages for dopamine agonist medications for PD?
Work by copying actions of dopamine in the brain
What are the advantages for COMT inhibitors medications for PD?
What are the advantages for MAO inhibitor medications for PD?
What are the advantages for anticholinergic agent medications for PD?
inhibits enzyme responsible for metabolism of levodopa
Slow the metabolism of dopamine
Used for treatment of tremor in younger patients
When would a patient be given deep brain stimulation?
In advanced stages of PD
it is a surgical implantation of electrodes into the brain
What are common ROM findings during the PT exam and eval with Parkinson’s?
What are common strength findings during the exam?
What are common coordination findings?
- rigidity
- posture misalignment
- limited cervical and trunk rotation
- hip flexor tightness
Strength should generally be WNL w/ a quick MMT screen
-you should do a 5x sit to stand to assess fall risk (over 16 seconds is correlated with fall risk)
Movements usually bradykinetic, i.e small and easily fatigued with repetition, usually dyskinesia are found however there should be no dysmetria
What sensory deficits are commonly observed in Parkinson’s patients? (as far as pain, occulomotor and visual deficits, olfactory disturbances, and proprioception)
MSK pain is common as well as central neuropathic pain
In early stages of PD visuoperceptual deficits are atypical but bradykinetic saccades is not uncommon in late stages of PD
typical to have olfactory disturbances such as loss of smell or odor detection/identification
decreased joint proprioception and sensory integration
How is cognition affected by Parkinson’s?
Dementia signs are common (poor planning, decision making and goal directed behavior)
True or False: There is a strong correlation between attention and the ‘pace’ domain of gait.
True, gait veloctiy, step length and step time are all correlated with attention as is gait variability and executive function
What MOCA score correlates with PD dementia?
Less than 21/30
Less than 26= mild cognitive impairment
How is a Pull test scored?
0=recovers independently, ankle reaction or takes 1-2 steps
1=3 or more steps backward but recovers independently
2=retropulsion, needs to be assisted to prevent fall
3=very unstable, tends to lose balance simulatneously
4=unable to stand without assistance
How do you score a Push-Release Test?
0=recovers independently with 1 step of normal length and width
1=two to three small steps backward, but recovers independently
2=four or more step backward, but recovers independently
3=steps but needs to be assisted to prevent a fall
4=falls without attempting a step or unable to stand w/o assistance
What functional assessments are useful for Parkinson’s evaluation?
- 6 MWT
- 10 meter walk test (tMDC =.18m/s for comfy pace .25 m/s for fast pace)
- Mini BESTest
- MDS-UPDRS-part 2 (covers speech, saliva management, eating, dressing, hygiene, etc.)
- FGA (MDC=4 points)
- 5x sit to stand 916 second cut off score for fall risk)
- 9 hole peg test (MDC is 2.6 sec for dominant hand and 1.3 sec for non-dominant)`
What test can assess dual tasking?
How do you calculate Dual Task Cost?
TUG cognitive
dual task cost= TUG cognitive-TUG/TUGx100=% od dual cost
What time on a 4 square step test correlates to increased fall risk?
over 9.68 seconds
What exam findings are atypical for idiopathic Parkinson’s?
early symptoms of incontinence, dementia, postural instability, or orthostatic hypotension
visual changes such as diddiculty looking down or complains of walking down stairs
How might giving PD patients external cues help them?
makes motor control cognitive rather than automatic by allowing cortical areas to initiate movement and bypass basal ganglia
shown to improve step length, stride length, gait speed, and UPDRS
self given cues are best
Which is more effective for Parkinson’s patients forced or voluntary exercise?
What should the intensity be?
Forced, because it forces them to push themselves and has shown global improvements and nueroplastic changes
intensity should be around 7-10 RPE
When is dual task training most effective?
For those a stages 2 and 3 on H&Y scale
What are the benefits of nordic walking with trekking poles for Parkinson’s patients?
improves gait speed, TUG, 6MWT, and QoL whcih lasts up to 5 months after training
-poles allow reciprocal motion and provide bilateral stability
What is the 4 S strategy for dealing with a freezing episode with Parkinson’s?
Stop
Stand Tall
Shift Weight
Step
What muscles are most important to target for strength training during Parkinson;s rehab?
back and hip extensors
eccentric training more effective
Which PD specific program focuses on amplitude of movement at a high intensity?
LSVT BIG-Lee Silverman Voice Treatment
focus on sensory awareness of the BIG movement
Which PD specific program teaches patients to “exercise for brain change” in order to reduce symptoms, decrease fall risk and improve quality of life?
PWR-Parkinsons Wellness Recovery
Between the LSVT BIG program and the PWR program for PD which one incorporates exercises which range from floor exercises to standing exercises?
Which addresses multiple symptoms of PD including non-motor symptoms and not just rigidity and bradykinesia?
Which is more structured?
Which usually has more patient engagement?
PWR
PWR
LSVT BIG
PWR
What are the benefits of dance for PD patients?
uses cues
social engagement
many different moves and strategies that use dynamic balance and strength
What are the benefits of boxing for PD patients?
aerobic exercise w/ rotational movements and multi-directional movements
high instensity and dual tasking
long and short term improvements
those with mild PD improved earlier than with mod. PD
What are the benefits of tai chi for PD patients?
Improves balance, gait and strength
retains benefits up to 3 months after treatment
improves non-motor symptoms
What signs or symptoms may indicate a diagnosis other than Parkinson’s?
- early postural unsteadiness
- rapid progression of signs
- respiratory dysfunction
- abnormal postures
- emotional unsteadiness
- cerebellar signs
- corticospinal dysfunction
- voluntary gaze dysfunction
What physical signs would suggest a diagnosis of Progressive Supranuclear Palsy?
Non-motor signs?
- Early onset unsteadiness with tendency to fall backward
- axial rigidity
- freezing of gait
- “leaning back” posture
Non-motor
- apathy
- depression
- slowed thinking
- psychosis
- rage attacks
What is Multiple System Atrophy?
What are the cerebellar signs of MSA?
What are common autonomic dysfunction signs?
Corticospinal tract dysfunction signs?
Progressive degenerative disease affecting basal ganglia, cerebellar, and autonomic systems, peripheral nervous system and cerebellar cortex
Dysarthria, truncal/gait ataxia
hypotension, B&B, decreased sweating/tears/saliva, impotence
motor function and UMN signs
What is Lewy Body Dementia?
What are the signs?
abnormal accumulations of proteins within neurons
early, generalized cognitive decline
visual hallucinations
motor signs indistinguishable from postural instability gait difficulty sub-type of PD
What are signs of a drug-induced parkinsonism?
-bilateral onset with rapid progression, early postural tremor, involuntary facial movement
What are the typical populations who suffer from chronic traumatic encephalopathy (CTE)?
victims of abuse, epileptics, military, and athletes
What characterizes Huntington’s Disease?
What is the typical onset age and cause?
What is the result of Huntington’s?
a hyperkinetic disorder which is characterized by Chorea (involuntary, jerky movements) and dementia
onset is usually 4-50 years old and the disease is inherited and progressive
causes degeneration in the brain, decreasing signals from the basal ganglia
disinhibition of the motor thalamus and the PPN leads to excessive output from motor areas of the cerebral cortex
