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Neuromuscular Practice 2 > Basal Ganglia and Parkinson's > Flashcards

Basal Ganglia and Parkinson's Flashcards

1
Q

What is the role of the basal ganglia?

A

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

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2
Q

What neurotransmitter is produced in the substantia nigra?

A

Dopamine

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3
Q

What are the two main feedback systems for refining motor system output?

A

basal ganglia and cerebellum

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4
Q

What does the motor loop link and what is it’s role?

A

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

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5
Q

What does the basal ganglia motor circuit regulate?

A
  • muscle contraction
  • muscle force
  • multi-joint movements
  • sequencing of movements
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6
Q

True or False: the basal ganglia works directly with lower motor nuerons

A

False, there is no direct output to LMNs so basal ganglia works through 3 routes, the motor thalamus, pedunculopontine nucleus, and midbrain locomotor region

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7
Q

What disorder stems from excessive inhibition of the basal ganglia. (hypokinetic disorders)

What disorder stems from inadequate inhibition of the basal ganglia. (hyperkinetic disorders)

A

Parkinson’s

huntington’s disease, dystonia, tourette’s disorder, dyskinetic cerebral palsy

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8
Q

What is Parkinson’s Disease?

What is the result of Parkinson’s?

What are the common populations that are affected by Parkinson’s?

A

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

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9
Q

What are the cardinal signs of Parkinson’s?

What other common movement symptoms are common?

A

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
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10
Q

What are common non-movement related symptoms for Parkinson’s?

A

-anosmia
-anxiety
-apathy
-bone health
-breathing difficulty
-cognitive changes
-nausea
-dysautonomia
-fatigue
hallucinations
-sleep disorders
-pain

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11
Q

True or False: The Rizzo diagnostic test for Parkinson’s is considered the gold standard for diagnosis.

A

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

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12
Q

What are the supportive criteria for diagnosing PD?

A
  • 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
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13
Q

What are the 9 absolute exclusions for diagnosing PD?

A

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
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14
Q

What is the prognosis for Parkinson’s?

What are the progressive signs of PD?

A

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
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15
Q

What are the stages for the Modified Hoehn and Yahr Scale?

A

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

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16
Q

What are common early presentation for Parkinson’s?

A
  • tremor
  • micrographia
  • slowness with ADL’s
  • voice changes
  • difficulty maneuvering in bed
  • lack of arm swing with gait
  • dragging the foot with walking
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17
Q

What is the primary objective for medical management for PD?

A

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

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18
Q

What are the advantages for levodopa/carbidopa medications for PD?

A

most effect for PD; prolongs capacity to perform iADLs

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19
Q

What are the advantages for dopamine agonist medications for PD?

A

Work by copying actions of dopamine in the brain

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20
Q

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?

A

inhibits enzyme responsible for metabolism of levodopa

Slow the metabolism of dopamine

Used for treatment of tremor in younger patients

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21
Q

When would a patient be given deep brain stimulation?

A

In advanced stages of PD

it is a surgical implantation of electrodes into the brain

22
Q

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?

A
  • 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

23
Q

What sensory deficits are commonly observed in Parkinson’s patients? (as far as pain, occulomotor and visual deficits, olfactory disturbances, and proprioception)

A

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

24
Q

How is cognition affected by Parkinson’s?

A

Dementia signs are common (poor planning, decision making and goal directed behavior)

25
Q

True or False: There is a strong correlation between attention and the ‘pace’ domain of gait.

A

True, gait veloctiy, step length and step time are all correlated with attention as is gait variability and executive function

26
Q

What MOCA score correlates with PD dementia?

A

Less than 21/30

Less than 26= mild cognitive impairment

27
Q

How is a Pull test scored?

A

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

28
Q

How do you score a Push-Release Test?

A

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

29
Q

What functional assessments are useful for Parkinson’s evaluation?

A
  • 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)`
30
Q

What test can assess dual tasking?

How do you calculate Dual Task Cost?

A

TUG cognitive

dual task cost= TUG cognitive-TUG/TUGx100=% od dual cost

31
Q

What time on a 4 square step test correlates to increased fall risk?

A

over 9.68 seconds

32
Q

What exam findings are atypical for idiopathic Parkinson’s?

A

early symptoms of incontinence, dementia, postural instability, or orthostatic hypotension

visual changes such as diddiculty looking down or complains of walking down stairs

33
Q

How might giving PD patients external cues help them?

A

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

34
Q

Which is more effective for Parkinson’s patients forced or voluntary exercise?

What should the intensity be?

A

Forced, because it forces them to push themselves and has shown global improvements and nueroplastic changes

intensity should be around 7-10 RPE

35
Q

When is dual task training most effective?

A

For those a stages 2 and 3 on H&Y scale

36
Q

What are the benefits of nordic walking with trekking poles for Parkinson’s patients?

A

improves gait speed, TUG, 6MWT, and QoL whcih lasts up to 5 months after training
-poles allow reciprocal motion and provide bilateral stability

37
Q

What is the 4 S strategy for dealing with a freezing episode with Parkinson’s?

A

Stop
Stand Tall
Shift Weight
Step

38
Q

What muscles are most important to target for strength training during Parkinson;s rehab?

A

back and hip extensors

eccentric training more effective

39
Q

Which PD specific program focuses on amplitude of movement at a high intensity?

A

LSVT BIG-Lee Silverman Voice Treatment

focus on sensory awareness of the BIG movement

40
Q

Which PD specific program teaches patients to “exercise for brain change” in order to reduce symptoms, decrease fall risk and improve quality of life?

A

PWR-Parkinsons Wellness Recovery

41
Q

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?

A

PWR

PWR

LSVT BIG

PWR

42
Q

What are the benefits of dance for PD patients?

A

uses cues

social engagement

many different moves and strategies that use dynamic balance and strength

43
Q

What are the benefits of boxing for PD patients?

A

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

44
Q

What are the benefits of tai chi for PD patients?

A

Improves balance, gait and strength

retains benefits up to 3 months after treatment

improves non-motor symptoms

45
Q

What signs or symptoms may indicate a diagnosis other than Parkinson’s?

A
  • early postural unsteadiness
  • rapid progression of signs
  • respiratory dysfunction
  • abnormal postures
  • emotional unsteadiness
  • cerebellar signs
  • corticospinal dysfunction
  • voluntary gaze dysfunction
46
Q

What physical signs would suggest a diagnosis of Progressive Supranuclear Palsy?

Non-motor signs?

A
  • 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
47
Q

What is Multiple System Atrophy?

What are the cerebellar signs of MSA?

What are common autonomic dysfunction signs?

Corticospinal tract dysfunction signs?

A

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

48
Q

What is Lewy Body Dementia?

What are the signs?

A

abnormal accumulations of proteins within neurons

early, generalized cognitive decline
visual hallucinations
motor signs indistinguishable from postural instability gait difficulty sub-type of PD

49
Q

What are signs of a drug-induced parkinsonism?

A

-bilateral onset with rapid progression, early postural tremor, involuntary facial movement

50
Q

What are the typical populations who suffer from chronic traumatic encephalopathy (CTE)?

A

victims of abuse, epileptics, military, and athletes

51
Q

What characterizes Huntington’s Disease?

What is the typical onset age and cause?

What is the result of Huntington’s?

A

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

Neuromuscular Practice 2 (9 decks)

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