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NMR II > Clinical Management of Parkinson Disease > Flashcards

Clinical Management of Parkinson Disease Flashcards

1
Q

What are the cardinal motor symptoms of Parkinson’s Disease?

A
  • Tremor
  • Rigidity
  • Bradykinesia
  • Postural instability
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2
Q

What is a tremor?

A

Involuntary oscillations resulting from contraction of opposing muscles

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3
Q

How does tremor present in the early stages of Parkinson’s Disease?

A
  • Distal hand or foot
  • One side of the body
  • Resting tremor
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4
Q

How does tremor present in the later stages of Parkinson’s Disease?

A
  • Increased severity
  • Bilateral
  • Action Tremor
  • Interferes with ADLs
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5
Q

What is rigidity?

A
  • Increased resistance to passive movement
  • Not velocity dependent
  • Both agonist & antagonist
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6
Q

What is cogwheel rigidity?

A

Jerky, ratchet like resistance

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7
Q

What is leadpipe rigidity?

A

Sustained rigidity

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8
Q

What does progression of rigidity over the disease course look like in Parkinson’s Disease?

A
  • Prox –> distal
  • Unilateral –> Bilateral
  • Increase in severity
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9
Q

What are some secondary complications to rigidity?

A
  • Contracture
  • Postural deformity
  • Fatigue
  • Energy expenditure
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10
Q

What is bradykinesia and some examples?

A
  • Slowness of movement
  • Ex: Increased reaction time
  • Ex: Increased movement time
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11
Q

What is hypokinesia and some examples?

A
  • Decreased movement (smaller amplitude & less movement)
  • Ex: Micrographia
  • Ex: Decreased arm swing
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12
Q

What is akinesia and some examples?

A
  • Absence of movement
  • Ex: Freezing
  • Ex: No arm swing
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13
Q

Describe the typical presentation of balance of a patient with Parkinson’s Disease

A
  • Decrease limits of stability
  • Slow anticipatory postural adjustments
  • Poor reactive balance (abnormal co- contraction)
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14
Q

Describe the typical posture of a patient with Parkinson’s disease

A
  • Decreased activation of antigravity muscles
  • Flexed posture
  • COM lowered towards the foward LOS
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15
Q

T/F: Patients with Parkinson’s disease are not at an increased risk of falls

A

False
- 70% single fall
- 50% recurrent fall

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16
Q

Describe the typical gait presentation in a patient with Parkinson

A
  • Slow pace
  • increased variability & asymmetry
  • Poor postural control
  • Decreased step size
  • Reduced arm swing/trunk rotation
  • Reduced APA prior to steps
  • Turn en bloc w/ more steps
  • Festinating
  • Freezing of gait
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17
Q

What is festination?

A

Unintentionally rapid short steps

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18
Q

What is freezing of gait?

A
  • Trembling or absent movement with transient inability to take a step
  • Triggered by confrontation w/ competing stimuli
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19
Q

T/F: There is a primary sensory loss associated with PD

A

False- There is no primary sensory loss associated with PD

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20
Q

When are patients with PD more hypersenstive to pain? (On or off their medication)

A

More common in off state of medication

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21
Q

What may be some reasons for a patient with PD to experience pain?

A
  • Musculoskeletal
  • Dystonic
  • Neuropathic/radicular
  • Central or primary
  • Akathisia (feeling of inner restlessness)
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22
Q

Patients with PD often have impaired perception of kinesthesia and proprioception. What does this cause?

A

A failure to recognize deficits in movement size

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23
Q

What is sensory loss that often occurs years before diagnosis and is an important early clinical sign?

A

Olfactory dysfunction
- Either decrease or loss of sense of smell

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24
Q

What is dysphagia a result from?

A

Rigidity and reduced movements

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25
Q

What may dysphagia impact?

A
  • Tongue control
  • Chewing
  • Bolus formation
  • Swallowing (delay)
  • Peristalsis
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26
Q

What are the complications of dysphagia?

A
  • Choking
  • Aspiration pneumonia
  • Poor nutrition
  • Weight loss
  • Sialorrhea
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27
Q

What are the symptoms of hypokinetic dysarthria?

A
  • Decrease volume
  • Monotone/ mono pitch
  • Imprecise articulation
  • Uncontrolled rate of speech
  • Hoarse
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28
Q

What are two speech disorders that can occur in patients with PD?

A
  • Hypokinetic dysarthria
  • Mutism
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29
Q

What are the contributing factors of speech disorders in patients with PD?

A
  • Motor symptoms (rigidity, hypokinesia, bradykinesia, & tremor)
  • Impacts muscles controlling respiration, phonation, resonation & articulation
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30
Q

T/F: Speech disorders impacts participation & contribute to social isolation

A

True

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31
Q

What is bradyphrenia?

A
  • Slowness of thought
  • Early symptom
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32
Q

What are some symptoms of mild cognitive impairment that may be present in patients with PD?

A
  • Processing speed
  • Set-shifting
  • Attention
  • Verbal fluency
  • Planning
  • Abstract reasoning
  • Visuospatial
  • Verbal & visual memory
  • Impacts motor learning & dual task performance
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33
Q

What are symptoms of levodopa toxicity?

A
  • Hallucinations
  • Delusions
  • Psychosis
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34
Q

Who is at greatest risk for dementia?

A

Older individuals

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35
Q

What are some cognitive symptoms that may present in patient with PD?

A
  • Bradyphrenia
  • Mild cognitive impairment
  • Dementia
  • Levodopa toxicity
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36
Q

What are some sleep disorders that patients with PD may have?

A
  • REM sleep behavior disorders
  • Excessive daytime somnolence
  • Insomnia
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37
Q

What is some characteristics of REM sleep behavior disorder?

A
  • Occurs prior to motor symptoms (in up to 60% of individuals)
  • Incomplete or absent paralysis during REM
  • Dream - enacting behaviors
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38
Q

What are some characteristics in insomnia?

A
  • Difficulty falling asleep
  • Difficulty staying asleep
  • Poor sleep quality
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39
Q

What are some neurobiological causes of depression, anxiety and apathy in patients with PD?

A
  • Alterations in levels of dopamine, serotonin, & NE
  • Apathy improves initially with dopamine therapy
  • Anxiety & depression worse during “off” medication times
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40
Q

What is hypomimia?

A

Reduced facial expression may be mistaken for depression or apathy

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41
Q

When is autonomic dysfunction seen in patients with PD?

A

Seen early in disease & progresses with disease course

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42
Q

What are the symptoms of autonomic dysfunction?

A
  • Impaired thermoregulation/ hyperhidrosis
  • Slow pupillary response to light
  • Decreased gastric motility / constipation
  • Urinary incontience
  • Blunted HR response to exercise (sympathetic denervation of heart)
  • Orthostatic hypotension
  • Pulmonary dysfunction (air trapping, decreased chest expansion)
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43
Q

How is PD diagnosed?

A
  • Based on history & clinical examination
  • No diagnostic test (MRI rule ot other causes or chemical markers can confirm dopamine deficits)
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44
Q

What is the difference between parkinsonism and PD?

A
  • Parkinsonism: Bradykinesia + tremor or rigidity)
  • PD: no symmetrical bilateral signs & clear + dramatic benefit from dopamine therapy
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45
Q

What is the mechanism of Levodopa/Carbidopa?

A
  • Dopamine replacement
  • Carbidopa prevents levodopa from conversion to dopamine before it crosses the BBB
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46
Q

What is the mechanism of dopamine agonist?

A

Stimulates dopamine receptors in the basal ganglia

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47
Q

What is the mechanism of COMT inhibitors?

A

Blocks breakdown of dopamine to prolong effects & reduce “wearing off”

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48
Q

What is the mechanism of MAO-B Inhibitors?

A

Blocks breakdown of dopamine to prolong effects & reduce “wearing off”

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49
Q

What is the mechanism of Anticholingerics?

A
  • Reduces excessive acetylcholine influence
  • May reduce tremor & dystonia
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50
Q

What is the mechanism of Amantadine?

A
  • Antiviral
  • Blocks effects of glutamate
  • May reduce dyskinesia
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51
Q

What is the mechanism of Norepinephrine precursors?

A
  • Increase NE levels
  • May reduce orthostatic hypotension
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52
Q

What is the mechanism of Cholinesterase Inhibitors?

A
  • Inhibits acetylcholine breakdown
  • May improve function & gait instability
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53
Q

What is the mechanism of Atypical antipsychotics?

A
  • Blocks some effects of serotonin
  • Used to treat hallucination & psychosis side effects
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54
Q

What are some common side effects of pharmacological management of PD?

A
  • Wearing - off
  • Dyskinesia
  • Dystonia
  • Low BP
  • Dizziness
  • Nausea
  • Dry mouth
  • Insomnia
  • Constipation
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55
Q

What is deep brain stimulation?

A

Electrodes implanted in brain with a subclavicular impulse generator & controlled by an external controller

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56
Q

Where can electrodes be placed during deep brain stimulation?

A
  • Subthalamic nucleus
  • Globus pallidus internus
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57
Q

What occurs if the deep brain stimulation is placed in subthalamic nucleus?

A
  • Improved motor symptoms & tremors
  • Reduce medication
58
Q

What occurs if the deep brain stimulation is placed in globus pallidus internus?

A
  • Improve motor symptoms & tremor
  • Suppression of dyskinesia
59
Q

T/F: Symptoms poorly controlled by levodopa will likely be improved with deep brain stimulus

A

False- Symptoms poorly controlled by levodopa will unlikely be improved with DBS and may worsen

60
Q

What type of diet can block levodopa absorption? What are the recommendations to combat this?

A
  • High protein
  • Reduce calories from protein
  • Eat protein later in day
61
Q

What are some tasks that you may choose to observe for a patient with PD?

A
  • Bed mobility
  • Transitions
  • Skill (sitting/standing)
  • Ambulation
  • W/C mobility (if applicable)
62
Q

What type of things should be taken note of when observing tremor?

A
  • Location
  • Persistence
  • Severity (amplitude)
  • Resting vs Action
  • Triggers
63
Q

What is highly recommended to use when examining bradykinesia?

A

9 Hole Peg test

64
Q

What are some ways to examine bradykinesia?

A
  • Movement speed (times RAM)
  • 9 Hole peg test
65
Q

What should you be observing when examining hypokinesia?

66
Q

What should you be observing when examining akinesia?

A
  • Freezing (duration, triggers, ability to overcome)
  • Start hesitation (reaction time)
67
Q

What should you be observing when examining rigidity?

A
  • Sustained (lead pipe) vs intermittent (cogwheel)
  • PROM
  • Spinal ROM
  • Distribution
  • Severity
68
Q

What are common posture deviation in patients with PD?

A
  • Forward head
  • Rounded shoulders
  • Kyphosis
  • Hip/knee flexion
  • Hand position
69
Q

What is the deviations of hand position in patients with PD?

A
  • Flexed MP
  • Extended IP
  • Ulnar dev
  • Wrist flex
  • Forearm pronation
70
Q

How can you examine resting posture in patients with PD?

A
  • Plumb line, grids, photography
  • Wall to occiput distance
71
Q

How can you examine AROM/PROM in patients with PD?

A
  • Goniometer
  • Inclinometer
  • CROM
72
Q

What are some potential caused of sensory loss in patients with PD?

A
  • Age related changes
  • Patterns of loss (comorbidity)
  • Perception (BG)
73
Q

What should be included in sensory screen for patient with PD?

A
  • Complaints of pain, tingling, numbness
  • Superficial, deep, cortical
  • Nerve conduction velocity normal
74
Q

What are some pain complaints in patients with PD and how can you examine them?

A
  • Mild achin/cramping
  • Postural stress
  • VAS, faces
75
Q

What is the vision complaint in patients with PD and how can you examine it?

A
  • Blurring
  • Smooth pursuit (cogwheeling)
76
Q

How can you examine strength in patients with PD?

A
  • MMT
  • Dynamometry (rate of force production, maximum torque)
77
Q

In the late stages of PD what is the patient’s perception of upright?

A

Forward of vertical

78
Q

What clinical measures can be used to examine postural control & balance? Which is highly recommended and which is recommended?

A
  • Highly recommended: BESTest/ miniBESTest
  • Recommended: ABC Scale
  • BBS
  • Functional reach test
  • Cognitive TUG
  • CTSIB
  • Dual task
79
Q

What standardized measures can be used for gait in patients with PD? Which are highly recommended?

A
  • Highly: 10 m Walk
  • Highly: 6 min walk test
  • Highly: Functional Gait Assessment
  • DGI
  • TUG
  • Dual task
80
Q

What are the parameters of gait that should be examined in patients with PD?

A
  • Start time
  • Gait speed
  • Stride length
  • Cadence
  • Stability
  • Turning
  • Safety
  • Quality (shuffling, festination, posture, arm swing)
81
Q

What are some triggers/ provoking factors to freezing of gait?

A
  • Doorways
  • Gait initiation
  • Change in environment
  • Change in attentional demands
  • Stress/anxiety
82
Q

What are some questionnaires that can be used to examine freezing of gait? Which is recommended?

A
  • Recommended: Freezing of Gait Questionnaire
  • New Freezing of Gait Questionnaire
83
Q

What outcome measure assesses gait through a course under single, dual & triple task conditions?

A
  • Freezing of Gait Assessment (FOGA)
  • Not well studied
84
Q

What is the highly recommended measure to examine cognition? Why is this test recommended over MMSE?

A
  • Montreal Cognitive Assessment (MOCA)
  • More sensitive to mild impairment
85
Q

What is recommended outcome measure to examine fatigue?

A

Parkinson’s Fatigue Scale

86
Q

What are some outcome measures that can examine psychosocial?

A
  • Geriatric Depression Scale
  • Hamilton Depression Rating Scale
87
Q

What are some outcome measures that can examine anxiety?

A
  • Geriatric Anxiety Inventory
  • Parkinson’s Anxiety Scale
88
Q

What are dyskinesias? How can they limit the patient? What outcome measure can be used to examine dyskinesias?

A
  • Side effect of medication
  • Limit both social & physiological function
  • Rush Dyskinesia Scale
89
Q

What symptoms indicate autonomic dysfunction?

A
  • Alter HR & BP response to exercise
  • Orthostatic hypotension (measure BP 1 min following position change & drop in SBP 20mmHg or DBP 10 mmHg + 10-20% increase in HR)
90
Q

What should you be on the look out for when examining the integumentary system?

A

Observe bruising/skin break down

91
Q

What are some global standardize outcome measures?

A
  • SF-36
  • Sickness Impact Profile
92
Q

What are some disease specific standardize outcome measure that can be used in PD? Which are highly recommended?

A
  • Hoehn-Yahr Classification of Disability
  • Highly Recommended: MDS- Unified Parkinson’s Disease Rating Scale (MDS-UPDRS)
  • Highly Recommended: Parkinson’s Disease Questionnaire (PDQ-39)
93
Q

What is MDS- Unified Parkinson’s Disease Rating Scale?

A
  • Comprehensive tool designed to monitor the burden & extent of Parkinson’s disease across the longitudinal disease course at body structure, activity, & participation level
  • Both self-report & examiner administered items
94
Q

In MDS- Unified Parkinson’s Disease Rating Scale do higher scores indicate more or less severity?

A

Higher scores = increased severity

95
Q

What is the Parkinson’s Disease Questionnaire?

A
  • Subjective report of impact on PD
  • Rate experiences during the last month
96
Q

Treatment plan of PD will be highly variable depending on what 4 factors?

A
  • Patient complaints & goals
  • Assessment findings
  • Prognosis
  • Stage of disease
97
Q

What does current evidence support for the management of PD?

A
  • Combined physical therapy & pharmacology management
  • Early Intervention
98
Q

What is the goal of early intervention for PD?

A
  • Maximize function
  • Minimize secondary complications
  • Provide education & support
  • Slow progression of disability
  • Possible slow disease progression
99
Q

Endurance training may improve what in patients with PD?

A
  • Improve VO2max
  • Improved gait speed, mood, motor function, QOL
  • Improve aspects of cognition
100
Q

What does regular exercise (>150 m/wk) improve in patients with PD?

A
  • Better QOL
  • Mobility
  • Physical function
  • Cognition
  • Less disease progression at 1 yr follow up
101
Q

T/F: PTs should implement mod to high intensity aerobic exercise for individuals with PD

102
Q

What is the aerobic exercise CPG?

A
  • 30-40 min, mod (60-75% max HR) or high (75-85% max HR) intensity, 3x/wk
  • Cycling & treadmill both effective
  • Screen for CV risk factors & orthostatic hypotension
  • Monitor VS & RPE
  • Must maintain or gains dissipate
103
Q

What motor learning strategies should be used with patients with PD?

A
  • Large number of reps
  • Complex movement broken down into components
  • Blocked practice
  • Minimize distraction/ dual task to improve performance
  • External cues
  • Progression to random practice & dual task should be done if able
104
Q

What external cues should be used with patients with PD? What happens if these cues are removed?

A
  • Visual, auditory, pulsed
  • Rhythmical, consistent & not rushed
  • Shifts automatic (conscious motor pathways)
  • Performance deteriorates if cues removed
  • Less effective in advanced disease/ dementaia
105
Q

Why should external cues be implemented with patients with PD?

A
  • Reduce motor disease severity
  • Reduce freezing of gait
  • Improve gait outcomes
106
Q

What type of cueing is best for patients with PD (external or internal)?

107
Q

What can auditory cues improve in patients with PD?

A
  • Cadence
  • Stride length
  • Gait velocity
108
Q

What can visual cues improve in patients with PD?

A

Stride length

109
Q

What are some examples of auditory cues that can be used with patients in PD?

A
  • Rhythmic auditory stimulation (RAS)
  • Metronome, Music
  • Attentional Cueing (ie “Big Step”)
110
Q

What are some examples of visual cues that can be used with patients in PD?

A
  • Parallel lines on floor perpendicular to direction of motion
  • Devices (laser, VR)
111
Q

Dual task performance may be improved by training what in patients with PD?

A
  • Walking velocity, stride length, & cadence
  • Carry over to untrained task
112
Q

Both integrated (simultaneous) & consecutive task training can be effective & safe. But what may be the safer alternative for freezing or MCI?

A

Consecutive task training

113
Q

Why do individuals with PD freeze?

A

Occurs with:
- Dual tasks
- Increased difficulty
- Response to environmental demands (doorway, turning corner, unexpected stimuli)

114
Q

How can cueing help freezing of gait in patients with PD?

A

Used to direct attention to gait & improve spatiotemporal parameters

115
Q

How should training using RAS cueing prior to freezing of gait be implemented?

A
  • 3x/wk (6 wk)
  • Train response to RAS (pace, step length, L-R coordination)
  • Progressively challenging courses
  • Secondary tasks
116
Q

What were the results of training using RAS cueing prior to freezing of gait?

A
  • Decreased frequency & duration of freezing
  • Retained at 4 wk follow-up
117
Q

How should amplitude training be implemented?

A
  • Cue to increase amplitude
  • Repetitive
  • High intensity
118
Q

What is the goal of amplitude training?

A
  • Larger movement carry over to un-cued movements after intervention
119
Q

What is a clinical example of amplitude training?

A

LSVT BIG training & PWR!Moves

120
Q

In people with PD, PTs should implement resistance training to?

A
  • Decrease motor disease severity (UPDRS- III motor scores)
  • Increase muscle strength & power
  • Improve non-motor symptoms, functional outcomes & QOL
121
Q

How often should strength training be implemented?

A
  • 30-60min, 2 non-consecutive days/wk
  • Performed during “on” period
122
Q

What are the parameters that should be used to improve strength in patients with PD?

A
  • Begin 40-60% 1RM or 1 set 20-30 reps
  • Progress to 80% 1RM or 3 sets 10 rep to fatigue
123
Q

What are the parameters that should be used to improve power in patients with PD?

A
  • Begin 20-30% 1RM
  • Progress to 40% 1RM
124
Q

T/F: Patients with PD should focus primarily on doing isometric exercises

A

False - Avoid isometric

125
Q

T/F: PT may implement flexibility exercises to improve ROM in individuals with PD

126
Q

How should Flexibility exercises be implemented?

A
  • May be part of a home program or part of your warm up/cool down
  • Literature does not support it being entirety of intervention
127
Q

What is the benefits of flexibility interventions?

A
  • Decrease pain
  • Increase QOL
  • Improve balance
128
Q

What PROM, AROM, facilitated exercises should be chosen?

A
  • Exercises that strengthen extensors & lengthen flexors
  • Combined movements helpful to conserve energy (PNF)
129
Q

How can stretching be implemented in patients with PD?

A
  • Precautions (sedentary, elderly, osteoporosis)
  • Combine w/ joint mobs
  • Passive positioning (prone lying, tilt table, “lying on the beach”)
130
Q

Name some relaxation techniques

A
  • Gentle rocking an temporarily relax rigidity
  • Slow, rhythmic rotational movements of extremities & trunk may proceed interventions
  • Breathing during exercises
  • HEP
131
Q

What are some relaxation techniques that can be taught as part of HEP?

A
  • Relax to move
  • Deep breathing, audio tapes, meditation, imagery, gentle yoga, tai chi
  • Stress management
132
Q

For individuals with PD, PTs should implement balance training intervention programs to?

A
  • Decrease postural control impairments
  • Improve balance, gait, & mobility
  • Increase balance confidence
  • Improve QOL
133
Q

What are some Balance training interventions and how should they be performed?

A
  • Static & dynamic activities, transition tasks & perturbations
  • COM & LOS control training
  • Practice under variety of sensory & environmental conditions
  • Practice in variety of positions
  • Combine w/ aerobic & gait training
  • Consider safety
134
Q

What are some functional or TST interventions that can be used for patients with PD?

A
  • Bed mobility skills
  • Sitting/standing (posture, mobility)
  • STS
  • Transfers
  • Floor to sit/stand transfers (falls) (4 pt creeping, trunk extension, kneeling to half kneel)
135
Q

For individuals with PD, PTs should implement gait training to?

A
  • Decrease motor disease severity
  • Improve stride length, gait speed, mobility & balance
136
Q

How often should gait training be implemented?

A

20-60 min, 3-5 d/wk, for 4-12 weeks

137
Q

What are the goals of functional gait training?

A
  • Increase step length
  • Increase gait speed
  • Encourage reciprocal arm swing
  • Improve upright alignment
  • Vary task & environmental; demands
  • Compensatory strategies (when necessary)
138
Q

What should be considered with performing functional gait training?

A
  • Cues
  • Harness or body weight supported treadmill training
  • Nordic walking
139
Q

What are some pulmonary rehabilitation interventions?

A
  • Diaphragmatic breathing, air shift techniques, strengthen accessory muscles
  • Manual technique
  • ROM/mobilize chest wall
  • Postural exercise
140
Q

For individuals with PD, PTs should recommend community based exercise to?

A
  • Reduce motor disease severity
  • Improve non-motor symptoms
  • Improve functional outcomes
  • Improve QOL
141
Q

What is the recommended frequency, intensity, time/volume and stage for community based exercises?

A
  • Frequency: 2x/wk
  • Intensity: Max intensity w/ optimal safety based on individual needs
  • Time/Volume: 45-60 min for at least 12 wks
  • Stage: Evidence supports for H&Y I-III
142
Q

Name some types of community based exercises

A
  • Yoga
  • Tai Chi
  • Pilates
  • Boxing
  • Dance
  • PWR! (Parkinson’s Wellness Recovery)
  • Group classes

NMR II (14 decks)

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