exam #2 - PD Flashcards
PD is the most common _________ disorder
-1 million Americans
-average age onset ____ - ____ yrs. old
-young onset _____ - ____ yrs. old
-juvenile-onset <___ yrs. old
-more common in males or females?
neurodegenerative
50-60
21-50
<21
male
Etiology: disturbance in the ________ system in the _______ ______
-typically less DA in the ______
dopamine (DA); basal ganglia
substania nigra
most common type of PD:
& subtypes
idiopathic (78%)
-postural instability gait disorder (PIGD)
-tremor dominant (TD)
Other types of PD:
genetic
secondary parkinsonism
atypical parkinsonism (Parkinson’s Plus Syndrome)
PIDG vs TD:
PIDG:
worse diagnosis
more bradykinesia
higher prevalence of non-motor symptoms
higher likelihood of dementia
TD:
better prognosis
less difficulty with bradykinesia and postural instability (less falls)
lower incidence of non-motor symptoms
lower risk of developing dementia
Genetic markers:
-_____% of cases are genetic
-some families share gene ______
-two types –>
—those that cause _____
—those that increase risk of _________
10%
mutations
PD
developing it
Secondary Parkinsonism Types: (2)
toxic parkinsonism
drug-induced parkinsonism
Toxic Parkinsonism: exposure to certain toxins or chemicals
exposed to pesticides, industrial chemicals –> agent - orange military
–manganese most common - miners often exposed
synthetic heron with chemical MPTP
Drug-induced Parkinsonism are drugs that interfere with the _______
dopaminergic systems
–neuroleptic drugs, antidepressants, some antihypertensive (wrong dosage shows PD symptoms)
PD Plus Syndromes Differential:
-don’t often respond to _____
-early onset of _______
-_________ in early stages
-_______ symptoms more prominent than limb symptoms
-_______signs present
-_________ symptoms more prevalent like ________
-levodopa
-postural instability and/or dementia
-more symmetry in early stages
-trunk
-ocular
-autonomic; postural hypotension or incontinence
Progressive Supranuclear Palsy (PSP):
rapid progression (3-5 years)
starts in late middle age
tremor is rare
emotional changes
limitations in vertical gaze (difficulty looking down)
difficulty keeping eyelids open
UMN only
have extension pattern rather than flx
NOT synonymous with ALS
Patients will lose balance backwards
Multiple System Atrophy (MSA):
orthostatic hypotension is common
less cognitive involvement
may have ataxia
will have MRI visible denigration in BG
ANS symptoms are more noticeable
progresses faster (6-8 years)
starts in late 50s
has motor symptoms like PD
doesn’t respond to levapoda
Aka shy Drager Syndrome
Corticobasalganglionic Degenration (CBD):
progresses quickly 6-8 years
a form of frontotemporal degeneration w/dementia component
loss of graphthesia
often present in one UE
“alien limb”
upgaze and horizontal gaze impaired but NOT downgaze
Lewy Body Dementia (LBD):
get deposits of alpha-synuclein in brain
having PD increases your risk of this
cognitive fluctuations
mood changes
early change in cognition
visual hallucinations
rigidity more severe
lack of asymmetry
median survival is 8 years
ALS is UMN or LMN?
____ is a disorder of the myelin, not a neurotransmitter or the BG
both UMN and LMN
MS
structures within the basal ganglia: (5)
Pathophysiology of PD:
-degeneration of dopaminergic neurons produces less ______
can get alpha-synuclein cytoplasmic inclusions (LBD) as the disease progresses
-_____ loop - signals from the BG go to the thalamus, then the cortex
caudate nucleus
putamen
globus pallidus
subthalamic nucleus
substantia nigra
dopamine (DA)
direct
PD: Direct Loop
-excitation putamen to globus pallidus (GP)
-GP to ventral lateral nucleus of thalamus
-VL nucleus of thalamus to supplemental motor area (SMA) of cortex
result: voluntary motor movement and positive feedback loop –> need dopamine from substantia nigra to help w/activation
PD = regular indirect pathway (inhibitory) + affected direct pathway (excitatory turned inhibitory) which leads to _____
bradykinesia (slowness of movement)
-excessive inhibition of the thalamus by the GPi/SNr (via the indirect pathway) and reduced facilitation of movement initiation (via the direct pathway).
cardinal motor symptoms of PD:
bradykinesia (low speech)
resting tremor
rigidity (cogwheel, lead pipe)
postural instability
Other motor S&S
muscle performance:
motor function:
gait:
dysphagia:
hypokinetic dysarthria:
muscle performance: delayed recruitment
motor function: difficulty w/speed and accuracy of task, dual tasking, starting/stopping motion
gait: up 25% initial symptoms, bradykinesia, flexed posture, decreased arm swing, freezing possible
dysphagia: 95% will have difficulty swallowing due to rigidity \
hypokinetic dysarthria: talk quieter
Non-Motor Symptoms: (4 clusters)
- rapid eye movement sleep behavior disorder
- cognition related
- mood related
- sensory and dysautonomia
rapid eye movement sleep behavior disorder:
frequent nightmares
dream enacting behavior (talking/walking in sleep)
insomnia (can’t sleep @ night)
cognition related symptoms:
memory complaints
cognitive fatigue
inattention (open vs. closed environments)
excessive day-time sleepiness
mild cognitive impairment –> difficulty w/dual tasks
mood-related symptoms:
anhedonia (lack of joy in things), apathy, flat affect (face shows no emotion), depression(40%), anxiety (31%), etc.
sensory and dysautonomia:
loss of taste
loss of smell; early signs of PD will happen in 100% of pts.
visual perception disturbances: spatial perception (hallucinations)
chest P!
unexplained P!
60-70% w/parathesias
hyperhidrosis (excessive sweating)
GI disorders -constipation, urinary incontinence
Orthostatic hypotension
Dx of PD: _____________ is the clinical diagnostic criteria for PD
(1):
(2):
Movement Disorder Society (MDS)
(1) bradykinesia in combination w/at least resting tremor and/or rigidity
(2) absence of absolute exclusion criteria, at least two supportive criteria (for example, responding well to dopaminergic agents), and no red flags
Medical Management of PD includes:
pharmacology
nutritional management: (3)
deep brain stimulation: (3)
referrals to other specialties
nutritional:
high protein diets and blocks the effectiveness of levodopa
need high-calorie, low-protein diet
some need PEG tubes (trouble swallowing)
deep brain stimulation:
for tremor typically
can impact gait, on/off symptoms
electrodes typically in GPi or subthalamic nucleus –> stop tremors
Pharmacology of PD:
-the point is to __________ dopamine
-what two medications replace DA?
-stimulate DA receptors in ______
-COMT/MAO-B inhibitors _____ breakdown of levodopa
-Anticholinergics reduce excessive _______ caused by decreased DA
increase
carbidopa/levodopa
BG
block
ACH
PT Exam/Eval for PD:
Need to screen many systems: (6)
1. cognition:
2. psychosocial function:
3. sensory:
4. musculoskeletal:
5. autonomic:
6. neuromuscular:
miniBest, Mocha, MiniMental
QOL questionnaires
spinothalamic tract
functional strength, joint restrictions (contracture, trunk rot. muscle length)
bowel/bladder, BP, constipation
balance, postural control, rapid alternating movements affected
Outcome measures for PD:
PD edge, Hoehn & Yahr, United Parkinsons Disease Rating Scale (UPDRS)
Modified H&Y scale:
1.0:
1.5:
2.0:
2.5:
3.0:
4.0:
5.0:
unilateral involvement only
unilateral and axial involvement
bilateral involvement without impairment of balance
mild bilateral disease w/recovery on pull test
mild to moderate bilateral disease; some postural
instability; physically independent
server disability; still able to walk or stand unassisted
wheelchair bound or bedridden unless aided
unilateral involvement only:
1.0
mild to moderate bilateral disease; some postural
instability; physically independent
3.0
unilateral and axial involvement
1.5
wheelchair bound or bedridden unless aided
5.0
mild bilateral disease w/recovery on pull test
2.5
severe disability; still able to walk or stand unassisted
4.0
bilateral involvement without impairment of balance
2.0
Gold Standard for determining the severity of PD:
UPDRS
The following statement is True or False regarding UDPRS?
-often done by a PT/OT.
-time consuming
false; neurologist
true
How is UPDRS scored and what are the measures (3) ?
score: 0-4 on ea. item (higher # = worse)
mentation, behavior and mood (4 items)
ADL’s (13 items)
motor scales (14 items)
additional section for other symptoms (11 items) on/off period, hypotension etc.
UPDRS section 1 (mentation, behavior, and mood) includes:
intellectual impairment
thought disorder
depression
motivation/initative
UPDRS section 2 (ADLs) includes:
speech, salivatiion, swallowing, cutting food and handlings utensils, dressing, hygeiene, walking, tremor, falling, etc.
UPDRS section 3 ( motor exam) incudes:
speech, faial expression, tremor at rest, rigidity, gait, posture, etc.
What are the PD Edge highly reccomended measures?
-body structure function:
-activity
-particpation
cognition = MOCA
gait + hand function = 6 min walk, miniBest, FGA, sit to stand, 9 hole peg test, etc.
questionnaires = PDQ-8 or PDQ 39
What are recommended Measures for these Specific Constructs?
-freezing gait
-fatigue
-fear of falling
-dual-task
freezing gait questionnaire
parkinsons fatuigue scale
ABC scale
TUG + cognitive
What innerventions are highly reccomended for PD?
aerobic exercises, reistance trianing, balance training, extenal cuing, community bases exercise, gait training, task specfici ,
behavior change approach, integrated care
Flexibility training is high edvidence on the CPG?
No, low evidence –> they have rigidity, activity based approach
Can pts. with PD remediate function? If yes, how?
Yes
DA= neurotransmitter –> chemical side affected –> use neuroplasticity principles:
-use or lose it
-rep. matters (high reps, high intensity)
-salilence
-use + improve it
-transpearence
*can push pts.
PD patients will have many MSK problems and as a PT you should treat them but keep __________ in mind.
-ex:
neurological condition
frozen shoulder: one arm doesn’t move as much = learned nonuse
back p! : no rotating trunk motion/tight hip flexors
PT intervention cueing techniques: (4)
visual cues help
auditory ques help (metronome)
too many cues aren’t helpful (cognitive deficits)
weight shift can help get out of freezing
PT POC:
remediation of function is possible
treatment of MSK is possible
this is still progressive
may consider skilled maintenance between remediation episodes
medication timing may matter (wearing off vs peak)
PT setting for PD:
OPPT but could see in any setting
