L29: Parkinson's Disease Flashcards
What is idiopathic Parkinson’s Disease?
PD is a clinical diagnosis of movement disorder that responds to dopamine medications
What are the medical tests or scans to confirm PD?
No medical tests or scans to confirm PD
What is premotor Parkinson’s Disease (PD)?
Increasing evidence that olfactory dysfunction, sleep abnormalities, cardiac sympathetic denervation, constipation, depression and pain may precede the onset of motor signs of PD.
What are the first signs ≤12 years prior in PD?
Loss of smell, constipation, REM sleep behaviour disorder
- 80% likely to develop PD in the next 12 years
- Starts in olfactory > guts > brainstem > midbrain > cortex
- REM sleep behaviour: Disconnection between movements & sleep
- REM sleep behaviour disorder: Disinhibition of movements when sleeping - they act out their dreams, often violent dreams, attacking partner next in bed or hurt themselves
- Ask about these things in patient interview
What is REM sleep behaviour?
Disconnection between movements & sleep
What is REM sleep behaviour disorder?
isinhibition of movements when sleeping - they act out their dreams, often violent dreams, attacking partner next in bed or hurt themselves
What are 3 risk factors for Parkinson’s Disease (PD)?
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Genetics: X autosomal dominant and recessive genes or gene loci have been linked to PD (e.g. LRRK2)
- 10-15% PD patients will have an affected first or second degree relative
- Environmental: Unclear, pesticides
- Neuroprotection: Caffeine , tobacco, hyperuricaemia
What are 6 characteristics of pathology for Parkinson’s Disease (PD)?
- Degeneration of substantia nigra cells which produce dopamine causes disruption of dopaminergic neurotransmission.
- Accumulation of Lewy bodies from the lower brainstem to the neocortex
- ≥5 parallel loops associated with projections from the basal ganglia
- Cortex - striatum - Gpe/Gpi/SNr - thalamus - cortex - with input from substantia nigra
- Subserve different functions: Motor, oculomotor, limbic, lateral premotor
- Based on excitatory and inhibitory connections
What is the Braak’s model for PD?
PD is proposed to be a progressive accumulation of intraneuronal alpha synuclein.
What are 3 characteristics of “increasing evidence of involvement of nondopaminergic systems (ACh) in pedunculopontine nucleus (PPN)” for PD?
- Nondopaminergic system is linked to difficulties with attention and dual tasking
- Reduced cholinergic activity in people with PD who fall
- Cholinesterase inhibitor can reduce falls and improve dual tasking in some small trials in older adults with Alzheimer’s Disease
What does a normal basal ganglia loop look like?
What does a PD basal ganglia loop look like?
What are 4 functions of basal ganglia?
- Automatic execution of learned motor plans
- Internally generated movement
- Sequential movement
- Learned motor plans (e.g. gait)
- PD basal ganglia loop
- Contributes to motor set - preparedness for movement
- Provides internal cueing to link sub-movements in sequential movements
- Not as involved in
- Externally generated, simple, or novel movements
- Therapy - make tasks more novel, so they are use cortex more than basal ganglia and will be better at doing those movements
What are 4 characteristics of motor control research in PD?
- PD has no deficit in formulation of motor programs
- Impaired execution of movement: Difficulty modulating amplitude and velocity - smaller amplitude & slower velocity
- Difficulty switching from one motor program to another within a motor plan in sequential movements
- Difficulty superimposing motor programs to form a motor plan in simultaneous movements (dual task)
______ has no deficit in formulation of motor programs
PD
What does “impaired execution of movement” mean?
Difficulty modulating amplitude and velocity - smaller amplitude & slower velocity
What are 2 motor control problems with people with PD?
- Difficulty switching from one motor program to another within a motor plan in sequential movements.
- Difficulty superimposing motor programs to form a motor plan in simultaneous movements (dual task)
What are the 2 subtypes of PD?
- Postural instability-gait disorder (PIGD)
- Tremor-dominant
What are 5 characteristics of Postural instability-gait disorder (PIGD) for Parkinson’s Disease (PD)?
- Initial symptoms of rigidity & hypokinesia
- Problems maintaining balance, gait, freezing
- More rapid course
- More problems with dementia & cognition
- More common than tremor-dominant
What are 4 characteristics of Tremor-dominant for Parkinson’s Disease (PD)?
- Tremor dominates as a symptom
- Disease progresses more slowly
- More problems with dementia & cognition
- More common than tremor-dominant
What are 3 progressions/stages of PD?
- Early stage (Hoehn & Yahr stage 1-2.5)
- Mid stage (Hoehn & Yahr stage 2-4)
- Late stage (Hoehn & Yahr stage 5)
What are 6 features of Early stage (Hoehn & Yahr stage 1-2.5) for Parkinson’s Disease (PD)?
- Unilateral symptoms
- Few limitations
- Resting tremor - minimal
- Reduced amplitude & speed
- Reduced arm swing in gait
- Early intervention is better
What are 2 features of Mid stage (Hoehn & Yahr stage 2-4) for Parkinson’s Disease (PD)?
- Activities affected
- Balance & falls are an issue
What are 2 features of Late stage (Hoehn & Yahr stage 5) for Parkinson’s Disease (PD)?
- Activities & participation limited
- Wheelchair/bed bound
What are 4 cardinal signs of PD?
- Hypokinesia/Bradykinesia
- Akinesia
- Tremor
- Rigidity
What are 8 clinical features of “Hypokinesia/Bradykinesia” as a cardinal sign of PD?
- 78% of people with PD
- Reduced speed and amplitude of movement
- Movements become smaller and slower
- Sequential movements get smaller and smaller
- Asymmetrical severity
- Symmetrical severity indicates other movement disorders - red flag
- More problems with sequential movements that are performed automatically (e.g. arm swing, facial expressions)
- Decrease in spontaneous movement
- Performing simultaneous movements becomes difficult
What are 4 clinical features of “Akinesia” as a cardinal sign of PD?
- 20% of people with PD
- Difficulty initiating movement
- Motor blocks (freezing): Sudden inability to move
- Context dependent - related to visuospatial processing?
- e.g. Turning, walking in confined space is harder than walking straight
What are 3 clinical features of “Tremour” as a cardinal sign of PD?
- “Pill rolling”
- 4-6 beats/second
- Resting tremor is more obvious
- Movement tremor is probably other movement disorders
What are 5 clinical features of “Rigidity” as a cardinal sign of PD?
- Hypertonia affecting agonists and antagonists
- Lead pipe rigidity: Same rigidity regardless of speed of movement or ROM
- Cogwheel rigidity if tremor is present: Jerky as going through ROM
- Typically shown in trunk and limbs
- Rigidity can be the first symptom - reason for visiting physio
- If rigidity is unresponsive to MSK treatment > refer to GP > neurologist
What is Lead pipe rigidity for PD?
Same rigidity regardless of speed of movement or ROM
What is Cogwheel rigidity for PD?
Cogwheel rigidity if tremor is present: Jerky as going through ROM
What are 7 additional clinical features of PD?
- Adaptive responses: Secondary MSK changes
- Orofacial Features
- Cognitive Deficits
- Dyskinesia
- Speech Disturbances
- Autonomic Symptoms
- Respiratory Symptoms
What are 6 adaptive responses (Secondary MSK changes) for PD?
- Muscle tightness
- Reduced ROM
- Muscle weakness
- Reduced activity
- Reduced aerobic capacity
- Fixed posture (flexion)
What are 4 orofacial features for PD?
- Mask-like face due to hypokinesia and akinesia
- Reduced blinking
- Drooling due to decreased frequency of swallowing
- Dysphagia
What are 9 cognitive deficits for PD?
- Cognitive deficits occur in later PD
- If cognitive deficits occur in early stage, then suspect other diseases
- Attention
- Planning
- Concentrating on two or more tasks
- Problem solving
- Organisation
- Slowness of thought
- Depression
- Anxiety
What are 5 features of dyskinesia for PD?
- Caused by too much dopamine medication in later stages
- Overactivity in muscle groups at rest
- Dystonia: Sustained contraction/cramps commonly in PF, forward and lateral trunk flexors
- Wriggling/writhing movements
- Chorea or rarely athetosis
What are 5 features of speech disturbances for PD?
- Dysphonia: Speech becomes soft, slow and indistinct
- Hoarse voice quality
- Monotone due to less amplitude modulation
- Imprecise articulation
- Vocal tremor
What are 2 autonomic symptoms for PD?
- Decreased mobility of bowels leads to constipation > leads to reduced general mobility
- Postural hypotension
What are 2 respiratory symptoms for PD?
- Decreased vital capacity and FEV1
- Increased pulmonary complications > death
What are 4 functional movements in PD that are affected cClinical features of PD are evident during functional tasks)?
- Gait
- Rolling
- Standing balance
- Fine motor tasks
What are 15 gait disturbances for PD patients?
- ↓ Velocity
- ↓ Stride length
- ↓ Foot clearance
- ↓ Arm swing
- ↓ Trunk and pelvic rotation
- Wide based in early PD
- Narrow based in advanced PD
- Increased cadence
- Stride length is shorter and cadence is higher at all speeds - fundamental deficit in gait hypokinesia is a disorder in step length regulation
- Festination or anteropulsion/propulsion as the cadence increased and the steps shorten
- Disordered timing (slower cadence): Gait rhythmicity is disturbed and results in disordered cadence, speed & variability
- Hesitance in initiation especially in crowds and confined spaces
- Difficulty terminating
- Freezing episodes
- All gait disturbances are worse when dual task
What are 2 bed mobility problems for PD patients?
- Rolling in bed is difficult
- Getting out of chairs/bed becomes slower and more difficult
What are 2 fine motor control problems for PD patients?
- Decreased ability especially with alternating movements
- Micrographia: Writing becomes slower and smaller
