Movement Disorders BG Flashcards
1
Q
BG - hypokinetic disorders
A
Direct path is not facilitated
Indirect path is not inhibited
Loss of movement
2
Q
BG - hyperkinetic disorders
A
Indirect pathway lost
GPe inhibits Gpi
Lose Gpi inhibition of thalamus
Movement facilitated/excessive movement
3
Q
Parkinsonism consists of
A
Idiopathic parkinson’s disease
Parkinson’s plus syndrome
4
Q
What percentage of parkinsonism is idiopathic
A
75%
5
Q
Clinical Diagnosis - Step 1
A
Diagnosis of Parkinsonian Syndrome Tremor - resting Rigidity Akinesia/Bradykinesia = must Postural instability
6
Q
Clinical diagnosis - what do you need to get through step 1
A
Slowness plus either T, R, or P
7
Q
Clinical diagnosis - step 2
A
Exclusion criteria for PD Cbm signs Hx of rx stroke Gaze palsies Early severe dementia Bilateral onset Early sever postural instability Poor response to levodopa
8
Q
Clinical diagnosis - step 3
A
Supportive features (need 3 or more in combination with step 1) Unilateral onset Progressive s/s with asymmetry Rest tremor Excellent early response to levadopa
9
Q
Single biggest risk factor for idiopathic PD
A
Age
10
Q
20 year and 10 year prodrome symptoms
A
20 year - hyposmia, constipation, bladder disorder
10 yr - sleep disorder, obesity, depression
11
Q
Clinical onset symptoms
A
unilateral tremor, rigidity, akinesia
12
Q
20 year disease stage (1 is clinical onset symtoms, what are 2, 3, 4 and 5)
A
2 - bilateral disease
3 - poor balance (10 yr)
4 - falls, dependency, cognitive decline
5 - chair/bed bound, dementia
13
Q
T or F: PD is NOT just a movement disorder
A
TRUE!
14
Q
Hoehn and Yahr Stages - Stage 1
A
1 s/s unilateral 2 sx mild 3 sx inconvenient but not disabling 4 tremor in one limb 5 friends comment on changes in posture, locomotion, facial expressions
15
Q
Hoehn and Yahr Stages - Stage 2
A
1 sx bilateral
2 minimal disability
3 posture and gait affected*
16
Q
Hoehn and Yahr Stages - Stage 3
A
1 significant slowing of body movements
2 Early impairment of equilibrium with gait and stance
3 Generalized dysfunction that is moderately severe
17
Q
Hoehn and Yahr Stages - Stage 4
A
1 severe sx 2 ambulation only with assistance 3 rigidity and bradykinesia 4 loss of ind. living 5 tremors may decrease in severity
18
Q
Hoehn and Yahr Stages - Stage 5
A
1 cachectic stage
2 confined to bed or wc
3 unable to stand or walk
4 requires constant nursing care
19
Q
Unified PD Rating Scale (UPDRS)
A
Composite rating scale by interview
6 areas including cognitive, ADLs, motor, neuro
20
Q
PD subtypes
A
Akinetic/Rigid (50%)
Tremor dominant (40%)
Mixed (10%)
21
Q
Akinetic/Rigid PD - what do you see (motor)
A
Akinesia/hypokinesia Bradykinesia Rigidity FOG Postural instability Resting tremor - often absent
22
Q
Akinetic/Rigid PD - what do you see (non motor)
A
Depression Cognitive dysfunction/dementia Autonomic dysfunction Orthostatic hypotension Constipation
23
Q
Akinetic/Rigid PD - what do you see - FOG
A
Feet appeared glued to ground
Occurs most commonly when there is a perceived obstacle (turning)
24
Q
Akinetic/Rigid PD - what do you see - postural instability tested with
A
tested with shoulder pull
25
Akinetic/Rigid PD - what do you see - gait/posture
Slow, shuffling
Festination
Flexed posture
26
Akinetic/Rigid PD - what do you see - others (handwriting, facial expression, speech)
Small handwriting (micrographia)
Decreased facial expression
Decrease speech volume/stuttering
27
Tremor dominant - what do you see
Resting tremor
Action tremor
Rigidity/akinesia mild
Rhythmic firing of neurons in STN correlated with tremor
28
Tremor dominant - what do you see - cognitive
NOT associated with cognitive/psychological symptoms
29
Tremor dominant - what do you see - resting tremor
pill rolling tremor
| 3-6 Hx
30
Medical tx for PD
Levodopa/Carbidopa (sinemet)
dopamine replacement
helps with bradykinesia/rigidity more so than tremor
31
Medical tx for PD - levodopa/carpidopa - side effects
hallucinations
delusions
psychosis
32
Medical tx for PD - levodopa/carpidopa - therapeutic window
4-6 years, after that the benefit wears off
33
Medical tx for PD - levodopa/carpidopa - phenomenons
On-Off: even when drug is active, time when mvmn is near normal and times with immobility
Wearing off: end of dose deterioration, worsening of sx
34
Big side effect with levadopa
Dyskinesias!
35
Other medical tx for PD besides levadopa
Dopamine agonists
Anticholinergics
Monoamine Oxidase B inhibitors
Deep brain stimulation
36
Other medical tx for PD besides levadopa - dopamine agonists
Ropinirole, Pramipexole
Mimics dopamine in the brain - directly activates dopamine receptors
Often first line because of narrow therapeutic window with L dopa
37
Other medical tx for PD besides levadopa - dopamine agonists - what do they do and what are side effects
Reduce rigidity, bradykinesia, motor fluctuations
| Side effects: nausea, dizziness, hallucinations
38
Other medical tx for PD besides levadopa - anticholinergics
loss of dopamine/excess cholinergic function
| Helps with tremor, little effect on other sx
39
Other medical tx for PD besides levadopa - anticholinergics side effects and examples
blurred vision, dry mouth, dizziness
| Artane, Cogentin
40
Other medical tx for PD besides levadopa - MAOB
MAOB is an enzyme that degrades dopamne - so we inhibit it to keep the dopamine around longer
Selegiline (eldepryl)
Rasagiline (azilect)
41
Other medical tx for PD besides levadopa - deep brain stimulation
surgical implantation of a stimulator and electrodes
| Electrodes STN or Gpi - stimulator/batteries inferior to clavicle
42
Other medical tx for PD besides levadopa - deep brain stimulation - what does it do when electrodes are on
When electrodes are on - inhibit that area
STN - reduce bradykinesia, rigidity, improve gait and postural stability
Reduce tremor - STN or thalamus
43
Other medical tx for PD besides levadopa - deep brain stimulation - problem
serious surgery
risks - hemorrhage, infection, malfunction
side effects - seizures, HA, emotional issues
also not a one time surgery and device isn't turned on until several wks/months after surgery
44
Current model - refer to PT when
After an acute event of change in status - multiple falls, ortho problem (rigidity/loss of flexibility), respiratory compromise
Generally not referred to us until stage 2 or 3, we would prefer stage 1
45
Proposed model - refer to PT `
Dental model - get baseline assessment when diagnosed
Prevention/Restoration focus
Exercise program with consistent adherence
Continuous monitoring and intervention
46
Proposed model - insurance companies
you want 10 sessions over the course of a year
47
Evidence based PT guidelines
Make cards?
48
Interventions
```
Treadmill trainings
Cueing during gait
LVST/Big
Boxing
Dancing
Forced cycling
Tai chi
```
49
Interventions for freezing
```
Change in meds
Imagine line on floor
Hum, count, music
Put foot in front of pt to step over
Rock side to side
Ask for a hand
Take big step
Imagery
```
50
Deep brain stimulators are NOT effective for what
freezing intervention!
51
Exercise summary - motor learning and neuroplasticity require
```
Exercise regularly
Active participation
Intensive with repetition
Task specific
Whole body movement
Timing
```
52
Exercise summary - motor learning and neuroplasticity require - Exercise regularly
Use it and improve it
| HEP
53
Exercise summary - motor learning and neuroplasticity require - Active participation
Teach pt self monitoring
Teach pt what normal mvmnt feels like
Vary context
Rewarding of tasks activates BG
54
Exercise summary - motor learning and neuroplasticity require - Intensive with repetition
Bigger, faster movements
Push beyond self-selected effort
Treadmill
Combine strength and balance
55
Exercise summary - motor learning and neuroplasticity require - Task specific
Not just repetition - need to produce significant changes in patterns to affect neural pathways
Dual tasks
Transitional movements
56
Exercise summary - motor learning and neuroplasticity require - Whole body movement
Bigger, faster movement
57
Exercise summary - motor learning and neuroplasticity require - timing
start before or at diagnosis
58
Parkinsons plus is caused by
other neurodegenerative disorders
59
Parkinsons plus - Progressive supranuclear palsy (PSP)
Brainstem, Cbm, BG, cortex
Build up of Tau protein
Onset after age 40, usually 60s
60
Parkinsons plus - Progressive supranuclear palsy (PSP) - s/s
```
Early gait instability with post falls
Depression
Psychosis
Gaze palsy!
Either vertical gaze palsy or prominent postural instability in first year of dx
```
61
Parkinsons plus - Diffuse Lewy Body Disease - Dementia
Progressive cognitive decline early
Memory impairment at onset is not prominent
Cognitive decline, visual hallucinations, parkinsonism, depression
Often no tremor
Poor response to L dopa
62
Parkinsons plus - multiple system atrophy (MSA)
Affects BG, Cbm, autonomic system, PNS, and cerebral cortex
Adult onset, rapidly progressive, fatal
Parkinsonism with cbm signs, autonomic dysfunction
Poor response to L dopa
63
Parkinsons plus - toxic, infectious, traumatic origin
Drug induced - parkinsonism side effect of antipsychotic meds
Traumatic encephalopathy - repeated trauma to head
64
Red flags for parkinsonism
```
Bilateral onset
Early postural instability
Early dementia
Rapid progression
Early autonomic dysfunction
```
65
Huntington's Disease - definition
Chronic, progressive disorder that is autosomal dominant
66
Huntingtons disease - autosomal dominant
all who carry the gene will manifest ds
| 50% of offspring will have ds
67
Huntingtons disease - movement
abnormal movement patterns - choreiform movements
No pattern or purpose
Ballistic
68
Huntingtons disease - mental
mental deterioration
| bx changes, depression, suicide
69
Huntingtons disease - pathology
targets specific neurons in caudate nucleus and putamen
Also cerebral cortex, particularly frontal lobe
Significant atrophy
70
Personality disorder with Huntingtons disease
```
Depression
Lack of initiative
Decreased communication
Increasing irritability
Psychosis
```
71
Mental deterioration with Huntingtons
Dec concentration
Dec problem solving, thinking ability
Dementia
72
Muscle disorders with Huntingtons
```
All mm groupd
Choreic mvmnts
Mvmnts dec with sleep and increase with stress
Akinesia and bradykinesia
Abnormal postural reactions
Problem with speech and writing
Wide base staggering gait
```
73
Diagnosis Huntingtons
```
Clinical lab tests
EEG with diffuse abnormalities
CT scan - enlarged ventricles
PET scan - hypometabolism putamen and caudate
Family hx
Genetic testing
```
74
Prognosis and tx Huntingtons
```
Progressive
Death within 15-17 yrs of dx
Meds for sx
Restore, prevent, compensate
Palliative care
```
75
Other BG disorders - Tourettes syndrome
involuntary movement such as tics
76
Other BG disorders - Focal dystonia
sustained mm contractions resulting in abnormal postures, prolonged twisting and repetitive movements
77
Other BG disorders - Hemiballismus
wild rapid flinging of proximal muscle/shoulder and hip
