Movement Disorders Review Sheet Flashcards
average age of onset for Parkinson’s
58-60 years old
PD is more often seen in which sex?
slightly more in men
What is the cellular mechanism behind PD?
clumping of proteins (Lewy bodies) appear in neurons of the substania nigra, brainstem and other areas of the brain
degenerationa nd death of dopamine-producing neurons in the substania nigra
What primary symptoms make up Step 1 of PD diganosis process
Tremor- resting
Rigidity
Akinesia or bradykinesia
Postural instability
What exclusion criteria make up Step 2 of PD diagnosis process?
poor response to large doses of levodopa
symptomatic parkinsonism syndrome where symptoms appear to be related to some other cause such as exposure to toxins, head trauma, vascular, etc.
other neurodegenerative conditions in addition to PD type signs
What are the features which support diagnosis of Step III?
unilateral onset
rest tremor (but one does not have to have this for diagnosis of PD)
excellent early response to levodopa
levodopa induced dyskinesias
progressive signs and symptoms, asymmetry of signs; at least initially
clinical onset > 10 years
Bradykinesia
major sign of PD
slow movement
can’t realease thalamus enough to generate bugger bursts to create bigger movements
Akinesia
major sign of PD
too much inhibition of the thalamus; can’t release it
masked facies (lack of expression) and reptilian stare (infrequent blinking)
arm swing decreased
difficulty stopping movement once started (festination)
difficulty stopping backwards movement (retropulsion)
“freezing” episodes
What makes akinesia or bradykinesia worse?
dual tasking
Rigidity
major sign of PD
increased resistance throughout the range
due to outputs to the pedunculopontine nuclei
-with a loss of dopamine, the pedunculopontine nucleus is inhibited so that it can no longer inhibit the reticulospinal and vestibulospinal tracts
-this leads to excitation of postural muscles
muscles are active even when the person is at rest
does NOT cause akinesia or bradykinesia
Resting tremor
major sign of PD
rhythmic, alternating bursts of antagonistic muscles
due to different output pattern from BG
goes away with purposeful movement
“pill rolling” is the most common form
over 90% of those with a PD tremor have some degree of an action tremor
Postural Instability
co-activation resulting in a rigid body and inability to recover stability
What ANS problems occur with PD?
postural hypotension
excessive salivation and sweating
constipation and urinary disturbance
What cranial nerve nucleus is involved with ANS problems
dorsal motor nucleus of X
Mood and cognitive deficits of PD
- mild to moderate cognitive impairment
- dysexecutive syndrome
- depression
- impulse control behavior disorder
- psychosis
- sleep disorders
- nutritional deficits
- speech
What are the symptoms of dysexecutive syndrome?
impaired attention
verbal fluency reduced but language is preserved
visuospatial deficits
difficulty initiating planning and sequencing
impaired free recall
personality change
What are the speech deficits of PD due to?
bradykinesia, akinesia and decreased chest excursion causes a decreased volume and slurred speech as the disease progresses
what is forward festination?
inability to stop forward movement once it has started
bradykinesia issue; difficulty releasing thalamus to generate bigger bursts
what is backward festination?
also called retropulsion
inability to stop backward movement
bradykinesia issue; difficulty releasing thalamus to generate bigger bursts
Elements PT addresses in Parkinson’s
Gait mobility deficits Balance and falls Loss of ROM/contracture/fixed, stooped posture muscle atrophy and weakness fatigue cardiopulm deconditioning osteoporosis ulcers
Gait of someone with PD
slow, shuffling and flat-footed
decreased arm swing
forward and backward festination
difficulty changing direction, going through doorways or over things which can trigger a freezing response
main medication used for PD
Levodopa
What are the major problems with this treatment?
- doesn’t help with tremors
- difficulty in delivery
- dual therapy with carbidopa has extreme side effects
- dyskinesias after prolonged use
- diminished response over time
Advantages of dopamine agonists
effective as an early monotherapy
avoids levodopa side effects
has neuroprotective effects
Disadvantages of dopamine agonists
less potent long titration requires levodopa addition eventually cognitive side effects confusion and hallucinations \$\$$ expensive
population for dopamine agonists
first line treatment for early PD in young, cognitively preserved patients
population for carbidopa/levodpa
patients with more advanced PD that are older and more cognitively impaired
Describe Chorea
Abrupt Brief Irregular Purposeless Unpredictable Non-stereotypical Involuntary movement
when do the first symptoms of Huntingtons occur
onset at 35 and 42
what NT are lost with huntingtons?
loss of Ach and GABA because there is too much dopamine and too much release of thalamus
general development of huntingtons
first symptoms are mood/mental disorder with depression being the most common
then neurobehavioral changes
chorea
what is a common sign of chorea?
milkmaids sign
increase and decrease in grip strength involuntarily
what is hemiballismus
rotary nature/choreatic movements on one side of the body
caused by lesion of the subthalamic nucleus
What causes tardive dyskinesia?
drug induced disorder secondary to use of antipsychotic drugs
signs and symptoms of tardive dyskinesia
involuntary fragmented movements of the tongue, mouth and jaw
smacking, sucking noises
choreoathetoid movements
dystonia of neck and trunk
characteristics of dystonia
PROLONGED muscle contractions of limbs/axial that are either repetitive or sustained
what triggers dystonia
VOLUNTARY movement
what worsens dystonia
fatigue and anxiety
what is the most common type of dystonia
focal which includes task specific (writer’s cramp, musicicians) and spasmodic toricollis
what is spasmodic torticollis
turning fo the neck that causes spasm
how can spasmodic toritcollis be suppressed
only be self-touch sensory trick “gest”
define a tic
major distinguishing characteristic is that if asked it can be suppressed
involves quick, involuntary movements that are repetitive at irregular intervals
tourette’s syndrome
a simple or complex motor tic that may involve vocal tics(swearing)
define myoclonus
quick muscle jerks, irregular or rhythmic that cannot be suppressed and result from cortical, cerebellar, brainstem or spinal cord disorders
types of tremors
resting: rhythmic, alternating bursts of antagonistic muscles that goes away with purposeful movement
postural: type of action tremor that is not seen at rest
Intentional: type of action tremor where the closer you get to the target the wilder the movement; successive overshoots an undershoots about a goal that leads to oscillations
