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Neuro Management > Parkinson Evaluation and Intervention > Flashcards

Parkinson Evaluation and Intervention Flashcards

1
Q

what is the function of the basal ganglia?

A
  • Assists motor cortex in running well learned motor skills via output to the
    1) supplemental motor cortex for internal cueing of movt. sequences and
    2) premotor cortex for motor readiness
  • Allows skilled movements to run with minimal attentional requirements
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2
Q

What happens when the basal ganglia is defective?

A
  • Degrades the programmed control movt
  • Creates difficulty with well learned complex tasks
  • Slows adapting response in changing environment
  • Decreased amplitude of movt
  • Difficulty switching from one task to another
  • Imprecise release of sub-movements
  • Inaccurate terminations.
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3
Q

what causes parkinsons disease? what are the primary symptoms?

A

Chronic progressive neurodegenerative disorder in which there is
- depletion of dopamine from the substantia nigra
- neuronal accumulation of the presynaptic protein synuclein
- variable degrees of paucity and slowness of movement, tremor at rest, rigidity, shuffling gait & flexed posture

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4
Q

what are the 4 cardinal signs of PD?

A
  • Tremors (4-5 HZ) resting large amplitude
    -Rigidity (cog wheel in UE)
  • akinesia, bradykinesia (hesitation, slow movement, impaired repetitive movement, freezing, diminished arm swing, facial masking)
    -postural instability
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5
Q

what are signs and symptoms of PD?

A
  • Inability to voluntary control all ADLs
  • Akinesia - difficulty initiating movt
  • Bradykinesia: slowness of movement
  • Rigidity: cogwheel hypertone both sides
  • Tremor: rhythmic oscillatory movt, 4-5 HZ, resting large amplitude.
  • Gait : slow, shuffling, festination
  • Speech: monotone, decreased volume
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6
Q

how does a tremor look like in someone with PD?

A

Rhythmic tremor often occurs at first in one hand, where it resembles the motion of rolling a pill between the thumb and forefinger

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7
Q

what type of posture does someone with PD show?

A

Leaning forward or backward when upright reflects impairment of balance and coordination.

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8
Q

what type of muscle rigidity is common in individuals with PD?

A

Muscle rigidity shows itself in the cogwheel phenomenon: pushing on an arm causes it to move in jerky increments instead of smoothly.

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9
Q

What activity/ ADL is difficult for people with PD?

A

Difficulty rising from a sitting position is a common sign of disordered control over movement. Some patients report feelings of weakness and of being constrained by ropes or other forces.

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10
Q

what is hypokinesia?

A
  • Reduced movement amplitude and speed
  • Reduced step length
  • Alterations in rate and timing of movement
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11
Q

what is freezing with regard to PD?

A
  • An inability to initiate walking sequences
  • A sudden cessation of stepping part-way through a locomotor task of due to environmental change or distraction
  • Difficulty restarting subsequent steps in a sequence once a block has occurred
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12
Q

what is gait festination?

A

Involuntary shortening of steps and hastening of cadence part way through a task

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13
Q

What is movement set? what is the typical order?

A

Preparation of motor cortical neurons in a state of readiness for performance of a movement sequence
Normal – BG –> SMC, PMC

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14
Q

what are the non-motor manifestations of PD?

A

Autonomic dysfunction
- Orthostatic hypotension
- Flushing
- Sweats
- Constipation
- Sphincter and sexual dysfunction
Sensory symptoms
- Paresthesia
- Pains
- Akathisia; visual, olfactory, vestibular dysfunction
Seborrhea, edema, fatigue, weight loss

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15
Q

what are behavioral abnormalities with PD?

A

Personality changes
apathy, lack of confidence, fearfulness, anxiety, emotional lability, social withdrawal, dependency
Slow thought processes, loss of concentration, difficulty with concept formation
Dementia
Paranoia, psychosis, hallucinations
Depression  
Sleep disturbance 

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16
Q

what scale can be used to measure fucntional status in people with PD?

A

The H & Y stages of PD
0 - No visible symptoms of Parkinson’s disease
1 - Symptoms on only one side of the body(slight tremor, some stiffness and slowing of movement.
2 - Symptoms on both sides of the body and no difficulty walking(as above with speech and face masking appearing)
3 - Symptoms on both sides of the body and minimal difficulty walking(as above still independent but with balance problem )
4 - Symptoms on both sides of the body and moderate difficulty walking (as above with increase assist on ADL )
5 - Symptoms on both sides of the body and unable to walk ( wheelchair dependent )

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17
Q

what ADLs should be tested during a PD evaluation?

A
  • Moving in bed
  • Arising to sit
  • Arising to stand
  • Standing and Gait
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18
Q

what qualitative measures should be considered during a PD eval? What quantitative measures should be used?

A

Qualitative:
Description of motor performance
-Phases of motion – initiation, execution, termination
- Reaction time
- Quality of motion
- Kinematics of the motion
- Use of compensatory techniques
- Balance challenges
Quantitative:
timing with stop watch

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19
Q

How does PD affect bed mobility? What should you assess with regard to bed mobility?

A
  • Problem: rigidity, decreased initiation, immobility of spine, flexor domination, forward head, decreased rotation
  • Assessment: reaction and movt time, phase of movement , quality, kinematics, compensatory techniques
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20
Q

how does PD affect arising to stand? What should you assess?

A
  • Problem: forward head, kyphosis, post pelvic tilt (PPT) inability to transfer weight anteriorly.
  • Assessment: Reaction and Movt time, phase, quality, kinematic compensatory techniques, balance
21
Q

how does PD affect gait? How should you assess?

A

Problem:
- Hypokinesis - decreased movement esp. in stride length
- Decreased postural adjustments ; forward head, kyphosis, PPT
- Delayed balance reactions
- Decreased stride length - ( festinating , speed , stride)
- Short quick, shuffling steps
- Increased double support
- Decreased rotation and arm swing
Assessment
- speed, distance, stride length, freezing (when, # of occurrences , where )

22
Q

how does PD affect motor planning?

A

Problem:
- decreased internal self cueing, initiation, execution, difficulty termination, inability to dual task
- Freezing: sudden abrupt inability to initiate any movt. E.g. Doorways , turns
- Festination : abrupt inability to control speed, festinating gait

23
Q

what objective measures should be included in a PD evaluation?

A

Range of Motion
Strength
Flexibility
Family/social context
Education level
Cognitive status
Depression

24
Q

what are two approaches a PT can take when making goals/ interventions for a patient with PD? what should be considered?

A
  1. approach the underlying cause in rigidity, ROM, reactions
  2. approach through the use of ADLs
    - exercises should be functionally relevant and repetitive
    - exercises should have familial involvement and long term strategies
25
Q

what are the primary neurotransmitters involved in PD?

A

Dopamine - primary inhibitory NT
Acetylcholine – primary excitatory NT

26
Q

what are common PD medications?

A

Levodopa/carbidopa
-L-dopa metabolized by dopa-decarboxylase to dopamine
Mainstay of therapy, best therapeutic index
- Dopamine agonists
Sinemet CR
100-2000 mg/d (TID to every 2 h)
Nausea, hypotension, constipation, , confusion, edema, hallucinations and psychosis, dystonic and choreiform dyskinesias

27
Q

what are the three key elements for PT treatment for PD patients?

A
  1. Teach ability to move with ease and postural stability strategies depend on disease stage
    - Compensation strategies
    - Learning strategies
  2. Management of secondary problems
    - Deconditioning
    - Decreased mobility
    - Comorbidities
  3. Promote physical activities and fall prevention
28
Q

Describe the brain mechanism behind compensation strategy training

A

Work to by-pass the defective basal ganglia
- increase reliance on cortical control mechanisms to initiate movement
- increase reliance on attention to sustain execution of complex movements
It is possible that normal movements can be obtained by teaching patients strategies to bypass BG pathology

29
Q

Describe components of compensation strategy training (3)

A
  1. Potential to enhance performance by:
    - Breaking down long or complex sequences into component parts
    - Focused attention
    - performing each part separately
    - performing one task at a time
    - Mental rehearsal & visualization
  2. Provide external cues
    - visual and auditory (utilize the intact premotor cortex to bypass BG)
    - static= stationary cues (lines on the floor)
    - dynamic= transportable cues (inverted cane)
    - negative effects of visual cues include freezing and distraction
    -auditory can include metronome to increase cadence with gait
  3. Practice multiple task conditions
    - varied speed, surface, direction, sensory input
30
Q

Describe management of secondary problems for PD patients? (3)

A
  1. Deconditioning
    - People with PD consume more oxygen than people without PD with gait at any speed
    - Aerobic activities
    - Endurance exercises
    - Mild strengthening ex
  2. Decreased mobility and posture
    - Axial structures-> trunk flexibility
  3. Comorbidities
    - Cardiovascular and Pulmonary
    - Orthopedic
31
Q

Describe promotion of physical activity and fall prevention for PD patients?

A
  1. Home exercise program
    - Daily to 3 x wk – flexibility, endurance, mild strengthening –> May promote neuroplasticity
    - Assist to prevent falls
  2. Periodic PT “check-ups”
    - Update HEP
    - Check for functional ability
    - Check for safety and efficiency
32
Q

Describe environmental constraints and freezing

A
  • Can be triggered or made worse by environment or the task
  • Narrow doorways
  • Small crowded rooms
  • May be a disorder of sensory-motor processing
  • Caudate integrates sensory info so attention can be prioritized to most relevant stimuli for action
  • Sensory overload
33
Q

What is important to consider for PD patients with regard to freezing and tasks?

A
  • More likely with long or complex locomotor skills rather than simple isolated mov’ts
  • Break tasks down into simple component parts with cues to switch
34
Q

what are some emotional constraints related to freezing for PD patients?

A
  • Anxiety and stressful situations are known determinants of the presence and severity of freezing
  • Crossing a busy road, hurrying to a ringing telephone, etc.
35
Q

what are medication constraints with regard to freezing for PD patients?

A
  • Occurs most often in the “off” phase
  • Occurs most often in patients who have been on PD meds for an extended time
36
Q

What are ways to avoid freezing?

A
  • Rhythmical sensory cueing
  • Relaxation
  • Stop, pause, restart task
  • Avoid complex, long sequenced mov’t
  • Cognitive compensation
  • Stairs
37
Q

According to CPG guidelines, what are ways to do external cueing?

A
  • cueing training should be performed 20-60 minutes; 2-5x/wk, 3-8 weeks
  • visual cues should be aimed to improve motor function (steeping on/ over targets, lasers to reduce FOG, clock-turning strategy for turning)
  • auditory cues should be before or during a movement to initiate or sustain a motor action ( metronome, rhythmic- based sounds set to a selected bpm based on patient cadence)
  • amplitude training: high velocity, high amplitude movement (LSVT BIG)
  • somatosensory: stimuli aimed to heighten afferent input (vibration)
38
Q

What are the CPG guidelines for aerobic exercise for patients with PD?

A
  • PTs should implement moderate- to- high intensity aerobic exercise to improve oxygen consumption, reduce motor disease severity, and improve functional outcomes
  • For PD patients H& Y 1-3 (mild-moderate PD)
  • For PD patients that are H&Y 3-4, stationary biking should be considered to minimize risk of falls
  • 3x/week; moderate intensity (60-75% max HR); 30-40 minutes
  • stationary cycling and treadmill walking appear to have the same benefit
  • aerobic exercise improves cardiovascular fitness, motor, and non-motor symptoms
39
Q

What are the CPG guidelines for resistance training for PD patients?

A
  • 2 non-consecutive days per week; 30-60 minutes per session
  • progress to 80% 1RM to achieve strength gains
  • beginner: 40-60% of 1 RM or 1 set 20-30 reps, progress to 2x15
  • experienced: 80% 1RM , 3x 10-12, working towards muscle fatigue
    -power: work at higher speeds to improve power (beginner: 20-30% 1RM), (experienced: 40% 1RM)
  • target extensor muscles (trunk and gluteal muscles)
40
Q

what are the CPG guidelines for task specific training for PD patients? (dual task)

A
  • dual task training can improve gait speed, FOG, and balance.
  • can be assessed with dual task gait speed, miniBESTest
41
Q

what are the CPG guidelines for task specific training for PD patients? (fall prevention)

A
  • Frequency: 1x/week for 8wks to 6mo
  • intensity: n/a
  • time: 1-2 hrs/session
    -type: task specific
  • volume: 16-18 hrs
    -progression: Based on RPE
    -can be assessed with MRPE, Fall rate, UPDRS, gait velocity, TUG, PDQ39, number of injurious falls, time to first fall
42
Q

what are the CPG guidelines for task specific training for PD patients? (UE)

A
  • UE task specific training to improve pinch grip strength and dexterity (maybe sensation)
  • frequency: 2-5 days/wk for 4 wks
    -intensity: high
  • time: 15-45 mins per session
  • type: 1:1 manner
    -volume: 6-12 hrs
  • can be assessed with 9 hole peg test, purdue peg board test
43
Q

what are the CPG guidelines for task specific training for PD patients? (turning)

A
  • has been proven to help turn 180 degrees
  • frequency: 2x/wk for 6wks
  • intesity: n/a
    -time: 30 minutes
  • type: 1:1 manner
  • volume: 120 total minutes
  • assessed with TUG, BERG, FOG questionnaire
44
Q

what are the CPG guidelines for task specific training for PD patients? (balance training with dynamic agit training mod to vigorous)

A
  • treadmill training may be better for dynamic balance during gait than balance training alone
  • frequency: 2x/wk
    -intesity: mod to high
    -time: 20-40 minutes
  • assessed with TUG, gait speed, sway area during gait
45
Q

what are the primary physical therapy goals for PD patients in H&Y stage I?

A

Primary PT goals
1. health promotion and maintenance of aerobic fitness, muscle force, and soft tissue extensibility
2. education to patient and caregiver about PD and ways to prevent secondary complications
3. train the person with PD in movement strategies for later use while the person still has intact cognition
- maintain regular physical activity; walk 3x week for 40 minutes concentrating on long strides and ground clearance, stepping on and off curbs, variety of terrains
- maintain upright posture (conscious, strengthen low back extensors and hip extensors)
-minimize microphagia
- practice standing up, turning, walking, moving form lying to supine to sitting up over the edge of the bed and use cueing

46
Q

what are the primary PT goals for PD patients in H&Y stage II?

A

Primary PT goals
1. train movement strategies for hypokinesia, bradykinesia, akinesia, dyskinesia
2. teach how to monitor effects of medication
3. teach ways to avoid secondary complications, maintain aerobic fitness, muscle, and soft tissue extensibility
4. environmental analysis to prevent falls
- stucture home to prevent falss
-implement muscle stretches and positioning programs (prone lying 30 minutes per day)

47
Q

What are the primary PT goals for PD patients in H&Y stage III?

A

Primary PT goals
1. train the person with PD in movement strategies for postural instability, hypokinesia, bradykinesia, akinesia, dyskinesia as needed
2. prevent falls
3. teach about “on” and “off” cycles
4. health promotion and maintanence of regular physical activity with aerobic components
5. teach caregiver to reinforce PT strategies in the home and community
- walk daily at least 100m with large strides and focus on ground clearance
- keep falls diary

48
Q

What are the primary PT goals for PD patients in H&Y stage IV?

A

Primary PT goals
1. train caregiver to reinforce PT strategies for preventing falls and coping
2. train patient on what to do if a fall occurs
3. ensure caregiver can correctly administer medications
4. maintain walking distance and enduracnce
5. ensure person with PD and caregiver are implementing strategies to prevent secondary musculoskeltal problems

49
Q

What are the primary PT goals for PD patients in H&Y stage V?

A

Primary PT goals
1. maintain activity and enhance comfort and QOL
2. prevent falls
3. reinforce movement strategies to assist with walking, moving in bed, reaching and grasping, standing up and turning
4. train caregiver for safe practice of transfers and ADLS
5. prevent skin breakdown
6. maintain clear airways and vital capacity
7. train for positioning in sitting and lying and frequency of repositioning
8. advocate for PD patient

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