Parkinson's Flashcards
What kind of disease is Parkinson’s?
Chronic, Progressive disease
What is parkinson’s characterized by?
Rigidity, Bradykinesia, Tremor, Postural instability.
What is the typical age on onset?
40-60, caucasian men most.
Parkinsonism
group of disorders that produce abnormalities of basal ganglia
Paralysis agitans
Primary parkinson’s disease, “shaking palsy”
How is the diagnosis arrived at?
Symptoms/Clinical Signs
Response to L-Dopa
Rate of Onset
Differential Dx: EEG, CAT scan
Types of Parkinson’s
Postural instability disturbed gait (PIDG)
Tremor predominant
Secondary Parkinson’s
Postinfectious parkinsonism
Toxic parkinsonism
Drug induced (pharmacological) parkinsonism
Metabolic causes
Postinfectious parkinsonism
Seen after influenza epidemic (encephalitis lethargica)
Infectious pathogen infects substantia nigra.
Toxic parkinsonism
Toxic industrial poisons/chemicals
Manganese (miners), etc.
Drug induced (pharmacological) parkinsonism
Drugs that produce extrapyramidal dysfunction . This is REVERSIBLE. (neuroleptic, antidepressant, antihypertensive)
Metabolic causes
Calcium metabolism disorder with basal ganglia calcification Hypothyroidism Hyperparathyroidism Hypoparathyroidism Wilson's disease
Parkinson-plus
Akinetic/rigid symptoms with parkinsonisan features
Typically DO NOT respond to parkinson drugs (L-Dopa)
Clinical Manifestations of PD
Rigidity (Cogwheel, leadpipe or both)
Bradykinesia/Akinesia (Difficulty initiating, freezing, hypokinesia, micrographia)
Tremor
Postural Instability (MSK changes)
What rate of tremor on EMG?
4 Hz resting tremor. Tremor may go away with movement. –> indicates involvement of basal ganglia.
Turning en block
Pelvis, head and shoulders all turn as a unit. Taking small steps to accomplish a turn.
Non-motor symptoms
Depression Excessive daytime sleepiness Sleep disturbances Fainting/Dizziness REM sleep behavioral disorder Bladder overactivity Constipation Sexual dysfunction (ED) Soft/lower voice volume Lack of smell
Clinical Impairments of PD (indirect impairments/complications)
Motor planning problems Gait disturbance Cognitive issues Autonomic dysfunction Cardio Pulm dysfunction Speech/voice/swallowing problems Sensorimotor/sensation disturbance
Indirect Impairment: Motor planning problems
Poverty of movement, fatigue, masked face (hypomimia)/decreased facial expression
Indirect Impairment: Gait Disturbances
Festinating gait, anteropulsive gait, retropulsive gait
Indirect Impairment: Sensorimotor/Sensation Disturbances
Parasthesias, Pain, postural stress syndrome, akathisia (extreme motor restlessness) Visual Disturbances (blurring, conjugate, saccadic eye movement impaired, decreased blinking), Anosmia
Indirect Impairment: Speech/voice/swallowing problems
Dysphagia
Sialorrhea
Hypokinetic dysarthria (low volume, monotone, etc)
Mutism – not talking
Indirect Impairment: Cognitive Issues
Dementia
Bradyphrenia
Visuospatial problems
Depression
Bradyphrenia
slowed thought process and lack of concentration, attention
Indirect Impairment: autonomic dysfunction
Thermoregulatory dysfunction, sebborheic dermatitis, slow pupillary reaction, GI discomfort (dec motility), bladder dysfunction
Indirect Impairment: CP dysfunction
Orthostatic hypotension (L- dopa can make worse) Suppressed tachycardia with exercise Respiratory problems (airway obstruction/restrictive dysfunction)
Hoen and Yahr
Classification of Disability in pts with PD
HY I
Minimal or Absent; unilateral if present
HY II
Minimal bilateral or midline involvement. Balance not impaired
HY III
Impaired righting reflexes. unsteadiness when turning/rising from a chair. Some activities are restricted but pt can live independently
HY IV
All symptoms are present and severe. Standing and walking possible only with assistance
HY V
Confined to bed or wheelchair.
Levadopa (L-dopa)
Precursor to dopamine that improves symptoms but does not change underlying disease.
Need drug holiday to maintain efficacy. 20-40 min to be effective, duration 2-4 hrs.
Carbidopa
helps to inhibit l-dopa breakdown in the periphery
Medication SE
Orthostatic Hypotension
Nausea (can take more carbidopa to offset)
Hallucinations
Somnilence; daytime sleepiness
Anticholinergics: dry mouth, sedation, confusion
Surgical Management
Pallidotomy, Thalamotomy, neural transplantation, deep brain stimulation
Palllidotomy
lesion in globus pallidus, reducing GP internus inhibitory activity that results in thalamic hypoactivity
Thalamotomy
ventral intermediate nucleus lesion to reduce tremor and rigidity
Neural transplantation
Implanting of embryonic stem cells
There is a lot of promise in this area but they aren’t that efficacious at this time.
Unified Parkinson’s Disease Rating Scale III
Outcome measure for this population. 5 point or greater improvement makes a clinical difference. Not only PT use.
Exercise training
Relaxation, flexibility, strength, functional, adaptive/supportive devices. Balance, locomotor, cardiopulm, group/home exercise.
Motor learning strategies
Structured instructional sets, visual cues (targets), rhythmic auditory stimulation (music/beat), pulsed cues (tactile tapping), multisensory cues
LSVT
Lee Silverman Voice Treatment. BIG AND LOUD.
Antifreeze
Imagine line & step over Count out loud with rhythm (ONE two THREE four) Heel stepping Look at ceiling Rock side to side March
BIG and LOUD
Pt speaks lous, movements as big as possible. May produce more dopamine.
Altering environment
Satin sheets/pajamas
Car: satin on seat
Wall handle/grab bars near fridge, to avoid retropulsion.
Deep Brain Stimulation
Later in the disease course usually. May be effective earlier.
