Parkinson's Flashcards by Eden McDaniel

What kind of disease is Parkinson’s?

Chronic, Progressive disease

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What is parkinson’s characterized by?

Rigidity, Bradykinesia, Tremor, Postural instability.

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What is the typical age on onset?

40-60, caucasian men most.

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Parkinsonism

group of disorders that produce abnormalities of basal ganglia

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Paralysis agitans

Primary parkinson’s disease, “shaking palsy”

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How is the diagnosis arrived at?

Symptoms/Clinical Signs
Response to L-Dopa
Rate of Onset
Differential Dx: EEG, CAT scan

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Types of Parkinson’s

Postural instability disturbed gait (PIDG)

Tremor predominant

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Secondary Parkinson’s

Postinfectious parkinsonism
Toxic parkinsonism
Drug induced (pharmacological) parkinsonism
Metabolic causes

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Postinfectious parkinsonism

Seen after influenza epidemic (encephalitis lethargica)

Infectious pathogen infects substantia nigra.

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Toxic parkinsonism

Toxic industrial poisons/chemicals

Manganese (miners), etc.

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Drug induced (pharmacological) parkinsonism

Drugs that produce extrapyramidal dysfunction . This is REVERSIBLE. (neuroleptic, antidepressant, antihypertensive)

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Metabolic causes

Calcium metabolism disorder with basal ganglia calcification
Hypothyroidism
Hyperparathyroidism
Hypoparathyroidism
Wilson's disease

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Parkinson-plus

Akinetic/rigid symptoms with parkinsonisan features

Typically DO NOT respond to parkinson drugs (L-Dopa)

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Clinical Manifestations of PD

Rigidity (Cogwheel, leadpipe or both)
Bradykinesia/Akinesia (Difficulty initiating, freezing, hypokinesia, micrographia)
Tremor
Postural Instability (MSK changes)

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What rate of tremor on EMG?

4 Hz resting tremor. Tremor may go away with movement. –> indicates involvement of basal ganglia.

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Turning en block

Pelvis, head and shoulders all turn as a unit. Taking small steps to accomplish a turn.

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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

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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

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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.