Parkinson's

Question 1

Define Parkinson’s disease

what are the 4 cardinal signs?

Answer 1

Neurodegenerative disease of the dopaminergic neurones of the substantia nigra, characterised by:

1 ○ Bradykinesia - MUST HAVE

With one of the following;
○ Rigidity
○ Resting tremor
○ Postural instability - cant maintain upright posture

Question 2

What is the pathophysiology of parkinsons

Answer 2

○ Degeneration of dopaminergic neurones projecting from the substantia nigra to the striatum

○ Patients are only symptomatic after the loss of > 70% of dopaminergic neurones

Question 3

Explain the aetiology/risk factors of Parkinson’s disease

Answer 3

• Sporadic/Idiopathic Parkinson’s Disease
○ Most COMMON
○ Aetiology UNKNOWN
○ May be related to environmental toxins and oxidative stress

• Secondary Parkinson’s Disease
○ Neuroleptic therapy (e.g. for schizophrenia)
○ Vascular insults (e.g. in the basal ganglia)
○ MPTP toxin from illicit drug contamination
○ Post-encephalitis
○ Repeated head injury

• There are some familial forms of Parkinson’s disease

Question 4

Summarise the epidemiology of Parkinson’s disease

Answer 4

• Very COMMON
• Prevalence: 1-2% of > 60 yrs
• Mean age of onset: 57 yrs

Question 5

Recognise the presenting symptoms of Parkinson’s disease

Answer 5

• INSIDIOUS onset

Earliest signs;
REM sleep behavioural disorder; act out in their sleep
Restless legs - fine in morning worse in evening
Frozen shoulder, carpal tunnel syndrome
-Progressive- micrographia

• Resting tremor (mainly in hands)
• Stiffness and slowness of movements
• Difficulty initiating movements
• Frequent falls
• Smaller hand writing (micrographia)
• Insomnia
• Mental slowness (bradyphenia)

Question 6

Recognise the signs of Parkinson’s disease on physical examination

Answer 6

• Tremor
○ Pill rolling rest tremor
○ 4-6 Hz
○ Decreased on action
○ Usually asymmetrical

• Rigidity
○ Lead pipe rigidity of muscle tone
○ jerking character can cause cogwheel rigidity
○ Rigidity can be enhanced by distraction

• Ataxia - Gait disorder;
○ Stooped
○ wide based
○ staggering gait
○ Shuffling -smaller steps
○ Small-stepped gait
○ Reduced arm swing + arms flexed at elbow
○ Difficulty initiating walking

• Postural Instability
○ Falls easily with little pressure from the back or the front

• Other features
○ Frontalis overactivation (leads to furrowing of the brow)
○ Hypomimic face
○ Soft monotonous voice
○ Impaired olfaction
○ Tendency to drool
○ Mild impairment of up-gaze
- scanning speech
- dysdiadochokinesia
- dysmetria, knocks things over instead of picking up

• Psychiatric
○ Depression
○ Cognitive problems and dementia (in later stages)

Question 7

Identify appropriate investigations for Parkinson’s disease

Answer 7

• CLINICAL diagnosis
• Levodopa Trial
○ Timed walking and clinical assessment after administration of levodopa
you would see an imporvement

• Bloods
○ Serum caeruloplasmin - rule out Wilson’s disease as a cause of Parkinson’s disease

• CT or MRI Brain
○ To exclude other causes of gait decline (e.g. hydrocephalus)

• Dopamine Transporter Scintigraphy
○ Reduction in striatum and putamen

Question 8

What types of rigidity are found at which part of the arm?

Answer 8

Lead pipe rigidity is @elbow

cogwheel rigidity is @ wrist

Question 9

Describe a parkinsonian face

Answer 9

A blank, mask-like facial expression
A reduction in the spontaneous blink rate
A soft monotonous voice

Question 10

What % of parkinsons patients have the resting tremor?

Answer 10

The resting tremor is present in 70-80% of cases.
It is worsened by stress.
Generally decreases or DISAPPEARS WITH action.
Pill-rolling’ tremor of the opposed thumb and fingers.
Postural tremor often present too.

The tremor can also sometimes be seen in the feet

Question 11

What causes the mask like face in parkinsons?

Answer 11

Bradykinesia.

Note bradykinesia is often one sided… see the parkinsons video :)

Question 12

What is balance like in parkinsons

Answer 12

they become increasingly unbalanced

Question 13

Name other important signs and symptoms not mentioned above

Answer 13

Micrographia - small handwriting due to the bradykinesia

Dysarthria
Dysphagia

Question 14

How is Parkinsons different from progressive supranucelar palsy?

Answer 14

PSP:

• More apparent difficulties with speech and swallowing: +earlier onset
• Spastic speech, echolalia, dysarthria
• Startled facies ; constantly anxious look
• Fewer have tremor
• Posture: stand straight may tilt head backwards = lots of backwards falls - earlier (within 1 year of ddx)
• Poor response to L-DOPA
• Axial > Limb rigidity - symmetric
• Dystonia; inc involuntary eyelid closure.
• TAUOPATHY!
  O/E:
• EYES: vertical gaze palsy!!
• Postural instability

Parkinsons:

• Limb > Axial rigidity - asymmetric
• Flexed, Stooped posture; late to start falling - forward falls
• Normal eye movements
• Alpha synuclein

Question 15

Difference between rigidity and spasticity?

does lead pipe rigidity appear on flexion or extension?

Answer 15

Rigidity is defined as increased resistance to passive movement about a joint.

It is similar to spasticity since both conditions show increased resistance to passive movement.

However, rigidity is not direction dependent, that means there is the same amount of resistance both in extension and flexion of the affected limb.
(spasticity gives resistance to extension)

Also, rigidity is not velocity dependent, meaning that the tone does not change based on the speed of passive motion.

Question 16

which direction is spasticity noted in upper and lower limbs?

Answer 16

Spasticity is more often found in the flexor muscles of the upper limb (fingers, wrist, and elbow flexors) and in the extensor muscles of the lower limb (knee and ankle extensors).

Question 17

Parkinsonism with urinary problems coudl indicate

Answer 17

Multiple system atrophy

Question 18

shy drager?

Answer 18

Parkinsonism + autonomic signs

poor response to levodopa