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SEMESTER 4 - REHAB > Parkinson's Disease > Flashcards

Parkinson's Disease Flashcards

1
Q

Epidemiology of parkinsons

A
  • 2% of population> 65 yrs old
  • Average age 50-60 yrs of age
  • 10 cases per 100,000 under age 50
  • 300 per 100,000 age 80-90
  • Young onset PD, onset before age 40
  • Men and women affected equally
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2
Q

Cardinal Features of parkinsons

A
  • Rigidity
  • Bradykinesia
  • Tremor
  • Postural instability
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3
Q

These are the main features below of parkinson. What are other symptoms you might see?

  • Rigidity
  • Bradykinesia
  • Tremor
  • Postural instability
A
  • movement and gait disturbances,
  • cognitive and behavior al changes,
  • speech,
  • voice and swallowing disorders,
  • cognitive and behavioral changes,
  • autonomic nervous system dysfunction,
  • GI changes,
  • Cardiopulmonary changes
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4
Q

Parkinson’s disease 
Ideopathic or secondary?

most common
Affects 78% of patients
78%:have a number of different identifiable causes
Virus, toxins, drugs, tumors

Parkinson’s first identified in 1817
Fall into 2 groups
Symptoms of postural instability and gait disturbance
tremor

A


Ideopathic

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5
Q

Parkinson’s disease 
Ideopathic or secondary?

Post infectious
Influenza of 1917 to 1996: onset of parkinsons symptoms started after years ?slow virus?
Toxic
Industrial poisonings and chemicals
Most common is manganese
Synthetic heroin (contains MPTP)

A

secondary

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6
Q
  • Drugs can produce extrapyramidal dysfunction
  • Drugs affect dopaminergic mechanism
  • Neuroleptic drugs, antidepressant drugs, antihypertensive drugs
  • Withdrawal of meds usually reverses symptoms
  • Occasionally can be due to calcium metabolism issues: BG calcification, hypothyroidism, hyperparathyroidism, wilson’s disease
A

Drug induced parkinsonism

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7
Q

Pathophysiology of parkinsons

A
  • BG: gray matter nuclei, composed of caudate and putamen plus globus pallidus, subthalamic nucleus and substancia nigra
  • Input to BG is striatrum and cerebral cortex
  • Output is to the thalamus and to cortex
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8
Q

Develop cytoplasmic inclusion bodies:

what does it mean?

A

lewy bodies

that someone has parkinsons

dr c says to remeber this

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9
Q

What part of the brain is involved?

  • Involved in planning and programming of movement
  • Selection and inhibiting specific motor synergies
  • PD assoc with degeneration of dopaminergic neurons that produce dopamine: if have 30-60% degen of neurons will have clinical symptoms
  • Develop cytoplasmic inclusion bodies: Lewy bodies
  • Other areas of predilection: dorsal motor nucleus of vagus, hypothalamus, locus ceruleus, cerebral cortex and autonomic ganglia
A

Basal ganglia

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10
Q
  • release phenomena
  • Loss of inhibitory influences within BG
  • Decreased binding sites for dopamine in BG: can explain loss of effectiveness for L-dopa
A

Tremor

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11
Q

A cardinal feature of parkinson

  • Heaviness and stiffness of limbs
  • increased resistance to passive motion
  • Constant in all movements, regardless of task, amplitude or speed of movement
  • Cogwheel rgidity: jerky, ratchet like: muscles tense and relax
  • Leadpipe rigidity: sustained resistance to passive movement
  • it is often asymmetrical, affects proximal mm, progress to face and extremities
A

rigidity

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12
Q

jerky, ratchet like: muscles tense and relax

A

Cogwheel rgidity

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13
Q

sustained resistance to passive movement

A

Leadpipe rigidity

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14
Q

Rigidity is often what?

A
  • asymmetrical,
  • affects proximal mm,
  • progress to face and extremities
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15
Q

Rigidity - how does it affect a pt?

A
  • Progresses over time
  • Progress to affect whole body
  • Affects ability to move easily
  • Be careful of bed ridden for even a short period of time
  • May lose bed mobility, reciprocal arm sway during gait
  • Active movement, mental concentration or emotional stress will increase rigidity
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16
Q

absence of movement

A

Akinesia

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17
Q

sudden break or block in movement

A

Freezing

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18
Q

reduced amplitude of movement

A

Hypokinesia

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19
Q

Movement; reduced in speed, range and amplitude

A

Bradykinesia

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20
Q

tremor- how does it present in a parkinson pt?

A
  • Initial symptom 70% of time
  • Involuntary involvement of body part, oscilating at slow frequency
  • Tremor disappears during voluntary movement
  • Pill roll tumor or will see tremor in pron/sup, jaw or tongue
  • Postural tremor: will see when muscles used to keep pt in upright position
  • Less severe when relaxed and unoccupied
  • Diminished by voluntary effort
  • Not present during sleep
  • Stress: makes it worse
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21
Q

Postural instability- how does this affect a parkinson pt?

A
  • Occurs after at least 5 years
  • Will see abnormal, inflexible posture, increased body sway
  • Postural instability increased by narrow BOS, increased attention demands and OK (don’t try to decrease their bos)
  • Will see more instability with self initiated movements
  • Problems with anticipatory adjustments during voluntary movements
  • Frequent falls occur with increased loss of balance
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22
Q

Falls- what are some statistics in parkinson pt?

A
  • 2/3 of PD pt experience falls
  • 1.3% fall at least once a week
  • Fall injury 40%
  • Increased risk for falls: freezing, poor gait, balance impairments
  • Other factors that increase falls; dementia, depression, postural hypotension, involuntary movements
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23
Q

why are parkinson pt falling- what might it be due to?

A
  • Torque production is decreased
  • Insufficient neural activation of agonist muscles
  • Firing rate of muscles is very delayed
  • Complex movements: difficulties are more apparent
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24
Q

Fatigue- how does it affect the parkinsons?

A
  • Very common
  • Cant sustain activity
  • Increased weakness and lethargy through the day
  • L-dopa therapy: initially will feel less fatigue, over time fatigue will reappear
  • Will see generalized deconditioning over time
  • Contractures in knee and hip flexors, hip rotators and adductors, plantarflexors. Dorsal spine, neck flexors, shoulder adductors, internal rotators, elbow flexors
  • kyphosis
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25
Q

what do Contractures look like in a parkinson pt?

A

knee and hip flexors,

hip rotators and adductors,

plantarflexors.

Dorsal spine,

neck flexors,

shoulder adductors,

internal rotators,

elbow flexors

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26
Q

planning is prolonged and movement times are somewhat prolonged

A

Start hesitation

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27
Q

Start hesitation

Complex movements are difficult

Microphagia

Freezing episodes -can usually break with external cues

A

Motor planning difficulties of parkinsons pt

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28
Q

handwriting that is small and difficult to read

A

Microphagia

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29
Q

competing stimuli: can happen when confront a narrow space or obstacle: occur because of bradykinesia and decreased neurotransmitters

Can usually break freezing episodes with what?

A

Freezing episodes

external cues- pt or PT-crumbling paper in hand and pitching it fw to initiate walking.

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30
Q
  • Decrease in total number and amplitude of movement
    • hypomimia: lack of facial expression
      • More complex task, less movement
A

Poverty of Movement

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31
Q

lack of facial expression

A

hypomimia

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32
Q

Procedural learning deficits are common?

true or false

A

true

Deficits in motor skill learning for complex and sequential tasks

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33
Q

what is the best type of practice to use for a parkinsons pt?

why?

A

Blocked practice

because -Dual tasks are difficult

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34
Q

Gait disturbance is common in parkinson pt?

true of false

A

true

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35
Q

what percent of parkinsons pts have postural instability?

A

13-33 percent

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36
Q

increased speed with shortening of stride- is common gait in parkinson pt

A

Festinating gait

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37
Q

plantar flex contractures with postural instability is due to what type of gait in a parikinson pt?

A

Toe walkers

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38
Q

what kind of steps should a parkinson pt use to change directions?

A

Small steps

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39
Q

sensation- how is it affected in a parkinson pt?

A
  • 50% have parasthesias and pain
  • Can have numbness, tingling, coldness, aching pain and burning
  • Can be linked to motor fluctuations
  • Akathisia; sense of inner resltessness
  • Decreased proprioceptive regulation of voluntary movement
  • Some drugs used for PD can cause worsening in visual changes
40
Q

sense of inner resltessness

A

Akathisia

41
Q

Speech, voice and swallowing- how are these affected in a parkinson pt

A
  • Dysphagia: impaired swallowing: occurs in 95% of patients: due to rigidity, decreased mobility and restricted range of movement
  • Problems in oral preparatory, ora, pharyngeal and esophageal phases of swallowing
  • Can see choking or aspiration pneumonia
  • Can lead to fatigue and exhaustion
  • Drooling; problematic
42
Q

impaired swallowing: occurs in 95% of patients: due to rigidity, decreased mobility and

A

Dysphagia

43
Q

Speech- how is this affected in parkinsons pt?

A
  • Impaired 75% - 89% of time
  • Hypokinetic dysarthria: decrease in voice volume, monotone/monopitch speech, imprecise or distorted articulation, uncontrolled speech rate
  • Speech is horse, breathy and harsh
44
Q

decrease in voice volume, monotone/monopitch speech, imprecise or distorted articulation, uncontrolled speech rate

A

Hypokinetic dysarthria:

45
Q

Cognitive function- how is this affected in parkinson pt?

A
  • Mild or severe
  • 20-40 percent of pts; PD dementia
  • Dementia associated with increase in mortality
  • Loss of planning, reasoning, abstract thinking, judgement
  • L-dopa toxicity: wil see hallucinations and delusions
  • Will see deficits in vertical perception, body scheme, and spatial relations
46
Q

what percentage of parkinson pt of dementia?

A

20-40 percent

47
Q

a parkinson pt will see hallucinations and delusions due to

A

L-dopa toxicity

48
Q

Depression- how does this affected parkinson pt?

A
  • Common
  • Major depression: occurs in 40% of patients
  • Depression can occur around time motor symptoms occur
  • Feelings of guilt, hopelessness, worthlessness, loss of energy, poor concentration
  • Deficits in short term memory, loss of ambition and enthusiasm, disturbed appetite and sleep
  • Dysthymic disorder
49
Q

Autonomic nervous system- how is this affected in parkinson pt?

A
  • Excessive sweat, sensation of warmth
  • Problem with vasodilation
  • seborrhea dermatitis
  • GI disturbance: poor mobility, chane in appetite, weight loss, constipation
  • Bladder dysfunction; urinary frequency, urgency, urge incontinence, nocuturia
50
Q

Cardiopulmonary function- how does this affected a parkinson pt?

A
  • Orthostatic hypotension is common
  • Light headed, blurred vision with position change or exercise
  • L-dopa meds can make symptoms worse
  • Respiratory impairments 84% of patients

Airway obstruction: lead to pulmonary failure

Can see restrictive lung dysfunction: restrictive lung function

51
Q

Long standing disease; LE exhibit circulatory changes due to venous __________?

A

pooling

52
Q

Medical diagnosis-how is parkinson dx?

A
  • Difficult to diagnose
  • Based on history and clonical ecam
  • Handwriting, speech, interview questions, PE
  • 2 of 4 cardinal features present: can diagnose PD
53
Q

Progression of PD disease

A
  • Slowly progressive
  • Before L-dopa: 28% died within 5 years of dx
  • L-dopa therapy: less than 9% died within 5yrs
  • Younger: more benign progression
54
Q

Medical Management of parkinsons

A

NO CURE
Slow progression
Medication, nutritional and surgical intervention

55
Q

Medications for PD

A
  • Neuroprotectiv therap
  • Monamine oxidase Inhibitors
    • Use early
    • Delays need for levadopa by 9 months
    • Slow progression of disease
56
Q
  • Started using this medication in 1960’s
  • Precursor of dopamine
  • Tries to correct neurochemical imbalance
  • Use with carbidopa: allows larger percentage of L-dopa to enter CNS (sinimet)
  • SE: anorexia, nausea, vomiting, constipation, confusion, hallucination, hypotension, arrythmia, dysuria, motor fluctuations, dyuskinesia, insomnia, sleep fragmentation
  • Therapeutic window: 5-7 y ears
A

Levodopa for

Symptomatic therapy

57
Q

when will they use Levodopa

A
  • End of dose deterioration: worsening of symptoms during expected period where medication should be effective
  • On-off phenomenon: 50% of pts treated greater than 2 years: random fluctuation in motor function
  • Dyskinesia: will see at end of dose deterioration
58
Q

will see this kind of movement at end of dose deterioration

A

Dyskinesia

59
Q

Act on post synaptic dopamine receptors
Help prolong effect of L-dopa

A

Dopamine agonists

60
Q
  • Use early in treatment
  • Help to monitor tremor and rigidity
  • Helps smooth motor fluctuation when used with L-dopa
  • Symmetrel: antiviral: potentiates dopamine
A

Anticholinergic drugs

61
Q

Physical therapy implications

A
  • Levodopa therapy: have to pay attention to fluctuations due to medication cycle
  • Watch for where peak dosage is
  • Pay attention to when medication seems to stop working: inform physician
62
Q

Nutritional management for PD

A
  • High protein diet: blocks effectiveness of L-dopa
  • Should be on high calorie, low protein diet
  • 15% cal from protein
  • Protein at evening meal
  • Eating may become difficult as is speech: OT and Speech should be involved
63
Q

Surgical management- for PD that can be used in advance stages

A

Ablative surgery

Deep brain stimulation

64
Q

Stereotactic surgery
Pallidotomy: destructive lesion on globus pallidus
Helps with diskinesia
Thalamotomy; reduces tremor

what type of surgery?

A

Ablative surgery

65
Q

Implant electrodes: block nerve signals
Helps with severe UE tremors
Pacemaker in chest, wire to brain electrodes

what type of procedure?

A

Deep brain stimulation

66
Q

Neural transplantation

cells are being transplanted to what?

A

deliver dopamine

67
Q

Rehabilitation for PD

A
  • Help reduce functional limitations
  • Help promote activity and independence
  • Promote quality of life
  • Know disease history, course, symptoms, impairments, functional limitations, disability
  • Team: physician, OT, PT, nurse, SLP, social worker

Focus on long range planning

68
Q

Physical Therapy Examination and Evaluation for PD pt.

A
  • Early and middle stages of PD, measures of impairment are stable
  • Cognitive function
69
Q

how is Cognitive function examined and evaluated?

A
  • Check memory, orientation, conceptual reasoning, problem solving
  • Psychosocial function: ask about sadness, apathy passivity, insomnia, anorexia, weight loss inactivity , dependence
  • Use geriatric depression Scale or Beck depression scale
70
Q

how is sensation examined and evaluated with PD pt?

A
  • Look for superficial and deep sensation problems, especially touch and proprioception
  • Parasthesia
  • Look for vision issues:
  • Vision:
  • Presence of pain is common
71
Q

What can be seen with vision in examination and eval

A
  1. acuity,
  2. peripheral vision,
  3. tracking,
  4. accommodation,
  5. light and dark adaptation,l
  6. ook for blurring and eye pursuit
72
Q

how is Musculoskeletal function examined and evaluated

A

Flexiblity; measure ROM impairments: tend to lose: hip and knee ext, dorsiflex, shoulder flex, elbow ext,dorsal spine and neck ext and axial rot

Posture; typically have a flexed, stooped posture

Muscle performance
Check strenght and endurance

73
Q

Rigidity - how is it examined and evaluated?

A
  • Can be agonists or antagonists and can change
  • Sustained or intermittent
  • Watch for changes in functional mobility or postural reactions
  • Watch for severity of rigidity
74
Q

what type of movements

  • Movements are slow, will decrease in amplitude and, over time become arrhythmic
  • Can test reaction time: use a stopwatch and time when they try to start something and how long it takes to accomplish the task
  • Time rapid alternating movement
A

Bradykinesia

75
Q

Tremor - how is this examined and evaluated

A
  1. Note location and persistence and severity
  2. Watch for affects of tremor on ADL’s
76
Q

Postural Instability- how is it examined and evaluated?

A

Examine balance

  • Upright or leaning forward?
  • Check/work on balance: small BOS, tandem walk, step stance, single limb stance, perturbations
  • Have them do duel tasks
  • Can use clinical test for sensory integration in balance
  • EOSS, ECSS, VCSS, EOMS, ECMS. VCMS
  • Timed get up and go
  • POMA
77
Q

Gait- how is this evaluated or examined?

A
  • Speed of walk, stride length, cadence, stability, variability, safety
  • 10 meter walk test: speed, average stride, cadence
  • Will see shuffling gait, cant pick up feet
  • Festinating gait pattern
  • Look at amb on varied surfaces and complex gait patterns
78
Q

Falling- how is this examined?

A
  • Risk of falls increases with severity and duration
  • Pts with balance and walking impairments, freezing, dyskinesias are more likely to fall
  • Other problems that increase risk: hypotension, dementia, depression
79
Q

Autonomic Function- how is this examined

A
  • Watch for excessive drooling, sweating
  • Greasy skin, problems with thermoregulation
  • Orthostatic hypotension
80
Q

Cardiopulmonary Function- how is this examined

A
  • Watch chest wall mobility
  • Thoracic expansion
  • Changes in breathing patterns with exercise
  • Check vitals pre and post exercise
  • As disease progresses, may have to limit exercise
  • Watch for dyspnea, dizziness, confusion, fatigue, pallor
81
Q

Integumentary Integrity- how is this examined?

A

Watch for skin breakdown, especially in bed ridden or wheelchair bound patient

82
Q

Functional Status- how is this examined?

A
  • FIM- functional independence measure
  • Watch for need of assistive devices
  • Will have a lot of difficult with transfers due to rotational component
  • Keep testing and exercise periods short
  • How much time does it take to complete the task?
83
Q

Global health measures looks at very broad spectrum how?

A
  • SF 36 (looks at how respond to tx), Sickness impact profile
  • Unified Parkinson’s Disease Rating Scale, Parkinson’s Disease Questionnaire
  • UPDRS helps rate disease severity and progression and response to drug therapy

all these do is look at how severy and how the progression is going

84
Q

More global questions
Helps with goals and outcomes

A

PDQ 39

85
Q

what are the goals of Intervention

A
  • improve motor function
  • Increase exercise capacity
  • Functional performance
  • Activity participation
86
Q

Motor learning strategies

A
  • Difficulty learning complex movement sequences
  • Lot of repetitions
  • Break down movement into component parts
  • Blocked practice
  • Avoid dual tasking
  • Focused instructions
  • Visual targets/external cues
  • Rhythmic auditory stimulation
  • Using more conscious pathways of brain
87
Q

Exercise training-

what are relaxation techniques

A
  • Gentle rocking
  • Slow rhythmic rotation before ROM/stretch/functional exercise
  • Rhythmic initiation
  • Diaphragmatic breathing
  • D2F
  • Daily schedule
88
Q

Flexibility exercises for PD-

A
  • AROM PROM
  • Strengthen weak extensor muscles, lengthen flexor muscles
  • PNF patterns: more bang for the buck
  • Use contract relax techniques
  • Gentle stretching
  • 20-30 sec
  • Avoid bouncing
  • Prone lying
  • Stretching for LE contractures
89
Q

Strength Training

A
  • Use for mm weakness: central and disuse
  • Increase strength helps with functional mobility, balance, gait, fall risk
  • Greater force with isokinetic exercises
  • Do exercise during “on” time
90
Q

Functional training for PD

A
  • Improve functional mobility
  • Work on axial structures
  • Rolling exercises: should concentrate on segmental rolling
  • Pelvic mobility exercises
  • Sit to stand: rocking, counting,
  • Standing: full standing, trunk rotation, reciprocal movement
  • Weight shift
  • Lateral step up
  • Upper trunk ext
  • Recover from fallen position
  • Face exercises
91
Q

Supportive Devices- what can these be good for?

A
  • Blocks to raise head
  • Hospital bed
  • Firm chair, slight tilt
  • Appropriate shoes and clothing
  • Cane, walker, poles
92
Q

Balance Training

A
  • COM and LOS
  • Avoid postural disturbances
  • Weight shift, reach, axial rotation
  • Seated disc, therapy ball ex
  • Marching
  • Sit to stand, half kneel
93
Q

Locomotor training

A
  • Slowed speed, shuffling gait, flexed position, dec arm swing
  • Vertical poles
  • Walk tall
  • Overhead harness
  • Large steps
  • Braiding
  • Different surfaces
94
Q

Cardiopulmonary Training

A
  • Diaphragmatic breathing
  • Ex to recruit neck shoulder and trunk mm
  • Deep breathing
  • Air-shifting
  • Monitor BP and HR
  • Keep ex sub max
95
Q

Group ex

A
  • Helpful for long term ex
  • Provides support
  • Stretching ex, combined movements, marching
96
Q

What could HEP involve?

A

relaxation,

flexibility,

strength,

cardiopulmonary function,

wall stretches

97
Q

Psychosocial Issues-where a phycologist would get involved.

A
  • Dysfunction in daily roles, functions, social activities
  • Coping skills

SEMESTER 4 - REHAB (16 decks)

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