Parkinson's Disease Flashcards
Epidemiology of parkinsons
- 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
Cardinal Features of parkinsons
- Rigidity
- Bradykinesia
- Tremor
- Postural instability
These are the main features below of parkinson. What are other symptoms you might see?
- Rigidity
- Bradykinesia
- Tremor
- Postural instability
- 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
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
Ideopathic
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)
secondary
- 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
Drug induced parkinsonism
Pathophysiology of parkinsons
- 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
Develop cytoplasmic inclusion bodies:
what does it mean?
lewy bodies
that someone has parkinsons
dr c says to remeber this
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
Basal ganglia
- release phenomena
- Loss of inhibitory influences within BG
- Decreased binding sites for dopamine in BG: can explain loss of effectiveness for L-dopa
Tremor
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
rigidity
jerky, ratchet like: muscles tense and relax
Cogwheel rgidity
sustained resistance to passive movement
Leadpipe rigidity
Rigidity is often what?
- asymmetrical,
- affects proximal mm,
- progress to face and extremities
Rigidity - how does it affect a pt?
- 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
absence of movement
Akinesia
sudden break or block in movement
Freezing
reduced amplitude of movement
Hypokinesia
Movement; reduced in speed, range and amplitude
Bradykinesia
tremor- how does it present in a parkinson pt?
- 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
Postural instability- how does this affect a parkinson pt?
- 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
Falls- what are some statistics in parkinson pt?
- 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
why are parkinson pt falling- what might it be due to?
- Torque production is decreased
- Insufficient neural activation of agonist muscles
- Firing rate of muscles is very delayed
- Complex movements: difficulties are more apparent
Fatigue- how does it affect the parkinsons?
- 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
what do Contractures look like in a parkinson pt?
knee and hip flexors,
hip rotators and adductors,
plantarflexors.
Dorsal spine,
neck flexors,
shoulder adductors,
internal rotators,
elbow flexors
planning is prolonged and movement times are somewhat prolonged
Start hesitation
Start hesitation
Complex movements are difficult
Microphagia
Freezing episodes -can usually break with external cues
Motor planning difficulties of parkinsons pt
handwriting that is small and difficult to read
Microphagia
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?
Freezing episodes
external cues- pt or PT-crumbling paper in hand and pitching it fw to initiate walking.
- Decrease in total number and amplitude of movement
- hypomimia: lack of facial expression
- More complex task, less movement
- hypomimia: lack of facial expression
Poverty of Movement
lack of facial expression
hypomimia
Procedural learning deficits are common?
true or false
true
Deficits in motor skill learning for complex and sequential tasks
what is the best type of practice to use for a parkinsons pt?
why?
Blocked practice
because -Dual tasks are difficult
Gait disturbance is common in parkinson pt?
true of false
true
what percent of parkinsons pts have postural instability?
13-33 percent
increased speed with shortening of stride- is common gait in parkinson pt
Festinating gait
plantar flex contractures with postural instability is due to what type of gait in a parikinson pt?
Toe walkers
what kind of steps should a parkinson pt use to change directions?
Small steps
sensation- how is it affected in a parkinson pt?
- 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
sense of inner resltessness
Akathisia
Speech, voice and swallowing- how are these affected in a parkinson pt
- 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
impaired swallowing: occurs in 95% of patients: due to rigidity, decreased mobility and
Dysphagia
Speech- how is this affected in parkinsons pt?
- 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
decrease in voice volume, monotone/monopitch speech, imprecise or distorted articulation, uncontrolled speech rate
Hypokinetic dysarthria:
Cognitive function- how is this affected in parkinson pt?
- 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
what percentage of parkinson pt of dementia?
20-40 percent
a parkinson pt will see hallucinations and delusions due to
L-dopa toxicity
Depression- how does this affected parkinson pt?
- 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
Autonomic nervous system- how is this affected in parkinson pt?
- 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
Cardiopulmonary function- how does this affected a parkinson pt?
- 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
Long standing disease; LE exhibit circulatory changes due to venous __________?
pooling
Medical diagnosis-how is parkinson dx?
- Difficult to diagnose
- Based on history and clonical ecam
- Handwriting, speech, interview questions, PE
- 2 of 4 cardinal features present: can diagnose PD
Progression of PD disease
- 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
Medical Management of parkinsons
NO CURE
Slow progression
Medication, nutritional and surgical intervention
Medications for PD
- Neuroprotectiv therap
- Monamine oxidase Inhibitors
- Use early
- Delays need for levadopa by 9 months
- Slow progression of disease
- 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
Levodopa for
Symptomatic therapy
when will they use Levodopa
- 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
will see this kind of movement at end of dose deterioration
Dyskinesia
Act on post synaptic dopamine receptors
Help prolong effect of L-dopa
Dopamine agonists
- Use early in treatment
- Help to monitor tremor and rigidity
- Helps smooth motor fluctuation when used with L-dopa
- Symmetrel: antiviral: potentiates dopamine
Anticholinergic drugs
Physical therapy implications
- 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
Nutritional management for PD
- 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
Surgical management- for PD that can be used in advance stages
Ablative surgery
Deep brain stimulation
Stereotactic surgery
Pallidotomy: destructive lesion on globus pallidus
Helps with diskinesia
Thalamotomy; reduces tremor
what type of surgery?
Ablative surgery
Implant electrodes: block nerve signals
Helps with severe UE tremors
Pacemaker in chest, wire to brain electrodes
what type of procedure?
Deep brain stimulation
Neural transplantation
cells are being transplanted to what?
deliver dopamine
Rehabilitation for PD
- 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
Physical Therapy Examination and Evaluation for PD pt.
- Early and middle stages of PD, measures of impairment are stable
- Cognitive function
how is Cognitive function examined and evaluated?
- 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
how is sensation examined and evaluated with PD pt?
- Look for superficial and deep sensation problems, especially touch and proprioception
- Parasthesia
- Look for vision issues:
- Vision:
- Presence of pain is common
What can be seen with vision in examination and eval
- acuity,
- peripheral vision,
- tracking,
- accommodation,
- light and dark adaptation,l
- ook for blurring and eye pursuit
how is Musculoskeletal function examined and evaluated
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
Rigidity - how is it examined and evaluated?
- 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
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
Bradykinesia
Tremor - how is this examined and evaluated
- Note location and persistence and severity
- Watch for affects of tremor on ADL’s
Postural Instability- how is it examined and evaluated?
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
Gait- how is this evaluated or examined?
- 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
Falling- how is this examined?
- 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
Autonomic Function- how is this examined
- Watch for excessive drooling, sweating
- Greasy skin, problems with thermoregulation
- Orthostatic hypotension
Cardiopulmonary Function- how is this examined
- 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
Integumentary Integrity- how is this examined?
Watch for skin breakdown, especially in bed ridden or wheelchair bound patient
Functional Status- how is this examined?
- 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?
Global health measures looks at very broad spectrum how?
- 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
More global questions
Helps with goals and outcomes
PDQ 39
what are the goals of Intervention
- improve motor function
- Increase exercise capacity
- Functional performance
- Activity participation
Motor learning strategies
- 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
Exercise training-
what are relaxation techniques
- Gentle rocking
- Slow rhythmic rotation before ROM/stretch/functional exercise
- Rhythmic initiation
- Diaphragmatic breathing
- D2F
- Daily schedule
Flexibility exercises for PD-
- 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
Strength Training
- 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
Functional training for PD
- 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
Supportive Devices- what can these be good for?
- Blocks to raise head
- Hospital bed
- Firm chair, slight tilt
- Appropriate shoes and clothing
- Cane, walker, poles
Balance Training
- COM and LOS
- Avoid postural disturbances
- Weight shift, reach, axial rotation
- Seated disc, therapy ball ex
- Marching
- Sit to stand, half kneel
Locomotor training
- Slowed speed, shuffling gait, flexed position, dec arm swing
- Vertical poles
- Walk tall
- Overhead harness
- Large steps
- Braiding
- Different surfaces
Cardiopulmonary Training
- Diaphragmatic breathing
- Ex to recruit neck shoulder and trunk mm
- Deep breathing
- Air-shifting
- Monitor BP and HR
- Keep ex sub max
Group ex
- Helpful for long term ex
- Provides support
- Stretching ex, combined movements, marching
What could HEP involve?
relaxation,
flexibility,
strength,
cardiopulmonary function,
wall stretches
Psychosocial Issues-where a phycologist would get involved.
- Dysfunction in daily roles, functions, social activities
- Coping skills
