Parkinson's Disease

Question 1

what are the 3 nuclei of the basal ganglia?

Answer 1

1- caudate
2- putamen
3- globus pallidus

Question 2

what are the 2 brainstem nuclei?

Answer 2

1- substantia nigra

2- subthalamic nucleus

Question 3

what are the functions of the basal ganglia?

Answer 3

Direct Loop:
cortex–> putamen–> globus pallidus–> thalamus

Indirect Loop:
cortex–> putamen–> globus pallidus–> subthalamic nucleus –> thalamus

In general, the direct pathway activates the thalamocortical pathway and the indirect pathway inhibits it.

The appropriate “gain” of the system is adjusted and information is sent to the muscles by way the thalamus and motor cortex.

Question 4

what is the physiology of the BG?

Answer 4

The BG would have a role in cortical activation and modulation

One Theory:

• under active direct pathway and/or an overactive indirect pathway= decrease activation of the cortex and bradykinesia/akinesia
• Overactive direct pathway and/or an under active indirect pathway= extraneous movements

Question 5

what are 3 neurotransmitters?

Answer 5

1- Dopamine (DA)

2- Acetylcholine (ACh)

3- Gamma-aminobutryric (GABBA)

Question 6

what is dopamine?

Answer 6

produced in the substantia nigra and both (-) and (+)

+ to the neurons in the direct pathway

• to the neurons in the indirect pathway

Question 7

what is ACh?

Answer 7

neurotransmitter of the caudate and putamen

(-) the action of dopamine

Question 8

what is GABBA?

Answer 8

inhibitory neurotransmitter bound throughout the brain

Question 9

what is the role of the BG?

Answer 9

1- automatic movement- involved in the preparatory stages but not in the excitation of movement

2- movement initiation and preparation- generator for ramp movement

3- postural adjustments

4- perception and cognitive function- procedural learning

Question 10

what is declarative learning?

Answer 10

can explain how to do it

Question 11

what is procedural learning?

Answer 11

knowing how to do something

Question 12

what are symptoms of parkinsons?

Answer 12

1- rigidity (cogwheel or lead pipe)

2- bradykinesia

3- tremor

4- postural instabilty

5- festinating gait

6- freezing

7- attentional and cognitive deficits

8- dysphagia

9- micrography

10- depression

11- bronchopneumonia (complication)

Question 13

what is bradykinesia?

Answer 13

all aspects of movement including initiation, alteration in direction and the ability to stop and begin a movement

spontaneous or associated movements such as arm swing, smiling to a funny story

difficulty performing simultaneous or sequential movements

difficulty with transition between movements

Question 14

what are resting tremors?

Answer 14

4-7 beats/sec in extremities and trunk (postural tremors)

Question 15

postural stability:

Answer 15

leads to increased episodes of falling

• flexed posture
• lack of equilibrium and righting response
• decrease in trunk rotation

ineffective sensory processing

decrease anticipatory postural adjustments

Question 16

what is a festinating gait?

Answer 16

characterized by a progressive increase in speed and shortening of stride

loss of heel toe progression–> decreased ability to step over obstacles or walk on uneven surfaces

Question 17

what is freezing?

Answer 17

treatment is to stop weight shift side, count to 5-10, get reorganized and then move ahead or give patient an imaginary line or real object to step over

Question 18

what attentional and cognitive deficits usually occur with Parkinson’s?

Answer 18

inability to shift attention

inability to quickly access “working memory”

difficulty with visuospatial perception and discrimination

impaired procedural learning

dementia

Question 19

what is dysphagia?

Answer 19

difficulty swallowing

Question 20

what are medical management options for parkinson’s?

Answer 20

dopamine replacement

COMT inhibitors

dopamine agonist

anticholinergics

apomorphine

MAO-B inhibitors

others

Question 21

what are dopamine replacement?

Answer 21

Sinemet
Sinemet CR
Stalevo
Parcopa

Question 22

what are COMT inhibitors?

Answer 22

Comtan (Entacapone)
Tasmar (Tolcapone)

decreases the breakdown of l-dopa in the blood

Question 23

what are dopamine agonists?

Answer 23

Parlodel (Bromocritine)
Requip
Permax (Pergolide)
Mirapex
Neupro
APOKYN injection

meds that act like dopamine

The dopamine agonist binds to and activates the stratal dopamine receptors

Question 24

what are anticholinergics?

Answer 24

Artane (trihyxuphenidyl)
Cogentin (benztropine)

decrease ACh –> increase DA

These meds are most helpful for tremors and stiffness and less for slowness, balance and gait deviations

Question 25

what is apomorphine?

Answer 25

fast acting dopamine agonist used to treat occasional episodes of immobility- injected subcutaneous

Question 26

what are MAO-B inhibitors?

Answer 26

Selegiline (Eldepryl)
Zelapar
Rasagiline (Azilect)

protect dopamine producing nerves delaying the onset of disability from slowness and tremors from mild PD

Question 27

what are other medical managements?

Answer 27

Symmetrel (Amanatadine)

blocks the activity of NMDA receptors which may protect neurons from dying and restore normal levels for the sub thalamic nucleus

Question 28

what are treatment principles for PD?

Answer 28

learn normal movement on a conscious level as opposed to automatic

use of sensory cues to reinforce normal patterns of rhythm

on-off syndrome- understand and work with or around

through intense repetitive drilling of simple movements building normal movement patterns

Question 29

what are treatment techniques for PD?

Answer 29

create independent recovery techniques for freezing

lower and upper trunk rotation/reciprocal movements

spinal extension

weight shifting activities

correct sequencing of transitional movement patterns (sit–> stand, gait, turning)

movement focusing on changing speed, direction, initiation and cessation of movement sequence

rhythmic movement (Tai chi, feldenkrais, yoga, music, treadmill)

functional retaining (including compensatory strategies- satin sheets, PJs hospital bed, bed railings, raised toilet seat, “sit to stand chair”, rolling walker with 4 swivel wheels)