Parkinson's Disease Flashcards

1
Q

What is PD?

A
  • Degenerative disorder of CNS
  • Result of decreased stimulation of motor cortex by basal ganglia
  • Chronic & progressive
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2
Q

What does PD cause?

A
  • Decreased speed & amplitude of movement
  • Tremor
  • Changes in muscle tone & posture
  • Inability to perform simultaneous or sequential motor tasks
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3
Q

What is the aetiology of PD?

A
  • Likely induced by environmental factors in people with genetic predisposition
  • 2-14 fold increase in incidence in close relatives of people with PD
  • 1 in 100 people > 65yo
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4
Q

What are the risk factors of PD?

A
  • Positive family history
  • Male
  • Exposure to pesticides
  • Rural living
  • Head injury
  • Consumption of well water
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5
Q

What are 4 nuclei that make up the basal ganglia?

A
  • Striatum (caudate & putamen)
  • Globus pallidus (internus & externus)
  • Subthalamic nuclei
  • Substantia nigra
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6
Q

What is the role of the basal ganglia?

A
  • Execution of complex motor tasks
  • With SMA run well-learned & predictable movement sequences
  • Provision of internal cues for starting/stopping movement sequences
  • Involved in aspects of memory & cognitive function
  • Loss of motor set
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7
Q

What is the pathophysiology of PD?

A
  • Loss of dopaminergic neurons in substantia nigra
  • Causes decreased inhibition of globes pallid us & increased inhibition of thalamus (decreased output)
  • Presence of Lewy bodies
  • Other neurotransmitters thought to be involved
  • Still not well understood
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8
Q

What is clinical diagnosis of PD based on?

A
  • Medical history
  • Physical examination
  • Improvement with dopaminergic treatment
  • Long pre-clinical/symptomatic period (many people are far progressed at diagnosis)
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9
Q

What is used in the medical management of PD?

A

Levodopa:
- Metabolic precursor to dopamine
- Initially effectively controls motor problems
- Associated with significant side effects (nausea, mood/behavioural issues, orthostatic hypotension)
COMPT inhibitors used to maintain therapeutic doses for longer

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10
Q

What are the long term effects (5-7 yrs) of levodopa (L dopa)?

A
  • Dyskinesia (impairment of voluntary movement, central writhing movement)
  • On-off phenomenon (on phase after medication causes peak in motor performance; as medication wears off causes decrease in quality of movement)
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11
Q

What does the surgical management of PD include?

A
  • Pallidotomy (removal of globus pallidus, which removes inhibition of thalamus)
  • Deep brain stimulation of globus pallidus internus or sub-thalamic nuclei - shown to improve QOL significantly in advanced PD
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12
Q

What are the primary impairments in PD?

A
  • Bradykinesia (slowness of movement)
  • Hypokinesia (decreased amplitude of movement)
  • Akinesia (difficulty initiating movement e.g. freezing)
  • Tremor (resting, rhythmical, consistent)
  • Rigidity (centrally mediated, in both directions)
  • Balance impairment
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13
Q

What are the secondary impairments in PD?

A
  • Dyskinesia
  • Disuse weakness
  • Flexed posture
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14
Q

What are the common activity limitations in PD?

A
  • Turning in bed
  • Sitting up from lying
  • Standing up
  • Reduced speed & balance, freezing & falling during walking/turning in standing
  • R&M esp handwriting
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15
Q

What should the assessment of PD include?

A
  • History
  • Observation
  • Assessment & measurement of impairments/activity limitations
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16
Q

What should be included in the history assessment of PD?

A
  • Time since diagnosis
  • Medications (what, when, how long, fluctuations, side effects)
  • Movement problems, including falls
  • Other problems associated with PD
  • Previous/current physio intervention
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17
Q

What should observation assessment of PD include?

A
  • Turning in bed
  • Supine to sitting over side of bed
  • STS
  • Walking
  • 360 deg turn in standing
  • R&M
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18
Q

What are some of the balance tests used when assessing PD?

A
  • Tandem stance
  • Single leg stance
  • Functional reach
  • Shoulder tug (Pastor’s test)
  • Mini Best test
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19
Q

What are some of the other impairments that should be assessed in PD?

A
  • ROM
  • Strength
  • Respiratory function (flexed posture)
  • Fitness
  • Falls diary
  • Dyskinesia diary
20
Q

What are some of the impairment measures used for PD?

A
  • Unified Parkinson’s disease rating scale (UPDRS)
  • Hoen & Yahr scale (0-5)
  • Freezing of gait questionnaire
  • Falls efficiency scale
  • Berg balance scale
  • Mini Best test
21
Q

What are some of the activity limitation measures used for PD?

A
  • 10MWT
  • 6MWT
  • TUG
  • 10 x STS
  • Time taken to turn in bed
  • Time taken to sit over side of bed
  • Number steps taken when turning 360 degrees
  • Handwriting sample & spiral test
22
Q

What are the characteristics of hypokinesia?

A
  • Most common impairment in PD
  • Most pronounced in complex sequential or simultaneous tasks
  • Bilateral
23
Q

What is hypokinesia caused by?

A
  • Reduction in initial agonist burst at each joint
  • Contributed to by weakness, tremor & rigidity
  • Correlated with reduced UL & LL ROM, poor ADLs and life satisfaction index
24
Q

What is the effect of hypokinesia on gait?

A
  • Reduced stride length in walking & turning
  • Caused by decreased amplitude of movement at all joints
  • Results in reduced gait speed
  • Exacerbated by dual tasking
  • Causes falls risk
25
Q

What are the intervention strategies for hypokinesia?

A
  • Attentional, visual & auditory cueing (normalises stride length)
  • Dual task training
26
Q

How do cueing strategies work?

A
  • External stimuli cause alternative circuits in the brain to engage in accomplishing the tasks
  • Avoids the defective basal ganglia circuitry
27
Q

What did Spaulding et al 2013 find regarding cueing for hypokinesia during walking?

A
  • Systematic review
  • Examined effects of visual & auditory cues on stride length, speed & cadence
  • Both had a clinically significant effect on increasing stride length
  • Auditory cues also had a significant effect on increasing speed & cadence
  • CIs: Train with visual & auditory cues
28
Q

How did the study by Canning 2005 look at the effect of instructions on walking performance in PD?

A
  • Compared effect of specific instructions on walking performance
    1. Comfortable walking alone
    2. Comfortable walking carrying a tray & glasses without instructions
    3. As above with instructions to concentrate on big steps
    4. As above with instructions to concentrate on the tray
29
Q

What were the results of the study by Canning 2005 looking at the effect of instructions on walking performance?

A
  • Prioritising attention to step length normalised walking speed & stride, task was 96% error free
  • Prioritising attention to tray significantly decreased walking performance
  • CIs: Train dual tasking while concentrating on main activity
30
Q

What did Brauer & Morris 2010 find regarding dual task training in PD?

A
  • Examined effect of dual task training on step length in mild/mod PD
  • 20 mins walking training with variety of cognitive tasks
  • 10MWT completed before & after with 6 different dual tasks
  • Step length improved significantly in all but 1 dual task conditions
  • Walking speed increased in 3/6 dual task conditions
31
Q

What is akinesia?

A
  • Difficulty initiating or continuing movements
  • AKA freezing
  • Often preceded by festination (rapid reduction in step length, increased cadence e.g. when approaching doorway)
32
Q

When does akinesia occur?

A
  • Initiating movement
  • During turning
  • Performing concurrent tasks
  • End dose
  • Narrow doorways
  • Cluttered/busy environment
33
Q

What are the intervention strategies for akinesia?

A
  • Self-generated cues
  • External auditory & visual cues
  • Modifying the environment
34
Q

What did Nieuwboer et al 2007 find in the RESCUE trial examining akinesia in gait?

A
  • Patients chose auditory, somatosensory or visual cues
  • Training 30 mins 3 x per week for 3 weeks in home
  • Showed reduction on freezing but no carryover at 6 weeks
35
Q

What did Brichetto et al 2006 find regarding the effect of cues on akinesia?

A
  • Looked at use of auditory & cognitive cues
  • Training involved gait practice in variety of environments using auditory then cognitive strategies
  • 45 mins 3 x week for 6 weeks
  • Significant improvement in FOG questionnaire & QOL immediately after training & at 1 month
36
Q

What is occurring in the basal ganglia at rest?

A
  • Only postural control
  • Thalamus is exciting the cortex
  • Basal ganglia globus pallidus is inhibiting the thalamus to prevent movement
37
Q

What happens in the basal ganglia in response to an external stimulus?

A
  • Cortex excites striatum
  • Causes inhibitory effect on globus pallidus which stops inhibition of thalamus
  • Thalamus excites cortex for movement tasks
38
Q

What happens in the basal ganglia as external stimuli increases?

A
  • Cortex firing rate increases allowing for bigger/faster movements
  • BG allows you to direct thoughts to different motor programs (movement, talking, mood etc) at the same time
39
Q

Of the primary impairments in PD, which impairments are the main cause of activity limitation?

A
  • Bradykinesia
  • Hypokinesa
  • Akinesa
  • Balance impairment
40
Q

What did Dibble et al 2006 find regarding eccentric strength training in PD?

A
  • RCT comparing standard care vs 12 week high intensity eccentric strength training
  • Looked at quads volume, strength & mobility
  • Strength training group has a 6% increase in quads volume, an increase in strength & improved 6MWT
41
Q

What were the specific treatment recommendations Keus et al compared in 2007?

A
  • Cueing strategies to improve gait
  • Cognitive movement strategies to improve transfers
  • Exercises to improve balance
  • Training of joint mobility & muscle power to improve physical capacity
42
Q

What did Keus et al 2007 find regarding specific treatment recommendations for PD?

A
  • PD patients with 1+ falls in last 12 months are likely to fall again in next 3 months
  • Falls occur during transfers & FOG
  • Cueing strategies may improve gait
  • Cognitive movement strategies may improve transfers
  • Balance exercises are more effective when combined with LL strengthening
  • Training of joint mobility & muscle power may improve ADLs
43
Q

What did the first experiment by Kamsma et al 1994 find regarding kinesiology of turning in bed & rising from a chair?

A
  • Compared PD patients with students & elderly
  • Turning in bed: PD patients used a variety of supports, movement was fragmented & slower
  • Rising from a chair: PD patients were non-fluent, required more effort
44
Q

What did the second experiment by Kamsma et al 1994 find?

A
  • Provided new motor strategies for turning in bed & rising from a chair
  • All pts received L-dopa
  • 6 x 1hr sessions
  • Errors decreased after 6 sessions
  • Errors were made in execution of movement
  • Significant improvement in performance in short term, even in severely affected pts
45
Q

What were the motor strategies used in the second experiment by Kamsma et al 1994?

A
  • Movement decided into small steps (starting distally)
  • Steps were sequential
  • Executed under conscious control
  • Pause between steps
  • Each step concluded with a stable position for the next to begin
  • Axial components limited