Parkinson's Disease Evaluation Part I Flashcards
Describe stage I of PD
- Unilateral involvement only, usually minimal or no functional impairment
- One of the earliest signs is minimal arm swing unilaterally or lack of trunk rotation
Describe stage II
- Bilateral or midline involvement without impairment of balance
Describe stage III
- 1st signs of impaired righting reflexes
- Unsteadiness as pt turns
- Pt is somewhat restricted in their activities but may have some work potential
- Pts are physically capable of leading independent lives & their disability is mild to moderate
Describe stage IV
- Fully developed
- Severely disabling disease
- Pt is still able to walk & stand unassisted but is markedly incapacitated
Describe stage V
- Confinement to bed or wheelchair unless aided
Define bradykinesia
- Slow movement
- General reduction of spontaneous movement (appearance of abnormal stiffness & decreased facial expressivity)
- Causes reduction in speed & amplitude of repetitive movements (finger tapping, walking)
- Short shuffling steps & hypo phonic speech are examples
Define hypomimia
- Masked facies
Cardinal signs of Parkinson’s Disease
- Bradykinesia
- Rigidity
- Resting tremor
- Postural instability
Describe rigidity
- Stiffness & inflexibility of the limbs, neck, & trunk
- Muscle tone of affected limb never relaxes sometimes contributing to decreased ROM
- Can manifest as: reduced arm swing, decreased trunk rotation, rolling & turning “en bloc”, reduced joint ROM during postural transitions & gait
Describe a resting tremor
- Initial onset: a slight tremor in the hand or foot on one side of the body or less commonly in the jaw or face
- Affected body part trembles when not performing an action
- Tremor usually ceases when person begins an action
- Tremor can be exacerbated by stress or excitement
- Tremor often spreads to the other side of the body as the disease progresses
- Not all people with PD will develop tremor
Describe postural instability
- Loss or slowing of some reflexes needed for maintaining upright posture
- PD pts may topple backwards if jostled even slightly
- Tendency to sway backwards when rising from chair, standing, or turning
- Difficulty when pivoting/turning/quick movements
- Pull test
Describe a pull test for postural instability
- Normal response: quick backwards step to prevent a fall
- Parkinson’s Disease response: unable to recover & might tumble backwards if neurologist were not right there to catch them
During the progression of PD, mobility is progressively constrained by
- Rigidity
- Bradykinesia
- Freezing
- Sensory integration
- Inflexible motor program selection (Set Switching)
- Attention and cognition
Functional outcomes of rigidity, in general, include
- Flexed posture
- Lack of trunk rotation
- Reduced joint ROM during postural transitions & gait
How is rigidity characterized
- By an increased resistance to passive movement throughout the entire ROM in both agonist & antagonist muscle groups
For rigidity what should your exercises focus on
- Minimize agonist-antagonist muscle co-contraction
- Promote axial rotation
- Lengthen the flexor muscles
- Strengthen the extensor muscles to promote an erect posture
Characteristics of bradykinetic gait
- Delayed time to lift the swing limb
- Weak push-off
- Reduced leg lift
- Small stride length
- Lack of arm swing
Poverty of Movement, Decreased Movement Amplitude, Delayed Initiation of Reactive and Anticipatory Movements, Hypokinesia cause/lead to
- Poor use of proprioceptive info
- Decreased perception of movement
- Over-estimation of body motion
- Over-dependence on vision
For bradykinesia what should your exercises focus on
- Increase speed
- Increased amplitude
- Temporal pacing of their self-initiated & reactive limb & body center of mass movements
- Promote weight shift control
- Promote postural adjustments in anticipation of voluntary movements
Define cog wheel rigidity
- Will feel a catch through the movement
- When a patient has both rigidity and a tremor in the same affected body part
Define lead pipe rigidity
- Will feel resistance/stiff throughout entire ROM
To reduce bradykinesia, patients should be encouraged to “__________” while increasing the speed and amplitude of large arm and leg movements
- Think big
Define freezing of gait
- A brief episodic absence or marked reduction of forward progression of the feet despite the intention to walk
- One of the most common reasons for falls & dependency
Freezing during gait occurs more often when a person is
- Negotiating a crowded environment
- Negotiating a narrow doorway
- Making a turn
- Attention is diverted by a secondary task
- Stepping over obstacles
- Change in surface
Describe the 3 phenotypes of freezing of gait
- Impaired set shifting ability: attention & executive function deficits are features of basal ganglia pathology even in early PD
- Increased step time variability: indicative of impairments in gait automaticity due to dopaminergic denervation
- Self reported anxiety & depression: may overload the capacity of the basal ganglia to process competing yet concurrent inputs
Typically, FoG episodes are brief (1 s or less) and are associated with a subjective feeling of “the feet being glued to the floor” (True/False)
- True
How to screen for freezing of gait
- Turning in place provoked freezing more than a 7m ITUG task
- Asking pt to repeatedly make 360º turns is efficient to elicit FoG: 180º in ITUG is not sufficient to elicit FoG; continuous 360º turning with direction reversals may induce FoG
- Often show longer turn durations & greater # of steps to complete turn even when walking speed is normal
Cut off scores for fall risk tests in Parkinson’s disease patients
- Functional reach test: 25.4 cm
- Dynamic gait index: 19/24
- Berg balance scale score: 45/56
- Up and go test: 8.5 sec
What should be considered the diagnostic gold standard for fall risk
- Self reported fall history
What fall risk assessment should be performed 1st
- Dynamic gait index (DGI) followed by berg balance scale (BBS - contains functional reach test)
What fall risk assessment has a ceiling effect in Parkinson’s disease patients
- Berg balance scale (BBS)
Which 3 tests moderately distinguish fallers from nonfallers in individuals with PD
- Fullerton Advanced Balance (FAB) scale
- Mini-Balance Evaluation Systems Test
- Berg Balance Scale (BBS)
Clinicians who analyze postural control deficits to identify patients being at risk for falls should particularly focus on the following items
- FAB:“tandem stance/walk”
- FAB, Mini-BEST, and BBS: “one-leg stance”
- FAB & Mini-BEST: “rise to toes”
- Mini-Best: “compensatory stepping backward”
- FAB & BBS: “turning 360°”
- BBS: “placing foot on stool.”
What values do we want for specificity and sensitivity tests
- Sensitivity: want is to equal 1.0
- Specificity: want it to be in the 80s-90s
Fallers with PD demonstrate the following
- Reduced reactive postural control
- Impaired tandem stand/walk
- Impaired single limb balance
- Increased number of steps (>7 steps) and time (>3.67) to turn 360º
Non-motor features of Parkinson’s disease
- Psychiatric depression
- Neuropsychiatric symptoms (general anxiety, phobia, panic attacks)
- Apathy
- Hallucinations
- Delusions
- Autonomic Dysfunction
constipation, orthostatic hypotension, sexual dysfunction, urinary disturbances - Cognitive impairment: involvement of executive functions, memory, and visuospatial functions up to dementia
- Sleep disorders: Restless legs, REM sleep disorder, excessive daytime somnolence, vivid dreaming, insomnia
- Olfactory dysfunction
- Pain
What non-motor features of Parkinson’s disease may be the earliest disease manifestations occurring years before any of the defining motor features are present
- Hyposmia
- Constipation
- Rapid eye movement (REM) sleep behavioral disorder
As the disease progresses, the therapeutic window for Levodopa ________________
- Narrows
How to manage end dose failure of Levodopa (wearing off)
- Decrease L-dopa interval
- ER formulation (Rytary)
- Add a dopamine agonist
- Add an L-dopa extender (COMT or MAO inhibitors)
- Consider advanced treatments: DBS or intestinal infusion
How to manage peak dose dyskinesias of Levodopa
- Decrease individual dose & increase frequency
- ER formulation (Rytary)
- Add an agonist or and extender & lower L-dopa dose
- Use amantadine (Gocovri)
- Consider advanced treatments: DBS or intestinal infusion
Medical management of motor fluctuations in PD
- Adjust the dose of levodopa
- Add different medications
- Try a controlled-release or extended-release
- Bring up surgical options like deep brain stimulation (DBS)
- Levodopa
- Dopamine agonists
- Amantadine
- Adenosine A2a antagonists
- COMT inhibitors
- MAO-B inhibitors
Regardless of medication status, PwPD demonstrate immediate improvements in performance on core outcomes across multiple domains of function following forced exercise cycling intervention. (True/False)
- True
Motor fluctuations include
- Wearing off
- Delayed on
- Partial on
- No on
- On off
Describe dyskinesias
- Choreic, ballistic, or dystonic involuntary movements
- Can be classified into peak-dose, diphasic, and square-wave dyskinesia
- Dystonia often accompanies motor fluctuations and dyskinesia and may appear in off and on phases
Aerobic exercise recommendations for PD patients
- 3 days/wk
- 30 min/session of continuous or intermittent exercise
- Moderate to vigorous intensity
Strength training recommendations for PD patients
- 2-3 days/week, non-consecutive
- 30 minutes/session
- 10-15 reps for major muscle groups
- Focus on Speed or Power
- Target ON time
- Focus on extensors
Balance training recommendations for PD patients
- 2-3 days per week, ideally DAILY
- Multi-directional stepping
- Weight Shifting (e.g. Tai Chi)
- Dynamic Balance Activities
- Large Movements
- Yoga, Dance, Boxing
Stretching recommendations for PD patients
- > 2-3 days/week; ideally DAILY
- Sustained stretching with deep breathing
- Dynamic Stretching before exercise
Define primary prevention
- Prevention of a disease or injury from occurring
Define secondary prevention
- Maintaining function, promoting QOL, & decreasing risk of cardiovascular complications
Define tertiary prevention
- Reducing the negative impact of ongoing illness or injury to improve function and QOL
Define motivational interviewing
- A collaborative, goal orientated style of communication with particular attention to the language of change
- Designed to strengthen personal motivation for & commitment to a specific goal by eliciting & exploring the person’s own reasons for change within an atmosphere of acceptance and compassion
What are the core skills of motivational interviewing
- Open questions
- Affirmations
- Reflective listening
- Summarise
Signs of readiness to change
- Decreased ambivalence
- Decreased discussion about the problem
- Resolve: client has reached some kind of resolution
- Change talk
- Questions about change
- Envisioning
- Experimenting
What does DARN CAT stand for
- Preparatory change talk (DARN)
- Desire statements
- Ability statements
- Reasons statements
- Need statements
- Mobilizing change talk (CAT)
- Commitment
- Activation
- Taking steps
How to respond to change talk
- Elaboration or details
- Affirm change talk through reinforcement, encouragement
- Reflect what the person is saying
- Summarise
How to evoke change talk
- Explore a typical day
- Asking evocative questions
- Using the importance ruler
- Querying extremes
- Looking back
- Looking forward
- Exploring goals & values
