Parkinsonism Flashcards
Parkinsonism Signs
Tremor Rigidity Bradykinesia Postural instability Gait dysfunction
Parkinson’s differential diagnosis
Degenerative : Parkinson’s , Atypical Parkinsonism disorders ( multiple system atrophy , progressive supra nuclear palsy, corticobasal degeneration )
Non-degenerative : Drug induced, vascular ,structural , toxins , infections , metabolic
Physiological affects of Parkinsonism
Mostly idiopathic , some are genetic.
Reduced dopamine levels due to degeneration of dopamine producing nerve cells
How is Parkinson’s diagnosed
Clinical Diagnosis : Bradykinesia + at least 1 other symptom
1- Bradykinesia : must be present for there to be clinical Parkinsonism
2- Other symptoms: muscular rigidity , 4-6Hz rest tremor , postural instability
What is Bradykinesia and how might a patient present with it
Slowness of initiation of voluntary movement with progressive reduction in speed and amplitude with repetitive movements.
Ex: difficulty buttoning shirts , general slowness , difficult brushing teeth , dragging leg , loss of arm swing , change in handwriting ( micrographic ) , difficulty turning in bed , reduced facial expression , reduced blinking , drooling overnight , hypophonia ( quieter speech )
Describe Parkinsonism tremor
Postural re-emergent tremor ( almost always point to Parkinsonism ).
Tremor starts a few seconds after movement is done , or at rest.
Not necessary to be present for clinical diagnosis of Parkinson’s
Explain Essential tremor
Flexion-extension, distal , symmetrical hand tremor : with action
- sometimes a head tremor
- no bradykinesia or Parkinsonism gait features , rigidity
- voice tremor
- usually have a family history of it & alcohol response
Describe Parkinsonism rigidity
Increased resistance to passive movement
- flexion & extension at wrist and elbow
- co-activation via Froment’s manoeuvre
- Asymmetric
- different than spasticity
Describe Parkinsonism Gait
Stooped posture, shuffling , arms flexed & shaking , destination = further along disease
Initially Presents as : reduced arm-swing ( asymmetrical & tremor ) , reduced foot-lift , reduced stride length , reduced cadence , loss of fluency when turning ( clock face/ en-bloc turning ) , narrow-based gait
Describe Parkinsonism Postural instability
Impairment of normal reflexes that maintain upright posture, leads to balance problems and vulnerability to falls.
Assessed via Pull test: from behind the patient you pull their shoulders back , patient with Parkinsonism will lose postural reflexes, take multiple steps backwards, can’t regain upright posture and would fall if Doctor is not there to catch them. Parkinsonism if person takes more than 3-4 steps
What are the causes of Parkinsonism
Degenerative : Parkinson’s most common
Non-degerative causes: drug induced and vascular
Features of non-degerative or secondary causes of Parkinsonism
1- repeated strokes / head injury
2- history of encephalitis
3- neuroleptic drug exposure : Antipsychotics, metoclopramide , prochlorperazine , lithium , sodium valproate , calcium channel blockers
Features of degenerative Atypical Parkinsonism disorders that would point away from Parkinson’s Disease
1- poor or un-sustained levodopa response : patient doesn’t improve when given levodopa
2- early recurrent falls ( in beginning of disease onset )
3- early cognitive decline ( ex: early dementia starting at disease onset or within 1 year )
4- prominent early speech or swallowing difficulties ( dysarthria and high pitch/quivering )
5- cerebellar , pyramidal signs , dyspraxia or supranuclear gaze palsy
6- prominent & early autonomic dysfunctions ( urinary symptoms )
7- wheelchair dependent in less than 3 years
8- absence of rest tremor or dyskinesia
Progressive supra nuclear palsy in MRI
Midbrain atrophy that resembles humming bird chase , or Mickey Mouse in axial section
Multiple system atrophy in MRI
Midbrain cross atrophy ( hotbun cross )
DAT scan
Dopamine transporter Scan. Shows that dopamine producing neurones from substantia Niagara to basal ganglia affected, shows up as Dots on scan.
Abnormal DAT can indicate what
1- Parkinson's disease 2- MSA 3 PSP 4- Dementia with LBs 5- cud 6- Wilson's disease 7- Spinocerebellar ataxia 2,3
Supportive criteria for Parkinson’s disease
1- Unilateral onset 2- persistent asymmetry 3- rest tremor 4- progressive 5- excellent levodopa response 6- levodopa induced dyskinesia 7- sustained response to levodopa for at least 5 years 8- visual hallucinations 9- clinical course generally greater than 10 years ( not as progressive as atypical Parkinsonism disorders )
