Parkinsons Flashcards
What is Parkinson’s Disease
A progressive neurological disorder primarily affecting motor function
Brain disease, age increases the risk, the cells that make dopamine in the brain die
Genetic mutation can increase risk
Can only ease PD, it can not be treated
Men vs women, Prevelance and incident rate
More prevalence in older age of PD in males vs females
Prevelance,: new case plus existing case
3 motor symptoms diagnosed is primarily based on
Bradykinesia, Rigidity, Tremor
Bradykinesia
Slowness of movement
Has to be present for diagnosis
Rigidity
Muscle stiffness, limiting movement
One of two has to be present
Tremor
Involuntary shaking
One of two has to be present
Bradykinesia Test and why is Bradykinesia important
Bradykinesia refers to the slowness of movement and difficulty in initiating voluntary actions, a hallmark of Parkinson’s disease. One way to test for bradykinesia is by assessing rapid alternating movements of the thumb and fingers:
Test Procedure: With the arm outstretched, the patient is asked to rapidly touch the thumb and fingers together. Both sides should be tested, as the condition can be asymmetrical in its early stages.
Signs: Over time, movements become slower and smaller, showing a decline in speed and amplitude.
Tips: Instruct the patient to make the movements BIG and FAST to observe changes in movement quality, which typically worsens with repetition.
Rigidity Test, difference with Splasticity
Rigidity is an increase in muscle tone that is not velocity-dependent (unlike spasticity). It often responds to medication, especially in conditions like Parkinson’s disease. To enhance or assess it, clinicians can use activation techniques:
Wrist Circumduction: Rotate the wrist passively while tapping with the opposite hand.
Cogwheel Phenomenon: A jerky, ratchet-like movement felt during passive joint motion, indicative of rigidity.
These techniques help in diagnosing and evaluating rigidity, particularly in neurodegenerative disorders.
Tremor Test and types
Tremors are involuntary rhythmic muscle contractions that can occur in various forms:
Resting Tremor: Appears when the limb is at rest, common in Parkinson’s. Ensure the patient isn’t suppressing it.
Postural Tremor: Seen when holding a position (e.g., arms outstretched). Less likely related to PD.
Action/Kinetic Tremor: Emerges during movement (e.g., finger-to-nose test). Movement worsens the tremor, and it’s often unrelated to PD.
Gait and balance Test
Sit-to-Stand Test: With arms crossed, have the patient repeatedly sit and stand. This evaluates balance and leg strength.
“Walking” Gait Analysis: Check stride length, heel strike, arm swing, asymmetry, and whether the patient freezes at turns.
Pull Test: Gently pull the patient backward. If they need more than 1-2 steps to recover balance, it’s a positive test (impaired balance).
Festinating Gait
Shuffling of steps
Parkinson’s Tremor
Resting
● large amplitude, medium
freq (3-7 Hz)
● low heritability (<10%)
● onset 55-65 (4% <50)
● levodopa
● hands>legs (less voice,
head)
● Prevalence: 0.2% (4.9% of
long term care)
Essential Tremor
Postural, Action/Kinetic ● variable amplitude, faster
freq (4-12 Hz)
● heritable (>50%)
● middle age, but across
lifespan
● drug resistant
● hands, some head/voice,
rare in legs
● Prevalence: 0.4-5.6%
Alcohol can reduce symptoms
Input structure
Caudate and the patamen, is the input structure, together they are called the striatum
Out put structure, and what does it do?
Globes pallidus, is the output, information is editing through this structure
Substantial Niagra Pars Compacta
It is the locaction of dopamine production
Alpha synuclein (dendrites
It’s a protein that clumps together to form a Lewy body ( main findings with people with Parkinson’s Disease)
Thyroxine in a control group vs PD
Thyroxine present in control group, No Enzyme present with PD
Paper airplane analogy ( early detection of PD)
Detecting misfolded alpha-synuclein proteins in fluids like CSF or blood is crucial for early Parkinson’s disease detection. These proteins accumulate abnormally, forming Lewy bodies in neurons, which disrupt brain function before motor symptoms appear. Early detection allows for potential interventions to slow disease progression.
Thalamus
relay station of all incoming motor (movement) and sensory information
Dopamine Production:
Dopamine is a neurotransmitter produced in various regions of the brain, including the substantia nigra in the midbrain
What is Dopamine and where is it Produced
Dopamine is a neurotransmitter produced in various regions of the brain, including the substantia nigra in the midbrain
Striatum
Caudate and the patamen
Direct Pathway function
Turning on the motor cortex, which is responsible for planning and executing voluntary movements.
Direct pathway steps
In the striatum, dopamine activates neurons that send inhibitory signals to the globus pallidus internus (GPi) and substantia nigra pars reticulata (SNr).
GPi and SNr, in response, send inhibitory signals to the thalamus.
The thalamus, when disinhibited by reduced signals from GPi/SNr, sends excitatory signals to the motor cortex.
Excitatory signals from the thalamus to the motor cortex facilitate the initiation and execution of voluntary movements.
Dopamines connection to direct and indirect pathway
Dopamine helps facilitate direct pathway while inhibiting indirect pathway and it is released from the substantia nigra pars compacta
Indirect pathway function
The indirect pathway helps suppress unwanted movements by inhibiting the motor cortex.
Indirect path way steps
In the striatum, inhibitory signals are sent to the globus pallidus externus (GPe).
GPe then sends inhibitory signals to the subthalamic nucleus (STN).
The STN, in turn, sends excitatory signals to the globus pallidus internus (GPi) and substantia nigra pars reticulata (SNr).
GPi/SNr send inhibitory signals to the thalamus.
Finally, the thalamus sends excitatory signals to the motor cortex, inhibiting movement. (Activation of inhibition)
Issue with dopamine
It cannot cross the blood brain barrier
Levodopa importance
It can cross the blood brain barrier, then an enzyme an convert it into dopamine
Levodopa issue
Too much of it will cause you to have involuntary movement, as people
Progress with Parkinson’s, the dosage must go up
On and off cycle
“On Time” symptoms is controls
“Off time” symptoms is not controlled
On:Off cycle importance
Working with clients on their on time will make things easier
On:Off cycle importance
Working with clients on their on time will make things easier
Orthostatic hypotension
↓20 mmHg systolic or
↓10 mmHg diastolic
… within 3 minutes after standing.
This drop in blood pressure can cause dizziness
Orthostatic hypotension
↓20 mmHg systolic or
↓10 mmHg diastolic
… within 3 minutes after standing.
Hohn and Yahir Scale
5 stages of Parkinson’s
Stage 1
Unilateral involvement only, usually with minimal or no functional impairment.
Hohn and Yahir Scale
5 stages of Parkinson’s
Stage 2
Bilateral (or midline) involvement, without impairment of balance.
Negative on the pull test
Hohn and Yahir Scale
5 stages of Parkinson’s
Stage 3
Bilateral: mild-to-modera te disability, impaired postural reflexes; physically independent
More one on one time
Hohn and Yahir Scale
5 stages of Parkinson’s
Stage 4
Able to walk or stand unassisted; more severe impairments
Hohn and Yahir Scale
5 stages of Parkinson’s
Stage 5
Confinement to bed or wheelchair unless aided.
No independence
Hypomimia
Reduced facial expression
Freezing
Temporary in ability to move while walking
Dyskinesia (mid stage PD)
involuntary movement
Dysphagia (Late stage PD)
Difficulty swallowing
Dysphagia
Difficulty swallowing
Other late stage PD
Postural instability
Gait disorder
Falls
Diagnostic delay
Issue with Non motor symptoms
The times of the first motor symptoms and confirmed diagnosis of the disease
The non motor symptoms are non specific we don’t take it into account when determining if individual have PD
Diagnostic delay
The times of the first motor symptoms and confirmed diagnosis of the disease
The non motor symptoms are non specific we don’t take it into account when determining if individual have PD
Young-one set PD
Diagnosis Delay:
Younger age may lead to initial misdiagnosis or delayed recognition of Parkinson’s symptoms.
Atypical symptoms like dystonia can complicate early diagnosis.
Young-one set PD
Genetics
SNCA, GBA, LRRK2: Genetic mutations in these genes are linked to early-onset Parkinson’s.
Young-one set PD
Genetics
SNCA, GBA, LRRK2: Genetic mutations in these genes are linked to early-onset Parkinson’s.
Young-one set PD
Symptoms (commonality) and risk
Less Common: Balance and cognitive issues are less typical in younger patients.
More Common: Dystonia (cramping) is often an early symptom.
Risk of Dyskinesia: Younger patients may experience drug-induced dyskinesia sooner after treatment starts.
Non motor symptoms (early stages)
Sleep
○ Prodromal, throughout, medication related
○ Restless leg syndrome (also separate from PD), REM sleep behaviour disorder
● Mood
○ Depression (Tx options), Anxiety
● Fatigue/Energy/Daytime Sleepiness
● Gastrointestinal issues
Non motor symptoms (later stages)
Blood pressure regulation
● Voice
○ Volume, rhythm (slurring)
● Sialorrhea (drooling)
● Cognitive impairment
○ Memory, thinking (word finding), attention
○ Executive function: organize, plan, problem solve
○ Visuospatial function
○ MoCA Test
● Hallucinations
Concept of intersectionality
- Varied symptom experiences: motor & non-motor
- Gender and societal expectations
- Cultural background
- Socioeconomic status
- Age of onset
- Support systems available
By considering these intersecting factors, we can develop more personalized and effective approaches to support people living with PD.
Seven Tenents for life with PD: 1
There is no “one size fits all” description of PD
It is different for everyone else, monitor your own PD, educate yourself on the disease, and become the top expert on you
Seven Tenents for life with PD: 2
Isolation can worsen symptoms.
You don’t have to manage this disease on your own. A team-based approach (including a movement disorder specialist and allied care professionals) can help you stay physically and emotionally strong. Keep open lines of communication with loved ones and consider joining a support group.
Seven Tenents for life with PD: 3
Don’t settle.
Parkinson’s disease varies, and so do treatment options. Designing a regimen that feels comfortable and effective for you will take time and, likely, more than one try. Keep working with your doctor and care team until you get there. Make changes to address progression as needed.
Seven Tenents for life with PD: 4
Hone your news instinct.
The latest research is the latest hope, but in our 24/7 media environment, there’s a learning curve to interpreting science news. Find experts you trust, seek out credible updates and commentary, and let go of the rest. Being news-savvy can help you maintain peace of mind.
Seven Tenents for life with PD: 5
Parkinson’s is a non-linear disease.
You can have good days, weeks and months even during trying times. Exercising, eating well and staying involved with your social circle, community and activities you enjoy can have a major influence on your Parkinson’s path.
Seven Tenents for life with PD: 6
Get engaged.
There are as many ways to contribute to better outcomes for yourself and others as there are people with Parkinson’s. Participating in research studies or advocacy, raising funds, starting a blog or support group - however you choose to get involved - can give you a sense of control and help bring us all closer to a world without Parkinson’s
Seven Tenents for life with PD: 7
Be prepared.
Parkinson’s diagnosis or not, we all face certain issues in our later years. Make sure your family understands your wishes for end-of-life care, and put your will and estate in order. Having challenging conversations at the beginning of your journey with Parkinson’s can help lighten the burden as the disease advances.
What are the instructions for the finger-tapping task in motor function testing?
Each hand is tested separately. The patient is instructed to tap the index finger on the thumb 10 times as quickly and as big as possible. Speed, amplitude, hesitations, halts, and decrementing amplitude are evaluated.
What characterizes a “normal” rating (0) for the finger-tapping task?
No problems. Speed, rhythm, and amplitude are normal.
What characterizes a “slight” impairment (1) in the finger-tapping task?
Any of the following:
a) 1-2 interruptions or hesitations in rhythm,
b) slight slowing,
c) amplitude decrements near the end of the 10 taps.
What defines a “mild” impairment (2) in the finger-tapping task?
Any of the following:
a) 3-5 interruptions during tapping,
b) mild slowing,
c) amplitude decrements midway in the 10-tap sequence.
What are the characteristics of a “moderate” impairment (3) in the finger-tapping task?
Any of the following:
a) more than 5 interruptions or one longer freeze,
b) moderate slowing,
c) amplitude decrements after the 1st tap.
What defines a “severe” impairment (4) in the finger-tapping task?
Cannot or can barely perform the task due to slowing, interruptions, or decrements.
What are the instructions for the “Arising from Chair” task in motor function testing?
The patient sits in a straight-backed chair with arms and feet on the floor. They are asked to cross their arms and stand up. If unsuccessful, the test can be repeated with different conditions, including moving forward in the chair or using hands for support.
What characterizes a “normal” rating (0) for the “Arising from Chair” task?
The patient is able to arise quickly without hesitation.
What defines a “slight” impairment (1) in the “Arising from Chair” task?
The patient arises slower than normal, may need more than one attempt, or needs to move forward in the chair. No need to use the chair’s arms.
What defines a “mild” impairment (2) in the “Arising from Chair” task?
The patient pushes themselves up from the arms of the chair without difficulty.
What are the characteristics of a “moderate” impairment (3) in the “Arising from Chair” task?
The patient needs to push off but may fall back, or they may need more than one attempt using the arms of the chair but can still get up without help.
What defines a “severe” impairment (4) in the “Arising from Chair” task?
The patient is unable to arise without help.
What are the instructions for assessing “Freezing of Gait”?
Observe for freezing episodes during gait, especially during starting, turning, and at the end of the task. Patients may not use sensory tricks during the assessment.
What characterizes a “normal” rating (0) for the “Freezing of Gait” task?
No freezing is observed.
What defines a “slight” impairment (1) in the “Freezing of Gait” task?
The patient freezes once when starting, turning, or walking through a doorway but continues smoothly during straight walking.
No freezing doing walking
What defines a “mild” impairment (2) in the “Freezing of Gait” task?
The patient freezes more than once when starting, turning, or walking through a doorway but continues smoothly during straight walking.
No freezing doing walking
What characterizes a “moderate” impairment (3) in the “Freezing of Gait” task?
The patient freezes once during straight walking.
What defines a “severe” impairment (4) in the “Freezing of Gait” task?
The patient freezes multiple times during straight walking.
Scale or test: Unified Parkinson Disease Rating Scale (UPDRS)
Variable assessed: Composite score for disease severity
Description: MDS-UPDRS scale has 4 subscales:
• Part I on mentation, behaviour and mood (13 questions, 0–52 points)
• Part II on activities of daily living (13 questions, 0–52 points)
• Part III on motor examination (18 items, 0–136 points)
• Part IV on motor and other complications of advanced disease (6 items, 0–24 points)
Higher scores indicate worse performance
What is the effect of a 6-month training period on MDS-UPDRS scores?
A 6-month training period is effective for achieving clinically meaningful improvement in MDS-UPDRS scores.
Not just 1 point
How long can training slow the progression of disease signs?
Training can slow the progression of disease signs for up to 12 weeks.
What improvements are associated with training in terms of physical function?
Training improves strength and aerobic capacity.
What are the benefits of balance training?
Balance training improves balance, gait, and mobility, and reduces falls for up to 12 months after treatment.
What are the primary questions asked in clinical trials?
Does the treatment work in people?
Is it safe?
Is the treatment better than the standard treatment for the disease?
What are the primary questions asked in clinical trials?
Does the treatment work in people?
Is it safe?
Is the treatment better than the standard treatment for the disease?
What is the focus of a Phase 1 clinical trial?
Basic safety, with a small sample size.
What is the focus of a Phase 2 clinical trial?
Futility trial; continues to monitor safety with a larger sample.
What is the focus of a Phase 3 clinical trial?
Multi-center, comparative efficacy.
Why must treatments go through many steps in clinical trials?
For ethical reasons, whether it is drugs or exercises, the treatments must go through many steps to ensure safety and effectiveness.
What defines the population (P) in this study?
Patients with Parkinson’s disease (H&Y stages 1 or 2, <5 years since diagnosis), aged 40-80, not on medication, and not currently exercising at moderate intensity >3x/week.
What was the intervention (I) in this study?
Aerobic treadmill exercise with 3 groups:
High-intensity (80-85% HRmax)
Moderate-intensity (60-65% HRmax)
Control group
4 days/week for 6 months, 40-50 minute sessions.
What was the comparison (C) in this study?
Control group: Wait-list and usual care.
What were the outcome measures (O) in this study?
Primary: Change in UPDRS over 6 months
Secondary: Adherence and safety
What are the key benefits of endurance exercise for brain and body function?
Increases dopamine metabolism
Promotes angiogenesis and neurogenesis (increases BDNF)
Enhances neuroplasticity and brain connectivity
Has anti-inflammatory effects (balances cytokines)
Improves mitochondrial function and reduces oxidative stress
Increases VO2 max and may improve walking economy
What were the key findings from Phase 2 of the study?
Participants could exercise at the prescribed intensity.
They averaged 3 days/week instead of 4.
UPDRS changes favored high intensity, slowing disease progression by 2.9 points over 6 months, indicating the treatment was not futile.
What were the key findings from Phase 2 of the study?
Participants could exercise at the prescribed intensity.
They averaged 3 days/week instead of 4.
UPDRS changes favored high intensity, slowing disease progression by 2.9 points over 6 months, indicating the treatment was not futile.
What are the key postural changes and balance considerations in Parkinson’s disease?
Kyphosis with a tendency toward flexion
Stoop posture, which may improve temporarily by pulling shoulders back
Hoehn & Yahr stage can indicate severity
If posture cannot be corrected, it may be time to consider using an assistive device to maintain mobility
What are the key considerations for motor fluctuations in Parkinson’s disease?
Medication On
cycle
Freezing when walking
Difficulty stopping ambulation
Best time to work with patients is 60 minutes after taking medication; if prone to drug-induced dyskinesia, wait 2 hours
What are the key aspects of autonomic impairment in Parkinson’s disease?
Impaired heart rate regulation and blood pressure control
Thermoregulation difficulties, especially poor sweat response in hot environments
Common in Hoehn & Yahr stages 3 and 4
Heart rate may not be reliable in stages 3 and 4; use RPE (Rate of Perceived Exertion) instead
How can exercise affect medication management in Parkinson’s disease?
Exercise may alter the bioavailability of medications, potentially reducing the need for L-Dopa as dopamine production increases. It’s important to partner with a neurologist for adaptive medication changes and report any new exercise routines to the clinician.
What is the role of genetic testing in Parkinson’s disease?
To inform family: Sometimes. This is one of those tricky ethical situations and different people and their families may want this information.
Research studies: there are a number of genetic trials that are mostly descriptive in nature.
If you are working as an exercise professional with someone in their mid-40’s that is diagnosed with PD, which symptoms may require adaptations as the disease progresses.
Flextion dystonia and motor fluctuation
epidemiology reported in Poewe et al. (2017).
Incidence 2x more in men
Prevelance 1-3% if >70 years
Idiopathic >90% of patients
Akinesia
No movement
What are motor fluctuations when taking L-DOPA in Parkinson’s disease?
Motor fluctuations refer to reduced motor complications in the ‘on’ state, followed by increased complications in the ‘off’ state. About 30% of people experience this 2-3 years after starting L-DOPA. Increasing the medication can lead to dyskinesias in the ‘on’ state.
What was the study population in Schenkman et al. (2017)?
Participants had an average age of 40-80 years, were at Hoehn and Yahr stages 1-2, and had never taken L-DOPA medication. The results apply specifically to this population and not to all individuals living with Parkinson’s disease.
What was the primary outcome measure in the SPARX2 study, and what were the results for the high-intensity group?
The outcome measure was the motor examination score of the UPDRS (or MDS-UPDRS). The change in the high-intensity group was zero.
Late stage PD
Motor
Postural instability
Gait disorder
Fall
Non motor
Dementia
Mid stage to late stage
Motor
Dysphagia
Axial deformity
Non motor
Psychotic symptoms
(Visual hallucinations)
Mid stage PD
Motor
Fluctuations
Dyskinesia
Non motor
Orthostatic hypotension
Urinary symptoms
Early stage PD
Motor ( Diagnosis of PD/Early stage)
Bradykinesia
Rigidity
Tremor
Non motor
Mild cognitive impairment
Apathy
Fatigue
Pain
Diagnostic Delay (symptoms)
Motor:
The main 3
Non motor
Excessive day time sleepiness
Predromal PD
Non motor
REM sleep behaviour disorder
Depression
Constipation
Anxiety
Hyposmia
