pD Flashcards
pathophysiology of parkinsonism
Global term used to describe a clinical syndrome with particular movement symptoms
Can also involve non-motor symptoms (moof, cognitive, sleep disturbances)
Primary disturbances in the dopamine systems of basal ganglia
Includes PD, progressive supranuclear palsy, drug-induced secondary parkinsonism, NPH, vascular, etc
pathophysiology of pd
Most common movement disorder
Second most common degenerative disease of CNS (first is Alzheimer’s)
Progressive CNS disorder with both motor and nonmotor symptoms
Insidious onset with slow rate of progression
Hallmark is loss of dopaminergic neurons in the substantia nigra
Clinical diagnosis is based primarily on motor features
Progressive Supranuclear Palsy - most common
Accumulation of tau protein
Truncal rigidity more prominent that limb rigidity
Prominent early postural instability and falls
Dysarthria/dysphagia
Limitation with vertical gaze, especially downward
Lewy body Dementia
Early presentation of cognitive symptoms
Fluctuations of alertness and attention; hallucinations
Rigidity more prominent than tremor/bradykinesia
Multiple System Atrophy (MSA) - 2 subtypes one parkinsonism dominant (bradykinesia/rigidity) and one cerebellar dominant (ataxia); less success with levodopa
Accumulation of alpha synuclein protein with an autonomic component
Babinski/hyperreflexia
Cerebellar dysfunction
Orthostatic hypotension
Labile BPs
Cognitive dysfunction less common
May have initial response to levodopa
Cortical Basal Syndrome
Cognitive impairments common and are often one of the first symptoms
Progressive numbness and loss of use of one hand
Symptoms similar to PD but faster progression
Primary/idiopathic PD
Development of Lewy-bodies in substantia nigra (SN), which causes oxidative stress and further dysfunction
Substantia nigra is responsible for production of dopamine
Gradual loss of dopaminergic cells in the SN and ability to initiate movement
Dopamine is the chemical messenger that transmits signals between two regions of the brain to coordinate activity
Dopamine deficiency leads to a person’s loss of movement control
Basal ganglia and movement
Plays primary role in production of smooth and coordinated movement
Consists of 5 nuclei
Striatum (caudate nucleus & putamen)
Globus pallidus
Subthalamic nucleus
Substantia nigra (dopaminergic nucleus)
Influence motor control through 2 pathways
Direct pathway- facilitates movement
Indirect pathway- inhibits movement
(see O’Sullivan, Chapter 18)
These two pathways work in a synergistic and complementary manner
Basal ganglia and the cerebellum are reciprocally interconnected
BG also thought to play a role in motivation (4Ms)
subtypes of idiopathic PD - traditional motor symptom
remor Dominant (TD)
More of an appendicular approach
Tremor is their main feature; typically demonstrate fewer problems with bradykinesia or postural instability, have lower prevalence of non-motor symptoms (lower risk of developing dementia).
Postural Instability Gait Disorders (PIGD)
More of an axial presentation
Dominant symptoms include postural instability and gait disturbances.
TD vs PIGD
Similar motor rate of progression
PIGD has more cognitive and behavioral involvement, including dopamine dysregulation syndrome (impulsivity)
medical diagnosis
No single definitive diagnostic test
Diagnosis based on history and clinical exam
At a minimum, bradykinesia plus either tremor or rigidity must be present to consider the diagnosis of PF
Symptoms are unilateral or worse on one side initially
Imagine - r/o other degenerative/brain processes or secondary causes (infarcts, NPH)
DaTscan
A drug that is injected into the bloodstream to assess dopamine containing neurons
cardinal signs of PD TRAP
Tremor
-Shaking movement on part of body
- Typically starts on one side
Rigidity
- Cogwheel rigidity - jerky resistance
- Lead pipe rigidity - sustained resistance
Akinesia or bradykinesia
- Slowed movement and reaction time
- External cues
- Can cause difficulty fastening buttons, cutting food, putting arms in sleeves, getting up from chair
Postural Instability
- Abnormal pattern of coactivation
- Can test with pull test
motor signs and symptoms
Dystonia: involuntary muscle contractions that cause slow repetitive, twisting movements or abnormal postures
Hypophonic speech: soft speech
Dysphagia: difficulty swallowing
Dysarthria: poor speech articulation
Micrographia: abnormally small handwriting, progressively smaller handwriting
Masked face (hypomimia): bradykinesia of facial muscles, reduction in facial expression
Sialorrhea: hypersecretion of saliva
Dyskinesia: involuntary, erratic writhing movements of the face/tongue, arms, legs or trunk
Drooling- impaired or infrequent swallowing
Dyskinesia- side effect of levodopa; dystonia can be side effect or from PD itself
non motor symptoms
Cognitive changes
Constipation
Early satiety
Excessive sweating
Fatigue
Hallucinations and delusions
Lightheadedness (neurogenic orthostatic hypotension)
Loss of sense of smell or taste
Low resting BP
Mood disorders
Pain
Psychiatric
Sexual/Erectile Dysfunction
Sleep disorders
Seborrheic dermatitis
Urinary urgency, frequency and incontinence
Vision problems
Weight loss
PD early stage
*Patients are functional and independent with minimal impairments.
Typically seen in outpatient setting
PD middle stage
*Activity limitations emerge
*May still be independent in gait and ADLs
*Some assist may be required
*Outpatient, home care, or brief inpatient stay
PD late stage
Severe impairments and complications
*May be dependent in functional mobility and ADLs
*Wc bound/bedridden
*Family/community resources are vital in maintaining pt in the home
*Goals must be reconstructed
*Preventative care
*Compensatory strategies
maintenance stage
*Clinical, educational, administrative services
*Specialized knowledge and judgment
UPDRS = unified PD rating scale
*Lower score means better performance
*Used in research, particularly MDS-UPDRS III
*Often done annually by neurologist/movement disorder specialist
*MCID- 4.3 points for minimal, 9.1 for moderate, and 17.1 for large
More objective- gold standard for measuring progression (more focus on non motor); OM of treatment efficiency
Requires training to perform
These estimates will assist in determining clinically meaningful changes in PD progression and response to therapeutic interventions
PT implications for medical management
*Aware of adverse affects
*Dopamine replacement effects
*Optimal performance
*Monitor drug effectiveness
*Selection individualized to patient’s characteristics with benefits vs side effects carefully weighed
*Starting early has been shown to slow the progression rate
*Delivery should be as close to constant as possible to avoid large peaks and valleys- needs to be on a fixed schedule (stress to pt and family)
Dopamine replacement- will eventually develop motor complications (dystonia, dyskinesias, motor fluctuations)
Dopamine Replacement: Essential for PD management but will eventually cause motor complications like dystonia or dyskinesias. The medication should be scheduled consistently to avoid fluctuations.
Levodopa: The gold standard for drug therapy. Over time, patients may develop motor complications.
Carbidopa + Levodopa: Carbidopa is used to help more levodopa cross into the brain, reducing side effects.
Medical management surgery
Deep Brain Stimulation (DBS): A treatment for advanced PD. Electrodes are implanted to stimulate brain regions like the subthalamic nucleus or globus pallidus internus. It helps with motor symptoms like tremor and rigidity.
Duopa Intestinal Pump: For continuous drug delivery, bypassing the stomach to improve absorption.
Nutritional management
Levodopa absorption can be hindered by proteins, so patients should avoid taking their medication with protein-heavy meals.
OT and SLP Consults: Essential for addressing dysphagia (swallowing difficulties) and adapting eating strategies
PT management
Evaluation: Includes a thorough systems review covering cardiovascular, musculoskeletal, cognitive, and neuromuscular systems.
Functional Assessment: Focuses on mobility, gait, and postural stability. Observe for tremor, freezing, and bradykinesia triggers.
Gait Considerations: Decreased arm swing, reduced trunk rotation, difficulty turning, and freezing of gait.
Impairment-Based Testing: Evaluates ROM, muscle performance (strength and endurance), rigidity, bradykinesia, tremor, and postural control.
Postural Control and Balance: Important tests include the Berg Balance Scale (BBS), Timed Up and Go (TUG), and Functional Reach Test (FRT).
outcome measures
MDS-UPDRS, Montreal Cognitive Assessment, and 6-Minute Walk Test are examples of measures used to track disease progression.
PDQ and TUG are also commonly used for assessing participation and mobility.
framework for rehab
A multidisciplinary approach is crucial: PT, OT, SLP, psychologists, and family members work together to address all aspects of the patient’s needs.
Early intervention, particularly with moderate-to-high physical activity, can slow disease progression.
CPG summary
Strong Evidence and Recommendations:
Aerobic Exercise
Resistance Training
Balance Training
Task-Specific Training
Integrated Care
Moderate Evidence:
Behavior-Change Approach (Moderate recommendation strength due to its indirect impact on motor symptoms).
Weak Evidence:
Telerehabilitation (While beneficial for balance, it lacks strong evidence and has a weak recommendation).
CPG aerobic exercise
Evidence Quality: High
Recommendation Strength: Strong
Supported Evidence: Moderate- to high-intensity aerobic exercise improves oxygen consumption (VO2), reduces motor disease severity, and improves functional outcomes in individuals with PD.
Key Point: Aerobic exercise is a strongly recommended intervention with proven benefits for PD management.
CPG resistance training
Evidence Quality: High
Recommendation Strength: Strong
Supported Evidence: Resistance training is effective in reducing motor disease severity, improving strength, power, non-motor symptoms, and functional outcomes. It also contributes to improving quality of life for PD patients.
Key Point: Strongly supported by evidence, this approach improves both motor and non-motor symptoms.
CPG balance training
Evidence Quality: High
Recommendation Strength: Strong
Supported Evidence: Balance training helps reduce postural control impairments and improves balance and gait outcomes. It also increases mobility, balance confidence, and overall quality of life.
Key Point: Strong evidence supports the benefits of balance training in PD rehabilitation.
CPG task specific training
Evidence Quality: High
Recommendation Strength: Strong
Supported Evidence: Task-specific training is highly effective in addressing task-specific impairments and improving functional outcomes.
Key Point: Another strongly supported approach, targeting improvements in specific tasks related to daily function.
CPG behavior change approach
Evidence Quality: High
Recommendation Strength: Moderate
Supported Evidence: The use of behavior-change approaches can improve physical activity levels and quality of life in individuals with PD.
Key Point: While evidence is strong, the recommendation strength is moderate because it’s more about encouraging sustainable physical activity than directly improving motor symptoms.
CPG integrated care
Evidence Quality: High
Recommendation Strength: Strong
Supported Evidence: An integrated care approach, involving collaboration between multiple healthcare providers (e.g., PT, OT, SLP, physicians), has been shown to reduce motor disease severity and improve quality of life.
Key Point: Strong evidence supports a multi-disciplinary approach in managing PD, as it addresses the holistic needs of the patient.
CPG telerehab
Evidence Quality: Moderate
Recommendation Strength: Weak
Supported Evidence: Telerehabilitation may improve balance, but the evidence is less robust compared to other interventions.
Key Point: While it shows some potential, it’s a weaker recommendation due to less conclusive evidence.
exercise examples for PD - sensorimotor agility exercises
Tai Chi: Improves coordination, postural control, and balance.
Boxing (e.g., Rock Steady Boxing): Focuses on anticipatory postural adjustments, rapid movements, and gait.
Dance: Used in therapy for improving motor planning, balance, and coordination.
