PD - Defining the Condition

Question 1

Cardinal PD Signs

Answer 1

Tremor, rigidity, bradykinesia, postural instability

Question 2

PT’s Role in PD

Answer 2

People with PD benefit from exercise - many questions regarding best approach

Clinician’s role –
Develop initial intervention program focused on
key issues for the patient
With the patient, transition the program into
activities that emphasize those key issues for
long-term adherence
Regularly re-evaluate and adjust the program

Question 3

Progressive supranuclear palsy (PSP)

Answer 3

Progressive supranuclear palsy (PSP):
 Progressive disorder
 Onset over age 50
 Impaired eye movements: can’t look down
 Reptilian or scared look
 Postural extension (extreme)
 Falls within the first year

Progresses faster than PD

Question 4

Multiple Systems Atrophy (MSA)

Answer 4

Cerebellar symptoms
Gait ataxia
Autonomic symptoms
Orthostatic (30mm sys or 15mm diast drop)
Impotence
Urinary incontinence (70% MSA), or urinary
retention (30% MSA)

Wide BOS, as opposed to narrow with PD

Question 5

Diagnosis of PD

Answer 5

Clinical determination
 Bradykinesia and one of:
 Tremor
 Rigidity
 Postural instability

No blood tests
MRI / PET Scan – possibly in the future

Question 6

Falls & Fractures for People with PD

Answer 6

70% - fall at least once a year
17.1% sustain fractures (Williams et al)
PD who fall are 3.2X more likely to sustain a
fracture than those without PD
27% have a femoral fracture within 10 years
of diagnosis

Question 7

Non-motor signs of PD

Answer 7

Cognitive decline (84%)
 Dementia (40-80%)
 Fatigue (33-58%)
 Pain (80%)
 Depression (50%)
 Daytime sleepiness (79%)
 Autonomic dysfunction (urinary incontinence,
postural hypotension – about 40%)
 Sensory disturbance (40%)

Question 8

Modified Hoehn and Yahr Stages of PD

Answer 8

Stage 1 Unilateral
Stage 1.5 Unilateral with some axial
Stage 2 Bilateral without impaired balance
Stage 2.5 Mild bilateral; recovery on pull test
Stage 3 Mild/mod bilateral; some postural
instability; can live independently
Stage 4 Severe disability; can walk
independently
Stage 5 w/c dependent; bedridden unless
assisted

Question 9

Stages of PD

Answer 9

Mild: responsive to medication
 H&Y 1, 1.5, and 2
 Moderate: motor complications from
medications
 H&Y 2.5 and 3
 Severe: minimal response to medication or
severe fluctuations
 H&Y 4 and 5

Question 10

PIGD versus Tremor Type PD

Answer 10

PIGD: Postural Instability and Gait Disorder
More problems with instability and gait dysfunction
More likely to have cognitive deficits
Faster decline
Tremor predominant PD
Based on summary scores on UPDRS motor
exam

Question 11

Pre-clinical and Clinical Disability

Answer 11

Difficulty without loss of independent function
< UPDRS 20
H&Y Stages I to II
Difficulty with loss of independent function
UPDRS 30-40
H&Y Stages II to III

Question 12

Neuroanatomy & pathophysiology of PD

Answer 12

Degeneration of substantia nigra (midbrain)
Loss of dopamine producing cells
Imbalance of neurotransmitters
(e.g., dopaminergic & cholinergic), especially in
the basal ganglia

Question 13

Dopamine and Brain regions

Answer 13

DA to frontal lobe: executive, motor planning, motor execution

DA to limbic area: mood, drive, memory

Question 14

Effects of L-DOPA

Answer 14

Most effective symptomatically
Bradykinesia
Tremor
Rigidity

Later motor complications

Not neuroprotective (no drugs for PD are - treat sx only)

Question 15

Dopaminergic Medication Side Effects

Answer 15

Sleepiness (worse with DA agonists)
 Confusion/hallucinations
 Impulsive behavior? (worse with DA agonists)
 Orthostatic hypotension
 Nausea

Question 16

Advanced PD: Complications of

Medical Therapy

Answer 16

 “Wearing-off”
 “Too much” movement (dyskinesias)
 Abnormal muscle contractions
(dystonia)
 Can be from too much or too little dopamine
 Unpredictable “off” periods; freezing
 Dose failures

Question 17

Surgery

Answer 17

Pallidotomy:
 Tremor
Thalamotomy:
 90% reduction in dyskinesia
 40% improvement in PD symptoms
Deep brain stimulation:
 Bilateral, subthalamic nuclei
Neurotransplantation?

Question 18

Late Stages of PD: DBS

Answer 18

 Used when dyskinesias and / or tremor
become highly disabling
 Does not resolve problems with postural
instability
 Maximum effectiveness is the persons
best on-state

Question 19

Who Benefits from DBS?

Answer 19

 H&Y 2-4
 Respond to L-DOPA with clear on / off
 Persistent and disabling motor
fluctuations
 Cognitively intact
 Strong support system

Question 20

DBS Benefits

Answer 20

UPDRS Motor improved 27.6%
L-dopa equivalent reduced by 55.9%
Dyskinesias reduced by 69.1%
Quality of life improved by 34.5%

Question 21

DBS Side Effects

Answer 21

Symptoms that are not improved
Postural instability / falls
May actually worsen

Dysarthria (9.3%),
 Weight gain (8.4%)
 Miscellaneous motor (4.0%)
 Intracranial hemorrhage (3.9%)
 Psychiatric (3.5%)
 Stimulation-induced dyskinesia (2.6%)