PD - Defining the Condition Flashcards
Cardinal PD Signs
Tremor, rigidity, bradykinesia, postural instability
PT’s Role in PD
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
Progressive supranuclear palsy (PSP)
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
Multiple Systems Atrophy (MSA)
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
Diagnosis of PD
Clinical determination Bradykinesia and one of: Tremor Rigidity Postural instability
No blood tests
MRI / PET Scan – possibly in the future
Falls & Fractures for People with PD
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
Non-motor signs of PD
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%)
Modified Hoehn and Yahr Stages of PD
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
Stages of PD
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
PIGD versus Tremor Type PD
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
Pre-clinical and Clinical Disability
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
Neuroanatomy & pathophysiology of PD
Degeneration of substantia nigra (midbrain)
Loss of dopamine producing cells
Imbalance of neurotransmitters
(e.g., dopaminergic & cholinergic), especially in
the basal ganglia
Dopamine and Brain regions
DA to frontal lobe: executive, motor planning, motor execution
DA to limbic area: mood, drive, memory
Effects of L-DOPA
Most effective symptomatically
Bradykinesia
Tremor
Rigidity
Later motor complications
Not neuroprotective (no drugs for PD are - treat sx only)
Dopaminergic Medication Side Effects
Sleepiness (worse with DA agonists) Confusion/hallucinations Impulsive behavior? (worse with DA agonists) Orthostatic hypotension Nausea
Advanced PD: Complications of
Medical Therapy
“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
Surgery
Pallidotomy: Tremor Thalamotomy: 90% reduction in dyskinesia 40% improvement in PD symptoms Deep brain stimulation: Bilateral, subthalamic nuclei Neurotransplantation?
Late Stages of PD: DBS
Used when dyskinesias and / or tremor become highly disabling Does not resolve problems with postural instability Maximum effectiveness is the persons best on-state
Who Benefits from DBS?
H&Y 2-4 Respond to L-DOPA with clear on / off Persistent and disabling motor fluctuations Cognitively intact Strong support system
DBS Benefits
UPDRS Motor improved 27.6%
L-dopa equivalent reduced by 55.9%
Dyskinesias reduced by 69.1%
Quality of life improved by 34.5%
DBS Side Effects
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%)
