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Neuromuscular practice 2 > PD: presentation, diagnosis, exam > Flashcards

PD: presentation, diagnosis, exam Flashcards

1
Q

Parkinson’s Disease

A

neurodegenerative disorder of subcortical gray matter in the basal ganglia
dopamine loss causes loss of inhibitory control of indirect loop and excitatory control over direct loop results in decreased movement

highest incidence among caucasians, males, and in early to mid 60s

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2
Q

PD cardinal signs (TRAP)

A

Tremor (resting): diminishes w/ effort, increase w/ stress/fatigue
Rigidity: not velocity dependent, common in trunk, extremities and neck
Akinesia/bradykinesia: correlates best with severity of loss of dopamine
Postural instability: not common early in diagnosis

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3
Q

Movement symptoms of PD

A
  • resting tremor
  • rigidity
  • bradykinesia
  • postural instability (later on)
  • micrographia (handwriting getting smaller over time)
  • festinating gait
  • freezing
  • soft speech
  • masked face
  • Sialorrhea (drooling) and dysphagia (motor function)
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4
Q

non-movement symptoms of PD

A
  • anosmia
  • anxiety
  • apathy
  • bone health
  • breathing difficulty
  • cognitive changes
  • constipation and nausea
  • dysautonomia
  • fatigue
  • hallucinations
  • pain & sensory disturbances
  • sleep disorders
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5
Q

T/F there is NO diagnostic test for PD

A

True

  • based on clinical exam
  • gold standard: neurological exam at autopsy
  • no biological marker that confirms diagnosis
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6
Q

Supportive criteria for diagnosing PD

A

Clear & dramatic response to dopamine therapy
Levodopa-induced dyskinesia (not unique to PD)
Resting tremor of a limb
Diagnostic testing: loss of olfaction & abnormal cardiac MIBG scintigraphy

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7
Q

9 absolute exclusions for diagnosing PD

A
  1. unequivocal cerebellar abnormalities
  2. downward vertical supranuclear gaze palsy
  3. Frontotemporal dementia (w/in first 5 yrs)
  4. parkinsonism restricted to lower limbs longer than 3 yrs
  5. treatment with dopamine receptor blocker (drug induced PD)
  6. absence of response to levodopa
  7. unequivocal cortical sensory loss
  8. normal functional neuroimaging of dopaminergic system
  9. documentation of alternative condition know to produce parkinsonism & plausibly connected symptoms
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8
Q

PD prognosis

A

Progressive disease with no cure

  • shift from unilateral to bilateral involvement
  • increasing rigidity and postural flexion
  • increasingly limited mobility and increasing need for assistance
  • eventually w/c and/or bed-bound
  • cause of death usually pneumonia
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9
Q

PD: Stage zero

A

no signs of disease

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10
Q

PD: stage 1

A

unilateral symptoms- tremor, stiffness, slowed movement

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11
Q

PD: stage 1.5

A

unilateral symptoms plus ataxial involvement- postural problems

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12
Q

PD: stage 2

A

mild bilateral involvement & minor sxs: swallow, talk, and decreased facial expression

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13
Q

PD: stage 2.5

A

bilateral involvement, recovers on pull test

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14
Q

PD: stage 3

A

bilateral involvement worsened. Postural instability noticed. Person is still independent

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15
Q

PD: stage 4

A

Severe disability, able to walk or stand unassisted, but will need help with ADL

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16
Q

PD: stage 5

A

person confined to w/c or bed; needs total assistance

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17
Q

common early presentation of PD

A 
tremor
micrographia
slowness with ADLs
voice changes (soft speech)
difficulty maneuvering in bed
lack of arm swing with gait
dragging the foot with walking
18
Q

common presentation of PD after 5 years

A

motor fluctuations: wearing off, on-off phenomena, narrowing therapeutic window
loss of postural control; retropulsion
gait freezing and festination
cognitive changes
medication side effects: dyskinesia, dystonia

19
Q

Primary objective of medical management of PD

A

maximize control over the “target” signs and symptoms

patient’s therapeutic response to any individual drug may change over time and requires regular visits and frequent communication between the medical team, the patient, and caregiver to maintain the best management of the disease with the fewest side effects possible

20
Q

Advantage and mechanism of Carbidopa/Levodopa

Dopamine agonists

COMT inhibitors

MAO inhibitors

Anticholinergic agents

A
  • most effective; prolongs capacity to perform ADLs
  • works by copying actions of dopamine in the brain
  • inhibits enzyme responsible for metabolism of levodopa
  • slow metabolism of dopamine
  • used for treatment of tremor in younger patients
21
Q

History questions during exam

A 
PMH/co-morbidities
symptom onset
medications: dosing schedule, time of last dose, on/off periods
falls
home set-up and current daily activities
equipment
social support
primary complaint and current symptoms
current exercise regimen
22
Q

MSK exam

A 
ROM
- rigidity
-posture assessment
-limited cervical and trunk rotation
-hip flexor tightness (thomas test)
Strength
-generally should be WNL
-5x sit to stand: >16 secs correlated with fall risk
23
Q

Coordination observations

A

movements bradykinetic, small, fatigue with repetition
no dysmetria
dyskinesia

24
Q

Sensory exam

A

Pain:
-MSK
-central neuropathic
Oculomotor and visual:
-visuoperceptual deficits
-abnormalities atypical in early stages of idiopathic PD
-impaired/bradykinetic saccades in late stages
Olfactory disturbances
-odor detection, discrimination, identification
Proprioception:
-decreased sensory integration: joint position sense, postural orientation
-decreased kinesthetic awareness: larger limb displacement required in order to detect movement

25
Q

cognitive exam

A

Dementia affects 40-80% of patients
-planning
-decision-making
-goal-directed behavior
Strong correlation between attention and the “pace” domain of gait.
-gait velocity, step length, and step time
-associations with gait variability and executive dysfunction
Outcome measure: MoCA (<26/30 = mild, <21/30= PD dementia)

26
Q

Outcome measures for body structure and function

A

MoCA
MDS-UPDRS
Pull test (aka retropulsion test)

27
Q

Retropulsive pull test

A

EDGE rating- 1, not recommended due to weak psychometrics
instruct patient to take a comfortable stance, examiner stands behind, instruct pt to do whatever it takes to not fall, and examiner provides a sudden, brief backward pull to the shoulders to cause pt to have to regain balance
Scoring 0-4
0= recovers independently, ankle reaction or takes 1-2 steps
1= 3 or more steps backward but recovers independently
2= retropulsion, needs to be assisted to prevent fall
3= very unstable, tends to lose balance simultaneously
4= unable to stand without assistance

28
Q

push-release test

A

higher sensitivity for both on/off states and specificity for on states vs. pull test

Scoring:
0= recovers independently with 1 step of normal length and width
1= 2-3 small steps backward, but recovers independently
2= 4+ steps backward, but recovers independently
3= steps but needs to be assisted to prevent a fall
4= falls without attempting a step or unable to stand without assistance

29
Q

functional assessment: 6 MWT

A

measures walking distance, submaximal aerobic capacity/endurance

30
Q

functional assessment: 10 meter WT

A

gait velocity
MDC comfortable place = 0.18 m/s
MDC fast pace = 0.25 m/s
age-related normative data

31
Q

functional assessment: mini BESTest

A

balance and mobility

  • APAs
  • RPAs
  • Sensory orientation
  • dynamic gait
32
Q

functional assessment: MDS-UPDRS part 2

A

motor experiences of daily living
covers speech, saliva mgmt, eating, chewing/swallowing, dressing, hygiene, handwriting, hobbies, bed mobility, walking/balance, freezing

33
Q

functional assessment: FGA

A

modified DGI:

  • removed walk around obstacle
  • added: gait w narrow BOS, backward walking, walking EC
  • 18/30 = fall risk
  • MDC = 4 pts
34
Q

functional assessment: 5x sit to stand

A

cut off score of 16 sec = fall risk

35
Q

functional assessment: 9 hole peg test

A

finger dexterity
MDC = 2.6 seconds for dominant hand; 1.3 sec for non-dominant hand
normative data by H&Y stage

36
Q

functional assessment: participation; PDQ-39 or PDQ-8

A 
dimensions:
mobility
ALDs
emotional well-being
stigma
social support
cognition
communication
bodily discomfort
37
Q

functional assessment: freezing of gait questionairre

A

score 0-24, higher = more severe
complete during ‘on’ phase
item 3: good single question for screening

38
Q

Parkinson’s fatigue scale

A

16-item patient-rated scale measuring patient’s perception of fatigue and its impact on daily activities

39
Q

fear of falling: ABC-scale

A

cut-off score 69% predictive of recurrent falls

MDC 11.12

40
Q

Dual task assessment

A

loss of automaticity of movements secondary to deficits in basal ganglia = increased difficulty with dual tasking

41
Q

4 square step test

A

> 9.68 seconds = increased risk for falls

42
Q

Atypical exam findings for idiopathic PD

A 
early symptoms of:
-urinary incontinence
-dementia
-postural instability
-orthostatic hypotension
visual changes:
-difficulty looking down or complaints of walking down stairs
types of parkinsonisms:
-progressive supranuclear palsy
-multiple system atrophy
-corticobasal ganglionic degeneration 
-lewy body dementia

Neuromuscular practice 2 (8 decks)

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