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Neuroscience and Rehabilitation 5MPT2015 (Y2) > Rehab of Parkinson's disease > Flashcards

Rehab of Parkinson's disease Flashcards

1
Q

Learning outcomes

A

By the end of this lecture, students should be able to:
- Discuss the epidemiology, aetiology, pathophysiology and clinical course of Parkinson’s
disease.

  • Explain the current pharmacological therapy used in the management of Parkinson’s
    disease.
  • Describe the role of the physiotherapist in assisting patients with PD
    Discuss the evidence base for physiotherapy management of people with Parkinson’s
    disease.
  • Describe appropriate elements of exercise prescription for the patient with PD.
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2
Q

What is Parkinsonism?

A

Clinical syndrome characterised by disorders of movement –

tremor, rigidity, bradykinesia and postural abnormality.

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3
Q

What are the 2 main types of Parkinsonism?

A
  • Parkinson’s disease (PD) or primary parkinsonism most common (78%)
  • Secondary parkinsonism – various causes
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4
Q

What can cause Parkinsonism?

List of 7

A
  • Degenerative diseases
  • Infections
  • Drug or Toxin induced
  • Vascular conditions
  • Trauma (Head injury)
  • Cerebral tumour (Alzheimer’s disease)
  • Other neurological conditions with Parkinson like features
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5
Q

What is Parkinson’s disease pathophysiology?

A

• Occurs in basal ganglia (striatum –caudate and putamen; Globus pallidus;
subthalamic N; substantia Niagra)

• Neuro-degeneration occurs mainly in the pars compacta of substantia Niagra – rich
in neuromelanin-containing cells.

  • In PD, there is apoptosis of neuromelanin containing neurones
  • Immune cells remove these dying cells
  • Dopamine is depleted as a consequence of this
  • Braak et al. 2006 produced a 6-stage model for the stages of development of PD
  • The ↓ dopamine leads to:
  • ↑ inhibitory drive to the thalamus, suppressing movement
  • Changes in background tone - rigidity
  • Releasing of inhibition of tremor
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6
Q

What occurs in Braak Parkinson’s disease stage 1&2?

A

Lower brainstem & Olfactory bulb.

= Loss of smell, constipation, altered sleep patterns

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7
Q

What occurs in Braak Parkinson’s disease stage 3&4?

A

Extend to Substantia Niagra.

= Gives rise to cardinal signs of PD

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8
Q

What occurs in Braak Parkinson’s disease stage 5&6?

A

Later distribution of Lewy bodies in the cortex.

= Cognitive e.g., dementia etc.

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9
Q

What are the cardinal features of Parkinson’s disease (PD)?

A
  • Resting disease
  • Rigidity
  • Bradykinesia
  • Gait disturbance/postural instability
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10
Q

What are some of the non motor features of PD?

A
  • Autonomic dysfunction
  • Communication difficulties
  • Sensory disturbances including pain
  • Mood disorders
  • Sleep impairment
  • Dementia
  • Falls
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11
Q

What are signs of a resting tremor?

A
  • Involuntary oscillation of body parts at slow frequency of about 4-7Hz.
  • This can look like they’re rolling a pill in their hands aka “pill-rolling”.
  • Postural tremor.
  • Aggravated by stress/fatigue.
  • Diminished voluntary movement that disappears with sleep.
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12
Q

What are signs of Rigidity?

A
  • Increases stiffness/ passive ROM
  • Cogwheel (Jagged resistance) and lead pipe (smooth resistance)
  • unequal in distribution
  • The rigidity will often affect neck, trunk and knees which leads to a stooped posture.
  • Affected by stress, anxiety and posture.
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13
Q

What are signs of Bradykinesia?

A
  • Bradykinesia - used interchangeably with akinesia and hypokinesia
  • Hypokinesia –reduced amplitude of movement
  • Bradykinesia – slowness of movement

• Akinesia – loss of movement, slowness to initiate, freezing while
moving

• Freezing –refers to the difficulty starting or continuing rhythmic
movement e.g. walking, handwriting , speech

• It is the most disabling manifestation of PD

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14
Q

What are signs of Freezing?

A

• Freezing – refers to difficulty starting or continuing rhythmic repetitive
movements

• Schools of thought exit which considers it a distinct clinical sign of PD

• Freezing of Gait (FOG) is an episodic gait disturbance typically
experienced when walking

• Festination often occurs prior to freezing

• Feet appears glued to the floor while momentum carries body mass
forward

• Occurs more frequently in cluttered environments, stressful
circumstances or when patient is distracted

• Likelihood of falls increases

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15
Q

What are some motor control and motor performance deficits present in PD patients?

A
  • Reduced reaction and movement time.
  • Reduced ability to execute sequential movements.
  • Reduced ability to execute simultaneous movements.
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16
Q

What gait abnormalities are typical for PD patients?

A
  • Slow movements.
  • Difficult in initiation of gait.
  • Decreased stride length.
  • Decreased reciprocal arm swing.
  • Small shuffling steps.
  • Loss of normal heel-toe progression
    • festinating gait / propulsive gait
    • turning or changing direction is difficult
    • Ability to dual task impaired
    • Gait ability varies with environmental demand
17
Q

What are some of the common non-motor symptoms associated with PD?

  • Cognitive deficits
  • Neuropsychiatric non-motor deficits
  • Autonomic non-motor symptoms 60%
A

Cognitive;

  • Dementia (40%)
  • Attention/executive function
  • memory

Neuropsychiatric;

  • Depression (22%)
  • Anxiety
  • Frontal executive dysfunction
  • Dementia (80%)
  • Psychosis
  • Sleep disorders (90%)

Autonomic;

  • Orthostatic hypertension
  • Urogenital dysfunction
  • Constipation

Fatigue

18
Q 
Clinical staging of PD can involve the use of the modified Hoehn & Yahn scale.
What are the signs for each stage of PD;
- 1
- 1.5
- 2
- 2.5
- 3
- 4
-5
A
  • 1; Unilateral involvement only
  • 1.5; Unilateral; and axial involvement
  • 2; Bilateral involvement without impairment of balance.
  • 2.5; Mild bilateral disease with recovery on pull test.
  • 3; Bilateral disease: Mild to moderate disability with some impaired postural instability; physically independent
  • 4; Server disability; still able to walk or stand unassisted.
  • 5; Wheelchair bound or bed ridden unless aided.
19
Q

Another outcome measure to asses a patients PD, is the unified Parkinson’s rating scale aka UPDRS. Its a 50 item questionnaire with each question being rated from 0-4, 0=normal, 4=severe.

What does each of the 4 sections cover?

  • 1
  • 2
  • 3
  • 4
A
  • Part I: Non-Motor Aspects of Experiences of Daily Living (13 items)
  • Part II: Motor Aspects of Experiences of Daily Living (13 items)
  • Part III: Motor Examination including staging (18 items)
  • Part IV: Motor complications (6 items)
20
Q

What medical management is available for PD?

Pharmacological

A

• Levodopa (L-dopa); mainstay of
therapy
- Usually reserved for patients in middle & late stages
- Initial improvement often dramatic “honeymoon
period”
- Long term use - effectiveness deteriorates
- End-of-dose deterioration; On-off phenomenon

  • COMT – catecholamine-Omethyltransferase inhibitors
  • Monoamine oxidase (MAO) inhibitors
  • Amantadine

• Dopamine agonists e.g., Apomorphine or
rotigotine

• Duodenal levodopa infusions

21
Q

What would you do in an objective examination of a client with PD?

A

• Gait assessment

  • Speed and distance, forward and backward , stride length, cadence
  • Ability to alter speed

• Transfers
- sitting, sit to stand, stand to sit, lying to sitting and back again, rolling in bed, getting in and
out of car

• Passive ROM
- Spine, UL & LL joints, muscles – calf, hamstrings etc

• Postural alignment
- Tragus to wall distance

• General Strength
- Trunk, knee, ankle, hip muscle groups etc

• Chest expansion
- Functional capacity and vital capacity

• Balance
- static & dynamic balance, multi-tasking, freezing - causes

22
Q

What outcome measure would you use for patients with PD?

A
  • UPDRS
  • Montreal cognitive assessment
  • Sit to stand 5 minutes (how many reps can they do)
  • Functional gait assessment
  • 9 Hole peg test
  • 6 minute walk
  • PDQ-8 (Parkinson’s disease questionnaire)
23
Q

What is the treatment goal for a physio with a PD patient in stage 1-2.5 (according to the modified Hoehn & Yahn scale AKA HY)

A 
Treatment goal
▪ Prevent inactivity
▪ Prevent fear of moving & falling
▪ Maintain or improve
physical capacity
24
Q

What interventions would a physio use with a PD patient in stage 1-2.5 (according to the modified Hoehn & Yahn scale AKA HY)

A 
Intervention
▪ Promote active lifestyle
▪ Supply info to prevent
inactivity & improve physical
capacity
▪ Active (group) exercises to improve balance, muscle
power, joint mobility, and
aerobic capacity
▪ Involve partner or carer
25
Q

What is the treatment goal for a physio with a PD patient in stage 2-4 (modified HY)

A

Added treatment goals to previous stage:
▪ Prevent falling
▪ Reduce limitations on core areas: transfers, posture, reaching & grasping, balance, gait.

26
Q

What interventions would a physio use with a PD patient in stage 2-4 (modified HY)

A 
Added Intervention
▪ Active & functional-task
exercises (at home) using:
▪ General strategies
▪ PD specific strategies:
▪ Cognitive movement,
▪ Cueing strategies
▪ Supply info to reduce
multitasking
27
Q

What is the treatment goal for a physio with a PD patient in stage 5 (modified HY)

A

Added treatment goal
▪ Maintain vital functions
▪ Prevent pressure sores
▪ Prevent contractures

28
Q

What interventions would a physio use with a PD patient in stage 5 (modified HY)

A 
Added Intervention
▪ Postural adjustments: bed, wheelchair
▪ Assisted active exercise
▪ Supply info to prevent
pressure sores and
contractures
29
Q

What are the general principals of physiotherapy management (middle stage) ?

A
  • Gait re-education
  • Improve balance and flexibility
  • Improve movement initiation
  • Improve functional independence
  • Provision of advice: safety at home
30
Q

How would you perform Gait training for PD patients in the disease stage?

A

Repetitive task practice
e.g., Walking
• May need cueing strategies, like tape on the floor where to step.

  • If possible try include dual tasking if sufficient cognitive ability
  • treadmill training with/without musical beat (cueing) to help pace their gait/stages correctly
  • Could use strategies to cue movement: visual, auditory, tactile, cognitive
31
Q

What are some visual cues a physio could use with a PD patient to help their gate.

And what parameters do these cues help?

A
  1. Lines on floor
  2. Patterned carpet
  3. Walking stick with
    LASER beams
  • ↑ Step size
  • Modify step rate
32
Q

What are some Auditory cues a physio could use with a PD patient to help their gate.

And what parameters do these cues help?

A
  1. Metronome beat
  2. Musical rhythm
  • Modify step rates
  • ↑ Step size
33
Q

What are some Somatosensory cues a physio could use with a PD patient to help their gate.

And what parameters do these cues help?

A
  1. Rhythmic vibrations
  2. Electrical pulse
  3. Touch
  4. Treadmill
  • Modify step rate
34
Q

What type of gait training would you provide for a PD client who started medication for PD 5-8years ago?

A

• Cognitive strategies continued
• Monitoring walking patterns and balance during tasks to avoid
tripping and falling
• Teach separate strategies for when “on” or “off” medication
cycle
• Turning strategies (Hulbert et al., 2014)
• Avoid secondary tasks

35
Q

What type of gait training would you provide for a PD client who was in the advanced disease stage?

A
  • Other strategies plus scanning environment

for hazards; walking aids: 4-wheeled walking frames

36
Q

What type of gait training would you provide for a PD client who was in the end-stage?

A
  • Education and support to enable

participation in daily life

37
Q

What are the benefits of aerobic training for PD clients?

A

• PwPD improve VO2 max with either low intensity or high intensity aerobic
exs (Shulman et al. 2013; Schenkman M et al 2012)

• Large study of aerobic walking trial found improvement in VO2 max, motor
signs, walking speed, executive function, fatigue, depression and quality of
life (Uc et al. 2014)

• Need to exercise at least at moderate intensity (65 -70% HR max)

38
Q

Summary

A

PD is a chronic, progressive disorder of the basal ganglia
characterised by the cardinal features of rigidity, tremor,
and bradykinesia

• Pharmacological interventions have become the mainstay
of treatment

• Physiotherapy interventions focus on management of
strength, ROM, endurance and functional skills, balance,
gait according to disease stage

• MDT involvement at all stages to provide psychosocial
support as needed and to direct patient towards
maintenance of function

Neuroscience and Rehabilitation 5MPT2015 (Y2) (20 decks)

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