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53 Cards in this Set
- Front
- Back
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% Degeneration of the Basal Ganglia (BG) before motor signs appear? |
30-60% |
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Purpose of the Basal Ganglia? |
Predict the effects of various actions Make and execute action plans Prevents unwanted movements |
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What are the collections of nuclei in the BG |
Striatum (main input receptors) --Caudate and putamen Globus Pallidus --Internus and externus Subthalamic nucleus (internal processing) Substantia Nigra --Compacta (internal processing) and Reticula (output) |
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What is the direct pathway |
Facilitation of desired movement |
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What is the indirect pathway |
inhibition of undesired movement |
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What is the role of the substantia nigra? |
Balances activity of direct and indirect pathways through effect of dopamine |
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How does Dopamine effect the direct/indirect pathway? |
Excites direct pathway through D1 receptors (facilitates facilitation)
Inhibits indirect pathway through D2 receptors (Inhibits inhibition) |
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How does ACh effect the direct/indirect pathway |
Inhibits the direct pathway (inhibits facilitation) Excites the Indirect pathway (facilitates inhibition) |
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What is the Pathophysiology of Parkinson's |
-Lesions of Substantia nigra cause death of neurons --This disrupts the balance between direct and indirect pathways (tipped toward indirect/inhibition) -Dopamine no longer released --Less cortical activity, less voluntary movement --Dec facilitation --Excessive contraction of postural muscles |
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Symptoms of Parkinson's reflect... |
The increase in inhibition and decrease in facilitation |
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What is the process that leads to bradykinesia? |
Depletion of pigmented dopaminergic neurons in SN --> Reduced dopaminergic output from SN + Inclusion bodies develop + Degeneration in other basal ganglia nuclei ---> Neurons in subthalamic nucleus become more active than usual in inhibiting activation of the cortex |
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What cluster of problems can present with parkinsonism? |
IPD Multiple systems atrophy Progressive supranuclear Palsy Lewy bodies dementia Vascular parkinsonism Drug induced parkinsonism |
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Etiology of IPD |
Younger than 60 = 1-2% Older than 60 = 2-4% Avg onset: 50-60 Early onset: <40 Young onset: 21-40 Juvenile: <21 Males 1.5-2 x female |
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Describe Toxic and drug induced parkinsonism |
Toxic: Pesticides and industrial chemicals (manganese) Drug: Neuroleptic, antidepressants, antihypertensive |
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What are parkinsonism-plus syndromes? |
Progressivesupranuclearpalsy Multi-infarct disease Alzheimer’s Normal pressure hydrocephalus |
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Review Slide 13 |
Differential Dx |
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What are the motor phenotypes of Parkinsons |
Postural instability, gait disturbed --Less levodopa responsive --More disabling Tremor dominant --Variable response to levodopa --Fewer problems with Bkinesia and postural instability Indeterminate |
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What are the cluster subtypes of Parkinsons |
Tremor Dominant Non-tremor Dominant Young Onset Rapid Disease Progression |
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Early Signs of Parkinson's |
Precede motor signs by years (at least 5, mean of 13) REM sleep disorder Foot dystonia and cramping Loss of smell Orthostatic hypotension Constipation |
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Describe the "Mild" Stage of PD |
1) Movement symptoms - do not affect daily activities 2) Movement symptoms unilateral or aymmetrical 3) Noticeable changes in posture, walking ability or facial expression 4) Meds suppress movement symptoms 5) Regular exercise improves and maintains mobility, flexibility, ROM and balance |
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Describe the "Moderate" Stage of PD |
1) Movement symptoms bilateral 2) Body moves more slowly developing trouble with balance and coordination 3) Freezing episodes may occur 4) Parkinson's medications may "wear off" between doses (Dyskinesias) 5) Regular exercise, PT for mobility and balance, OT for strategies to maintain independence |
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Describe the "Advanced" Stage of PD |
*Not all will reach this level of disability* 1) Great difficulty walking - WC or bed most of the day 2) Assistance needed with ADL - cannot live alone 3) Cognitive prolembs may be prominent, including hallucinations and delusions 4) Balancing the benefits of medications with their side effects becomes more challenging |
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How is parkinsonism clinically dx |
Presence of 2/3 Bradykinesia Rigidity Resting Tremor Postural instability will arise out of the above symptoms |
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Resting vs intention tremor
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R: Occurs at rest or when distracted I: Increases as target is reached Tremor is alternating contraction of agnoist and antagonist -Can affect arms, legs, jaw and tongue |
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Describe Rigidity |
Lead pipe or cogwheel Increased with concentration and emotional stress Contributes to contracture, postural deformity (flexed) fatigue Often Asymetrical Proximal muscles affected first - difficulty with bed mobility, lack of arm swing during gait |
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Lead pipe vs cogwheel rigidity |
LP: Resistance to passive motion in both directions Not velocity dependent CW: Tremor coexisting with rigidity Cogwheeling has same fq as tremor |
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Describe BradyKinesia |
--May be due to combined effects of tremor, weakness, and rigidity --Underscaling of movement --Difficulty initiating movement --Poor rapid fine movements (fingers) --Facial immobility --Reduced spontaneous blinking --External cues can help |
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Describe the types of loss of movement with PD |
Hypokinesia - slowed and reduced movement Akinesia - Lack of spontaneous movement Freezing - sudden stop in movement |
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Describe Postural instability seen in PD |
Loss of postural reflexes Retropulsion Difficulty making turns Difficulty maintaining CoM within BoS --Narrowed BoS and dynamic destabilizing activities Abnormal coactivation resulting in rigid body and inability to utilize normal postural strategies Impaired sensorimotor integration Visuospatial impairment |
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Describe the 'Typical Stooped Posture' |
Weakness to extensors Changes in Center of Alignment - at forward limits of stability Contractures -Rigidity dorsal spine -Hip and knee flexors, Hip rotators, adductors, PF -Shoulder adductors, IR, Elbow flexors |
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Describe PD gait |
Stooped Slow to initiate Reduced arm swing and trunk rotation Shortened stride Rapid small steps often on tiptoe Tendency to pick up speed - difficulty stopping (festinating) Impaired balance on turning |
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Sensory symptoms |
No primary sensory loss Parethesia and pain Depression Postural stress syndrome |
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Vision, swallowing, and speech problems |
-Conjugate gaze and saccadic eye movements impaired -Dysphagia -Abnormal Tongue control, problems chewing -Sialorrhea (drooling) -Hypokinetic dysarthria -Hypophonia - dec voice volume - monotone |
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Cognition symptoms |
Dysexecutive disorder (planning sequencing) Bradyphrenia (slow thought) Depression (40%) and dysthymic disorder --Deficiencies of dopamine, serotonin. norephinephrine Anxiety (38%) Hallucinations, delusions, psychosis (caused by medications) |
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Sleep disorders |
REM sleep behavior disorder 50-60% --Dream enacting behavior Insomnia Hypersomnia |
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Autonomic Dysfunction |
Orthostatic hypotension ThermoReg Dysfunction --Excessive sweating, abnormal warmth/cold Seborrhea GI disorders --Changes in appetite, Weight loss Constipation Urinary incontinence Sexual dysfunction Diminished heart function |
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What is the Retropulsive Pull test? |
-Pt stands in comfortable position with eyes open -Instruct pt to do whatever it takes not to gall -Give brief, firm backward pull to the shoulders with sufficient force to cause the pr to have to regain their balance |
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Retropulsion scoring |
–0 =recovers independently may take 1 or 2 steps or an ankle reaction –1 = 3steps or more backward but recovers independently –2 = retropulsion,needs to be assisted to prevent fall –3 =very unstable, tends to lose balance spontaneously –4 =unable to stand without assistance (UPDRS method) |
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What is the 360 turn test |
Ask pt to turn in a complete circle Record time and steps H&Y 1-1.5 - 3.33s - 6 Steps H&Y 2 - 3.91s - 8 Steps H&Y 2.5 - 4.81s - 9 Steps H&Y 3 - 7.34s - 11 Steps |
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What does the Mini-Best test analyze? |
Anticipatory postural control Reactive Postural control Sensory Orientation Dynamic Gait |
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Outcomes not recommended for PD |
CTSIB Tug-c Tug-m Supine to Stand FIM Falls efficacy Scale |
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Efficacy of L-dopa |
-Reduces bradykinesia and rigidity -Less effective in tremors and postural instability -Complications - dyskinesias (avg w/5) and on/off phenomenon |
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Treatment Planning H&Y 1-2.5 |
Prevention of inactivity Prevention of fear of falling Improve physical capacity Education: self management |
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Treatment Planning H&Y 2-4 |
Maintain or improve -Transfers -Posture -Reaching and grasping -Balance gait |
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Treatment Planning H&Y 5 |
Maintain vital function Prevent pressure sores Prevent contracture |
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How to decrease rigidity |
Rhythmic Rotation distal > proximal Rocking chair Relaxation Aquatic Therapy Inversion |
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Gait Training and PD |
Gait is most common problem by H&Y 2.5 Changing surfaces - doorways Walking in varied environments and crowds Consider trekking poles for higher level patients Rollator walker may be best U-Step |
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Balance for Parkinsons |
Equilibrium reactions in all plans and under different controls Turning the body and turning the head All three balance strategies Consider computerized games that target balance Tai Chi and other martial arts |
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ADL training and PD |
Functional strengthening Emphasize transitional movements Normal Posture adjustments are no longer automatic Visualization can help |
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Ther Ex for PD |
>/= 1x/week HIIT on exercise bike/resistance training Supported treadmill Tai Chi Sensory Attention Focused Exercise (SAFEx) |
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What is the purpose of therapeutic Exercise |
Promote context dependent responses Promote Fitness and Inc ROM |
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Strength and Power Training
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HIIT bike HIIT resistance High resistance eccentric exercise Sports activities |
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Considerations for treating PD |
Breathing exercises are crucial Incorporate the use of voice into exercises Avoid fatigue Activities must be engaging for the patient Procedural learning will be slow - use declarative learning and visualization to facilitate |
