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185 Cards in this Set
- Front
- Back
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What are 2 parts of the BG that are afferent or receive info from the motor cortex?
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1. caudate
2. putamen |
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What is the caudate and putamen together called?
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The striatum
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What 3 places does the caudate receive info from?
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1. frontal areas of the cortex
2. prefrontal areas 3. limbic system |
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What 3 outcomes will the BG be involved with?
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1. executive function
2. emotions 3. motivation |
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Where does the putamen receive info from?
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Sensorimotor cortex
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What efferent structure receives info from the caudate and putamen and are both in contact with the subthalamic nucleus?
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Globus pallidus
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What are the 2 output nuclei?
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1. substantia nigra pars reticularis
2. globus pallidus internis (GPi) |
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Where is dopamine made?
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substantia nigra compacta
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What are the 5 different BG nuclei?
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1. substantia nigra compacta
2. substantia nigra reticularis 3. GPi 4. GPe 5. pedunculopontine |
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What is the pathway from alpha/gamma motor neurons to the BG to cortex?
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Only through descending systems (via thalamus)
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How does the direct pathway facilitate movement?
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by disinhibition from putamen to tonically active output nuclei which will affect the thalamus and pedunculopontine nucleus
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What do the output nuclei do?
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Are tonically active and inhibit movement
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What will dopamine do in the direct pathway or circuit?
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Enhance activity to facilitate movement or increase thalamocortical drive
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What 2 structures are in the indirect pathway?
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1. GPe
2. subthalamic nucleus |
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What does the putamen inhibit in the indirect pathway?
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GPe, which inhibits the subthalamic nucleus
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What does the putamen inhibit in the direct pathway?
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output nuclei (GPi and substantia nigra reticularis)
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What type of structure is the subthalamic nucleus? Inhibitory or excitatory and what does it do?
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Excitatory structure that will facilitate the inhibition coming from the output nuclei to stop movement
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What will the indirect pathway do?
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Stop or break movement
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What needs to be present for both direct and indirect pathways to facilitate movement?
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Dopamine
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Is dopamine inhibitory or excitatory in the indirect pathway?
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Inhibitory--inhibits the inhibition (disinhibition), so less facilitation of the subthalamic nucleus onto the output nuclei
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What are the effects of output nuclei on the pedunculopontine nucleus?
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disinhibition of the pedunculopontine nucleus which lessens its inhibition to the RST and VST allowing more postural tone to occur
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What is the main problem with the BG in PD pts?
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Substantia nigra pars compacta stops producing dopaminergic cells
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What does an underactive direct pathway result in with PD pts?
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Bradykinesia
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What does an underactive indirect pathway result in with PD pts?
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Extraneous movement
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What does an overactive direct pathway result in with PD pts?
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Extraneous movement
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What does an overactive indirect pathway result in with PD pts?
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Akinesia
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The loss of dopamine will lead to ____ in the direct and _____ in the indirect which results in loss of movement
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LOSS of excitation in the direct
EXCESS of excitation in the indirect |
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What are the 7 functions of the BG?
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1. postural set or readiness
2. sensory integrative function 3. regulates and sets muscle tone 4. generates appropriate amount of force contraction 5. striatum initiates automatic and well-learned movements 6. sequences motion to turn on/off 7. perceptual and cognitive failures |
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How would postural set or readiness to move be a problem with PD pts?
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Exciting the trunk muscles to move the pelvis into neutral or anterior tilt before reaching for an object
PD pts have high tone and are rigid with postural muscles |
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How is sensory integrative function problematic for PD pts?
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Can't use sensory info to set the environmental context (what motor plan will be used)
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How can the muscle tone be affected with PD pts?
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Can't regulate or set postural muscle tone via RST and VST (typically high tone)
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How can the amount of muscle force contraction be affected with PD pts?
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Can't generate the appropriate amount force contraction b/c of disruption of motor planning
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What does the striatum initiate in BG? (4)
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1. automatic
2. repetitive 3. rhythmical 4. overlearned skills |
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How does sequencing affect PD pts?
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BG no longer turns motions on or off in order to move in any direction with sequencing (flexion and extension in walking)
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What are 3 cognitive and perceptual failures from damaged BG of PD pts?
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1. visualoperceptual deficits
2. interpersonal and intrapersonal space 3. cognitive set |
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What is an example of a visualoperceptual deficit of a PD pt?
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Difficulty using vision to guide movements (objects seem to "block" movement--freeze)
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What is an example of a cognitive failure for a PD pt?
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inability to shift and divided their attention
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What is bradykinesia compared to hypokinesia?
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Bradykinesia = slow movement
Hypokinesia = low amplitude movment |
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What are the 3 cardinal signs of PD (clinical triad)?
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1. resting tremor
2. bradykinesia 3. rigidity |
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What age does PD increase?
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Increases over the age of 80
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What is the average age of PD onset?
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60
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How much dopamine is lost before symptoms of PD usually appears?
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60-80%
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What are 3 types of PD?
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1. idiopathic
2. young adult onset 3. junvenile onset |
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What are 2 kinds of idiopathic parkinson's?
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1. postural instability gait disorder (PIGD)
2. tremor predominant |
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What is the most common type of Parkinson's?
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Idiopathic
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What type of Parkinson's is problematic with motor sequencing activity of turning on and of motions?
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Tremor predominant
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What is the age range for young adult onset of PD?
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Under 40 yo
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Describe young adult onset of PD
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Predominant tremor
Autosomal dominant with family history (problem with alpha synuclein gene on chromosome 4) Progression is typically slower Freezing, balance and dementia is fairly uncommon; mainly tremors |
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What type of PD is freezing, balance and dementia fairly uncommon; mainly tremors?
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Young adult onset
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What age does juvenile PD typically occur?
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<21yo
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What type of PD is the primary complaint dystonia?
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Juvenile PD
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What is dystonia?
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Sustained muscle contraction that is often painful
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What are the symptoms of juvenile PD?
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1. dystonia
2. achiness in shoulders 3. cramping in LEs 4. tingling in extremities 5. coldness |
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Is juvenile PD genetic?
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No family hx involvement
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What gene is associated with juvenile PD?
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related to abnormal parkin2 gene on chromosome 6
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What are 2 types of Parkinsonin or Parkinson Plus Syndromes?
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1. Progressive supranuclear palsy (PSP)
2. Corticobasilar degeneration |
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What deficits do you see with Progressive supranuclear palsy (PSP) pts?
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1. rapid progression and will fall over like a tree--no automatic postural response
2. vertical gaze problem--difficulty looking up or down 3. cognitive deficits early in the disease |
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How is PSP diagnosed to separate it from Parkinson's?
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Dx by giving dopamine to see if there is an effect and if no effect, then PSP
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What is corticobasilar degeneration?
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Type of Parkinsonin that is fast degeneration in CNS
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What are 2 ways to classify stages of Parkinson's?
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1. modified hoehn and yahr staging
2. unified parkinson's disease rating scale |
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Describe stage 1 of the modified Hoehn and Yahr (4)
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1. unilateral involvement
2. mild symptoms--not disabling 3. presents with tremor of one limb 4. friends notice changes in posture, locomotion and facial expression |
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Describe stage 1.5 of the modified Hoehn and Yahr (3)
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1. unilateral involvement
2. trunk involvement, esp rotation 3. might see tremor in walking |
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Describe stage 2 of the modified Hoehn and Yahr (4)
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1. bilateral involvement
2. trunk involvement 3. minimal disability 4. NO balance impairment |
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What stage of the modified Hoehn and Yahr would you start to see balance deficits?
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stage 2.5
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Describe stage 2.5 of the modified Hoehn and Yahr (4)
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1. bilateral involvement
2. trunk involvement 3. recovery on the pull test (ankle, hip and step strategies), which is used to gauge their postural instability **See balance deficits! |
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What strategy will you see with a small perturbation on the pull test?
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ankle strategy
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What strategy will you see with a large perturbation on the pull test?
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stepping strategy
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What stage of the modified Hoehn and Yahr will you see parkinsonin gait (small shuffling steps)?
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stage 3
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Describe stage 3 of the modified Hoehn and Yahr (4)
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1. significant slowing of body mvmts (brady/hypokinesia)
2. early impairment of equilibrium on walking or standing 3. generalized dysfunction that is moderately severe 4. person is still independent **will see parkinsonin gait! |
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What stage of the modified Hoehn and Yahr will you see the PD pt with an AD or HH assistance?
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stage 4
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Describe stage 4 of the modified Hoehn and Yahr (5)
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1. severe symptoms
2. can still walk to a limited extent 3. rigidity and bradykinesia 4. no longer able to live alone (not totally independent) 5. tremor may be less than earlier stages **difficulty with walking (AD or HHA) |
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Describe stage 5 of the modified Hoehn and Yahr (4)
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1. cachectic stage (wasting b/c not eating)
2. pulmonary complications b/c in bed or chair 3. cannot stand or walk 4. requires constant nursing care |
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What stage of Hoehn and Yahr entails the cachectic stage?
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stage 5
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What stage of Hoehn and Yahr entails pulmonary complications and why?
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stage 5 due to immobility to bed or chair
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What are the 3 parts to the UPDRS?
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1. mentation, behavior and mood
2. ADLs 3. motor |
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What 2 parts of the UPDRS is done by interview?
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1. mentation, behavior and mood
2. ADLs |
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Who does the motor component to the UPDRS?
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Either the physician or PT
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What are 4 parts of the mentation, behavior and mood?
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1. intellectual impairment in advanced dz
2. thought disorders--vivid dreams/hallucinations 3. depression--early, could be from limbic 4. motivation/initiative--loss of tc drive |
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What are some ADLs that are assessed in the UPDRS?
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Speech
Salivation Swallowing Handwriting Cutting food/utensils Dressing Hygeine Bed mobilities Falling Freezing when walking Walking Tremors Sensory complaints |
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What are 10 things that are looked at with the motor portion of the UPDRS?
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1. speech
2. facial expressions 3. tremor at rest (very rhythmical) 4. rigidity 5. amplitude and speed of mvmts 6. rising from chair 7. posture 8. gait 9. postural stability 10. brady/hypokinesia |
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What is an examiner looking for when evaluating speech in the UPDRS?
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Looking for monotone, no expression to words eventually dysarthria
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What is an examiner looking for when evaluating facial expressions in the UPDRS?
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Hypomymia--less expression in face (poker face) that is mask-like
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What is hypomimia?
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Poker face with less expression in the face that is mask-like
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What types of tremors are evaluated with the UPDRS?
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1. pill-rolling--supination to pronation with thumb across fingers
2. postural tremors |
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What is dyskinesia?
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Abnormal posturing; writhing movement (not the same as tremors at rest)
*Medication effects |
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What are 2 types of rigidity that examiners look at in the UPDRS?
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1. lead pipe--can't move the limb in either direction
2. cogwheel--see catches in circular motion when wrist ext or ankle is DF |
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What is lead pipe rigidity? What jts are checked?
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When you can't move the limb in either direction (in passive flexion and extension)
Shoulders, elbows, hips and knees |
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How does rigidity occur?
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B/c of lost ability to sequence movement
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What is cogwheel rigidity and where is it tested?
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Breaks in circular mvmt when doing PROM usually interrupted by resistance/tremor
Tested in wrists in ext and ankles in DF and little PF |
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What are 4 tests that measure amplitude and speed of mvmts?
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1. finger taps
2. hand mvmts 3. rapid alternating mvmts 4. heel tapping |
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Describe finger taps to measure amplitude and speed of motion
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Index finger and thumb open/close (opposition) quickly, will tend to get smaller in mvmts (amp less and velocity slower)
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Describe hand mvmts to measure amplitude and speed of motion
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Bilateral hand opening with rapid mvmts, will tend to get smaller in mvmts (amp less and velocity slower)
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How is rising from a chair evaluated in the UPDRS?
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pt stands with arms folded across chest
--evaluate the # of times done and whether it was fast |
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What exam will measure ADLs with those with PD?
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Schwab and England ADLs exam
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What are 10 signs/symptoms of PD?
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1. bradykinesia/akinesia
2. no advanced planning (inflexibility of motor planning) 3. freezing 4. rigidity 5. tremor 6. postural instability 7. loss of attention/cognitive deficits 8. gait 9. micrographia 10. microphonia |
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Does rigidity cause bradykinesia or akinesia?
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No, caused by decreased dopamine in the system
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Describe freezing in PD pts
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pt freezes in motion and will attempt to move but can't; however, their COG keeps going which leads to falls (don't know why this occurs in circuitry)
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How is postural stability a problem with PD pts?
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Difficulty using sensory information (BG integration of environment) to change their mvmt
Not a vestibular problem! |
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Rigidity and weakness can influence what?
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balance
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What is weakness due to?
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disuse!
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What is rigidity?
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Inability to move in other direction and won't be able to use their postural responses
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Where in the body is their usually a loss of ROM for postural stability?
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trunk and extremities
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What are the automatic responses like in PD pts?
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Delayed and hypokinetic
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What latency is typically affected with PD pts and how?
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Medium latency is enhanced with amplitude that is large, which is a destabilizing influence with PD
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What type of learning is a problem with PD pts later in their stages?
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Procedural learning is difficult--won't learn from practice, but declarative learning is preserved
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What would you observe in gait with a PD pt? (3)
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Slow, short steps (shuffle)
Walk on toes or foot flat Hesitation in stepping |
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What is festination?
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Pt is chasing their COG when walking (shuffling of feet)
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What are 2 types of festination?
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1. anteropulsion
2. retropulsion |
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What is anteropulsion?
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Type of festination when pt has difficulty stopping due to forward COG and will look like they are going to fall (forward posture flexion)
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What is retropulsion?
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Type of festination when pt steps backwards if their COG is behind them
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What is micrographia?
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small handwriting
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What is microphonia?
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Low voice
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Overall, what are 3 problems PD pts often have trouble with?
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Automatic, well-learned, rhythmical mvmts (ex. swallowing, chewing and walking)
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Is dyskinesia a result of PD?
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No, it's a SE of meds!!
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What are 3 dopamine replacement drugs for PD?
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1. Levodopa (L-dopa)
2. Sinemet (Carbidopa + L-dopa) 3. Stavelo (Sinemet + Entacapone) |
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What are 4 SE of dopamine replacement drugs (Sinemet, L-dopa and Stavelo)?
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1. drowsiness
2. nausea 3. dry mouth 4. dizziness |
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What is Levodopa?
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Dopamine replacement drug that is a precursor to dopamine
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What is Sinemet?
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Carbidopa + L-dopa (dopamine replacement drug)
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How does Sinemet work?
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Carbidopa is a decarboxylase inhibitor that won't break down rapidly in the gut so more L-dopa can cross the BBB
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With dopamine replacement drugs, what can PD experience that is unpredictable and could be disabling?
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On/off phenomena
If drug is supposed to last 4-6hrs, may last only 2hrs |
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After taking dopamine replacements, what can PD pt experience as a SE 3-5yrs later?
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Dyskinesia or excess mvmts in UE/LEs (writhing mvmts)
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What does Stavelo do and how does it work?
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Sinemet + Encapapone extends time of L-dopa b/c it blocks the enzyme that tends to break it down
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What medications can help with the on/off phenomena? (2)
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Apomorphine (Apokyn) (dopamine agonist)
Stavelo (dopamine replacement) |
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What are 5 dopamine agonists for PD pts?
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1. bromocriptine (Parlodel)
2. pergolide (Permax) 3. ropinirole (Requip) 4. pramipexole (Mirapex) 5. apomorphine (Apokyn) |
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What are 7 SE to using dopamine agonists?
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1. drowsiness
2. nausea 3. dry mouth 4. dizziness 5. hypotension 6. confusion 7. hallucinations |
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What do neuroprotective (monoamine oxidase inhibitors) do?
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Blocks enzymes that break down dopamine so dopamine stays longer
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What are 4 example neuroprotective (monoamine oxidase inhibitors) drugs?
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1. selegiline (Deprenyl, Eldepryl, Atapryl)
2. rasagaline 3. coenzyme 10 4. NSAIDs |
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What drug may be prescribed as a first choice rather than a dopamine replacement drug?
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Selegiline (Deprenyl, Eldepryl, Atapryl) (MAO inhibitor/neuroprotective)
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What drug is sometimes given with dopamine agonists and replacements?
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Rasagaline (MAO--neuroproctective drug)
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What neuroprotective drug is a supplement OTC that some believe wards of Alzheimers?
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Coenzyme Q-10
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What question arises when NSAIDs are used as a neuroprotective agent?
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Is PD an inflammatory process since it shows to be helpful?
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What type of drugs are used for tremors in PD?
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Anticholinergics to decrease ACh
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What are 3 anticholinergic drugs used for PD?
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1. Trihexaphenadryl (Artane)
2. Procyclidine (Kemadrin) 3. Benzotropine Mesylate (Cogentin) |
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What are 4 SE to using anticholinergics?
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1. dry mouth
2. sedation 3. blurred vision 4. sometimes confusion and nervousness |
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What are COMT inhibitors?
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Keep the enzyme from breaking down dopamine
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What are 2 COMT inhibitors?
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1. tolcapone (Tasmar)--given as last resort due to liver toxicity
2. entacapone (Comtan) |
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What drug is given as a last resort due to toxic liver effects?
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COMT inhibitor
tolcapone (Tasmar) |
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What drug is used for dementia?
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Rivastigmine (Epsilon) (cholinesterase inhibitor or indirect cholinergic)
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What drug is prescribed for fatigue and dystonia, can also be used for MS symptoms?
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amantadine (Symmetrel) anti-viral dopamine agonist
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What are 14 secondary impairments to which PTs have the most impact of PD pts?
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1. dyskinesias--due to med effects of Sinemet after period of time
2. on/off phenomenon 3. kyphosis 4. osteoporosis 5. cardiopulmonary 6. muscle atrophy/weakness 7. loss of flexibility/contractures 8. venous pooling 9. ANS changes 10. decubiti 11. decrease speech production 12. drooling 13. pain 14. fatigue |
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Where do dyskinesias often appear after being on meds?
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posturing of head, arm/hands, legs and/or feet with rotation and writhing
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What drug may help on/off phenomena, but may increase dyskinesias?
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Stalevo
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What rescue drug is given during the off state when experiencing on/off so the pt can move?
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Apomorphine (Apokyn)
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What does a PD pt look like posture wise when in off state of meds?
What may result over time? |
Flexed ankles, knees, spine and forward head
Extensors can become overstretched and weak *when taking dopamine, will stand upright |
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Why is osteoporosis a secondary problem to PD?
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Lack of muscle movement and increase risk of OP
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What secondary impairment is most affected by PD?
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Cardiopulm
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What are 3 cardiac problems that can occur with PD pts?
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1. OH with position changes and exercise
2. SE of drugs can cause arrhythmias 3. HR is blunted b/c of dysautonomia when exercising and must use other methods to measure (use RPE) |
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What 4 pulmonary problems can occur with PD pts?
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1. long-term immobility can lead to clots
2. flexed posture can cause decreased rib excursion and vital capacity 3. pulmonary failure (brady/akinesia in respiratory mm) 4. lack of mvmt decreases work ability |
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Is weakness or muscle atrophy a primary cause in PD?
What muscles are often effected? |
No, it's secondary...mainly from disuse
PF, quads and glutes |
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What muscles often lose flexibility and can develop contractures due to immobility?
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PF, flexors, hamstrings, trunk (lateral flexion and rotation), neck in all direction (not as much in flexion) and pecs
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How does venous pooling affect those with PD?
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Pools from the lack of mvmt, especially when "off" with symptoms of vasodilation and loss of muscle pump in LEs
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What 3 ANS changes with PD?
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1. thermoregulation changes to which pt will feel really cold or warm
2. decreased pupil response to light (bright/glare sensitive) 3. decreased gut motility and appetite (leads to wt loss, malnutrition and dysphagia) *Can also have dysautonomic HR due to meds |
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How is speech affect with PD?
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Decreased speech production with inability to project voice and use breath over their vocal cords (won't speak much)
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How can drooling be a problem for PD?
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Secondary implication that can result from weakness of the muscles around the tongue and mouth (dysarthria), in addition to forward flexed posture
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What are 2 kinds of pain PD pts experience?
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1. postural stress--from forward posture being stretched
2. dystonia--cramping in gastrocs or feet muscles (painful to stand) |
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What can help with dystonia pain in PD pts?
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Teaching stretching exercises, supplying FOs can also help due to cramping in gastrocs and feet
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What are 4 surgical treatments for PD?
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1. palliodotomy
2. deep brain stimulation 3. fetal tissue transplant 4. gene therapy |
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Describe a pallidotomy procedure. What structure does it affect? Why does it work?
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Pt is awake during sx, when burrhole is drilled into skull
Use heat probes to destroy GPi (output nuclei), listening for static sounds for correct location GPi is burned in order to decrease the amount of inhibition to the thalamus and pedunculopontine nucleus (increase thalamocortical drive) |
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Is a palliodotomy done unilateral or bilateral?
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Unilateral, used to be bilateral but caused cognitive deficits
Unilateral still affects both sides for some odd reason |
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What surgery looks as though the patient is on dopamine meds with no dyskinesia side effects?
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Palliodotomy
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What does a palliodotomy help? (3)
What doesn't it help? |
1. bradykinesias/hypo
2. akinesisas 3. rigidity with walking and balance (balance eventually deteriorates) Won't help with freezing |
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What is the average time span a palliodotomy will be effective?
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2-5 yrs
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What were deep brain stimulations originally used for?
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Tremors
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What structure is affected with deep brain stimulation?
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Lesion on the thalamus
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How does deep brain stimulation work?
Where are the electrodes placed? |
Lesion is made on the thalamus, transmitter placed on chest and physician sets parameters for stimulation so pt can turn it off and on
Electrodes are in the output nuclei to try to break the brady/akinesias and rigidity |
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What won't be helped with a deep brain stimulation ?
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Freezing
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How is fetal tissue transplant for PD used?
Is it successful? |
stem cells are placed in substantia nigra to help produce own dopamine
Not successful treatment |
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How does gene therapy work for PD?
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Deliver genes by viral vector (glutamic acid decarboxylase--precursor to GABA) to the subthalamic nucleus
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What are 11 treatment options for PD pts?
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1. decrease rigidity or tone
2. improve postural control 3. increase mvmt initiation 4. facilitate normal gait 5. correct postural deficits 6. respiratory exercises 7. swallowing, chewing and facial exercises 8. pt/family education 9. group activities 10. order equipment 11. functional activities |
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What are some ways to decrease rigidity or tone? (3)
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P/AROM
slow rocking motions using rotation/counter rotation mvmts meditation, yoga, tai chi, deep breathing to decrease stress |
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How would you treat postural control with PD pts?
When would you use this tx to challenge pts vs teaching compensations? |
Use balance exercises
Early stages--challenge pts (stage 1 and 2) Later stages--use external cues and compensations |
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What are some different balance exercises that can be used to improve postural control in PD pts during stages 1 and 2?
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Different surfaces, speeds, walking over obstacles, perturbations, LOS, DGI (destabilizing exercises)
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What are some different balance exercises that can be used to improve postural control in PD pts during later stages of the dz?
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No multi-tasks--single task, break down activities into single parts using 1 motion at a time before using the next) and external cueing
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How can you improve mvmt initiation with PD pts in moderate stages or later?
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use external cues (auditory, visual, self-talk and think BIG ideas)
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How can auditory cues be used to increase mvmt initiation for PD pts?
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metronome used to push pts outside of their comfort speed
music and dancing with large movements |
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What are some visual cues be used to increase mvmt initiation for PD pts?
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Lines, ladderes or yard sticks on floor to guide
Upturned canes or PT foot in front Laser pointers on walkers to help with spatial parameter of gait |
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How can visual cues help with mvmt initiation? (2)
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1. decrease freezing
2. increase stride length |
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What is think "BIG"? What does it affect with mvmts?
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12 motions that are large, full ROM emphasizing amplitude which also increases gait speed
Slapping thighs before starting/stopping mvmt is used an external cue |
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Why can PD pts respond to external cues rather using their own?
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Can receive cue from pre-motor cortex rather than rely on supplemental motor
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How can you facilitate normal gait with PD?
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Use external cues to get:
stride lengths normal speed (no shuffle) automatic arm swing (can use poles with PT behind pt to initiate) |
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How can you correct postural deficits with PD pts?
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Stretch tight muscles such as pecs, PFs, anterior trunk and neck
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What respiratory exercises can be applied to PD pts?
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1. D2 patterns (PNF) for breathing (esp. bilateral)
2. All respiratory exercises learned from SCI (air-shift, intercostal resistance, coughing, etc) 3. diaphragmatic exercises 4. chest expansion |
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How can PTs help with swallowing, chewing and facial exercises for PD pts?
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Work on posture training to allow easier swallowing
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What pt/family education is needed for PD?
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Explain the dz process and when to seek medical attention
also, explain what not to do during different stages such as multi-task around stage 3 or later (mod-severe stages) |
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When should you think about ordering equipment for PD pts? What would they need?
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In later stages
Need tub benches, BSC, beds, RW |
