High Yield PD + HD

Hoehn & Yahr Stage 0?

No symptoms

Hoehn & Yahr Stage 1?

Unilateral symptoms

Hoehn & Yahr Stage 1.5?

Unilateral symptoms + axial involvement

Hoehn & Yahr Stage 2?

Bilateral symptoms

Hoehn & Yahr Stage 2.5?

Mild bilateral disease + recovery on pull test

Hoehn & Yahr Stage 3?

Balance impairment + mild-moderate disease, but patient can still live independently

Hoehn & Yahr Stage 4?

Severe disability; walking or standing possible only with assistance

Hoehn & Yahr Stage 5?

Wheelchair-bound or bedridden

What is the main PT focus during early PD (Stages 1-2)?

Correct/improve impairments
Prevent MSK/cardiovascular impairments
Improve spinal ROM
Return to prior functional level

Why is spinal ROM emphasized in early PD?

To improve functional mobility

What is the primary PT focus during Stage 3 PD?

Fall prevention
Maximizing functional mobility
Combine corrective + compensatory strategies

What is the primary PT focus during Stages 4-5 PD?

Prevent further pathology
Maximize comfort + QoL
Support caregivers

What complications are PTs trying to prevent in late-stage PD?

Fractures
Pneumonia
Skin breakdown
Contractures

What areas may PT address in late-stage PD?

ROM
Pain management
Pulmonary care
Toileting
Seating
Equipment
Caregiver training

What is Idiopathic Parkinsonism?

Primary neurodegeneration of the dopaminergic system

What are the classic manifestations of Idiopathic Parkinsonism?

Bradykinesia
Rigidity
Tremor
Postural Instability

What is Secondary Parkinsonism?

Parkinsonism caused by a known condition such as stroke, tumor, infection or toxin

What are the manifestations of Secondary Parkinsonism?

Bradykinesia
Rigidity
Tremor
Postural Instability

What is Parkinsonism-Plus Syndrome?

Conditions that mimic PD but result from other neurodegenerative diseases

What distinguishes Parkinsonism-Plus Syndromes from typical PD?

Parkinsonian signs PLUS additional neurological features

What are the key features of Multiple System Atrophy (MSA)?

Autonomic dysfunction + parkinsonian or cerebellar symptoms

What autonomic symptoms are associated with MSA?

Orthostatic hypotension
Urinary incontinence
Erectile dysfunction

What are the hallmark features of Progressive Supranuclear Palsy (PSP)?

Early falls
Balance problems
Vertical gaze problems
Axial rigidity
Bradykinesia/akinesia
Cognitive decline

What is a key eye movement finding in PSP?

Vertical gaze impairment

What are the key features of Corticobasal Degeneration (CBD)?

Asymmetric rigidity/parkinsonism
Apraxia
Myoclonus
Dystonia
Cognitive difficulty
Alien hand phenomenon

What is the “alien hand” phenomenon associated with?

Corticobasal degeneration

What are the key features of Dementia with Lewy Bodies (DLB)?

Early cognitive impairment
Fluctuating attention/alertness
Visual hallucinations
REM sleep behavior disorder
Parkinsonsian symptoms

Which Parkinsonism-Plus Condition is particularly associated with early autonomic dysfunction?

Multiple System Atrophy

Which Parkinsonism-Plus condition is associated with asymmetric symptoms?

Corticobasal Degeneration

Which Parkinsonism-plus condition is particularly associated with early falls + vertical gaze problems?

Progressive Supranuclear Palsy

Which Parkinsonism-plus condition is associated with visual hallucinations + fluctuating cognition?

Dementia with Lewy Bodies

What gait interventions can be used for PD?

Pole/Nordic Walking
Visual/Auditory Cues
Marching/High Stepping
PNF Braiding
BWSTT
Treadmill Training

What is a major reason for using external cues during PD gait training?

To improve movement when automatic movement is impaired

What gait problem can external cueing help address in PD?

Freezing of gait

How does motor learning change from early/middle to later PD?

Early/Middle: performance can improve with practice and additional sensory information
Later: learning becomes less successful due to pronounced cognitive deficits

What is explicit memory?

Ability to verbally recall factors/events

What type of knowledge is associated with explicit memory?

Declarative knowledge = knowing what to do

What is implicit memory?

Ability to behaviorally recall a motor task

What type of knowledge is associated with implicit memory?

Procedural knowledge = knowing how to do something

What does procedural learning require?

Large number of repetitions

What type of practice should initially be used in PD?

Block practice

What is block practice? example?

AA, BB, CC - practice one task repeatedly before switching
transfer, transfer, gait, gait, bed mobility, bed mobility

Why can dual-tasking be problematic in PD?

Competing attentional demands can trigger freezing

How should the PT modify the environment when dual-tasking is problematic?

Reduce clutter and competing attentional demands

When is external cueing particularly effective in PD?

Mild-to-moderate PD

What are examples of auditory cues for PD?

Metronome or music

How should the auditory cue rate compare with the patient’s preferred walking pace?

Approximately 25% faster

What do visual cues improve during PD gait?

Stride length and velocity

What is the role of the premotor cortex?

Generates movement in response to visual and auditory stimuli

What is the role of the supplementary motor cortex?

Self-generated movement and well-learned repetitive movement sequences

What is the overall motor-learning strategy used in PD?

Shift from impaired automatic movement pathways toward conscious movement pathways using external cues

What is motor impersistence?

Inability to maintain a voluntary muscle contraction at a constant level

What is apraxia?

Impaired ability to perform complex coordinated movements without a primary muscular or sensory impairment

What is dysdiadochokinesia?

Diminished ability to perform rapid alternating movements

What cognitive impairments can occur in HD?

Impaired attention
Planning
Sequencing
Problem solving
Decision making
Cognitive flexibility

What is visuospatial impairment in HD?

Reduced awareness of body position and the surrounding environment

Why are cognitive impairments important for PT in HD?

Cognitive and motor impairments can interfere with functional movement and performance

What are the goals of PNF in PD?

Decrease rigidity and improve movement

What PNF technique can be used to decrease rigidity/improve movement in PD?

Rhythmic initiation

What bilateral PNF pattern can be paired with breathing in PD?

Bilateral symmetrical D2 flexion with inhalation and D2 extension with exhalation

What PNF patterns can be used for bed mobility in PD?

D1 flexion patterns of UE + LE

What does context-dependent exercise mean in PD?

Exercise that promotes a movement response that transfers to meaningful functional contexts

Examples of context-dependent exercise?

Outdoor walking
Karate/martial arts
Dancing
Ball sports
Cross country / downhill skiing
Low-impact aerobics
Guided treadmill training

What types of exercise improve fitness but are NOT considered context-dependent?

Unguided treadmill
Stationary bike
Strengthening (machines/free weights)
Rowing
Swimming
Step climbers/exercise

What genetic mutation causes HD?

Autosomal dominant CAG repeat expansion on chromosome 4 in the HTT gene

What is the normal range of CAG repeats in HD?

11-30 repeats

What happens with ≤35 CAG repeats?

HD does not develop

What does 36–40 CAG repeats indicate?

May or may not develop HD

What does ≥41 CAG repeats indicate?

Expected to develop HD

What is the relationship between CAG repeat number and age of onset?

More CAG repeats → earlier age of onset

What is the typical age of onset for adult HD?

30-50 years old

What is juvenile HD?

HD onset before age 20

How does juvenile HD differ from adult-onset HD?

Chorea is less common; rigidity, bradykinesia, abnormal gait, cognitive/behavioral problems, and seizures are more prominent

What does an earlier age of onset generally indicate about CAG repeats?

More CAG repeats

Why are CAG repeats relevant to PT?

They can help understand expected age/onset patterns and disease progression, which can help anticipate functional needs.

Should PT management be based solely on the CAG repeat number?

No. PT management should primarily be based on current impairment, activity limitations, disease stage, cognition, behavior, falls, balance, and functional status

What does the HD Total Functional Capacity (TFC) score measure?

Functional status across occupation, finances, domestic responsibilities, ADLs, and care needs.

What is the TFC score range for Stage 1 HD?

11–13.

What is the TFC score range for Stage 2 HD?

7–10.

What is the TFC score range for Stage 3 HD?

3-6

What is the TFC score range for Stage 4 HD?

1–2.

What is the TFC score for Stage 5 HD?

0

How is occupation scored on the TFC?

Normal = 3; reduced capacity = 2; marginal work only = 1; unable = 0.

How are finances scored?

Normal = 3; slight assistance = 2; major assistance = 1; unable = 0.

How are domestic chores scored?

Normal = 2; impaired = 1; unable = 0.

How are ADLs scored?

Normal = 3; minimal impairment = 2; gross tasks only = 1; total care = 0.

How is care scored?

Home = 2; home with chronic care = 1; full-time skilled nursing = 0.

What are the main PT goals in early-stage HD?

Maintain strength, ROM, mobility, balance, and endurance; address gait/balance deficits; prevent falls.

Why should stair training be addressed early in HD?

Cognitive and motor learning abilities are better earlier in the disease.

What learning strategies can be helpful in early HD?

Mental practice and explicit instructions.

What changes occur in middle-stage HD that affect PT?

Increasing cognitive impairment, apathy, chorea, and dystonia.

What motor-learning approach should be emphasized in middle-stage HD?

Implicit motor learning + repetition.

How should activity be structured during middle-stage HD?

Short, structured activity bouts. (minimize dual tasking)

What functional activities should PT prioritize during middle-stage HD?

Safe transfers, gait, stairs, and fall prevention.

What is the primary PT focus during late-stage HD?

Safety, positioning, transfers, wheelchair mobility, ROM/contracture prevention, caregiver training, and environmental modifications.

What is a walker with a laser/light cue used for in PD?

Helps freezing of gait through a visual external cue for stepping.

What is the purpose of a standard walker/rollator in PD?

Improve gait stability and safety.

What may be needed in later-stage PD as mobility declines?

Additional ADs

What assistive device is particularly useful for HD?

Rollator

What is the purpose of a walker with a seat + cue card in HD?

The cue helps with transfers/sit-to-stand and encourages an appropriate movement strategy.