NM Unit 5-6

what is parkinsons disease

a slowly progressive neurodegenerative disorder of the CNS

how likely is it to get PD as you age

5-10times greater risk in 60-90 year olds

what is the average onset n PD

60 years with young onset between 21-50 years

what gender is affected more by PD

men

what is the cause of PD

90% is idiopathic

10% has a genetic form of the disease

what are the two subgroups of PD

postural instability gait disorder phenotype

tremor dominant phenotype

what is seen in postural instability gait disorder PD

postural instability and gait disturbances are the primary presentation

what is seen in tremor dominant PD

tremors are seen and they have less issues with posture instability, bradykinesia, and non-motor symptoms and depression

what is secondary parkinsonism

PD due to an identifiable cause such as viral toxin or drug induced symtomology

what is Parkinson plus syndromes

a group of neurodegenerative diseases that affect the substantia nigra and produce parkinsonian symptoms

what may be seen in Parkinson plus syndrome that is not seen in idiopathic PD

it has a very rapid disease progression and other neurologic signs

what matter makes up the basal ganglia

gray matter which is the pathways

what occurs in the brain in PD

there is a degeneration of neurons in the substantia nigra

what happens when the neurons in the substantia nigra die

they stop producing dopamine who's role is to help these structures communicate with one another

what is the role of the striatum

it receives input from both the cortex and the substantia nigra and processes it

what happens to the information that was processes in the striatum

it leaves the basal ganglia through the globus pallidus and back out through the substantia nigra to the thalamus and then back to the cortex completing a loop

what is affected due to the dopamine deprivation in the striatum due to neuron death in the substantia nigra

there is overactivity of both loops in the brain leading to parkinsonian symptoms

what kind of loops are seen in the substantia nigra

a direct loop and an indirect loop because dopamine can be faciliatory or inhibitory depending in the receptor

what is the direct loop responsible for

the oscillatory pathway responsible for initiating voluntary movement

what is the role of the indirect loop

it suppresses or inhibits voluntary movement

what is the gold standard drug therapy for PD

carbidopa/levodopa (Sinemet or Rytary)

why is levodopa used instead of dopamine

dopamine can't cross the BBB in the brain so levodopa is used

what are the complications seen with dopamine replacement therapy (3)

motor fluctuations

dyskinesias

dystonia

what is the on-off phenomenon

abrupt random fluctuations in motor performance and responses

what is the end of dose deterioration

worsening of symptoms towards the end of the expected time frame of med effectiveness

what are levodopa induced dyskinesias

dynamic, uncontrolled, and involuntary movements that are typically present within the on-off cycle of the meds

what are dystonias

involuntary contractions that cause twisting or tortioning of the body

what are the side effects of dopamine replacement meds (6)

psychiatric toxicity (hallucinations, delusions, paranoia)

depression

GI changes

cardiovascular changes (HTN)

dysuria

sleep disturbances (insomnia)

what diet changes need to occur in PD with levodopa

a high calorie, low protein diet (<15%) is needed because high protein blocks the effectiveness of levodopa

increased water and fiber intake

what is deep brain stimulation (DBS)

an electrical stimulation delivered deep into the basal ganglia

how is DBS implanted

a battery pack is surgically implanted under the skin in the chest and a wire lead goes up under the scalp with an electrode that is used to stimulate basal ganglia structures

where are the two most common sites of electrode placement in DBS

the subthalamic nucleus or the globus pallidus internus

if a pt is not responding well to carbidopa/levodopa should DBS be used

it will likely not be effective

if a pt has DBS do they still need Sinemet?

Yes but the dose can be reduced

what is DBS effective in reducing (4)

tremors

motor fluctuations

med amount

dyskinesias

how is the stimulation and frequency determined for DBS

the physician controls the amount

what are the cons to DBS

they can worsen balance, gait and speech

they can cause confusion, depression, and headaches

what are the cardinal motor signs of PD

TRAP

Tremor

Rigidity

Akinesia/Bradykinesia

Postural instability

what is tremor

involuntary shaking or oscillating movement of a part or parts of the body

what is rigidity

increased resistance to passive motion regardless of velocity

where is rigidity seen

the agonist and antagonist muscle in movements of both directions

how do pts report rigidity

a feeling of heaviness or stiffness

what is cogwheel rigidity

jerky resistance to passive movement as the muscles alternately tense and relax

what is leadpipe rigidity

sustained resistance to passive movement in all directions with no fluctuations

what is bradykinesia

slow movement

what causes bradykinesia

a result of insufficient recruitment of muscle force during initiation of movement

what is akinesia

lack of spontaneous movement often seen as masked fascial expressions and gait freezing

what is seen in postural instability in PD

pts have a hard time keeping their COM within their BOS and have limited stability

what balance deficits are seen in PD

very slow feedforward anticipatory balance

what postural changed are seen in PD

stooped posture or increased flexion due to weakness of antigravity extensor muscles and flexor muscle tightness

are PD pts commonly fall risk

yes due to forward posture and postural instability

what is often seen when pts are performing tasks with PD along with tremors and motor symptoms

fatigue, weakness, and lethargy especially as the day progresses

when are gait disturbances commonly seen in PD

earlier in the course of the disease

what are continuous gait control problems (6)

slowness

increased variability and asymmetry

poor postural control

decreased arm swing and trunk rotation

stooped posture

en bloc gait

what is en bloc gait

turning style with decreased speed and more steps to complete the turn

what do PD pts steps look like

short stride length and asymmetry with arm swings

what are episodic gait disturbances

festinating gait

freezing of gait

what is festinating gait

unintentional and rapid short steps

what is freezing of gait

trembling of the legs and the inability to effectively step

absence if leg movements seen as the legs appear stuck to the ground

what are the types of festinating gait

anteropulsive (forward direction)

retropulsive (backward direction)

when does freezing of gait commonly occur

when the pt is exposed to an obstacle, hallway, crowd, or floor pattern change

how many nonmotor symptoms do most pts with PD experience

between 8-13 regardless of duration or stage of disease

what are the common nonmotor symptoms seen in PD (11)

sensory symptoms

olfactory dysfunction

visual and visuospatial perception

vestibular dysfunction

auditory dysfunction

dysphagia

speech disorders

cognitive impairment

depression, anxiety, and apathy

autonomic dysfunction

sleep disturbance

when is the most common onset of nonmotor symptoms in PD

often 2-10 years before motor symptoms which are often smell loss, constipation, sleep disturbances, and mood disorders

what is the average duration of PD

10-20 years

what PD type has a slower progression

young onset PD

tremor dominant DP

what PD subtype has a faster progression

postural instability gait disturbance

what can help slow the progression of PD

early intervention and dopaminergic therapy

what is the most common cause of death in PD

CV disease and pneumonia

what is stage 1 of Hoehn and Yahr

minimal or absent symptoms

unilateral symptoms if present

what is seen in stage II of Hoehn and Yahr

minimal bilateral or midline involvement where balance is not impaired

what is seen in stage III of Hoehn and Yahr

the pt has impaired righting reflexes, unsteadiness when turning or rising from a chair

some activities are restricted but they can live independent and continue some work

what is seen in stage IV of Hoehn and Yahr

all symptoms are present and severe

standing and walking are possible with assistance only

what is seen in stage V of Hoehn and Yahr

the pt is confined to a wheelchair or bed

What is the gold standard for measuring progression of PD

the Movement Disorders Society United PD rating scale (MDS-UPRS)

what is the UPDRS

A scale that includes non-motor aspects of experiences of daily living, motor experiences of daily living, motor examination, and motor complications

what can early PT do for PD (3)

reduce the rate of decline

optimize function

prevent secondary impairments

what can early high intensity exercise in PD do

it has a neuroprotective effect slowing the progression of motor decline and delating the need for increased meds

when do pts with PD see a specialist clinician

every 6-12 months

what are the core 6 outcomes for neuro pts

Berg balance scale

FGA

activities specific balance confidence scale

10 m walk test

6 min walk test

5x STS

what are the recommended outcome measures for participation limitations in PD (4)

Movement disorders society united Parkinson disease rating (MDS-UPDRS)

Parkinson disease questionnaire 30 or 8 (PDQ-39/8)

New freezing of gait questionnaire (NFOG-Q)

Activities specific balance confidence scale

what is the PDQ-39/8 used for

assess PD, health, quality of life via a self reported measure

may be used to see how PD impacted the pts life

what does the NFOG-Q assess

assesses the severity and impact of freezing of gait during the past month

higher scores indicate more severe freeezing

what does the activities specific balance confidence scale assess

a self reported measure assessing a pts confidence performing various home and community tasks

a higher score indicates increased balance confidence

what are the recommended activity limitation outcome measures for PD (9)

Parkinson fatigue scale-16

Movement disorders society united Parkinson disease rating scale (MDS-UPDRS)

New freezing of gait questionnaire (NFOG-Q)

DGI

mini-BESTest

TUG

timed up and go cognitive

functional reach test

nine hold peg test

what is the Parkinson's fatigue scale (PFS-16)

a self reported measure of the impact of physical fatigue on daily function

what does the DGI assess

fall risk during gait with various changes in task demands such as gait with head turns, stepping over obstacles, and changing speeds

what does the mini-BESTest asssess

balance in 4 domains

what is the TUG cognitive test

uses the TUG and adds a secondary task such as counting serial sevens backwards or counting by 7s backwards

what does the nine hole peg test assess

measures manual dexterity by removing and placing nine pegs to a peg board one at a time

what are the outcome measures used to assess body function and structure in PD (4)

Montreal cognitive assessment (MoCA)

mini BESTest

Parkinson fatigue scale

MDS-UPDRS

What does the Montreal cognitive assessment measure

screens multiple cognitive domains to detect mild cognitive impairment

what are the classifications of autoimmunity

systemic

organ specific manifestation

what is systemic autoimmunity

the entire body is somewhat affected

what are examples of systemic autoimmunity (3)

systemic lupus erythematosus

rheumatoid arthritis

dermatomyositis

what is organ specific manifestation autoimmunity

the organ that is targeted by the immune system is based on the receptor sensitivity of the organ

what are examples of organ specific autoimmune diseases (4)

Hashimoto's thyroiditis

Graves disease

Type I diabetes

Myasthenia's gravis

what tissue is effected in multiple sclerosis and Guillain Barre syndrome

myelin

what is affected in Guillain barre syndrome

PNS

what is affected in MS

CNS