Exam 2 practice questions pt.1

What does “TRAP” stand for in reference to Parkinson's symptoms?

Tremor, Rigidity, Akinesia or Bradykinesia, and Postural Instability.

What type of tremor is more likely to be seen in a Parkinson’s patient?

Resting tremor

Parkinson’s patients are likely to have what kind of posture?

Stooped posture or a “small” posture

Is the typical onset of idiopathic Parkinson’s disease symmetrical or asymmetrical?

Asymmetrical

How does the levodopa response differ between Idiopathic Parkinson’s Disease and Atypical Parkinsonism?

Idiopathic Parkinson’s typically has a good levodopa response, whereas atypical parkinsonism is likely to have a limited response to levodopa.

What are some key clinical features of atypical parkinsonism (aka Parkinson’s plus syndrome)?

May involve early falls, autonomic dysfunction, gaze abnormalities, apraxia, cognitive changes, or limited levodopa response

What are the 3 motor phenotypes of idiopathic Parkinson’s disease?

• Tremor-dominant

• Postural instability/gait difficulty

• Mixed/intermediate

What are the 6 “red flags” that separate atypical parkinsonism from regular, idiopathic PD?

1. Early and frequent falls (often in the first year)

2. Early cognitive impairment

3. Rapid progression

4. Poor to no response to levodopa

5. Severe autonomic dysfunction

6. Early bulbar signs (dysphagia, dysphonia, dysarthria)

“Mild bilateral disease with recovery on pull test” represents which stage on the Hoehn and Yahr scale?

Stage 2.5.

What characterizes Stage 1 of the Hoehn and Yahr scale?

Unilateral involvement only, typically with minimal to no functional impairment

What is the clinical presentation of an individual labeled at Stage 3 on the Hoehn and Yahr scale?

Impairment of postural reflexes, mild to moderate disability, but the individual is still physically independent.

What characterizes Stage 1.5 of the Hoehn and Yahr scale?

Unilateral involvement with some axial involvement

A patient presents with rigidity and bradykinesia that affects the right arm and left leg, but their balance and postural reflexes are completely intact. Which Hoehn and Yahr stage is this?

Stage 2 (bilateral involvement without impairment of balance)

A Parkinson’s patient has bilateral bradykinesia and unsteadiness when turning quickly, leading to occasional stumbles. However, they continue to cook, clean, and manage their own household safely without assistance. Which H&Y stage are they in?

Stage 3 (impaired postural reflexes with preserved physical independence)

How does Stage 4 of H&Y differ from Stage 3?

In Stage 4, the individual is no longer physically independent. Symptoms are severely disabling. They may still walk or stand, but they are markedly limited and cannot live alone.

How is H&Y Stage 5 characterized?

Wheelchair-bound or bedbound

During a neuro examination, a clinician performs the pull test on a patient with mild bilateral Parkinsonian signs. The patient takes several retropulsion steps backward but is ultimately able to stabilize themselves without falling. Where is this patient on the H&Y scale?

Stage 2.5.

Which category of atypical parkinsonism is the only one with asymmetrical presentation?

CBD (corticobasal degeneration)

What are 2 common side effects of carbidopa-levodopa that can impact PT performance?

• Orthostatic hypotension

• Dyskinesia (loss of control of movement)

20. Where is the most sensitive place to test for rigidity?

The wrist.

How should one test to see if a patient is “stimmable” to cues?

First perform the test without cues to identify the deficit. Then perform it again with cues and determine whether the patient's performance improves

What is “start hesitation” in PD?

Difficulty initiating movement

In Parkinson’s, high-intensity locomotor training increases __________ excitability and enhances __________ signaling in the basal ganglia

corticomotor ; dopaminergic

What are some potential triggers for freezing of gait?

• Changing direction

• Approaching furniture

• Narrow spaces

• Changes in floor patterns

• Stress or anxiety

• Crowds

• Turning

Festination of gait is often caused by what postural abnormality?

It is often a mechanical response to the forward center of mass (COM) associated with a stooped posture. Treatment should focus on maintaining a tall, upright posture.

What kind of walkers might be appropriate for individuals who experience festinating gait?

Weighted or “reverse-braking” walkers, such as the U-Step walker, which resist forward acceleration

The breakdown of which 2 brain structures results in failed internal timing for movements in individuals with PD?

• Basal ganglia

• Supplementary motor area (SMA)

Why are external cues beneficial for individuals with PD?

External cues bypass the damaged basal ganglia/SMA pathways and shift motor control to the premotor cortex. This allows for more conscious motor control rather than relying on automatic motor control

Why is cueing less effective in individuals with dementia or during dual-tasking?

Because cueing requires conscious attention

A patient’s initial response to cueing can help us predict…

Long-term success.

Parkinson’s patients typically benefit from which type of practice for motor learning?

Blocked practice

How does dual-task training impact freezing of gait?

Dual-task training (DTT) improves reaction time and stepping rhythmicity while reducing the frequency of freezing of gait (FOG) episodes.

What intensity of aerobic exercise is recommended for Parkinson’s?

Moderate (60–75% HRmax) to high intensity (75–85% HRmax), with a minimum frequency of 3 times per week

What are other names for a PICA stroke?

Wallenberg syndrome or lateral medullary syndrome.

What is a key indicator of medial medullary syndrome?

Ipsilateral paralysis of half the tongue, with deviation toward the unaffected side when protruded

Which medullary stroke involves ataxia?

Lateral medullary syndrome (also known as PICA stroke or Wallenberg syndrome)

Which medullary stroke presents with crossed sensory impairments?

Lateral medullary syndrome, which causes:

• Ipsilateral loss of pain and temperature sensation in the face

• Contralateral loss of pain and temperature sensation in the body

What are the symptoms of locked-in syndrome?

Tetraplegia with only upward gaze spared, coma, and intact cognition.

Why might a patient with a left-sided brainstem stroke demonstrate right-sided body weakness and ipsilateral cranial nerve deficits?

Due to the organization of the cranial nerve nuclei and descending motor pathways. Cranial nerve deficits are ipsilateral, while involvement of the corticospinal tract produces contralateral body weakness

Which cranial nerve nuclei are found in the medulla?

CN IX, CN X, CN XI, and CN XII

Which cranial nerve nuclei are found in the pons?

CN V, CN VI, CN VII, and CN VIII

Locked-in syndrome is also known as…

Complete basilar artery syndrome

An AICA stroke is also known as __________ syndrome

Lateral inferior pontine syndrome

Prior to beginning high-intensity gait training, what blood pressure levels would concern you?

Greater than 180/110 mmHg or less than 90/60 mmHg. If the blood pressure is high, begin HIGT and reassess after 5 minutes

During HIGT, what blood pressure reading would indicate a need to take a rest and reassess after 5 minutes?

Greater than 250/115 mmHg

What is a defining feature of right MCA strokes vs. left MCA strokes?

Right MCA strokes cause spatial deficits, while left MCA strokes cause neglect and aphasias.

Which extremity is more affected by ACA strokes?

The lower extremity

Which extremity is more affected by MCA strokes?

The upper extremity

Which stroke type can result in deafness and tinnitus?

Lateral pontine syndrome (AICA stroke)

Which stroke type can result in ipsilateral dysphasia/dysphonia, as well as crossed sensory deficits and Horner’s syndrome?

Lateral medullary syndrome (PICA or Wallenberg syndrome)

What is Weber syndrome?

A stroke in the ventromedial midbrain that presents as a “crossed” syndrome with ipsilateral oculomotor palsy and contralateral hemiplegia

What are some symptoms of medial pontine syndrome?

• Loss of ipsilateral conjugate gaze

• Nystagmus

• Vertigo

• Diplopia

• Ataxia

• Contralateral loss of proprioception

• Contralateral paralysis of the upper extremity, lower extremity, and face

What blood glucose level may make exercise contraindicated?

Greater than 250 mg/dL

A patient presents with acute onset of vertigo, nausea, hoarseness, dysphagia, ipsilateral Horner syndrome, loss of pain and temperature on the ipsilateral face, and contralateral loss of pain and temperature on the body. Which blood vessel is involved?

Posterior inferior cerebellar artery (PICA), resulting in lateral medullary syndrome (Wallenberg syndrome)

A patient exhibits a right-sided oculomotor (CN III) palsy and a left-sided hemiplegia. This is also known as Weber syndrome, which is caused by a lesion localized to the:

Ventral midbrain (cerebral peduncle)

Medial medullary syndrome is characterized by contralateral hemiparesis, contralateral loss of vibration and position sense, and ipsilateral hypoglossal (CN XII) palsy. This syndrome results from the occlusion of the:

Paramedian branches of the anterior spinal artery or vertebral artery

A patient presents with acute vertigo, ipsilateral facial paralysis, ipsilateral sensorineural hearing loss/tinnitus, and contralateral loss of pain and temperature sensation on the body. Which artery is involved?

Anterior inferior cerebellar artery (AICA), resulting in lateral pontine syndrome

Bilateral infarction of the ventral pons, often due to basilar artery thrombosis, results in “locked-in” syndrome. Despite total quadriplegia, which motor function is typically preserved?

Vertical eye movements and blinking

A patient with a brainstem infarct exhibits impaired adduction of the right eye during left lateral gaze, accompanied by horizontal nystagmus in the abducting left eye. Where is the lesion?

Right medial longitudinal fasciculus (MLF)

According to the rule of fours, which cranial nerve nuclei are located along the midline of the brainstem?

CN III, CN IV, CN VI, and CN XII

A patient presents with right-sided face and arm weakness and Broca’s aphasia, with relatively spared leg function and normal speech comprehension. An occlusion of which artery is involved?

Left MCA (superior division)

What group of 3 clinical symptoms are typical of an ACA stroke?

• Contralateral lower-extremity-dominant motor and sensory loss

• Abulia

• Urinary incontinence

A patient presents with a right contralateral homonymous hemianopsia accompanied by macular sparing and visual agnosia. This presentation is classic for ischemia in the territory of the:

Posterior cerebral artery (PCA)

What types of clinical signs more strongly point to a CORTICAL stroke rather than a brainstem stroke?

Cortical signs involving higher-level functions or processing, such as:

• Aphasia

• Apraxia

• Agnosia

• Spatial neglect

A patient is experiencing sudden onset of severe vertigo, diplopia, dysphagia, hoarseness, and ipsilateral facial sensory loss with contralateral body pain and temperature loss. Which vascular territory is most likely involved?

Posterior inferior cerebellar artery (PICA), resulting in lateral medullary syndrome.

What are the 7 outcome measures that are considered the “core set” of measures for individuals with neurologic conditions?

1. Berg Balance Scale (BBS)

2. Functional Gait Assessment (FGA)

3. 10-Meter Walk Test (10mWT)

4. 6-Minute Walk Test (6MWT)

5. 5 Times Sit-to-Stand Test (5xSTS)

6. Activities-specific Balance Confidence Scale (ABC)

7. Goal Attainment Scale (GAS)