VCU DPT - Rehab 2 Parkinson's Disease

what is at the root cause of parkinsons disease

dopamine loss

________ is involved with reward feedback loop and motor control

dopamine

less dopamine leads to _____ excitation

less

what must be present in order for the parkinson's clincal diagonsis to be made

bradykinesia

AND

rigidity or resting tremor

is rgidity velocity depenent or not

it is NOT

clincally established PD must have what 3 things (kinda weird)

no absolute exclsuion criteria

at least 2 supportive criteria

no red flags

what is REQUIRED for a clinical PD diagnosis

how do we evaluate it

limb bradykinesia

motor exam section of MDS-UPDRS

explain the following types of rigidity:

- lead pipe

- cogwheeling

if ___________ does not have _______, then patient does not mean minimum requirements

lead pipe: velocity independent resistance

- cogwheeling: jerking in response to constant force application (juttering)

if cogwheeling does not have lead-pipe, then......

can a resting tremor increase with mental/physical exertion?

yes

what is gold standard for PD disease staging

what is most historically used

movement disorders society (MDS-UPRDS)

modified hoehn and yahr scale

what does MDS-UPDRS stand for?

is higher score better or worse

which of the 4 parts of the exam is the 'motor exam'

movement disorders society - unified parkinson's disease rating scale

higher score is more disease, so worse

part 3 is the motor exam

match the 3 biomarkers for PD to the trait of them

1. syn-one skin biopsy

2. dopamine transporter scan (DaTscan)

3. magnetic resonance imaging (MRI)

a. good for determining central tremor vs PD

b. highly sensitive and specific

c. can show areas of atrophy to support diagnosis

1. syn-one skin biopsy

b

2. dopamine transporter scan (DaTscan)

a

3. magnetic resonance imaging (MRI)

c

parkinsons medication that adds dopamine is usually: _________________________

is it the gold standard?

when does evidence say you should begin taking it

carbidopa/levadopa

yes

there is no evidence in supporting delay, so take it ASAP

what are some clinical considerations to make with dopamine

visit timing, and medication schedule

on/off times

blood pressure regulation

hydration/food intake; drink water!!!

dopamine agonists and amantadine work to make dopamine ________

MAO-B inhibitors, COMT inhibitors, DA re-uptake inhibitors will ____________ dopamine

work better

take away less dopamine

what benefit does deep brain timulation have

is there people who should not get this treatment

what structures does it target

improves some motor fns

if someone is cognitively impaired, likely should not

subthalamic nucleus, globus pallidus internus

MR-guided focused ultrasound thalamotomy is effective to treat _____ only

tremor

what are some non-motor factors to consider when working with parkinson's patients

cognition

- visuospatial, attention, memory, slowed processing

behavior

- apathy, depression, anxiety

sleep disorders

autonomic dysfunction

- things like BP regulation, temp regulation, gut issues

why is apathy such a big issue with parkinson's patients

becuase apathy will lead to decreased activity and praticipation, and secondary disuse/atrophy

name some autonomic implications of PD patients (6)

Blood pressure

heart rate

body temp

bowel/ GI

bladder function

sexual function

describe the relationship between exercise and PD

1. prevention

2. progression

1. sustained moderate to intense exercise can lower then PD risk up to 40%!!!

2. exercise is the ONLY treatment for PD that has evidence of lowing progression

also, get same benefits that people without PD get; cognitive, sleep, depression, autonomic benefits

________ is the only treatment for PD that has evidence showing to slow the disease progression

exercise

what areas of benefit might a PD patient see with exercise

cognition improvement

sleep improvement

depression/anxiety

autonomic dysfunction

10 principles of neuroplasticity

use it or lose it

use it and improve it

task specificty

repitition matters

intensity matters (PD criminally underdosed)

time matters (start ASAP)

salience matters

age matters

transference (use skills between tasks)

interference (bad habits impair learning)

which if the following is not a principle of neuroplasticity:

a. use it or lose it

b. use it and improve it

c. task specificty

d. repitition matters

e. intensity matters

f. time matters

g. limit feedback until mastery

h. salience matters

i. age matters

j. transference

k. interference

g, limit feedback

name some common motor manifestations of idiopathic PD

emphasize the most common/clinically important ones

bradykinesia (must be present for clinical diagnosis)

rigidity (this or resting tremor for diagnosis)

resting tremor (this or rigidity for diagnosis)

might also see:

postural changes, shuffling/fenstinating of gait

freezing of gait

occulomotor signs

explain how bradykinesia leads to impairments of people with PD

people may lose ability recruit muscles early in the diagnosis

also, force production is lower than in healthy indivuals

therefore, decreased ability to recruit, decreased force production leads to less ROM and strength

- more impairment!!!

what are good types of exercise to do with paitents who have PD and bradykinesia (2)

- then name a specific reason for each type

progressive resistance exercise

- retain full ROM, address specific positons and posture

HIIT

- helps get a higher intensity level for more total time

why do we do things like HITT and progressive resistance exercise in PD patients, instead of traditional strength training

typical lacks intesnity, has not enough reps, typically has poor specifictiy, and might not be important to patient (not sailent)

overall, does not address many principles of neuroplasticicty!!

is high speed, power based reistance training effective of brady kinesia?

yes, for both UE and LE

- also saw strength and power increased

how might fixing posture help with PD patients

it can help promote recovery and maintenance of ROM

enforce AUTOMATICITY of ROM

help with antigravity muscle strength

- keep the muscle loss to a minimum

what are some conditions/systems that cntribute to balance impairment of people with PD (6)

bradykinesia

impaired posture reactions

impaired stepping reaction

sensory cue integration dysfunction

visuspatial deficit

vestibular hypofunction

does reactive step training help people w PD

two weeks of training shows improvements in PwPD who were at risk for falls, and may reduce their fall risk

bradykinetic limbs, decreased trunk rotation/UE swing, decreased step length and clearance, downward gaze, and freezing all contribute to issues with what

gait

- it is multifaceted

people with parkinson's have issues with gait because of:

- ____________ limb

- decreased _______ rotation, and UE _________

- _____ stance

- _____ gaze (why?)

- turning issues

- ___________ of gait

people with parkinson's have issues with gait because of:

- ___bradykinesic_______ limb

- decreased ___trunk____ rotation, and UE _____swing____

- __narrow___ stance

- ____downward___ gaze (why: fear of falling)

- turning issues

- ______freezing_____ of gait

freezing of gait is usually a __________________ issue

therefore, if you can get patient to ________________, then you can help them overcome it

weight shifting

shift side to side

should a patient fight through freezing?

if yes: how long roughly do they have to push before they stop freezing

if no: what other verbal strategy can we employ to help

no!!!!!! instead, we should instruct them to use the 4 S's:

Stop

Stand

Shift

Step

what are some compensatory strategies we can do to help PD patients overcome gait freezing

step counting

visual cues

give someone something to stop on or over

helps use different brain pathways

name some common freezing of gait triggers (just hit a few)

initiation or stopping of walking

turning/ direction change

walking through doors

floor surface change

distraction

tight spaces

you see a PD patient freeze while they turn.

what is a common movement pattern that will result in this happening?

what education can you provide to help them avoid this in the future?

if the patient moves trunk first, weight now gets put on the foot that needs to lift; however, they can not shift weight as easily, so are stuck

start the turns with your legs, not trunk!

there is a strong association between gait instability and ______________

therefore, resistnace training with a focus on instability improvements can help improve......

cognition

cognition!!!!

what are some ways to benefit cognition through exercise

what are some other benefits we may get

do dual tasking, or set switching

might see an extra boost of benefit for gait

- gait speed, stride length, cadence

when you provide a PD patient with cueing, you should make it have an _______ focus

why (3)

external

- promotes automatic control

- uses unconcsious reflexive processes

- internal response may RESTRICT motor

is it beneficial to have a nice set of PD cues to have in your back pocket for every patient you work with

no, cues must be patient specific

what are 4 types of cues that we can provide

visual

tactile

audtiry

action-observation

describe goal of visual cueing , and give an example

promotr automaticity of movements

- bypass the executive function

agility ladder on the floor; something to actively look at

describe the goal of tactile cueing, and give an example

to provide biofeedback and direct attention there

- kicking a physioball on a treadmill

describe the goal of external audtiry cueing, and provide an example

to help promote compensatory strategies

- metronome or music

describe the goal of internal auditory cueing, and proide an example

to help activate the pons, basal ganglia, thalamus, cerebellum

- AKA different brain areas

this might be step counting, or singing

what is action-observation cueing? what should you as the PT do?

what beneifts exist

as the PT, you model activity but EXXAGERATE the hell out of it

- use only the words "do exactly as I do"

see improved outcome measures like TUG, 10mWT

what is big picture focus with cueing

do no layer too many things on at one time, or you will overwhelm and then see no progress

what is the "super 6" outcome measures

10 meter walk test

MiniBest

Functional Gait assessment

Five time sit to stand

timed up and go

BErg

what is the gold standard for PD patients, in terms of outcome measure, when mild-moderate disease

miniBEST

what is the benefit of 10 meter walk test

gait speed

what is the benefit of Berg

static balance

what is benefit of miniBest

everything!

what is benefit of functional gait assessment (FGA)

assess gait instability (and some dual tasking)

what is benefit of five-time-sit-to-stand

leg strength and power

what is benefit of timed up and go

cognitive and functionality, dual tasking

preventive, restorative, and compensatory are three types of treatment methods.

with early parkinson's, you want to focus on which 2 of the 3:

with middle/late stage PD, which 2 do you want to focus on?

early: preventative and restorative

middle/late: compensatory/preventative