Clinical Management of Parkinson Disease Flashcards
(142 cards)
1
Q
What are the cardinal motor symptoms of Parkinson’s Disease?
A
- Tremor
- Rigidity
- Bradykinesia
- Postural instability
2
Q
What is a tremor?
A
Involuntary oscillations resulting from contraction of opposing muscles
3
Q
How does tremor present in the early stages of Parkinson’s Disease?
A
- Distal hand or foot
- One side of the body
- Resting tremor
4
Q
How does tremor present in the later stages of Parkinson’s Disease?
A
- Increased severity
- Bilateral
- Action Tremor
- Interferes with ADLs
5
Q
What is rigidity?
A
- Increased resistance to passive movement
- Not velocity dependent
- Both agonist & antagonist
6
Q
What is cogwheel rigidity?
A
Jerky, ratchet like resistance
7
Q
What is leadpipe rigidity?
A
Sustained rigidity
8
Q
What does progression of rigidity over the disease course look like in Parkinson’s Disease?
A
- Prox –> distal
- Unilateral –> Bilateral
- Increase in severity
9
Q
What are some secondary complications to rigidity?
A
- Contracture
- Postural deformity
- Fatigue
- Energy expenditure
10
Q
What is bradykinesia and some examples?
A
- Slowness of movement
- Ex: Increased reaction time
- Ex: Increased movement time
11
Q
What is hypokinesia and some examples?
A
- Decreased movement (smaller amplitude & less movement)
- Ex: Micrographia
- Ex: Decreased arm swing
12
Q
What is akinesia and some examples?
A
- Absence of movement
- Ex: Freezing
- Ex: No arm swing
13
Q
Describe the typical presentation of balance of a patient with Parkinson’s Disease
A
- Decrease limits of stability
- Slow anticipatory postural adjustments
- Poor reactive balance (abnormal co- contraction)
14
Q
Describe the typical posture of a patient with Parkinson’s disease
A
- Decreased activation of antigravity muscles
- Flexed posture
- COM lowered towards the foward LOS
15
Q
T/F: Patients with Parkinson’s disease are not at an increased risk of falls
A
False
- 70% single fall
- 50% recurrent fall
16
Q
Describe the typical gait presentation in a patient with Parkinson
A
- Slow pace
- increased variability & asymmetry
- Poor postural control
- Decreased step size
- Reduced arm swing/trunk rotation
- Reduced APA prior to steps
- Turn en bloc w/ more steps
- Festinating
- Freezing of gait
17
Q
What is festination?
A
Unintentionally rapid short steps
18
Q
What is freezing of gait?
A
- Trembling or absent movement with transient inability to take a step
- Triggered by confrontation w/ competing stimuli
19
Q
T/F: There is a primary sensory loss associated with PD
A
False- There is no primary sensory loss associated with PD
20
Q
When are patients with PD more hypersenstive to pain? (On or off their medication)
A
More common in off state of medication
21
Q
What may be some reasons for a patient with PD to experience pain?
A
- Musculoskeletal
- Dystonic
- Neuropathic/radicular
- Central or primary
- Akathisia (feeling of inner restlessness)
22
Q
Patients with PD often have impaired perception of kinesthesia and proprioception. What does this cause?
A
A failure to recognize deficits in movement size
23
Q
What is sensory loss that often occurs years before diagnosis and is an important early clinical sign?
A
Olfactory dysfunction
- Either decrease or loss of sense of smell
24
Q
What is dysphagia a result from?
A
Rigidity and reduced movements
25
What may dysphagia impact?
- Tongue control
- Chewing
- Bolus formation
- Swallowing (delay)
- Peristalsis
26
What are the complications of dysphagia?
- Choking
- Aspiration pneumonia
- Poor nutrition
- Weight loss
- Sialorrhea
27
What are the symptoms of hypokinetic dysarthria?
- Decrease volume
- Monotone/ mono pitch
- Imprecise articulation
- Uncontrolled rate of speech
- Hoarse
28
What are two speech disorders that can occur in patients with PD?
- Hypokinetic dysarthria
- Mutism
29
What are the contributing factors of speech disorders in patients with PD?
- Motor symptoms (rigidity, hypokinesia, bradykinesia, & tremor)
- Impacts muscles controlling respiration, phonation, resonation & articulation
30
T/F: Speech disorders impacts participation & contribute to social isolation
True
31
What is bradyphrenia?
- Slowness of thought
- Early symptom
32
What are some symptoms of mild cognitive impairment that may be present in patients with PD?
- Processing speed
- Set-shifting
- Attention
- Verbal fluency
- Planning
- Abstract reasoning
- Visuospatial
- Verbal & visual memory
- Impacts motor learning & dual task performance
33
What are symptoms of levodopa toxicity?
- Hallucinations
- Delusions
- Psychosis
34
Who is at greatest risk for dementia?
Older individuals
35
What are some cognitive symptoms that may present in patient with PD?
- Bradyphrenia
- Mild cognitive impairment
- Dementia
- Levodopa toxicity
36
What are some sleep disorders that patients with PD may have?
- REM sleep behavior disorders
- Excessive daytime somnolence
- Insomnia
37
What is some characteristics of REM sleep behavior disorder?
- Occurs prior to motor symptoms (in up to 60% of individuals)
- Incomplete or absent paralysis during REM
- Dream - enacting behaviors
38
What are some characteristics in insomnia?
- Difficulty falling asleep
- Difficulty staying asleep
- Poor sleep quality
39
What are some neurobiological causes of depression, anxiety and apathy in patients with PD?
- Alterations in levels of dopamine, serotonin, & NE
- Apathy improves initially with dopamine therapy
- Anxiety & depression worse during "off" medication times
40
What is hypomimia?
Reduced facial expression may be mistaken for depression or apathy
41
When is autonomic dysfunction seen in patients with PD?
Seen early in disease & progresses with disease course
42
What are the symptoms of autonomic dysfunction?
- Impaired thermoregulation/ hyperhidrosis
- Slow pupillary response to light
- Decreased gastric motility / constipation
- Urinary incontience
- Blunted HR response to exercise (sympathetic denervation of heart)
- Orthostatic hypotension
- Pulmonary dysfunction (air trapping, decreased chest expansion)
43
How is PD diagnosed?
- Based on history & clinical examination
- No diagnostic test (MRI rule ot other causes or chemical markers can confirm dopamine deficits)
44
What is the difference between parkinsonism and PD?
- Parkinsonism: Bradykinesia + tremor or rigidity)
- PD: no symmetrical bilateral signs & clear + dramatic benefit from dopamine therapy
45
What is the mechanism of Levodopa/Carbidopa?
- Dopamine replacement
- Carbidopa prevents levodopa from conversion to dopamine before it crosses the BBB
46
What is the mechanism of dopamine agonist?
Stimulates dopamine receptors in the basal ganglia
47
What is the mechanism of COMT inhibitors?
Blocks breakdown of dopamine to prolong effects & reduce "wearing off"
48
What is the mechanism of MAO-B Inhibitors?
Blocks breakdown of dopamine to prolong effects & reduce "wearing off"
49
What is the mechanism of Anticholingerics?
- Reduces excessive acetylcholine influence
- May reduce tremor & dystonia
50
What is the mechanism of Amantadine?
- Antiviral
- Blocks effects of glutamate
- May reduce dyskinesia
51
What is the mechanism of Norepinephrine precursors?
- Increase NE levels
- May reduce orthostatic hypotension
52
What is the mechanism of Cholinesterase Inhibitors?
- Inhibits acetylcholine breakdown
- May improve function & gait instability
53
What is the mechanism of Atypical antipsychotics?
- Blocks some effects of serotonin
- Used to treat hallucination & psychosis side effects
54
What are some common side effects of pharmacological management of PD?
- Wearing - off
- Dyskinesia
- Dystonia
- Low BP
- Dizziness
- Nausea
- Dry mouth
- Insomnia
- Constipation
55
What is deep brain stimulation?
Electrodes implanted in brain with a subclavicular impulse generator & controlled by an external controller
56
Where can electrodes be placed during deep brain stimulation?
- Subthalamic nucleus
- Globus pallidus internus
57
What occurs if the deep brain stimulation is placed in subthalamic nucleus?
- Improved motor symptoms & tremors
- Reduce medication
58
What occurs if the deep brain stimulation is placed in globus pallidus internus?
- Improve motor symptoms & tremor
- Suppression of dyskinesia
59
T/F: Symptoms poorly controlled by levodopa will likely be improved with deep brain stimulus
False- Symptoms poorly controlled by levodopa will unlikely be improved with DBS and may worsen
60
What type of diet can block levodopa absorption? What are the recommendations to combat this?
- High protein
- Reduce calories from protein
- Eat protein later in day
61
What are some tasks that you may choose to observe for a patient with PD?
- Bed mobility
- Transitions
- Skill (sitting/standing)
- Ambulation
- W/C mobility (if applicable)
62
What type of things should be taken note of when observing tremor?
- Location
- Persistence
- Severity (amplitude)
- Resting vs Action
- Triggers
63
What is highly recommended to use when examining bradykinesia?
9 Hole Peg test
64
What are some ways to examine bradykinesia?
- Movement speed (times RAM)
- 9 Hole peg test
65
What should you be observing when examining hypokinesia?
arm swing
66
What should you be observing when examining akinesia?
- Freezing (duration, triggers, ability to overcome)
- Start hesitation (reaction time)
67
What should you be observing when examining rigidity?
- Sustained (lead pipe) vs intermittent (cogwheel)
- PROM
- Spinal ROM
- Distribution
- Severity
68
What are common posture deviation in patients with PD?
- Forward head
- Rounded shoulders
- Kyphosis
- Hip/knee flexion
- Hand position
69
What is the deviations of hand position in patients with PD?
- Flexed MP
- Extended IP
- Ulnar dev
- Wrist flex
- Forearm pronation
70
How can you examine resting posture in patients with PD?
- Plumb line, grids, photography
- Wall to occiput distance
71
How can you examine AROM/PROM in patients with PD?
- Goniometer
- Inclinometer
- CROM
72
What are some potential caused of sensory loss in patients with PD?
- Age related changes
- Patterns of loss (comorbidity)
- Perception (BG)
73
What should be included in sensory screen for patient with PD?
- Complaints of pain, tingling, numbness
- Superficial, deep, cortical
- Nerve conduction velocity normal
74
What are some pain complaints in patients with PD and how can you examine them?
- Mild achin/cramping
- Postural stress
- VAS, faces
75
What is the vision complaint in patients with PD and how can you examine it?
- Blurring
- Smooth pursuit (cogwheeling)
76
How can you examine strength in patients with PD?
- MMT
- Dynamometry (rate of force production, maximum torque)
77
In the late stages of PD what is the patient's perception of upright?
Forward of vertical
78
What clinical measures can be used to examine postural control & balance? Which is highly recommended and which is recommended?
- Highly recommended: BESTest/ miniBESTest
- Recommended: ABC Scale
- BBS
- Functional reach test
- Cognitive TUG
- CTSIB
- Dual task
79
What standardized measures can be used for gait in patients with PD? Which are highly recommended?
- Highly: 10 m Walk
- Highly: 6 min walk test
- Highly: Functional Gait Assessment
- DGI
- TUG
- Dual task
80
What are the parameters of gait that should be examined in patients with PD?
- Start time
- Gait speed
- Stride length
- Cadence
- Stability
- Turning
- Safety
- Quality (shuffling, festination, posture, arm swing)
81
What are some triggers/ provoking factors to freezing of gait?
- Doorways
- Gait initiation
- Change in environment
- Change in attentional demands
- Stress/anxiety
82
What are some questionnaires that can be used to examine freezing of gait? Which is recommended?
- Recommended: Freezing of Gait Questionnaire
- New Freezing of Gait Questionnaire
83
What outcome measure assesses gait through a course under single, dual & triple task conditions?
- Freezing of Gait Assessment (FOGA)
- Not well studied
84
What is the highly recommended measure to examine cognition? Why is this test recommended over MMSE?
- Montreal Cognitive Assessment (MOCA)
- More sensitive to mild impairment
85
What is recommended outcome measure to examine fatigue?
Parkinson's Fatigue Scale
86
What are some outcome measures that can examine psychosocial?
- Geriatric Depression Scale
- Hamilton Depression Rating Scale
87
What are some outcome measures that can examine anxiety?
- Geriatric Anxiety Inventory
- Parkinson's Anxiety Scale
88
What are dyskinesias? How can they limit the patient? What outcome measure can be used to examine dyskinesias?
- Side effect of medication
- Limit both social & physiological function
- Rush Dyskinesia Scale
89
What symptoms indicate autonomic dysfunction?
- Alter HR & BP response to exercise
- Orthostatic hypotension (measure BP 1 min following position change & drop in SBP 20mmHg or DBP 10 mmHg + 10-20% increase in HR)
90
What should you be on the look out for when examining the integumentary system?
Observe bruising/skin break down
91
What are some global standardize outcome measures?
- SF-36
- Sickness Impact Profile
92
What are some disease specific standardize outcome measure that can be used in PD? Which are highly recommended?
- Hoehn-Yahr Classification of Disability
- Highly Recommended: MDS- Unified Parkinson's Disease Rating Scale (MDS-UPDRS)
- Highly Recommended: Parkinson's Disease Questionnaire (PDQ-39)
93
What is MDS- Unified Parkinson's Disease Rating Scale?
- Comprehensive tool designed to monitor the burden & extent of Parkinson's disease across the longitudinal disease course at body structure, activity, & participation level
- Both self-report & examiner administered items
94
In MDS- Unified Parkinson's Disease Rating Scale do higher scores indicate more or less severity?
Higher scores = increased severity
95
What is the Parkinson's Disease Questionnaire?
- Subjective report of impact on PD
- Rate experiences during the last month
96
Treatment plan of PD will be highly variable depending on what 4 factors?
- Patient complaints & goals
- Assessment findings
- Prognosis
- Stage of disease
97
What does current evidence support for the management of PD?
- Combined physical therapy & pharmacology management
- Early Intervention
98
What is the goal of early intervention for PD?
- Maximize function
- Minimize secondary complications
- Provide education & support
- Slow progression of disability
- Possible slow disease progression
99
Endurance training may improve what in patients with PD?
- Improve VO2max
- Improved gait speed, mood, motor function, QOL
- Improve aspects of cognition
100
What does regular exercise (>150 m/wk) improve in patients with PD?
- Better QOL
- Mobility
- Physical function
- Cognition
- Less disease progression at 1 yr follow up
101
T/F: PTs should implement mod to high intensity aerobic exercise for individuals with PD
True
102
What is the aerobic exercise CPG?
- 30-40 min, mod (60-75% max HR) or high (75-85% max HR) intensity, 3x/wk
- Cycling & treadmill both effective
- Screen for CV risk factors & orthostatic hypotension
- Monitor VS & RPE
- Must maintain or gains dissipate
103
What motor learning strategies should be used with patients with PD?
- Large number of reps
- Complex movement broken down into components
- Blocked practice
- Minimize distraction/ dual task to improve performance
- External cues
- Progression to random practice & dual task should be done if able
104
What external cues should be used with patients with PD? What happens if these cues are removed?
- Visual, auditory, pulsed
- Rhythmical, consistent & not rushed
- Shifts automatic (conscious motor pathways)
- Performance deteriorates if cues removed
- Less effective in advanced disease/ dementaia
105
Why should external cues be implemented with patients with PD?
- Reduce motor disease severity
- Reduce freezing of gait
- Improve gait outcomes
106
What type of cueing is best for patients with PD (external or internal)?
External
107
What can auditory cues improve in patients with PD?
- Cadence
- Stride length
- Gait velocity
108
What can visual cues improve in patients with PD?
Stride length
109
What are some examples of auditory cues that can be used with patients in PD?
- Rhythmic auditory stimulation (RAS)
- Metronome, Music
- Attentional Cueing (ie "Big Step")
110
What are some examples of visual cues that can be used with patients in PD?
- Parallel lines on floor perpendicular to direction of motion
- Devices (laser, VR)
111
Dual task performance may be improved by training what in patients with PD?
- Walking velocity, stride length, & cadence
- Carry over to untrained task
112
Both integrated (simultaneous) & consecutive task training can be effective & safe. But what may be the safer alternative for freezing or MCI?
Consecutive task training
113
Why do individuals with PD freeze?
Occurs with:
- Dual tasks
- Increased difficulty
- Response to environmental demands (doorway, turning corner, unexpected stimuli)
114
How can cueing help freezing of gait in patients with PD?
Used to direct attention to gait & improve spatiotemporal parameters
115
How should training using RAS cueing prior to freezing of gait be implemented?
- 3x/wk (6 wk)
- Train response to RAS (pace, step length, L-R coordination)
- Progressively challenging courses
- Secondary tasks
116
What were the results of training using RAS cueing prior to freezing of gait?
- Decreased frequency & duration of freezing
- Retained at 4 wk follow-up
117
How should amplitude training be implemented?
- Cue to increase amplitude
- Repetitive
- High intensity
118
What is the goal of amplitude training?
- Larger movement carry over to un-cued movements after intervention
119
What is a clinical example of amplitude training?
LSVT BIG training & PWR!Moves
120
In people with PD, PTs should implement resistance training to?
- Decrease motor disease severity (UPDRS- III motor scores)
- Increase muscle strength & power
- Improve non-motor symptoms, functional outcomes & QOL
121
How often should strength training be implemented?
- 30-60min, 2 non-consecutive days/wk
- Performed during "on" period
122
What are the parameters that should be used to improve strength in patients with PD?
- Begin 40-60% 1RM or 1 set 20-30 reps
- Progress to 80% 1RM or 3 sets 10 rep to fatigue
123
What are the parameters that should be used to improve power in patients with PD?
- Begin 20-30% 1RM
- Progress to 40% 1RM
124
T/F: Patients with PD should focus primarily on doing isometric exercises
False - Avoid isometric
125
T/F: PT may implement flexibility exercises to improve ROM in individuals with PD
True
126
How should Flexibility exercises be implemented?
- May be part of a home program or part of your warm up/cool down
- Literature does not support it being entirety of intervention
127
What is the benefits of flexibility interventions?
- Decrease pain
- Increase QOL
- Improve balance
128
What PROM, AROM, facilitated exercises should be chosen?
- Exercises that strengthen extensors & lengthen flexors
- Combined movements helpful to conserve energy (PNF)
129
How can stretching be implemented in patients with PD?
- Precautions (sedentary, elderly, osteoporosis)
- Combine w/ joint mobs
- Passive positioning (prone lying, tilt table, "lying on the beach")
130
Name some relaxation techniques
- Gentle rocking an temporarily relax rigidity
- Slow, rhythmic rotational movements of extremities & trunk may proceed interventions
- Breathing during exercises
- HEP
131
What are some relaxation techniques that can be taught as part of HEP?
- Relax to move
- Deep breathing, audio tapes, meditation, imagery, gentle yoga, tai chi
- Stress management
132
For individuals with PD, PTs should implement balance training intervention programs to?
- Decrease postural control impairments
- Improve balance, gait, & mobility
- Increase balance confidence
- Improve QOL
133
What are some Balance training interventions and how should they be performed?
- Static & dynamic activities, transition tasks & perturbations
- COM & LOS control training
- Practice under variety of sensory & environmental conditions
- Practice in variety of positions
- Combine w/ aerobic & gait training
- Consider safety
134
What are some functional or TST interventions that can be used for patients with PD?
- Bed mobility skills
- Sitting/standing (posture, mobility)
- STS
- Transfers
- Floor to sit/stand transfers (falls) (4 pt creeping, trunk extension, kneeling to half kneel)
135
For individuals with PD, PTs should implement gait training to?
- Decrease motor disease severity
- Improve stride length, gait speed, mobility & balance
136
How often should gait training be implemented?
20-60 min, 3-5 d/wk, for 4-12 weeks
137
What are the goals of functional gait training?
- Increase step length
- Increase gait speed
- Encourage reciprocal arm swing
- Improve upright alignment
- Vary task & environmental; demands
- Compensatory strategies (when necessary)
138
What should be considered with performing functional gait training?
- Cues
- Harness or body weight supported treadmill training
- Nordic walking
139
What are some pulmonary rehabilitation interventions?
- Diaphragmatic breathing, air shift techniques, strengthen accessory muscles
- Manual technique
- ROM/mobilize chest wall
- Postural exercise
140
For individuals with PD, PTs should recommend community based exercise to?
- Reduce motor disease severity
- Improve non-motor symptoms
- Improve functional outcomes
- Improve QOL
141
What is the recommended frequency, intensity, time/volume and stage for community based exercises?
- Frequency: 2x/wk
- Intensity: Max intensity w/ optimal safety based on individual needs
- Time/Volume: 45-60 min for at least 12 wks
- Stage: Evidence supports for H&Y I-III
142
Name some types of community based exercises
- Yoga
- Tai Chi
- Pilates
- Boxing
- Dance
- PWR! (Parkinson's Wellness Recovery)
- Group classes
