Lecture 7: Parkinsons Evaluation

Question 1

PD

Progressive disorder of the cns

has both motor and non motor symptoms

motor symptoms: cardinal features - these are what makes it unique
* bradykinesia
* tremor
* rigidity
* postural instability

onset is insidious w/ slow rate of progression

disruptions in daily functions, roles, and activities

Question 2

what is the scale for pd

Answer 2

Hoehn-Yahr classidication
* stage 1 = minimal
* stage 5 = severre

Question 3

what si 1 on the modified hoen yahr scale?

Answer 3

unilater involvement only

typically not diagnosed because dr. will just say they need sleep/too much stress causing that little tremor

Question 4

what is 1.5 on modified hoehn yahr

Answer 4

unilateral and axial inolvement
* but not postural

Question 5

what is a 2.0 on the modified hoen and yahr

Answer 5

bilateral W/O impairment of balance
* they can feel balance problems coming but dont actually have them yet.

Question 6

what is a 2.5 on the modified hoen and yahr

Answer 6

mild bilater disease w/ recovery on pull test - so they dont fail it

Question 7

what is a 3.0 on the modified hoehn yahr

Answer 7

mild to moderate bilaterl disease; some postural instability; physically indepdent

Question 8

what is a 4.0 on the modified hoen yahr

Answer 8

severe disability; atill able to walk/stand unassited - will be very ugly gait
* but can use an assited device? ask

Question 9

what is a 5.0 on modified hoehn yahr?

Answer 9

wc bound or bedridden unless aided

Question 10

what is the pull test?

Answer 10

you pull them backwards and they catch themsevlves - should pull enough where they must take a step correct
* you catch them if they fall

Question 11

hoen yahr unmodified

Question 12

Question 13

movement disorder society-sponsored revision of the unifed parkinsons disease rating scale
* modification renamed
* goals of revision: improve ability to detetct slower and smaller changes in mildly disabiled pts and increase focus on nonmotor symptoms
* 4-part structure with reworking of questions and additional 6 items
* total 48
* four point scale (0, no, or 1, yes, in the original scale)
* 0 normal or no problems; 1, minimal problems, 2, mild problems, 3, moderate problems; and 4, sevre problems
* part 1 = non-motor aspects of experiences of daily living
* 2 = motor experiences of daily living
* 3 = motor examinination
* 4 = renamed motor complications
* 30 mins to adminster
* parts 1 and 2 designed to be self adminstered by pt

detect smaller changes - pt is saying they’ve having small changes but other tests fail to catch these small things

Question 14

this questionaire is supposed to be the subjective portion of how pd affects their lives

motor and non-motor symptoms in pd progress together - duh

Question 15

non motor symptoms w/ pd come before or after motor?

Answer 15

they come first (up to 10 years earlier!)

orthostatic hypotension - may not be super severe initially

lack of sleep/sense of smell common

Question 16

early symptoms - before motor - before disease really becomes apparent

apthy = lack of feeling or emotion

Question 17

stuff about pd
* second most common neurodegenerative disorder
* estimated 1 in a millin americans
* 7 to 10 million people world wide
* incidence increases 5-10x in 60s to 90s

Prevelence
* under 1% of people aged 45 to 54
* 4% of men and 2% of women aged 85 and older

• prevelence expected to more than double by 2040
• average age of onset=60
• 4% to 10% of patients diagnosed before age 50
• early onset PD/Young onset PD: between 21 and 50
• juvenile onset <21
• men 1.2-1.5 times more likely than women

not asking these #’s

Question 18

clinical course PD
* progressive
* Long preclinical/prodromal period estimed 5-25 years
* variability in the rate of pression
* young age or tremor predominant typically more benign progression - so these are good things
* postural instability and gait distruabnces more pronouced deterioration with more rapid diseqse progression - so these are bad things
* neurobehavioral disturbances and dementia common - end stage - makes you mean
* common causes of death-cardiovascular disease and pneumonia

Question 19

if they respond to levadopa they have parkinsons

Question 20

Question 21

anything that can impact the bg can cause parkinsons symptoms

Question 22

dont memorize

Question 23

Rigidity - comes w/ pd - velocity indpendent and doesnt matter the direction
* clinical hallmark sign of pd
* increased resistance to passive motoin - quiz - not active (because bsically the agonst and antagonst are both firing making it hard to move extrememity)
* fairly constant regardless of task, amplitude, or speed of movement
* onset assymetrical, espeically in early stages - so think one arm will move more than the other
* tyically impcts proximal muscles first-shoulders and neck-cprogresses to muscles of face/extremitites)
* decreases ability to move easily
* active movement, mental concentration, or emotional stress may all increase rigiditty
* prolonged rigidity results in decreased rom and serious, secondary cimplications of contracture and postural deformity
* direct impact on increasing resting E (- they have to use more e at rest) expenditure and fatigue levels
* can vary during day, point in medication cycle, and w/ stress

dont use modified ashworth - use PROM

Question 24

Question 25

Question 26

bradykinesia - slowness of movement * cardinal feature pd * weakness, tremor, and rigidity may contribute to bradykinesia but do not fully explain it * **insufficient recruitment of muscle force during initiation of movement** * underscale movement commands internally generated movements * one of the most disabling symptoms of pd, with prolonged movement and reaction times resulting in increased time on task and dependence in daily activities * **bradyphrenia-slowness of thought can contribute to brandykinesia** - quiz * hypokinesia-decrease in amlpitude of movement * later stages, movements become arrhythmic w/ frequent start hesitations and arrrests (akinesia) we treat the bradykinesia the most * w/ this big movements

Question 27

how we test bradykinesia can take a stop watch and time how long it takes for them to start a motion after being told to start * can do tug etc... * rapid alternating movements timed (dysdiadochokinesia)

Question 28

when someone w/ pd walks that trunk motion goes away = hypokinesia micrographia - handwriting gets smaller as they write

Question 29

tremor * cardinal feature of pd * **involventary shaking or oscillating movement of part or parts of body resulting from contractions of opposing muscles** * early stages of the disease = 70% of pts * tremor = less severe when pt is relaxed * aggreavted by stress * later stages tremors become severre * fluctuations in frequency and intensity are common

Question 30

explain a resting tremor

Answer 30

pt at rest suppressed briefly by voluntary movement, and disappears w/ sleep * typically if they do movement it goes awat * this is just a tremor when theyre hanging out

Question 31

postural tremor

Answer 31

tremor of head and trunnk seen when muscles are used to maintain an upright posture against gravity * gets worse when they have to use those muscles

Question 32

action tremor

Answer 32

(intention of kinedtic) tremor that continues w/ movement, can occur in pts w/ advanced disease * more in advanced stages

Question 33

Question 34

if this is their first sign thats bad lots of different things impact this * some can be improved in pd, we really need to know what stage of the disease were in * early = thinking more recovery * late = compensation/comfort

Question 35

postrusl deformity progressive weakness of antigravity m (spinal extensors) contributes to a flexed, stooped posture with increased flexion of the neck, trunk, hips, and knees change in center of alignment position, positioning individual at forward limits of stability LE contracture * hip and knee flexors * hip rotators and adductors * pf's spine * dorsal spine nad neck flexors ue contracture; * shoulder adductors and ir * elbow flexors deverive the above by knowing they're in a forward hunched posture fucntion becomes progressively more limited by msk constraints standing, typically flexed, stooped posture (kyphosis w/ forward hd) w/ com placed forward within limits of stability * so some of these body mechanical deviations can lead to worse postural instability - not jsut weak m supine flexed posture w/ forward hd still evident (shadow pillow posture) LE contracture more evident than UE * more contractures = less function | shadow pillow contracture

Question 36

pts w/ pd fall a lot * they have balance problems hip fx common in acute care they wont want them to get up if they're a fall risk - however we need them moving medication management is very importnt w/ pd - needs a very specific time - and multiple doses a day

Question 37

first fall = more likely to fall again scared of falling = increased risk of falls do outcome measures to see if they're at risk for falls

Question 38

protective responses 6,8,10 * can test these as well in adults

Question 39

know: tinneti is not sensitive to sensing change in gait for pts easy to ceiling on berg * dont do this unless u actually see balance problems or they're going to score 100

Question 40

not going to have us dilinate between primary and secondary impairments * becuase some of the things on our secondary impairment list can also be primary

Question 41

m performance w/ pd - lots of reason - because muscles don't fire the same way, its asynchronous (meaning some muscles myofibrils contract and other dont) - timing of actually turning on the muscles is altered * reduction in strength * torque production decreased at all speeds * activity limitations and muscle weakness * changes in strength may be dopamine related * "on" state demonstrate increases in strength * EMG motor unit recruitment delayed w/ under recruitment of muscles * once initiated contraction characyrrized by multiple bursts and asynchronizayion-pauses and inabiliy to smoothlu increase firing rate as contraction continues * compounded during production of complex movements * disuse weakness evolves from inactivity and increases movement difficulties - keep pts moving w/ pd

Question 42

more worried about functional than mmt

Question 43

gait w/ pd * 13-33% of pts present w/ postural instsbility and gait disturbanced * gait disturbnces common in late-onset or advanced * reduction in arm swing w/ asymmetry * **some pts can only stop when they run into something**

Question 44

if you see the word festinating giat pattern pick pd as the answer

Question 45

progressive increase in speed w/ shortening of stride- multiple short steps to catch up w/ com to avoid falling, and may eventually break into run or trot

Answer 45

festinating of gait cannot stop themselves * can get so bad that they cant stop unless they run into something

Question 46

a forward festinating gait

Answer 46

anteropulsive

Question 47

a backwards festinating of gait

Answer 47

retropulsive * less common

Question 48

need multiple steps to change directions decreased step length freezing of gait when you tell them to walk faster they increasenthe cadence and decrease step length * a normal person increases stride length

Question 49

so measure how long it takes from when you say go and they actually start walking * if you get any time its too long variability = can be path deviations * assymerical in pd - typically perfurred to one side * i think this is pirimairly due to rigidity being assymetrical they might have a hard time stopping when you say stop. count the # of steps they take after saying to stop (festinating of gait) freezing of gait is vairable so its hard to measure * typically happens when walking through something/some kind of distraction incressed double limb support * anyone w/ balance difficulties spends more time on both legs

Question 50

Question 51

fear of falling = give them a dual task in walking and this can decrese the fer of falling and they'll go faster - w/ pd * only works in early stages complex environments = harder time walking

Question 52

becomes a social problem because people notice * will make them want to isolate

Question 53

fatigue -different than just feeling tired "entire body slows down" - cogntive fatigue can be frusturating - takes more energy all thre time because of the rigidity * one of the most common symptoms * difficulty in sustaining activity and increasing weakness and lethargy as day progresses * activitiws start strong but decrease in strength and amplitude as activity progresses * performance decreases dramatically w/ physical effort or stress * rest or sleep may restore mobility * L-dopa therapy-less fatigued * long standing disease and drug therapy, fatigue typically reappears * increased sense of effort associated w/ movement

Question 54

helps classify how fatigued someone is

Question 55

Sensory symptoms * **do not suffer from primary sensory loss** * up to 50% experience paresthesias and pain * Pain may be due to diseases effect on central nociception - this is positionaly and intermittent * symptoms typically intermittrnt and vary in intensity and location * pain more intense in off state * postual stress syndrome secondary to faulty posture, ligamentous strain, lack of movement, and muscle rigiidty

Question 56

most pts get dysphagia by end stage (difficulty swallowing) * can come on at any stage problem is aspiration * can even do this on own spit and cause pneumonia * could make them just not want to eat

Question 57

sialorrhea

Answer 57

excessive drooling as result of increased saliva production and decreased spontaneous swallowing * can make them apsirate on nothing but spit can also make them not want to go out in public

Question 58

are very monotoned * uncontrolled = can talk to fast or slow * basiclly sounds like a whisper - we tell them to yell * we work on this by improving breath support / head support / posture - makes it easier to talk * they think they're talking loud

Question 59

psychosis = hallucinations hallucinations impacted by medications they're on

Question 60

neurochemical imbalances psychosocial problems multifacotral

Question 61

hypomimia

Answer 61

reduction in facial expressiveness, can give the appearance of depression

Question 62

anyone who has all the stuff mentioned above would give a noraml person anxiety agroaphobia - not leaving house at all

Question 63

autonomic dysfunction go from hot to cold etc...

Question 64

orthostatic hypotension * common in middle to late pd * sharp drop in bp w/ positional changes * typical symptsoms: lightheadedness or dizziness, pallor, diaphoresis, weakness, trembling, nausea, difficulty thinking, or syncope * risk for lob, falls, and injury * medications levodopa/carbidopa, bromocriptine * drop in systolic bp of 20 mmhg or drop of 10mmhg in diastolic bp and a 10-20% increse in pulse rate is diagnostic to test: * supine for 2-3mins - resting hr and Bp are taken * supine to sitting wait at least 1 minute, bo and hr are taken * pt stable after at least 3 mins -move to standing * stanf bp and hr again taken after at least 1 min and repeated between 3 to 5 mins * bp that continues to drop after at least 1 min of standing = problematic and evidence of advanced disease

Question 65

cardiac response to pd * early and progressive sympathetic denervation of the heart occurs in the majority of pts * results in diminished heart function-may be contributory factor in fatigue * advanced pd exhibit altered hr and bp during ex w/ decreased ex efficiency * mild to moderate do not appear to demonstrate significantly different exercise capacity (maximal hr, maximal o2 consumption) when compared to age-matched controls

Question 66

often due to lack of ambulation * m pump gets rid of it

Question 67

rem sleep beahvior disorder = lack of sleep paralysis so move all over the place at night * wake up not rested because they were moving half the night

Question 68

**<15% of calories should be from protein** * high protein can block the effect of L-dopa * should be high calorie diet low in protein

Question 69

Question 70