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Flashcards in Parkinson's Disease Deck (97):

Epidemiology of parkinsons

  • 2% of population> 65 yrs old
  • Average age 50-60 yrs of age
  • 10 cases per 100,000 under age 50
  • 300 per 100,000 age 80-90
  • Young onset PD, onset before age 40
  • Men and women affected equally


Cardinal Features of parkinsons

  • Rigidity
  • Bradykinesia
  • Tremor
  • Postural instability


These are the main features below of parkinson.  What are other symptoms you might see?
  • Rigidity
  • Bradykinesia
  • Tremor
  • Postural instability

  • movement and gait disturbances,
  • cognitive and behavior al changes,
  • speech,
  • voice and swallowing disorders,
  • cognitive and behavioral changes,
  • autonomic nervous system dysfunction,
  • GI changes,
  • Cardiopulmonary changes


Parkinson’s disease 
Ideopathic or secondary?

most common
Affects 78% of patients
78%:have a number of different identifiable causes
Virus, toxins, drugs, tumors

Parkinson’s first identified in 1817
Fall into 2 groups
Symptoms of postural instability and gait disturbance



Parkinson’s disease 
Ideopathic or secondary?

Post infectious
Influenza of 1917 to 1996: onset of parkinsons symptoms started after years ?slow virus?
Industrial poisonings and chemicals
Most common is manganese
Synthetic heroin (contains MPTP)



  • Drugs can produce extrapyramidal dysfunction
  • Drugs affect dopaminergic mechanism
  • Neuroleptic drugs, antidepressant drugs, antihypertensive drugs
  • Withdrawal of meds usually reverses symptoms
  • Occasionally can be due to calcium metabolism issues: BG calcification, hypothyroidism, hyperparathyroidism, wilson’s disease

Drug induced parkinsonism


Pathophysiology of parkinsons


  • BG: gray matter nuclei, composed of caudate and putamen plus globus pallidus, subthalamic nucleus and substancia nigra
  • Input to BG is striatrum and cerebral cortex
  • Output is to the thalamus and to cortex


Develop cytoplasmic inclusion bodies:


what does it mean?

lewy bodies

that someone has parkinsons

dr c says to remeber this



What part of the brain is involved?

  • Involved in planning and programming of movement
  • Selection and inhibiting specific motor synergies
  • PD assoc with degeneration of dopaminergic neurons that produce dopamine: if have 30-60% degen of neurons will have clinical symptoms
  • Develop cytoplasmic inclusion bodies: Lewy bodies
  • Other areas of predilection: dorsal motor nucleus of vagus, hypothalamus, locus ceruleus, cerebral cortex and autonomic ganglia

Basal ganglia


  •  release phenomena
  • Loss of inhibitory influences within BG
  • Decreased binding sites for dopamine in BG: can explain loss of effectiveness for L-dopa



A cardinal feature of parkinson

  • Heaviness and stiffness of limbs
  • increased resistance to passive motion
  • Constant in all movements, regardless of task, amplitude or speed of movement
  • Cogwheel rgidity: jerky, ratchet like: muscles tense and relax
  • Leadpipe rigidity: sustained resistance to passive movement
  • it is often asymmetrical, affects proximal mm, progress to face and extremities




jerky, ratchet like: muscles tense and relax

Cogwheel rgidity


sustained resistance to passive movement

Leadpipe rigidity


Rigidity is often what?

  •  asymmetrical,
  • affects proximal mm,
  • progress to face and extremities


Rigidity - how does it affect a pt?

  • Progresses over time
  • Progress to affect whole body
  • Affects ability to move easily
  • Be careful of bed ridden for even a short period of time
  • May lose bed mobility, reciprocal arm sway during gait
  • Active movement, mental concentration or emotional stress will increase rigidity


absence of movement



sudden break or block in movement



reduced amplitude of movement



Movement; reduced in speed, range and amplitude



tremor- how does it present in a parkinson pt?

  • Initial symptom 70% of time
  • Involuntary involvement  of body part, oscilating at slow frequency
  • Tremor disappears during voluntary movement
  • Pill roll tumor or will see tremor in pron/sup, jaw or tongue
  • Postural tremor: will see when muscles used to keep pt in upright position
  • Less severe when relaxed and unoccupied
  • Diminished by voluntary effort
  • Not present during sleep
  • Stress: makes it worse


Postural instability- how does this affect a parkinson pt?

  • Occurs  after at least 5 years
  • Will see abnormal, inflexible posture, increased body sway
  • Postural instability increased by narrow BOS, increased attention demands and OK (don't try to decrease their bos)
  • Will see more instability with self initiated movements
  • Problems with anticipatory adjustments during voluntary movements
  • Frequent falls occur with increased loss of balance


Falls- what are some statistics in parkinson pt?

  • 2/3 of PD pt experience falls
  • 1.3% fall at least once a week
  • Fall injury  40%
  • Increased risk for falls: freezing, poor gait, balance impairments
  • Other factors that increase falls; dementia, depression, postural hypotension, involuntary movements


why are parkinson pt falling- what might it be due to?

  • Torque production is decreased
  • Insufficient neural activation of agonist muscles
  • Firing rate of muscles is very delayed
  • Complex movements: difficulties are more apparent


Fatigue- how does it affect the parkinsons?

  • Very common
  • Cant sustain activity
  • Increased weakness and lethargy through the day
  • L-dopa therapy: initially will feel less fatigue, over time fatigue will reappear
  • Will see generalized deconditioning over time
  • Contractures in knee and hip flexors, hip rotators and adductors, plantarflexors. Dorsal spine, neck flexors, shoulder adductors, internal rotators, elbow flexors
  • kyphosis


what do Contractures  look like in a parkinson pt?

knee and hip flexors,

hip rotators and adductors,


Dorsal spine,

neck flexors,

shoulder adductors,

internal rotators,

elbow flexors


planning is prolonged and movement times are somewhat prolonged

Start hesitation


Start hesitation

Complex movements are difficult


Freezing episodes -can usually break with external cues

Motor planning difficulties of parkinsons pt



handwriting that is small and difficult to read



competing stimuli: can happen when confront a narrow space or obstacle: occur because of bradykinesia and decreased neurotransmitters

Can usually break freezing episodes with what?

Freezing episodes

external cues- pt or PT-crumbling paper in hand and pitching it fw to initiate walking.


  • Decrease in total number and amplitude of movement
    • hypomimia: lack of facial expression
      • More complex task, less movement

Poverty of Movement


lack of facial expression



Procedural learning deficits are common?

true or false


Deficits in motor skill learning for complex and sequential tasks


what is the best type of practice to use for a parkinsons pt?


Blocked practice

because -Dual tasks are difficult


Gait disturbance is common in parkinson pt?

true of false



what percent of parkinsons pts have postural instability?

13-33 percent


increased speed with shortening of stride- is common gait in parkinson pt

Festinating gait


plantar flex contractures with postural instability is due to what type of gait in a parikinson pt?

Toe walkers


what kind of steps should a parkinson pt use to change directions?

Small steps


sensation- how is it affected in a parkinson pt?

  • 50% have parasthesias and pain
  • Can have numbness, tingling, coldness, aching pain and burning
  • Can be linked to motor fluctuations
  • Akathisia; sense of inner resltessness
  • Decreased proprioceptive regulation of voluntary movement
  • Some drugs used for PD can cause worsening in visual changes


sense of inner resltessness



Speech, voice and swallowing- how are these affected in a parkinson pt

  • Dysphagia:  impaired swallowing: occurs in 95% of patients: due to rigidity, decreased mobility and restricted  range of movement
  • Problems in oral preparatory, ora, pharyngeal and esophageal phases of swallowing
  • Can see choking or aspiration pneumonia
  • Can lead to fatigue and exhaustion
  • Drooling; problematic


impaired swallowing: occurs in 95% of patients: due to rigidity, decreased mobility and 



Speech- how is this affected in parkinsons pt?

  • Impaired 75% - 89% of time
  • Hypokinetic dysarthria: decrease in voice volume, monotone/monopitch speech, imprecise or distorted articulation, uncontrolled speech rate
  • Speech is horse, breathy and harsh


decrease in voice volume, monotone/monopitch speech, imprecise or distorted articulation, uncontrolled speech rate

Hypokinetic dysarthria:


Cognitive function- how is this affected in parkinson pt?

  • Mild or severe
  • 20-40 percent of pts; PD dementia
  • Dementia associated with increase in mortality
  • Loss of planning, reasoning, abstract thinking, judgement
  • L-dopa toxicity: wil see hallucinations and delusions
  • Will see deficits in vertical perception, body scheme, and spatial relations


what percentage of parkinson pt of dementia?

20-40 percent


 a parkinson pt will see hallucinations and delusions due to

L-dopa toxicity


Depression- how does this affected parkinson pt?

  • Common
  • Major depression: occurs in 40% of patients
  • Depression can occur around time motor symptoms occur
  • Feelings of guilt, hopelessness, worthlessness, loss of energy, poor concentration
  • Deficits in short term memory, loss of ambition and enthusiasm, disturbed appetite and sleep
  • Dysthymic disorder


Autonomic nervous system- how is this affected in parkinson pt?

  • Excessive sweat, sensation of warmth
  • Problem with vasodilation
  • seborrhea dermatitis
  • GI disturbance: poor mobility, chane in appetite, weight loss, constipation
  • Bladder dysfunction; urinary frequency, urgency, urge incontinence, nocuturia


Cardiopulmonary function-  how does this affected a parkinson pt?

  • Orthostatic hypotension is common
  • Light headed, blurred vision with position change or exercise
  • L-dopa meds can make symptoms worse
  • Respiratory impairments 84% of patients

    Airway obstruction: lead to pulmonary failure

    Can see restrictive lung dysfunction: restrictive lung function



Long standing disease; LE exhibit circulatory changes due to venous __________?



Medical diagnosis-how is parkinson dx?

  • Difficult to diagnose
  • Based on history and clonical ecam
  • Handwriting, speech, interview questions, PE
  • 2 of 4 cardinal features present: can diagnose PD


Progression of PD disease

  • Slowly progressive
  • Before L-dopa: 28% died within 5 years of dx
  • L-dopa therapy: less than 9% died within 5yrs
  • Younger: more benign progression


Medical Management of parkinsons

Slow progression
Medication, nutritional and surgical intervention


Medications for PD

  • Neuroprotectiv therap
  • Monamine oxidase Inhibitors
    • Use early
    • Delays need for  levadopa by 9 months
    • Slow progression of disease


  • Started using this medication in 1960’s
  • Precursor of dopamine
  • Tries to correct neurochemical  imbalance
  • Use with carbidopa: allows larger percentage of L-dopa to enter CNS (sinimet)
  • SE: anorexia, nausea, vomiting, constipation, confusion, hallucination, hypotension, arrythmia, dysuria, motor fluctuations, dyuskinesia, insomnia, sleep fragmentation
  • Therapeutic window: 5-7 y ears

Levodopa for 

Symptomatic therapy


when will they use Levodopa

  • End of dose deterioration: worsening of symptoms during expected period where medication should be effective
  • On-off phenomenon: 50% of pts treated greater than 2 years:  random fluctuation in motor function
  • Dyskinesia: will see at end of dose deterioration


will see this kind of movement  at end of dose deterioration



Act on post synaptic dopamine receptors
Help prolong effect of  L-dopa

Dopamine agonists


  • Use early in treatment
  • Help to monitor tremor and rigidity
  • Helps smooth motor fluctuation when used with L-dopa
  • Symmetrel: antiviral: potentiates dopamine

Anticholinergic drugs


Physical therapy implications

  • Levodopa therapy: have to pay attention to fluctuations due to medication cycle
  • Watch for where peak dosage is
  • Pay attention to when medication seems to stop working: inform physician


Nutritional management for PD

  • High protein diet: blocks effectiveness of L-dopa
  • Should be on high calorie, low protein diet
  • 15% cal from protein
  • Protein at evening meal
  • Eating may become difficult as is speech: OT and Speech should be involved


Surgical management- for PD that can be used in advance stages

Ablative surgery

Deep brain stimulation


Stereotactic surgery
Pallidotomy: destructive lesion on globus pallidus
Helps with diskinesia
Thalamotomy; reduces tremor

what type of surgery?

Ablative surgery


Implant electrodes: block nerve signals
Helps with severe UE tremors
Pacemaker in chest, wire to brain electrodes

what type of procedure?

Deep brain stimulation


Neural transplantation

cells are being transplanted to what?

deliver dopamine


Rehabilitation for PD

  • Help reduce functional limitations
  • Help promote activity and independence
  • Promote quality of life
  • Know disease history, course, symptoms, impairments, functional limitations, disability
  • Team: physician, OT, PT, nurse, SLP, social worker

    Focus on long range planning


Physical Therapy Examination and Evaluation for PD pt.

  • Early and middle stages of PD, measures of impairment are stable
  • Cognitive function


how is Cognitive function examined and evaluated?

  • Check memory, orientation, conceptual reasoning, problem solving
  • Psychosocial function: ask about sadness, apathy passivity, insomnia, anorexia, weight loss inactivity , dependence
  • Use geriatric depression Scale or Beck depression scale


how is  sensation examined and evaluated with PD pt?

  • Look for superficial and deep sensation problems, especially touch and proprioception
  • Parasthesia
  • Look for vision issues:
  • Vision: 
  • Presence of pain is common


What can be seen with vision in examination and eval

  1.  acuity,
  2. peripheral vision,
  3. tracking,
  4. accommodation,
  5. light and dark adaptation,l
  6. ook for blurring and eye pursuit


how is Musculoskeletal function examined and evaluated

Flexiblity;  measure ROM impairments: tend to lose: hip and knee ext, dorsiflex, shoulder flex, elbow ext,dorsal spine and neck ext and axial rot


Posture; typically have a flexed, stooped posture

Muscle performance
Check strenght and endurance


Rigidity - how is it examined and evaluated?

  • Can be agonists or antagonists and can change
  • Sustained or intermittent
  • Watch for changes in functional mobility or postural reactions
  • Watch for severity of rigidity


what type of movements

  • Movements are slow, will decrease in amplitude and, over time become arrhythmic
  • Can test reaction time: use a stopwatch and time when they try to start something and how long it takes to accomplish the task
  • Time rapid alternating movement



Tremor - how is this examined and evaluated

  1. Note location and persistence and severity
  2. Watch for affects of tremor on ADL’s


Postural Instability- how is it examined and evaluated?

 Examine balance

  • Upright or leaning forward?
  • Check/work on balance: small BOS, tandem walk, step stance, single limb stance, perturbations
  • Have them do duel tasks
  • Can use clinical test for sensory integration in balance
  • Timed get up and go
  • POMA


Gait- how is this evaluated or examined?

  • Speed of walk, stride length, cadence, stability, variability, safety
  • 10 meter walk test: speed, average stride, cadence
  • Will see shuffling gait, cant pick up feet
  • Festinating gait pattern
  • Look at amb on varied surfaces and complex gait patterns


Falling- how is this examined?

  • Risk of falls increases with severity and duration
  • Pts with balance and walking impairments, freezing, dyskinesias are  more likely to fall
  • Other problems that increase risk: hypotension, dementia, depression


Autonomic Function- how is this examined

  • Watch for excessive drooling, sweating
  • Greasy skin, problems with thermoregulation
  • Orthostatic hypotension


Cardiopulmonary Function- how is this examined

  • Watch chest wall mobility
  • Thoracic expansion
  • Changes in breathing patterns with exercise
  • Check vitals pre and post exercise
  • As disease progresses, may have to limit exercise
  • Watch for dyspnea, dizziness, confusion, fatigue, pallor


Integumentary Integrity- how is this examined?

Watch for skin breakdown, especially in bed ridden or wheelchair bound patient


Functional Status- how is this examined?

  • FIM- functional independence measure
  • Watch for need of assistive devices
  • Will have a lot of difficult with transfers due to rotational component
  • Keep testing and exercise periods short
  • How much time does it take to complete the task?


Global health measures looks at very broad spectrum how?

  • SF 36 (looks at how respond to tx), Sickness impact profile
  • Unified Parkinson’s Disease Rating Scale, Parkinson’s Disease Questionnaire
  • UPDRS helps rate disease severity and progression and response to drug therapy

all these do is look at how severy and how the progression is going 


More global questions
Helps with goals and outcomes

PDQ 39


what are the goals of Intervention

  • improve motor function
  • Increase exercise capacity
  • Functional performance
  • Activity participation


Motor learning strategies

  • Difficulty learning complex movement sequences
  • Lot of repetitions
  • Break down  movement into component parts
  • Blocked practice
  • Avoid dual tasking
  • Focused instructions
  • Visual targets/external cues
  • Rhythmic auditory stimulation
  • Using more conscious pathways of brain


Exercise training-

what are relaxation techniques

  • Gentle rocking
  • Slow rhythmic rotation before ROM/stretch/functional exercise
  • Rhythmic initiation
  • Diaphragmatic breathing
  • D2F
  • Daily schedule


Flexibility exercises for PD- 

  • Strengthen weak extensor muscles, lengthen flexor muscles
  • PNF patterns: more bang for the buck
  • Use contract relax techniques
  • Gentle stretching
  • 20-30 sec
  • Avoid bouncing
  • Prone lying
  • Stretching for LE contractures


Strength Training

  • Use for mm weakness: central and disuse
  • Increase strength helps with functional mobility, balance, gait, fall risk
  • Greater force with isokinetic exercises
  • Do exercise during “on” time


Functional training for PD

  • Improve functional mobility
  • Work on axial structures
  • Rolling exercises: should concentrate on segmental rolling
  • Pelvic mobility exercises
  • Sit to stand: rocking, counting,
  • Standing: full standing, trunk rotation, reciprocal movement
  • Weight shift
  • Lateral step up
  • Upper trunk ext
  • Recover from fallen position
  • Face exercises


Supportive Devices- what can these be good for?

  • Blocks to raise head
  • Hospital bed
  • Firm chair, slight tilt
  • Appropriate shoes and clothing
  • Cane, walker, poles


Balance Training

  • COM and LOS
  • Avoid postural disturbances
  • Weight shift, reach, axial rotation
  • Seated disc, therapy ball ex
  • Marching
  • Sit to stand, half kneel


Locomotor training

  • Slowed speed, shuffling gait, flexed position, dec arm swing
  • Vertical poles
  • Walk tall
  • Overhead harness
  • Large steps
  • Braiding
  • Different surfaces


Cardiopulmonary Training

  • Diaphragmatic breathing
  • Ex to recruit neck shoulder and trunk mm
  • Deep breathing
  • Air-shifting
  • Monitor BP and HR
  • Keep ex sub max


Group ex

  • Helpful for long term ex
  • Provides support
  • Stretching ex, combined movements, marching


What could HEP involve?




cardiopulmonary function,

wall stretches


Psychosocial Issues-where a phycologist would get involved.

  • Dysfunction in daily roles, functions, social activities
  • Coping skills