Parkinson's disease

Question 1

define parkinsons

Answer 1

Parkinsonism: a syndrome manifested by part or all of symptoms of resting tremor, bradykinesia, and rigidity (with resulting postural instability)

Parkinson’s disease is a specific chronic progressive neurodegenerative disease with features of Parkinsonism
Key factor: loss of dopamine-producing cells in basal ganglia
First described by James Parkinson in 1817
No cure

Question 2

aetiology

Answer 2

Characteristic feature: degeneration of dopamine-producing cells in substantia nigra pars compacta of the basal ganglia

Unknown cause

Environmental factors + genetic predisposition

Cellular mechanisms: Oxidative stress, premature apoptosis, loss of neurotrophic factors, glutamate toxicity, mitochoncrial dysfunction, inflammation

Question 3

differential diagnosis

Answer 3

secondary Parkinsonism

Parkinson’s plus syndrome

Question 4

epidemiology

Answer 4

2nd most common neurodegenerative disease (after Alzheimer’s)
Incidence rises steeply with age
Most common over age 60  1% of people over age 60  4% over age 80
5-10% onset age 20-50 (young onset PD) 
Higher incidence in Causasians
M:F 1.5:1
slightly more common in men
1.2 million people in Europe affected

Question 5

secondary Parkinsonism

Answer 5

Multiple possible causes:
Toxins
Carbon monoxide, manganese
Structural brain damage
Tumour, trauma, hydrocephalus
Drugs
Neuroleptic drugs, dopamine-depleting agents
Infections
Post-encephalitis, AIDS, Creutzfeldt-Jakob Disease

Question 6

parkinson’s plus syndrome

Answer 6

Idiopathic

Includes other syndromes:
Progressive supranuclear palsy (PSP) Multiple system atrophy (MSA) Corticobasal degeneration (CBD) Dementia with Lewy Bodies (DLB)

Beyond the scope of this lecture

Question 7

diagnostic criteria

Answer 7

No single laboratory test
(Pathological diagnosis based on Lewy bodies in basal ganglia)

Diagnosis based on clinical exam and presence of 2 out of 3 cardinal symptoms of resting tremor, bradykinesia and rigidity
+ Absence of other cause of Parkinsonism
+ Absence of upper motor neurone signs
+ Response to levodopa (clinical improvement 4-8 weeks)

must be given by a neurologist

Question 8

basal ganglia

Answer 8

Many proposed function 
Not all related to movement 
Different nuclei of BG make loop 
Info from pre motor cortex 
Impulse to striatum 
Made up of caudate and putamen 
Take in signal first 
Message to output nuclei 
Output then to thalamus 
Ventral anterior and ventral lateral nuclei 
Series of inhibitory loops 

Motor plan of body – postural stability plan for standing
To walk – turn off postural control mechanisms and turn on step mechanisms

BG give automatic mechanism ensuring good amplitude movement at the right time

Walking – don’t think about step length
No dopamine – too inhibitied steps are too small
BG not functioning in park –have to use other ways to achieve good movement

excitatory pathways Glutamate
Inhibitory pathways
GABA
Modulatory pathways
Dopamine

Question 9

clinical features

Answer 9

Three cardinal symptoms:
Resting tremor
Bradykinesia
Rigidity

Leading to:
Postural instability and impaired balance reactions
Gait impairment (shuffling, freezing)

Plus many other symptoms and signs

Question 10

resting tremor

Answer 10

Often first symptom noticed

Occurs at rest, diminishes when hands moved
Frequency 4-6 Hz (slow)

Hands affected first, then legs, chin, mouth, tongue
Often unilateral, may progress to other side
Characteristic: flexion of fingers, rotation of
wrist joint (“pill-rolling”)

Question 11

bradykinesia

Answer 11

Slowness of movement
Difficulty with repetitive automatic tasks, e.g. writing, walking, playing music
Limbs have decreased amplitude on all movement tasks

Manifestations:
Micrographia
Shuffling gait
Hyphonia

Tests: finger tap tests - tap finger on table at certain amplitude

hand open / close, heel tapping

speaking - quiet tone
feature of the Parkinson’s disease

Question 12

postural instability

Answer 12

Combined effect of rigidity and bradykinesia

Loss of postural reflexes: anticipatory adjustments and righting reactions

Festination in gait

Also associated with freezing

Question 13

freezing gait

Answer 13

Sudden inability or hesitancy in moving
limbs during gait

Most commonly in gait initiation and
turns

Once freezing is overcome, movement might be normal (“thawing”)

Falls can occur during freezing episodes

FOG = freezing of gait

Question 14

non-motor symptoms

Answer 14

Neuropsychiatric: cognitive impairment, depression, anxiety, psychosis (late stage)
Sleep disturbance
Autonomic dysfunctions: hypotension, urinary dysfunction, sweating
Gastrointenstinal: drooling, dysphagia, nausea, constipation
Sensory: olfactory disturbance, pain, paresthesia
Other: fatigue, weight changes

Non-motor and cognitive symptoms indicate that PD is not just a disease of the basal ganglia, but that cortical functions are also impaired

Question 15

impairments in execute functioning

Answer 15

Internal control of attention
Set shifting: changing attention between one or more stimuli
Planning
Conflict resolution
Concentration
Retaining and using information
Dual task performance
Decision-making (considering advantages and disadvantages of options)
Social interaction (understanding others’ intentions, desires and humour)

Consider the implications for physiotherapy.

Question 16

imaging

Answer 16

MRI and CT no useful

PET studies demonstrate reduced uptake in striatum SPECT can quantitatively measure dopamine in basal ganglia

Question 17

medical management

Answer 17

The goal is to replace Dopamine (DA)

Levodopa = precursor of DA
Converts to DA once it crosses BBB by dopa decarboyxlase (DDC)
Combined with DDC inhibitors to prevent conversion in peripheral tissues

Sinemet = levodopa + carbidopa Madopar = levodopa + benserazide

Gradual introduction of L-Dopa
Maintenance dose 300-600 mg / day
Marked improvement in rigidity and tremor
Less improvement in gait
Side effects
Gastrointestinal Cardiovascular Psychiatric
Half life = 1.5 hours
Best effect after 20-30 mins, can last 8 hours

Question 18

problems with L-dopa

Answer 18

Effectiveness decreases over time

“End-of-dose” deterioration: worsening of motor symptoms before next dose due

Morning dystonia, nocturnal akinesia

Dyskinesias emerge in 50% after 5 years

Question 19

other medication

Answer 19

Dopamine agonists
Apomorphine, rigotine, pramipexole  More side effects than L-dopa  Delay dyskinesias
COMT inhibitors
Catecholamine-O-Methyltransferase
Adjunctive with L-dopa
Monoamine Oxidase B Inhibitors
Anticholingergics
Amantadine

Question 20

surgical treatment

Answer 20

Considered where limits of medication are reached: worsening, non-responsive symptoms

Neurosurgical options: Thalamotomy Pallidotomy
Deep brain stimulation (DBS)

Question 21

assessment

Answer 21

observation Posture
Speech, saliva
management
Tremor
Facial expression

posture and gait Flexion
Shuffling
Freezing
TUG

movement
tone
ROM
strength

Question 22

gait feature

Answer 22

Slowness of movement
Difficulty with gait initiation
Temporal-spatial changes:  Uneven step lengths  Slow speed
Reduced cadence
Increased double support time
Kinematic changes:
Flexed hips and knees
Reduced angular displacement hips /  knees / ankles
Reduced arm swing
Reduced foot clearance

destination
freezing
falls

Question 23

PD symptoms affected by

Answer 23

Constipation
Illness / surgery
Stress episode
Dehydration
Withdrawal / medication change / non compliance
Use of contraindicated medications (neuroleptics)
Depression
Pain
Anxiety, panic attacks
Poor sleep

Question 24

goals of physio

Answer 24

maximise
independence
safety
function

maintain or improve Prevent deconditioning
Maintain strength
Manage bradykinesia, rigidity Reduce falls
Maintain flexibility
Optimise gait
Improve gross motor coordination Maintain balance

Question 25

core areas of physio

Answer 25

gait transfers posture balance exercise strengthen CV balance cognitive movement strategies cueing Tf training LSVT -BIG

Question 26

neuroplasticity

Answer 26

Process of encoding experience in the brain and learning new behaviour through modification of synapses Exercise Planned, structured and repetitive physical activity for the purposes of conditioning any part of the body motor learning practice to induce a relatively permanent change in motor performance and skill

Question 27

strengthening

Answer 27

weakness in PD limbs: quads hams DF PF axial rest swallow and pelvic floor resistance training is effective in PD in improving mobility improving strength and is safe Under-dosing is the standard of care Concentric then eccentric Intensity: 60-70% 1RM, 8-12 reps x 3 sets 6-12 sessions then load increased Frequency 2-3 times per week Duration 8-16 weeks

Question 28

aerobic training

Answer 28

Counteract decreased physical activity Increase exercise capacity  can perform more vigorous activity Increase exercise efficiency  can perform everyday activities with less effort Possible cognitive benefits Potential to decrease cardiovascular risk profile Possible other non-motor benefits (improve sleep, reduce depression and fatigue) Potential for neuroplasticity

Question 29

cues

Answer 29

Off L-dopa: generalised reduction in movement amplitude On L-dopa + cues: marked increase in movement at all joints Evidence for mismatch between cortically selected movement amplitude & actual size of movement due to defective basal ganglia output to SMA & pre-motor cortex Overcome by cues which use a different input system (visual or auditory) RESCUE trial by Neiuwboer (2007) Cues in the home environment Significant improvements in gait speed, step length, freezing (only in freezers), falls efficacy Limitations: Carryover can be low, may need permanent cueing devices Considerations: Identify the best cue: visual or auditory, and tempo / rhythm How to implement: headphones (outdoors – safety), music

Question 30

key points for PT RX

Answer 30

Exercise capacity can be increased with judicious exercise prescription in mild – moderate PD Strength training: Underdosing is the standard of care Cardiovascular training: Consider trade-off between intensity and duration Always exercise “on” medication Consider non-motor symptoms and individual preferences Monitor with HR or RPE

Question 31

exercise options for Parkinson's

Answer 31

``` CV - cycling walking treadmills +/- cues dancing boxing tai chi functional activities LSVT BIG PRE strengthening movement ```

Question 32

movement strategies

Answer 32

Cognitive Use intact frontal cortex: think things through Conscious performance of sub-movements Conscious planning and ending of movement execution Practicing sequences Attentional movement strategies Conscious attention Part practice Mental rehearsal

Question 33

cognitive movement strategies

Answer 33

Sitting Down Approach the chair with firm steps, at good pace Make a wide turn in front of the chair and stop straight in front of the chair. You must have the feeling that you walk around something first (first, practise this, for example, with a cone in front of the chair, later without the cone. If necessary, turn at the rhythm of the cue you already used when you were approaching the chair) Place your calf or back of the knee against the seat Bend slightly forward and bend through the knees, keep your weight well above your feet Move with your hands towards the arms of the chair or the seat, seek for support with your arms Lower yourself in a controlled manner. Sit down well, at the back of the chair.

Question 34

dual tasking

Answer 34

Often a trigger for freezing Deficits in planning of movement Inability to produce and time force Example: draw a triangle while squeezing a ball with your other hand Dual task training when walking is effective in improving step length (Brauer, Morris 2010) Increase dual tasks in difficulty

Question 35

transfers

Answer 35

``` roll in bed lie to sit sit to stand onto floor back up in and out of car ``` training cog movement strategies reps and practice aids bed rail rise recliner raised toilet seat

Question 36

MSK changes

Answer 36

Think of posture: which muscles are in a shortened position? Stretch flexors (gastrocs, hamstrings, hip flexors) Prone lying Thoracic / cervical spine and shoulder girdle BIG exercise strategies

Question 37

family and MDT

Answer 37

``` Patient and caregiver education Support group Occupational therapy Speech and language therapy Diet and nutrition Psychosocial interventions ```

Question 38

later stages

Answer 38

Hoehn and Yahr Stage IV and V: limited mobility Physiotherapy goals and management move towards Maintain and Prevent Continue to manage mobility and maintain activity, e.g. chair- based exercises, active-passive trainers, assisted standing, sitting out Prevent pressure sores and contractures Respiratory management (saliva) Palliative care principles and practice may apply Support the patient, family and carers