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Parkinson’s Disease

Clin Med II

After what age do people normally get Parkinson's Disease? It is typically diagnosed after age 50.
What kind of disease is Parkinson's Disease? Is is a slow, chronic, progressive disease of the CNS.
How is Parkinson's Disease characterized? The disease is characterized by movement, though it does effect more than this.
How does Parkinson's Disease begin? It begins unilaterally and progresses to bilateral involvement
What is the incidence rate for Parkinson's? "It affects 1% of adults over the age of 65 3:2 male to female ratio 0.2% of the general population"
Parkinson's Disease is the most common _______ disorder of the elderly. Neurological (most common neurological disorder of the elderly)
Among neurodegenerative diseases, Parkinson's is 2nd only to? Alzheimer's
What area of the brain does Parkinson's Disease effect? This neurodegenerative disease affects the Basal Ganglia
What is the Basal Ganglia made of? It consists of 5 nuclei
Which part of the Basal Ganglia has the largest effect on movement? The substantia nigra
How does the substantia nigra help to control movement? "It helps control movement to be smooth and coordinated It has both input and output to the cortex."
What happens when the substantia nigra is damaged? "When damaged you will have impairments in motor, behavior, and cognition It is not strictly a movement disorder."
Name 5 other associated diseases with the Basal Ganglia. Huntington's Corea, Tourette's disorder, Obsessive Compulsive Disorder, Attention-deficit hyperactivity disorder, Tardive dyskinesia
What is Huntington's Chorea? "corea and dementia, it affects movement and behavior It causes involuntary dance-like movements that are fluid and uncontrolled."
What is Tourette's Syndrome? "motor and vocal tics motor can be facial"
What is Tardive dyskinesia? "involuntary repetitive movements caused by long term use of antipsychotic meds meds can mimic symptoms of Parkinson's Disease"
What is dyskinesia? involuntary movement, often in the face involving the tongue and blinking
Why might PT be called to the psych ward? to evaluate a pt for fall risk
What causes the symptoms of Parkinson's Disease? Cell death int he substantia nigra and depletion of dopamine
How far progressed is Parkinson's Disease by the time the pt becomes symptomatic? 80-90% of the dopamine has already been depleted.
What imbalance does dopamine depletion cause? it affects the neural transmitter balance, as dopamine is depleted and acetylcholine goes unchecked as a result.
How does dopamine normally perform? It serves as a chemical messenger allowing communication between the substantia nigra and the corpus striatum. This coordinates smooth and balanced muscle movement
What is the primary cause of symptoms for Parkinson's Disease? Loss of dopamine producing cells is the primary cause of symptoms.
What is the most common form of Parkinson's Disease? Idiopathic is the most common form of the disease.
How many cases of Parkinson's Disease have a genetic link? 5-10% of the cases for this disease have a genetic link.
What is an Environmental Factor? Factors that mimic symptoms of a disease.
What are the 3 Environmental Factors for Parkinson's Disease? toxins, free radicals, and infections are Environmental Factors for this disease
What are toxins for Parkinson's Disease? Can be heroin, CO, manganese, cyanide for Parkinson's Disease
"What are 2 types of Parkinson's Disease? (not idiopathic or familial)" Pharmalogical and Metabolic are 2 types of this disease.
What is Pharmalogical Parkinson's Disease? It is caused by an adverse drug reaction (ADR), and is usually reversible with immediate discontinuation of the drug in question.
What is Metabolic Parkinson's Disease? "It involves disorders of calcium metabolism such as hypoparathyroidism It is rare and can go untreated for a long time, needs to be ruled out by the doctor"
What are 4 primary clinical features of Parkinson's Disease? Rigidity, Bradykinesia/akinesia, Resting Tremor, Postural Instability
What is Rigidity? A person can get stuck in a certain position. They can't easily bend or straighten.
What is Bradykinesia? "A slowness of movement which progresses to no movement If everything is stiff, it won't move easily"
What is Postural Instability? "The pt can't react in time if nudged or shoved, and can go down easily. This makes the pt a high fall risk. If they lose balance while walking, they can't react in time to catch themselves"
How will rigidity affect the trunk? It causes shallow breathing.
What muscles does rigidity affect throughout ROM? It affects both the agonist and antagonist throughout ROM.
How should PROM be performed on a Parkinson's pt? PROM should be performed slowly on these pts.
What is cogwheel rigidity? It is a ratchet like movement throughout ROM.
What is lead pipe rigidity? It is a constant slow resistive bend.
What results from prolonged rigidity? pt can get joint contractures and postural deformities.
How does bradykinesia present? "Delays in initiation of movement Decline in coordination Decline in reciprocal movement Reduction in force production (delay in muscle recruitment)"
What is a resting tremor? 4-7 involuntary oscillations per second that cease away with voluntary movement.
Where does a resting tremor primarily occur? It primarily occurs in the hands as "pill rolling".
What are secondary resting tremors? They can occur secondarily in the head, lips, tongue, jaw and foot.
How many Parkinson's pts will have a resting tremor? Approximately 50-70% of these pts will have a resting tremor.
When do resting tremors decrease in presence? "They decrease with voluntary movement and relaxed states. They are absent during sleep. vs. an intention tremor (cerebellar dysfunction) or essential tremor (familial disorder) which show up with volitional movement and does not occur at rest"
What causes resting tremors to increase? They increase with stress, excitement, and fatigue.
What are signs of Postural Instability? pt will have difficulty perceiving upright posture, and will have impaired balance reactions.
How will Postural Instability affect daily living? pt will have deficits with walking, turning, and standing.
What is postural dysfunction? It is a decreased ROM.
How will postural dysfunction affect the pt? pt will have a decrease in extension of the hips, knees, and ankles. In the trunk and cervical spine pts have difficulty with extension, rotation, and lateral flexion
What position should you encourage a Parkinson's pt to sleep in? Encourage these pts to lay flat in bed when they sleep.
What position is a Parkinson's pt generally stuck in? pt is generally stuck in flexion
What are common characteristics of gait in pts with Parkinson's Disease? They lack reciprocal arm swing and have a festination in their gait.
How do Parkinson's pts move their feet? They move their feet in short, shuffling steps that get more rapid. They will have trouble initiating movement and then lose control; taking fast, tiny steps. Their feet don't leave the floor. (propulsion and retropulsion)
How are Parkinson's pts with facial expression? They have a lack of expression with a reduced blinking reflex. Their faces often appear "mask-like".
How does Parkinson's affect a pt's ability to swallow? 50% of pts have dysphagia.
What effect does dysphagia have on the overall health of a pt? It can cause weight loss, malnutrition, and aspiration.
What might a Parkinson's pt have in place to combat the effects of dysphagia? "They may have a G-tube into the stomach or a J-tube into the jejunum (if prone to acid reflux). Placement requires a surgical procedure, so pt may temporarily have an NG tube. pt cannot lay flat, and also cannot work with pt until placemen
What speech impairments might Parkinson's pts have? pts may present with dysarthria, hyppophonia, monotone, or mutism.
What is dysarthria? It is a lack of motor control that presents with slurred speech.
What is hypophonia? "pt speak at a reduced volume. It is a result of having a rigid trunk. They can't get enough air in to make noise across the vocal cords."
What does it mean to speak monotone? They lack the ability to modulate their tone.
What causes mutism? pt can't take in enough air to speak.
What are the autonomic nervous system impairments of Parkinson's Disease? Impairment causes hyperhydrosis (increased perspiration), increased salivation (drool), poor core temperature regulation, bladder dysfunction, depressed appetite, depressed GI motility, CV abnormalities (cardiovascular - OHTN, arrhythmia).
What are 3 secondary clinical features of Parkinson's Disease? Secondary clinical features include sleep disturbances and fatigue (80%), visual pursuit deficits, and cognitive changes
What cognitive changes might a Parkinson's pt experience? "Dementia affects 40% within 4 yrs, 92% within 8 yrs Depression and anxiety affect 25-30%"
What kind of task do Parkinson's pts have difficulty performing? They have difficulty performing two step tasks.
What are 7 secondary impairments of Parkinson's Disease? Secondary impairments include musculoskeletal deconditioning, contractures, postural deformities (thoracic kyphosis, FHP), osteoporosis (pt is sedentary), pulmonary (aspiration pneumonia), skin (decubitis ulcers), circulatory (not activating calf muscles
What can infection lead to in Parkinson's pts? Infection could lead to sepsis and then death.
How is Parkinson's Disease diagnosed? It is diagnosed with a history and clinical exam focusing on movement, balance, and coordination.
What differential diagnostic tests will appear normal for Parkinson's Disease? EEG, CAT Scan, MRI, and diagnostic lab tests will appear normal for these pts.
What challenge does dopamine present with drug therapy? It does not cross the blood brain barrier (BBB) which is problematic for drug therapy.
How does neurotransmitter replacement therapy help Parkinson's pts? It reduces the motor symptoms in Parkinson's pts.
What disease is treatment/therapy for Parkinson's Disease similar to? "Insulin for diabetes Myelitus reduces symptoms, but is not a cure, nor will it slow the progression of the disease. It is similar to the treatment/therapy of this neurodegenerative disease."
What can long term use of neurotransmitter replacement therapy cause? Long term use can cause dyskinesia.
What is Levadopa? It is a precursor to dopamine that can cross the BBB. It dramatically reduces symptoms of Parkinson's Disease.
What symptoms is Levadopa most effective in reducing? This drug is most effective at reducing bradykinesia and rigidity.
What symptoms is Levadopa least effective in reducing? This drug is least effective at reducing tremors and postural instability.
How is Levadopa taken? It is taken orally.
When is Levadopa at its peak effectiveness? This drug is at its peak effectiveness one hour after it is taken.
What converts L-dopa into dopamine? Dopadecarboxylase converts this drug into dopamine.
How much of the L-dopa ingested will cross the BBB? About 3% of this drug will cross the BBB.
What drug is used in conjunction with L-dopa? It is used in conjunction with carbidopa.
What is Carbidopa? It is a decarboxylase inhibitor that reduces peripheral conversion of L-dopa into dopamine.
How is Carbidopa helpful? "It allows L-dopa to stay in the periphery longer, so more L-dopa is able to cross the BBB. It reduces side effects of elevated dopamine in the periphery"
What is the Gold Standard in Rx for Parkinson's Disease? Sinement the Gold Standard Rx for this disease.
What is Sinement made up of? It is L-dopa + Carbidopa.
What happens with prolonged use of Sinemet? There is a diminish response to the drug with prolonged usage of 4-5 yrs.
What side effects does Sinemet cause? The drug can cause GI disturbances (nausea, diarrhea), arrhythmias, OHTN, dyskinesia (long term use), mental changes (psychotropic effects - depression, anxiety, confusion, hallucinations),
What is End Dose akinesia? When the effectiveness of the drug wheres off before the next dose (everyone).
How do they remedy End Dose akinesia? They can increase the dose, use sustained release sinemet, or add other classes of meds.
What is the On-Off Phenomenon? It is a spontaneous diminished response to Sinemet (not everyone).
What is a "Drug Holiday"? When there is a sudden increase in side effects, along with a lose of the effectiveness of L-dopa, they will remove all drugs and hope to return to L-dopa at a lower level.
What is a Dopamine Agonist? A drug developed to stimulate receptor sites for dopamine.
Who uses a Dopamine Agonist? It is used in young, cognitively intact, pts in the early stages of the disease only.
Why isn't a Dopamine Agonist used more broadly? It has no effect on late stages when complete cell death has occurred.
What are the side effects of Dopamine Agonists? Side effects include confusion, hallucinations, impulsivity, GI disturbances, and OHTN.
What are Dopamine Agonists used in conjunction with? They are used in conjunction with Sinement.
Name 4 of the Dopamine Agonists? Bromocriptine, pramiprexole, ropinirole, apomorphine
What does COMT stand for? Catechol-o-methyltransferase (an inhibitor - newest class of drugs approved for Parkinson's)
What does COMT do? It blocks metabolism of L-dopa, prolonging its effect.
When is COMT prescribed? It is prescribed when L-dopa becomes less effective by itself.
What are adverse effects for COMT? It can cause GI disturbances and effect liver function.
What is Amantidine? It is an antiviral drug that increases the release of dopamine from nerve terminals
How does Amantidine help in the Early stages of Parkinson's Disease? Amantidine helps to reduce tremors in this stage of Parkinson's Disease.
How does Amantidine help in Late stages of Parkinson's Disease? "Amantidine reduces dyskinesia in this stage of Parkinson's Disease.a side effect from long term use of L-dopa"
Are there any adverse effects to Amantidine? It can cause constipation, hallucinations, and rash.
What is a MOA-B inhibitor? "It is a drug that prevents the enzyme, MOA-B, from breaking down L-dopa. a precursor for dopamine"
How effective is a MOA-B inhibitor? It can prolong the dopamine effect by 10-25%.
When is a MOA-B inhibitor used in Parkinson's pts? It is used in the early stages of Parkinson's Disease. It can be an early substitute for L-dopa (?).
What is another potential benefit of MOA-B inhibitors? It is thought to slow the progression of PD. It has a neuro protective effect.
Name 2 MOA-B inhibitors. Rasagiline, Selegiline
What Anticholinergic drugs are used? Acetylecholine blockers are used, as ach goes unchecked without dopamine.
What are Acetylcholine blockers used in conjunction with? They are used in conjunction with L-dopa.
What do Acetylcholine blockers have the biggest effect on? It is mostly effective with tremor.
Are Acetylcholine blockers used regularly? No, it is not used regularly due to availability of better drugs.
Are there any adverse effects to Acetylcholine blockers? They can cause mood changes, drowsiness, hallucinations, cardiac irregularities, and GI disturbances.
What indicates the need for surgical management in Parkinson's pts? It is indicated when Parkinson's symptoms are not adequately managed by drugs.
What are the 4 surgical options for Parkinson's Disease? Stereotactic Thalamotomy, Deep Brain Stimulation (DBS), Fetal cell implant (experimental), Gene Therapy (NY Presbyterian)
How does Gene Therapy in Parkinson's pts work? It packs genes that make GABA into non-infections viruses and inserts them into the brain
What is Stereotactic Thalamotomy? It is the surgical lesion of the Thalamus using 3-D localization.
How is Stereotactic Thalamotomy performed? The pt is awake for the procedure. They need to make sure they lesion the correct area.
How do they reduce adverse effects of a Stereotactic Thalamotomy? They perform a unilateral lesion.
What effect does a Deep Brain Stimulation have? It reduces medication requirements by decreasing tremors, rigidity, and dyskinesia. IT has benefit up to 3 yrs.
How much improvement is expected from Stereotactic Thalamotomy? 86% improvement for 2-6 yrs, with reduced tremors, increased muscle activation, and improved balance
What is Deep Brain Stimulation? It is the stimulation of the thalamus, subthalamus, or globus pallidus to block electrical signals from these areas.
How is Deep Brain Stimulation performed? They surgically implant an electronic neuro stimulator.
What does research show about DBS? Research indicates that pts have reduced symptoms when used in conjunction with medications.
What PT interventions help Parkinson's pts (backed by research)? "Gait training, task specific training, strengthening, and cardiovascular endurance training strengthening needs to be task specific with lots of training"
What does research show in regard to Parkinson's Disease and exercise? It has been shown to delay the onset of more symptoms, so the sooner the better, and the harder the better. It has been shown to improve quality of life, gait speed, and strength.
What kind of direction do Parkinson's pts respond best to? They respond well to visual and audible cues.
How can visual cues be implemented? We can use sensory cuing and integration. We want to minimize distractions in the environment (clear pathways) and use visual cuing to enhance gait velocity and stride length (short term effect; laser cane; perpendicula
How can auditory cues help with Parkinson's pts? Auditory cuing can effect gait speed and cadence. There is rhythmic auditory stimulation.
What kind of commands will help Parkinson's pts? Use simple, not complex commands. Cue ahead of time, so they can plan (pts don't react quickly). Use external over internal cues.
Name 11 rehabilitation indications Strength training, ROM, Flexibility, Endurance training, Balance training, Functional training, Postural training, pt/family education, Respiratory management, w/c management, adaptive equipment
What is the special walker designed for Parkinson's pts? USTEP Walking Stabilizer is heavier, turns more easily, and has hand breaks that you squeeze to permit movement instead of breaking. It also has knobs that can be adjusted to regulate walking speed.
Should you let the Parkinson's pt select the level of exercise? No, there have been more benefits shown from "forced exercise" that is above self-selected levels of exercise.
When is it best to schedule PT? In the morning, one hour after they have taken their medication. The drug is at its peak effectiveness, and pts are less fatigued, less symptomatic, so they can gain the maximum benefits.
Why should you monitor vitals of Parkinson's pts? Many have OHTN, so vitals will change with postural changes in positions. you need to be ready to catch, have a reclining chair next to the bed, and give them time to adjust by sitting on the edge of the bed
What are Parkinson's pts at increased risk for? Falls.
What is the largest symptom PTs are contending with for Parkinson's Disease? We want to combat the effects of immobility.
What 6 outcome measures are used most with Parkinson's Disease? "Unified Parkinson's Disease Rating Scale (42 categories assessed during On and Off periods), Modified Hoehn and Yang Staging (0-5 stages from no signs to w/c bound)6 minute walk test, Functional Reach, FIM, etcBerg, Tinetti, and TUG (tested for validity
Where can pts find free public resources? "www.parkinsons.orgExercise/Fitness, ADL Modifications, Speech/Swallowing, Mind/Mood/Memory, Nutrition, Medications"
Where can PTs go for free Continuing Education online courses? APTA Learning Center has 4 courses.
Created by: Susie234



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