Parkinson's Disease

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Parkinson's Disease
2014-05-03 17:42:16

review of Parkinson's disease lecture 4-18
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  1. The incidence of Parkinson's Disease ______ w/ age.
  2. The median age of onset for all forms is:
    61.6 years
  3. Onset before age 30 is rare, but up to __ of cases of idiopathic PD begin by age 40.
  4. What is the largest risk factor for Parkinson's disease?
    advancing age
  5. Do men or women have an elevated risk of Parkinson's disease?
  6. Individuals w/ a first-degree relative affected by PD are estimated to have a _____ risk for developing PD.
  7. The single factor that has been most consistently associated w/ a reduced risk of PD is...
    cigarette smoking
  8. ______ consumption is associated w/ a reduced incidence in men and women.
  9. PD may be due in the vast majority of cases to the interactions of...
    genes and the environment
  10. Environmental causes are presumed to be one or more ubiquitous but weak toxins, whose cumulative effects lead to:
    disease in genetically predisposed individuals
  11. The risk of PD is increased by rural living, exposure to well water, and agricultural work, suggesting that...
    pesticides and/or herbicides may cause or contribute to PD
  12. Primary cause:
    • degeneration of dopaminergic neurons in substantia negra in the mid brain
    • visible in brain sections as depigmentation of substantia nigra in the midbrain
    • results in severe loss of NT dopamine
  13. What is dopamine responsible for?
    smooth and coordinated movement (among other things)
  14. Neurological Basis:
    • asymmetric loss of dopamine terminals, which progresses over time leading to further clinical deterioration
    • normally: balance b/w dopamine and acetylcholine in the basal ganglia
  15. decreased dopamine in increased ACH
    • Parkinson's
    • 60% to 70% of the SN dopamine cells are lost by the time pt first notices a problem
  16. Changes in projections:
    • exhibit tremor, rigidity/stiffness, and bradykinesia/slowed movements
    • degeneration of dopamine projections leads to alteration in the pathways of basal ganglia
    • causes decrease in inhibitory response from basal ganglia
  17. idiopathic PD characteristically starts on one side of the body, and remains...
    more severe on that side throughout the course
  18. Symptoms of PD
    • difficulty w/ everyday function
    • anxiety depression, social isolation
  19. Symptom:
    difficulty w/ everyday function
    • postural instability
    • constipation
    • difficulty swallowing
    • choking, coughing, or drooling
    • excessive salivation
    • excessive sweating
    • loss of bowel and/or bladder control
    • loss of intellectual capacity
    • anxiety, depression, isolation
    • scaling, dry skin on face or scalp
    • slow response to questions
    • small cramped handwriting
    • soft, whispery voice
    • decreased cognitive function
  20. OT Goals:
    • self management of disease
    • empowerment to prevent psychosocial impact
    • improve ability to carry out ADL and IADL
    • correct postural instability
    • maintain flexibility and strenght
  21. Diagnosis of PD:
    • like many other diseases...this is a disease of exclusion
    • if CT/MRI show no other disorder; if spinal fluid, urine, and blood work is all negative
    • and if pt has the 3 major signs of PD
    • the definitive test is a pt's reaction to dopamine drugs
  22. Tremor
    resting "pill rolling" tremor
  23. Direct or Primary Impairments of PD Pathology
    • muscle rigidity (cogwheeling, leadpipe)
    • hypokinesia (bradykinesia)
    • resting or "pill rolling" tremor
    • motor "freezing" during movement
    • loss of motor planning ability
    • visuoperceptive dysfunction
    • postural instability
  24. Depression
    • affects about 40%
    • develops w/ motor deficits
    • sensory deprivation causes behavioral changes
    • drug-related psychoses
  25. Cardiopulmonary complications:
    • orthostatic hypertension
    • cardiac arrythmias
    • airway dysfunciton-aspiration pneumonitis
    • venous pooling in LE
  26. Disease course
    slowly progressive w/ long subclinical period before DX is made 15-20 years after DX most are quite disabled
  27. Assessments and Outcome Measures
    • need to have accurate assessment of functional and psychosocial status of pts to formulate tx programs
    • need to accurately and appropriately quantify measures used in research studies to determine efficacy of tx
    • fluctuating symptoms and abilities experienced by pts related to disease, medication, and side effects challenge the reliability and validity of testing measures
    • no single measure is able to comprehensively assess all aspects of disease
    • present measures target more specific aspects of disease, such as motor function, ADL, quality of life, psychosocial status
  28. Assessing Disease Progression
    • Parkinson's Disease Questionnaire (PDQ)
    • UPDRS - Unified Parkinson's Disease Rating Scale
    • Modified Hoeh and Yahr Scale
    • Schwab and England ADL Scale
  29. Unified Parkinson's Disease Rating Scale (UPDRS)
    • most widely used scale
    • considered gold standard
    • four parts
    • -mentation, behavior, mood (cognition, motivation)
    • -ADL - speech, handwriting, dressing
    • -Motor - tremor, rigidity, posture, gait
    • -Complications of therapy - dyskinesia, motor fluctuations
  30. Strengths of UPDRS:
    • comprehensive coverage of motor symptoms
    • most tested of all the scales
    • standardized ratings allow good communication among clinicians
    • excellent test-retest reliability
    • video available to train raters
  31. Weaknesses of UPDRS
    • floor effects - limits sensitivity in mild disease
    • ambiguous wording of instructions
    • failure to cover some symptoms (anxiety, sexual dysfunction, fatigue)
    • ADL scale unclear as it measures things not always associated w/ ADL
  32. Hoehn and Yahr Disability Index
    • quantifies severity of PD by classifying the disease into 6 stages:
    • 0=no clinical signs evident
    • 1=unilateral involvement
    • 2=bilateral involvement only
    • 3=first evidence of impaired postural and righting reflexes by exam or history
    • 4=fully developed severe disease; disability marked
    • 5=confinement to bed or WC
  33. Strengths of Hoehn and Yahr Disability Index
    • quick to score
    • administered in any setting
    • widely used and accepted
    • stages correlate w/ neuroimaging of dopaminergic loss
    • guides theapy
  34. Weaknesses of Hoehn and Yahr Disability Index
    • mixes impairments and disability
    • nonlinear
    • does not address non-motor problems
    • reliability and validity studies are limited
  35. **PD stage 1:
    • mild disability, usually unilateral
    • more inconvenient than disabling
    • pts usually able to continue regular work and activities w/ minimal accommodation
  36. **PD Stage 2
    • bilateral symptoms
    • both posture and gait are affected
    • shuffling, festinating gait
    • minimal disability
  37. **PD stage 3
    • moderately severe generalized dysfunction
    • significant slowness
    • equilibrium impairments in standing and walking
  38. **PD Stage 4:
    • significant disability requiring assistance w/ ADLs
    • increased bradykinesia
    • increased postural instability
    • rigidity
    • festinating gait
  39. **PD Stage 5:
    • completely dependent for ADLs
    • may not be able to stand and walk, even w/ assistance
    • difficulty swallowing
    • communication deficit
    • 20% have dementia
  40. Stereotactic Surgery:
    • surgical interruption of basal ganglia circuits
    • -pallidotomy
    • -thalamotomy
    • -deep brain stimulation (DBS)
  41. Therapy intervention:
    • not enough evidence to prove or disprove benefit of therapy
    • no consensus of best practice
  42. Principles of Intervention for PD:
    • perform client-centered assessment and intervention
    • prevent activities and roles being restricted or lost, and develop appropriate coping strategies when needed
    • support what the person needs and wants to do
    • develop goals in collaboration w/ the individual based on their perceived strengths and deficits
    • design and implement a plan to improve performance and participation including altering the activity demands, modifying the environment, or teaching compensation/adaptation
  43. Promoting Self-Management
    • using a problem solving approach to work toward solutions to self-identified issues
    • develop insight into their disease process
    • learn to anticipate problems and how to deal w/ them
    • education, coaching, encouragement
    • empowerment
  44. Promoting performance
    • difficulty w/ dividing and switching attnetion
    • benefits from explicit learning strategies
    • -use focused attention
    • -step-by-step instructions
    • -one thing at a time
    • -instructions before and after performing the task not during
    • -need for more time and practice
  45. Cuing strategies
    visual or verbal cues:
    • auditory: walkman, metronome, counting
    • visual: step over stripes on the floor; focus on object
    • tactile: tap the hip or knee
    • cognitive: mental picture of appropriate step length
  46. LSVT Beginnings - LOUD
    • Lee Silverman Voice Treatment
    • Intensive amplitude-based exercise program for the speech motor system
    • -sustained ah
    • high and low ah
    • functional phrases
    • hierarchy
  47. What is the single focus of LSVT BIG?
  48. cognitive movement strategies:
    • complex cognitive strategies are substituted for more automatic movement pattern that is missing
    • re-organize movements to perform activity cognitively
    • can guide own movements
  49. Work on balance:
    • emphasize visual and vestibular feedback
    • combine w/ leg strengthening to improve efficiency of motor balance strategies
  50. Physical capacity:
    • ROM
    • Stretching
    • functional mobility and ADL training
    • strength training
  51. Be creative:
    • Tai Chi
    • Group exercise that makes work fun
    • dance therapy
    • bicycle therapy
    • supported bodyweight treadmill training
    • function!!!
  52. Summary of tx evidence:
    • instruct in individualized HEP prior to discharge
    • task specific interventions appear most effective for pts w/ PD
    • lower limb weakness can contribute to functional mobility losses, so strengthening exercises considered to be beneficial