Chapter 2: Parkinson's Disease

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dmshaw9
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298115
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Chapter 2: Parkinson's Disease
Updated:
2015-03-10 22:06:19
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Parkinson Disease
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NPTE,Chapter2
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NPTE: Chapter 2
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  1. Definition
    • A chronic, progressive disease of the CNS
    • Degeneration of dopaminergic subtantia nigra neurons and nigrostriatal pathways
  2. Etiology
    • Several different causes identified: 
    • Infectious/postencephalitic
    • Atherosclerosis
    • Idiopathic
    • Toxic
    • Drug induced 

    • Deficiency of dopamine within basal ganglia corpus striatum with degeneration of substantia nigra
    • Loss of inhibitory dopamine → excessive excitatory output from cholinergic system (acetylcholine) of basal ganglia
  3. Characteristics
    • Rigidity (leadpipe or cogwheel)
    • Bradykinesia (hypokinesia)
    • Resting tremor
    • Impaired postural reflexes
    • Slowly progressive with emergence of secondary impairments and permanent dysfunction
  4. Stages
    • I: minimal or absent disability, unilateral symptoms
    • II: minimal bilateral or midline involvement, no balance involvement
    • III: impaired balance, some restrictions in activity
    • IV: all symptoms present and severe, stands and walks only with assistance
    • V: confined to bed/WC
  5. History
    • Symptoms
    • Disease progression
    • Functional deficits
  6. Cognitive/Behavioral Status
    • Intellectual impairment/dementia occurs in advanced stages
    • Memory deficits
    • Bradyphrenia (slowing of thought processes)
    • Depression
  7. Examination: Communication
    • Dysarthria
    • Hypophonia (decreased volume)
    • Mutism (in advanced stages
    • Mask-like face with infrequent blinking and expression
    • Writing progressively smaller
  8. Examination: Oromotor Control/Nutritional Status
    • Dysphagia common
    • Problems chewing and swallowing
  9. Examination: Respiratory Status
    • Breathing patterns
    • Vital capacity 
    • Decreased chest expansion
  10. Examination: ROM/Deformity
    • Contractures common in flexors and adductors
    • Persistent posturing in kyphosis with forward head
    • Many its osteoporotic with high risk of fracture
  11. Examination: Sensation/Perceptual Function
    • Aching/stiffness
    • Abnormal sensations (cramp-like, poorly localized)
    • Problems in spatial organization, perception of vertical
    • Extreme restlessness (akathisia)
  12. Examination: Vision
    • Blurring
    • Cogwheeling eye pursuit
    • Eye irritation from decreased blinking
    • Decreased pupillary reflexes
  13. Examination: Skin Integrity and Circulatory Changes
    • Edema may occur in LE's
    • Increased sweating (ANS dysfunction)
    • Decubitus ulcers in late stages
  14. Examination: Muscle Tone, Strength, and Motor Function
    • Rigidity
    • Weakness (associated with disuse and atrophy)
    • Bradykinesia/akinesia
    • Ability to initiate movement (freezing)
    • Reaction time vs movement time
    • Tremor/pill-rolling (resting, during movement may occur in advanced stages)
  15. Examination: Balance
    Impaired postural reactions common (worse with severe rigidity of trunk, lack of trunk rotation)
  16. Examination: Gait
    • Generalized lack of extension
    • Festination common (abnormal, involuntary increase in the speed of walking, often with forward acceleration - may occur with backward progression)
  17. Patients on Levodopa
    • Examine for fluctuations in symptoms related to dosing (end of dose deterioration, on-off phenomenon, dyskinesia)
    • Common with disease progression and long-term use of levodopa (2-3 years)
  18. Standardized Tests and Measures
    • Revised Unified Rating Scale for Parkinsonism: documents overall effects of disease on individual
    • Parkinson's Disease Questionnaire: QOL questionnaire that focuses on subjective report of impact of Parkinson's disease on daily life
  19. Medical Management
    • Sinemet (levodopa/carbidopa) or sustained-release Sinemet: provides dopamine (crosses blood-brain barrier) and decreases effects of disease 
    • Dopamine agonist drugs: enhance effects of Sinemet therapy
    • Anticholinergic drugs: for control of tremor
    • Amantadine: enhances dopamine release 
    • Selegiline (deprenyl): monoamine oxidase inhibitor increases dopamine, used during early disease to slow profession
    • Deep brain stimulation in thalamus or subthalamic nucleus 
  20. Sinemet Adverse Effects
    • Nausea and vomiting
    • Orthostatic hypotension
    • Cardiac arrhythmias 
    • Involuntary movements (dyskinesias) 
    • Psychoses and abnormal behaviors (hallucinations)
    • On-off phenomenon - its experience sudden changes from normal function to immobility to severe dyskinetic movements
  21. PT Goals, Outcomes, and Interventions
    • Monitor changes associated with disease progression and pharmacological interventions 
    • Prevent/minimize secondary impairments associated with disuse and inactivity 
    • Teach compensatory strategies to initiate movement (unlock freezing episode), repetitive auditory stimulation
    • Improve strength, improve overall mobility, rotational patterns (PNF, rhythmic initiation)
    • Improve postural control and balance
    • Improve gait
    • Promote independence in FMS and ADLs
    • Improve cardiovascular endurance
    • Teach energy conservation

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