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Which ADL is most affected due to rigidity in PD?
- Cogwheel
- Lead pipe
- Unilateral, bilateral, or axial
- Proximal or distal
- Upper vs. lower extremity
Rigidity
- Arm swing
- Trunk rotation
- Trendelenburg
- Foot clearance
- Cadence
- Step length
- Base of support
- Deviation of trajectory
- Ability to stop, start, turn
Gait assessment
Scoring:
- Scale from 0 = normal to 4 = severe
- Higher scores indicate greater impact of PD symptoms
Time to administer: 30 minutes
Part I: non-motor experiences of daily living
Part II: motor experiences of daily living
Part III: motor examination
Part IV: motor compliances (movement disorders)
Movement disorders society - unified Parkinson's disease rating scale (MDS-UPDRS)
- Festination
- Freezing
- Retropulsion
- backwards
- side stepping
- Add a cognitive task
Gait assessment for PD
- MDS UPDRS
- 6 minute walk test
- 10 meter walk test
- Mini BESTest
- PDQ-8 or PDQ-39
- FGA
- Sit to stand 5 times
- 9 hole peg test
- Freezing of gait questionnaire
- Parkinson's fatigue scale
- ABC scale
- TUG
Outcome measures specific to PD
A type of rigidity that is a jerky motion characterized by a catch and release
Cogwheel
- A blockade of or interference with dopamine's action in the BG
- Vascular
- head trauma
- carbon monoxide poisoning
- Drug use
- environmental toxins
- Brain inflammation, viral infections
Secondary parkinsonism
Which type of rigidity is throughout the whole movement?
Lead pipe
- 16 item test to assess multiple cognitive domains
- Time to administer: 10 minutes
- Total possible score: 30
- PD - mild cognitive impairment: <26/30
- PD - dementia: <22/30
Montreal cognitive assessment (MoCA)
Health related QOL
Domains: mobility, ADLs, emotional well-being, stigma, social support, cognition, communication, bodily discomfort
Scoring:
MCID on PDQ-8: about 6 points
PDQ
- Most common atypical parkinsonism
- Tauopathy: accumulation of Tau protein in brain
- Onset: usually in mid 60's
- Disease duration: 5-6 years
- Lots of visual changes
- Do not find out about this until autopsy
Progressive supranuclear palsy
What is one of the main things we need to check for secondary parkinsonism?
Looking at vision issues
- Eye movement dysfunction
- Upper motor neuron signs
- Cerebellar signs: dysmetria, ataxia
- Autonomic dysfunction:
- Orthostatic hypotension
- Urinary incontinence
- Early onset/rapid progression (length of disease is much shorter 5-7years)
- Falls
- Dementia
- Poor response to dopamine replacement meds
Differential diagnosis
- 14 item test scored on a 3 level ordinal scale
- components
- anticipatory postural adjustments
- Reactive postural control
- Sensory orientation
- dynamic gait
- Scored out of 28 points
- Fall risk: < 20/32
- MCD: 5.5 points
Mini Balance evaluation systems test (Mini BesTest)
- Cerebral atrophy of the parietal cortex and substantia nigra
- can be seen on MRI
- Asymmetrical
- Tauopathy: tau aggregates in astrocytes
- Progression: gradual and slow
- onset: around 60 yo
Corticobasal degeneration (CBD)
- Parkinsonian features: rigidity, bradykinesia, tremor
- Shuffling gait, instability, frequent falls
- Cognitive impairments occurs early
- Hallucinations
- depression, paranoid ideation
- Dopamine replacement medications increases hallucinations
- Antipsychotics worsen PD motor symptoms
LBD impairments
- Asymmetric
- Early posture and gait impairment
- Ideomotor and ideational apraxia
- Neglect
- Early and progressive cognitive disorder
- Aphasia
- Astereognosis and agraphesthesia
- eye movements limited in horizontal and upward gaze
- can present like stroke
- 30% will have alien limb syndrome -- arm will just move without the patient noticing
CBD impairments
- Overproduction of alpha synuclein protein in the brain
- Causes more widespread atrophy in the brain: basal ganglia, cerebellum, brainstem
- Onset: 30-60 years old with average being 54 years
- Poor prognosis
- Cognitive deficits are less common
Multiple systems atrophy (MSA)
- Limited vertical eye movement
- Limited blinking
- Light sensitivity
- Loss of righting reactions: RETROPULSION
- Severe axial rigidity
- Extensor tone
- Wide base
- Dysphasia and dysarthria
- Cognitive dysfunction and emotional lability
PSP (progressive supranuclear palsy) impairments
- Dysautonomia
- Orthostatic hypotension, supine hypertension
- Urinary and sexual dysfunction
- Respiratory and breathing problems
-Pisa syndrome: frequent falls (they are in a lateral shift and think it is upright)
- MSA-P: symptoms are similar to PD
- MSA-C: Gait and limb ataxia, wide base of support, irregular tremor
MSA impairments
- Involuntary muscle contractions that cause slow repetitive movements or abnormal posturing
- Opposing muscles contract simultaneously
- Subgroups: idiopathic, genetic, acquired
- Chronic disorder
- Anatomic distribution
-Focal: cervical, limb
- Generalized: whole body (usually genetic and in younger people)
Dystonia
- Posture
- Tricks - how can they get it to relax
- Positions of comfort
- frequency
- Duration
- Pain
- Speech and swallow
- Toronto Western Spasmodic Torticollis Rating Scale
Dystonia screening
- Most common movement disorder
- Most common > 40 yo
- Can affect any part of the body
- Tremors worsen with movement
- Common complaints include difficulties with IADLs
- With disease progression, can see more gait and balance impairments
- Pharmacological treatments: beta blockers, anti-seizure, tranquilizers
- Surgical treatment: deep brain stimulation
Essential tremor
- Second most frequent cause of major neurocognitive disorder in the elderly
- Lewy bodies found in the cortex and subcortical areas
- Lewy bodies also contain deposits of alpha synuclein
- Difficult to distinguish from Alzheimer Disease
- Slowly progressive
Lewy body dementia (LBD)