N
differential diagnosis:
- not secondary to any known cause
- shows a sustained +response to dopaminergic medicine
-Lewy bodies are only seen in basal ganglia
idiopathic parkinsons
differential diagnosis related disorders:
Symmetrical onset, incontinence and orthostatic hypotension are early signs
Tremor is rare, dysmetric, UMN and LMN signs, vocal cord paresis is common, Shy-Drager syndrome, striatonigral degeneration, olivopontocerebellar atrophy.
Does NOT respond to dopaminergic meds
multiple sclerosis
what happens when there is not sufficient dopamine?
increased inhibition of the thalamus leads to movement deficits
describe rigidity including the different types (cogwheel, lead pipe, dystonia)
Made worse with active movement, mental concentration, emotional tension
Increase in muscle tone
Cogwheel rigidity: combo of rigidity and tremor results in jerky response to PROM
Lead Pipe rigidity: sustained resistance to PROM throughout range
Dystonia: fixed positioning of hands and feet (twisting and/or repetitive)
pre-clinical parkinson symptoms
Olfactory loss****
Autonomic dysfunction
sweating***
Heart rate changes
May have blunted response to exercise without beta blockers
Orthostatic hypotension
Syncope
Constipation
Sleep behavior disorder
Violent dreams
Striking out a spouse
Depression
Decreased shoulder ROM***, shoulder pain
Low back pain and stiffness
If you have a patient that is slowly losing ROM for no reason then possibly PD
differential diagnosis: parkinsons
- subcortical white matter infarct
- usually affects lower body only
-
vascular parkinsons
differential diagnosis related disorders:
Asymmetrical onset with rigidity and dystonia of involved arm.
Cortical apraxia, sensory loss, reflex myoclonus, and speech/language disorders, alien hand
It is progressive and usually people die within 10 yrs
Does NOT respond to dopaminergic meds
corticobasal degeneration
what happens when you excite the direct pathway?
excitation of this pathway causes thalamic excitation which facilitates movement
describe akinesia including the difference between bradykinesia and hypokinesia
Freezing of gait and difficulty initiating movement
Fall risk and instability occur because movements are too small or slow
Bradykinesia:
Decreased movement velocity, slowness of movement, and increased time for ADLs, decreased gait speed
Hypokinesia
Decreased mvmt amplitude, shuffling gait, and small reaches
how does levadopa affect a parkinsons pt
Very good symptom control early in disease, but requires increasing doses with increasing side effects over time
differential diagnosis: parkinsons
- meds-> antipsychotics, antidepressants or reglan
- environmental toxins
- MPTP
drug or toxin induced parkinsons
differential diagnosis related disorders:
Development of dementia within less than one year of the development of motor symptoms
Aggregations of alpha-synuclein protein that develop within nerve cells.
Lewy bodies are seen only in basal ganglia and cortex
PD meds cause confusion, psychosis, and frightening hallucinations
Lewy body disease
what happens when you excite an indirect pathway
excitation of this pathway inhibits the thalamus, resulting in inhibition of movement
what are some gait disorders seen in parkinson patients
Decreased arm swing, decreased step length, shuffling, decreased speed, festinating gait, retropulsion, freezing of gait especially when walking, turns, stressed, floor changes, and through narrow spaces
how does parcopa affect parkinsons pts
Dissolves under tongue for immediate release
Used for patients in advanced stages of disease
differential diagnosis: parkinsons
- resulting from chronic head trauma, accompanied by dementia and cerebellar defects
post-traumatic parkinsons
differential diagnosis related disorders:
Affects lower body, classic PD gait presentation, incontinence and dementia, NO tremor, retropulsion with STS
Dx made via imaging or LP
Tx: VP shunt
normal pressure hydrocephalus
What does TRAP stand for
tremor
rigidity
akinesia
postural inability
motor signs/symptoms of parkinsons
Gait Disorder
Freezing
Flexed Posture
Dyskinesias (med side effect)
Dysphagia
Sialorrhea (drooling)
Dysarthria, Microphonia
Dystonia
Micrographia
Fatigue
Hypomimia (Mask Like Facies) - facial nerve dysfunction
got tired
sorry
differential diagnosis: related disorders
Often confused with idiopathic PD.
Early freezing and falling, symmetrical axial onset, impaired vertical gaze, dysphagia, dysarthria, emotional lability.
Meds for PD may work at first but then lose their efficacy→poor prognosis
progressive supra-nuclear palsy
Where are dopaminergic neurons located? What does dopamine modulate?
substantia nigra pars compacta
activity at the striatum, disinhibiting the thalamus, and facilitating voluntary movement
describe parkinson tremor
Resting tremor and tends to have pill rolling nature
Can affect hand, foot, occasionally jaw and some report internal tremor
Worsens with stress and fatigue
4-6Hz
nonmotor signs/symptoms of parkinsons
Cognitive Changes
Mood disorders (depression, anxiety)
Olfactory dysfunction
Constipation
Urinary urgency/incontinence
Sleep Disturbance
Hyperhidrosis
Seborrhea (oily skin)
Sexual Dysfunction
:)
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