Parkinson's Disease PDF

Philippine College of Health Sciences (PCHS) MF2 TRANS PARKINSON’ S DISEASE Incidence of PD Increases with Age, but an estimated...

Philippine College of Health Sciences (PCHS) MF2 TRANS PARKINSON’ S DISEASE Incidence of PD Increases with Age, but an estimated 4 % people with PD are diagnosed age Parkinson's Disease 50. Idiopathic Parkinsonism Men are 1.2 x to 1.5 x more likely to AKA “ Paralysis Agitans” / “ Shaking have PD than Women (Male Palsy” Predominance) Chronic, progressive disease of the Westerners > Easterners nervous system Cardinal Features: There is a Robust Data for Dairy Product Consumption, Urate Levels Tremor and Physical Activity in the West while (Resting) Studies on certain Risk Factors like Head Injury and Alcohol show Rigidity Conflicting and mixed results. , (Abbas, et. al, 2017) Bradykinesia ETIOLOGY (Akinesia) Genetic and Environmental or Unknown Factors Postural Instability Genetic Variation is Estimated to Contribute Approximately 25% to the EPIDEMIOLOGY Overall Risk of Developing PD. (Day and Mullin, 2021 ) Expected to inc. substantially in the coming years due to the aging of the Several Different Causes Identified: population Infections/Postencephalitic Average Age Onset: 50 – 60 yrs Atherosclerosis 4 % - 10% - Diagnosed with Early- Idiopathic Toxins Onset PD (less than 40yrs. of age) Drug - Induced Nearly 1 million will be Living with PD in the U. S. by 2020 Deficiency of Dopamine within BG Corpus Striatum with Degeneration of Approximately 60, 000 Americans are Substantia Nigra Diagnosed with PD each year Loss of Inhibitory Dopamine Results in More than 10 million people Excessive Excitatory Output from Worldwide are living with PD Cholinergic System (Acetylcholine) of BG TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS RISK FACTOR (S) Production Workers Age (70-79yrs) Machine Operators Toxic Exposure (Cyanide) Fabricators Heavy Metal: Metal Workers Manganese Engineers Iron Genetics Copper Lead, Aluminum Zinc Infection Exposures : Measles Virus Rubella Virus Herpes Simplex Virus Type 1 and 2, and Cytomegalovirus) Carbon Monoxide Methanol Hormonal Therapy Estrogen Pesticide Exposure (1 - Methyl- 4 - Phenyl - 1 , 2 , 3 , 6 - Tetrahydropyridine INVERSE CORRELATION C PD ( MPTP)) ; ( 2 -25 % risk) Smoking Neuroleptics can Produce Cigarette smokers have lower rates of Parkinsonian Syndrome PD than Non - Smokers. Nicotine stimulates the Nicotinic Acetylcholine Occupation receptor (nAchR), mimicking the brain Construction Chemical Acetylcholine. Extractive Workers Miners It is well known that Acetylcholine has effects on the brain circuitry that is Oil Well Drillers involved in PD. (APDA, 2018) TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS Caffeine Consumptions CLASSIFICATION OF PD Reduce risk for 25% IDIOPATHIC PARKINSON DISEASE Late-onset (>40 yrs; sporadic) Caffeine is associated with a low risk of developing PD in healthy individuals Early-onset (40 yrs; familial)- Young- and the deceleration in the onset (>21 yrs)- Juvenile ( 3yrs is necessary to meet this requirement) Substantial and SUSTAINED response to LEVODOPA or a DOPAMINE AGONIST has been documented Criteria for definite PD ALL criteria for probable Parkinson’s are met Histopathological CONFIRMATION of the diagnosis is obtained at Autopsy (Lewy Bodies and Depletion of Substancia Nigra) HOEHN-YAHR CLASSIFICATION OF DISABILITY AND UNIFIED PARKINSON’S DISEASE RATING SCALE TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS ANCILLARY PROCEDURE Initially appears as Facial Grimacing c Twitching of the Lips and Tongue CT SCAN Protrusion MRI DOC: Amantadine POSITRON EMISSION TOMOGRAPHY MANAGEMENT Early-Stage Tx (5yrs) SINGLE-PHOTON EMISSION CT Dopamine Agonist PRONOUNCED LOSS OF OLFACTION MAO - B Inhibitor (Monoamide DISTINGUISH PD FROM OTHER Oxidase PARKINSONISM Anticholinergics PROGNOSTICATING FACTOR Late-Stage Treatment (>5yrs) Dopamine Agonist MAO-B Inhibitor Catechol O-methyltransferase (COMT) Inhibit SURGICAL MANAGEMENT MANAGEMENT Deep Brain Stimulation of STN Early-Stage Treatment Reduces Motor Fluctuations, Dyskinesia, and Antiparkinsonian SINEMET (Gold Standard) Medication Use Levodopa (able to pass BBB) + Carbidopa (Decarboxylase Inhibitors) Fetal Cell Transplantation HONEYMOON PERIOD Potential Replenish of Dopaminergic Neurons in the Substantia Nigra No Long - Term Effect 7-8 years When the Drug is Very Effective NUTRITIONAL MANAGEMENT Side effect of excessive dosage of Levodopa: High Calorie Dyskinesias Low Protein Diet Uncontrolled or involuntary movement that occur typically at Peak Evening Protein Meal L - dopa dose or when the pt. is transitioning between “on” and “off” Dietary Supplements (Vitamins, states (Chorea - Athetotic in Quality) Minerals, Water and Fiber TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS SUMMARIZE PT MANAGEMENT (Mx) Symptomatic Tx 1. Motor Learning Strategies To improve S/Sx of PD Difficulty Learning Long and Complex Mov’t Sequences, Simultaneous Protective Tx Motor/Cognitive Tasks and Mov’ts To Interfere with the Depend on the Internally Generated Pathophysiological Mechanism of Cues vs External Cues Neuronal Cell Death Early: Restorative Treatment (Surgical) Practice Improves Learning; Less To Provide New Neurons or to successful in Later Stages stimulate Grown and function of the Remaining Cells Blocked Practice to Improve Procedural Memory OTHER MOVT DISORDER O’Sullivan Mov’t Decomposition No dual/ Multi - Tasking: Use Structured Instructional Set Use External Cues: Visual, Auditory, Tactile (Hand, Earlobes) Multisensory Cueing is better than Individual Cueing PT MANAGEMENT External Cues Utilized more intact areas of the brain (SMA) and bypass diminished internal cueing for BG (for automatic to more conscious motor pathway) Cueing is ineffective Adv, severe PD PD c Dementia Medication instability 1. Exercise Training Relaxation Exercise Gentle Rocking (↓ Rigidity) TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS Rocking Chair, Slow Rhythmic Exercise machines safer than Free - Rotational mov’t of Extremities and Weight trunk preceding other interventions 4. Functional Training RI, diaphragmatic ex, D2F UE (insp) Bed Mobility and D2 E (exp); cognitive imaging or mediation, progressive relaxation Segmental Rotation Patterns (D1F), techniques, audiotape, yoga, Taichi, from Firm to Soft stress ex Sitting Posture Flexibility Ex ROMEx Pelvic Mob (Ant and Post Pelvic Tilts, Side to Side Tilts, Pelvic Clock, WS) Strengthen extensors, lengthen flexors ; From Therapy Ball to Stationary UE: (B) D2F (Prevent Kyphosis) Surface BiSy D2F, D2E (Upper Trunk Ext), Lift/Reverse Lift (Upper Trunk Ext LE: D1E c Rotation) HR and CR (CR better than HR: Sit-to-stand autogenic inhibition c rotation) GPS of elbow flexors, hip and knee flexors, Initial Rocking Fwd and Bwd, Scooting, ankle PF (20-30sh x 3-5 reps) Cueing (Counting), Firm, Seat, Varied chair height, modified wall squats, Passive Pos’t modified plantigrade pos’t) Prevent phantom or shadow pillow in supine; daily prone l ying (early stage) Standing 3. Strength Training Tactile cueing on hip extensors, WS c Effects of Weakness trunk rotation (Reciprocal Arm Swing or Reaching Movts), Side Steps, Step - Flexed, Stoop, posture, Functional Ups on low platforms for hip ABD, Deficits, postural instability, falls sitting wall push-ups Balance Training Falls High - Intensity R training of the Knee Extensors and Flexors, Ankle PF Quadruped creeping kneeling half- Kneeling Standing Coincide with “on” period of Medications: 45mins – 1hr after meds Facial MM mobility Massage, stretch, manual contacts, verbal Isokinetic > isometric contraction cueing, mirror for visual feedback CI: Isometrics Frenkel’s Exercise (for coordination) TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS Frenkel’s Exercise: 6. Locomotor Training In sitting position Gait Impairments Lifting the Thigh with the Knee Flexed Slowed Speed and Returning the Foot Firmly on the Ground. Shuffling Sitting Down with the Knees Flexed and the Body Bent Slightly Forward. ↓ Arm Swing and Trunk Movts Standing up when the Feet are Firmly Flexion Attitude while Walking Planted on the Ground. Strategies Flexion attitude (pole walking, verbal cueing: walk tall, harness (no asst. device that promotes flexed posture) Step Length , Velocity, and Arm Swing Verbal Cue: Take large steps and arm swing Use 5. Balance Training of footprints/ grids for foot placement WS Training, platform training (c Step Height verbal, tactile, proprioceptive cues) Marching in place → Exaggerated high Task stepping pattern Dynamic Stability Task: Brisk marching Music WS, Reaching, Axial Rotation c WS Side Stepping/ Cross Stepping Seat Surface using Therapy Ball: Compliant Seat → Therapy Ball Ideal: Braiding (Lower Trunk Rotation c Stepping and Side Stepping Arm position: Arm Swing Arms Outside, Folded Across Chest Hold 2 Dowels (PT and pt), Practice in Marching in Place and Fxnal reach Changing Directions, Turns and (Using Marching Song) Negotiating Obstacles Vary envt’l demands: Alter Support Stair climbing, ramp walking Surface and Visual Inputs (Reduced Lighting, Eyes Closed), Open Envt (Busy Env’t Demands Clinic) Floor Surface, Visual Input, Open Env’t KITCHEN SINK EXERCISES 7. Cardiopulmonary Training Respiratory TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS DBE, Air Shift Maneuvers, Exercise MULTIPLE SCLEROSIS (MS) Recruiting Neck, SH and Trunk mm INTRODUCTION: MULTIPLE SCLEROSIS Perform in unsupported sitting to Demyelinating Disease caused by an promote trunk stability Autoimmune Process that involves different regions of the brain and Cardio Spinal Cord. Submax Intensity (40-50%), Longer Duration, or more Frequent Sessions Is a Chronic, Inflammatory, Neurodegenerative Disorder of the 3-5x/Wk CNS affecting the Young and Middle Aged Adult. BIG AND LOUD EXERCISE “LSVT BIG” or “Lee Silverman Voice Presentation can be any Neurologic Therapy” s/sx which can consist of Paresis, Spasticity, Ataxia, Paresthesias, Visual Improved Movts for Any Activity, Problems, etc. whether “Small Motor” Tasks like Buttoning a Shirt or “Large Motor” Also known as the “Great Crippler of tasks like getting up from Sofa or Chair Young Adults” or Maintaining Balance while Walking Characterized by Remissions and Floor to Ceiling Excacerbations EPIDEMIOLOGY Rock and Reach Side to Side Female > Male Walking Big Americans > Asians and Native Americans Peak of Diagnosis and Onset: 20-40 Years Old High Frequency Areas Include Scandinavian Countries, Northern United States, Southern Canada, New Zealand, Southern , Australia. Areas of Medium Frequency Closer to the Equator include Southern United Statedes and Europe, rest of Australia, and Low Frequency Tropical Areas include Asia, Africa, and South America. TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS Birth Month: May and June Cerebellar Peduncles ETIOLOGY Dorsal part of Spinal Cord Residents before 15 y/o in temperate TYPES OF LESIONS climate environmental factor: Epstein Barr Virus (EBV) TYPE 1- Risk Factors: Cell - Mediated destruction of Myelin by T cells Cigarette Smoking and BMI of >20. TYPE 2- Genetic Factors: Cell - Mediated destruction of Myelin HLA-DRB 1*1501 (Ch 6p21) Sheath with Immunoglobulin and Activated Complement HLA- DR2555 TYPE 3- Absence of the Inhibitory Gene Is a Primary Oligodendrogliopthy with KIR2DL3 Gene Apoptosis Interleukin-1b Receptor TYPE 4 Interleukin-1 Receptor Antagonist Neurodegeneratice Oligodendrogliopathy Immunoglobuliln Fc factor TYPES OF MS PATHOLOGY Relapsing-Remitting MS (RRMS)- Inflammation > Demylenation > Axon Most common type of MS and is Loss characterized by periods of exacerbations followed by periods of Predominantly a T - Cell Mediated remission. Inflammatory Disorder with overproduction of Proinflammatory Secondary Progressive MS (SPMS)- Cytokines cause Cells to be more Begins with Relapsing - Remitting Susceptible to Apoptosis followed by Progression to Steady and HALLMARK: Irreversible Decline with or without Occasional Acute Attacks. Demylenation, earliest abnormality seen is localized breakdown of blood- Primary Progressive MS (PPMS)- bearing barrier. Nearly continuous Worsening of the disease from the Onset without Lesions are called Plaques, areas Distinct Attacks. Predilection Includes: Progressive-Relapsing MS (RPMS)- Periventricular Areas of Cerebrum, Begins with a Progressive Disease Optic Nerve course from the Onset and Steady Deterioration. RAREST FORM OF MS. Perivenous Area TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS CLINICAL MANIFESTATION CLINICAL MANIFESTATION: EARLY SIGNS MARCUS GUNN PUPIL Paresthesia a.k.a. Relative Afferent Pupil Defect (RAPD) Visual Blurring Abn. Response of the Eye wherein Diplopia Pupil continues to Dilate after Exposure to Bright Light, thus making Weakness the Tt. Two Pupils become Different Sizes Balance Problems CLINICAL MANIFESTATION CLINICAL MANIFESTATION: VISUAL DISTURBANCES (80%) SENSORY DISTURBANCES Optic Nerve Leads to Altered Visual Paresthesia (Earliest s/sx) Acuity Impaired Proprioception Optic Neuritis Impaired Vibratory Sense of LE Diplopia Affects Light Reflexes Affects One Extremity or in the Head Marcus Gunn Pupil and Face Scotoma CLINICAL MANIFESTATION: MOTOR DISTURBANCES Paresis Spasticity Movement Disorders Vertigo TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS CLINICAL MANIFESTATION: Truncal Weakness PAIN Dysmetria MC Presenting Sx Dyssynergia Paroxysmal Pain Dysdiadochokinesia Trigeminal Neuralgia (Tic Doulourex) GAIT AND MOBILITY: Paroxysmal Limb Pain Ataxic gait Trunk Pain SPEECH AND SWALLOWING Hyperpathia Dysarthria Headache Dysphonia Chronic Neuropathic Pain Dysphagia (+) Lhermitte’s Sign COGNITIVE DEPRESSION EMOTIONAL: Pseudobulbar Effect (PBE) BLADDER: Spastic Bladder CLINICAL MANIFESTATIONS Flaccid Bladder FATIGUE: Dyssynergic Bladder MC CLINICAL MANIFESTATIONS Sx; Most Disabling BOWEL: WORST IN THE AFTERNOON Constipation COORDINATION AND BALANCE: SEXUAL: Ataxia Sexual dysfunction CLINICAL MANIFESTATIONS: Postural and Intentional Tremors CN INVOLVEMENT Hypotonia CN 2,5,7,8 TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS NYSTAGMUS: FATIGUE Induced Nystagmus Modified Fatigue Impact Scale INTRANUCLEAR OPTHALMOPLEGIA (INO) AEROBIC CAPACITY AND ENDURANCE: VS EXACERBATING FACTORS Exertional Sx. Viral or Bacterial Infections Perceived Exertion Diseases of Major Organ Systems LABORATORY TEST Stress MRI Pregnancy Contrast - Enhanced T1 - Weighted Images Fatigue Evoked Potentials Heat LP with CSF Analysis SMOKING TESTS AND MEASURES COGNITION MACFIMS and MMSE AFFECTIVE AND PSYCHOSOCIAL FUNCTION Beck Depression Inventory SENSATION: Superficial and deep sensation testing DIAGNOSTIC CRITERIA PAIN: Lhermitte’s Sign; McGill Pain Questionnaire or Neuropathic Pain Scale VISUAL ACUITY: Acuity Tracking, and Accommodation CN INTEGRITY Motor and Sensory Testing Regrrdehfdfg TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS 2.5 SLIGHTLY GREATER DISABILITY IN TWO FUNCTIONAL SYSTEMS 3.0 MODERATE DISABILITY IN ONE FUNCTIONAL SYSTEM; FULLY AMBULATORY 3.5 DIAGNOSTIC CRITERIA: KURTZKE EXPANDED FULLY AMBULATORY BUT WITH MOD. DISABILITY STATUS SCALE DISABILITY IN ONE FUNCTIONAL SYSTEM AND MORE THAN MINIMAL DISABILITY IN SEVERAL OTHERS 4.0 FULLY AMBULATORY WITHOUT AID, SELF SUFFICIENT, UP AND ABOUT 12 HRS A DAY, ABLE WALK WITHOUT AID OR SOME 500 METERS 4.5 FULLY AMBULATORY WITHOUT AID, SELF SUFFICIENT, UP AND ABOUT 12 HRS/DAY, ABLE TO WALK WITHOUT AID OR REST FOR SOME 300 METERS 5.0 DIAGNOSTIC CRITERIA: KURTZKE EXPANDED DISABILITY STATUS SCALE AMBULATORY FOR ABOUT 2OO METERS WITHOUT AID OR REST; O.0 DISABILITY SEVERE ENOUGH TO NORMAL NEUROLOGIC EXAM IMPAIR ADLs 1.0 5.5 NO DISABILITY, MIN. Sx AMBULATORY FOR ABOUT 100 METERS WITHOUT AID OR REST; 1.5 DISABILITY SEVERE ENOUGH TO NO DISABILITY, MIN. SIGNS IN MORE PRECLUDE ADLs THAN ONE FUNCTIONAL LEVEL 6.0 2.0 INTERMITTENT OR UNILATERAL CONSTANT ASSISTANCE (CANE, SLIGHTLY GREATER DISABILITY IN ONE FUNCTIONAL SYSTEM CRUTCH, BRACE); REQUIRED TO WALK ABOUT 100 METERS WITH OR WITHOUT RESTING TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS 6.5 10.0 CONSTANT BILATERAL ASSISTANCE DEATH FROM MS (CANE, CRUTCH, BRACES) REQUIRED DIAGNOSTIC CRITERIA TO WLAK ABOUT 20M WITHOUT RESTING 7.0 UNABLE TO WALK BEYOND APPROX. 5M WITH AID; ESSENTIALLY RESTRICTED TO WC; WHEELS SELF IN STANDARD WC AND TRANSFERS ALONE; UP AND ABOUT IN WC 12 HRS/DAY. 7.5 UNABLE TO TAKE MORE THAN FEW STEPS; RESTRICTED TO WC; MAY NEED DRUG THERAPY AID IN TRANSFER’ WHEELS SELF BUT CAN NOT CARRY ON IN STANDARD WC Immunomodulatory Drugs : IN A FULL DAY; MAY REQUIRE First Line Injectible Drugs (Synthetic MOTORIZED WC Interferon Drugs) 8.0 Corticosteroids ESENTIALLY RESTRICTED TO BED OR CHAIR OR PRE-AMBULATED IN WC BUT Oral Baclofen MAY BE OUT OF BED ITSELF MUCH OF THE DAY; RETAINS MANY SELF-CARE Tricyclic antidepressants FUNCTIONS; HAS EFFECTIVE USE OF ARMS Carbamazepine 8.5 Amitriptyline ESENTIALLY RESTRICTED TO BED MUCH OF THE DAY; HAS SOME EFFECTICE USE Phenytoin OF ARMS; RETAINS SOME SELF-CARE FUNCTIONS. Diazepam 9.0 Gabapentin Amitriptyline HELPLESS BED PATIENT; CAN Imipramine COMMUNICATE AND EAT Desipramine Antiepileptic Drug 9.5 TOTALLY HELPLESS BED PATIENT; Amantadine and Modafinil UNABLE TO COMMUNICATE Hydroxyzine EFFECTIVELY, EAT, OR SWALLOW Clonazepam TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS PT MX: Propanolol PHYSICAL THERAPY INTERVENTION Buspirone Resistance and Balance Training Ondansetron Aquatic Therapy Primidone Aerobic Exercise Antidepressants Anticholinergic Medications Alphaadrenergic Blocking Agents PT MX: RESTORATIVE INTERVENTION Min. Potential Complications, Impairments, Activity Limitations, or Disability as the Disease Progresses SECONDARY PREVENTION: Decrease the Duration and severity of Sx. or Delaying the Emergence of Disease sequelae through Early Detection TERTIARY PREVENTION: Min. Degree of Disability GOAL AND OUTCOME STATEMENTS: FOCUS ON PROMOTION OF HEALTH, WELNESS, AND FITNESS, AND PRESERVATION OF OPTIMAL FUNCTION. PT MX: COMPENSATORY INTERVENTION Aimed at Modifying Tasks, Activities, or Environment to Maintain Optimal Function within the Scope of Existing Impairments and Limitations GOAL AND OUTCOME STATEMENTS: REFOCUS ON REGAINING/ MAINTAINING FUNCTION TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO  Philippine College of Health Sciences (PCHS) MF2 TRANS TRANSCRIPT BY: GABRIEL, JOHN MICHAEL ORQUEZA PROF: DR. PHILILIP OBILO