Points from an expert physical therapist – on PD and parkinsonism

I attended Marilyn Basham’s presentation this afternoon on “Caregiving Made Easy for Parkinson’s Individuals.”  She’s the physical therapist (PT) at The Parkinson’s Institute (TPI).  I picked up a few tidbits at the presentation that I thought I’d pass along.  As the presentation was focused on Parkinson’s Disease (PD), not everything applied to the situations we are dealing with but there were still many interesting points that apply.

Here are the points I found interesting….  (with some of my comments in parantheses)

People with PD and Parkinsonism MUST use a walker or wheelchair to make them as safe as possible.  It’s very important to have mobility and postural strategies worked out with a physical therapist and/or neurologist.

PD is evident when 60-80% of the cells in the basal ganglia have died.

The “automatic motor programs” we have are stored in the basal ganglia.  One of these “programs” is what tells us that to stand up from a low chair, we need to scoot to the edge, put our feet underneath us, lean forward, and push up.  PD folks must either receive cues as to the steps of these programs, or they must practice it so many times that doing it becomes somewhat automatic again.

To overcome freezing (called “gait initiation failure”), you can put masking tape on the floor to provide a visual cue.  Put the tape at thresholds or where ever the person often has the freezing problem.  (Of course this won’t work for those with PSP who have downward gaze palsy.)

A suggested verbal cue to give someone who wants to speak is:  “Swallow.”  (pause to let the person swallow)  “Take a deep breath in and then, at the top of your breath tell me what you want.”  (pause to let this happen)  Swallowing is important because fluid accumulates in the back of the throat and those with PD are not aware of it.  You can give them gum to initiate a swallow response.

Before someone with MSA (or PD with blood pressure fluctuations) stands up, give them a glass of water with salt in it or Gatoraid.  This will increase the blood pressure.  Obviously the person’s diet and blood pressure medication needs to be taken into account before following this suggestion.

We must give time for those with these diseases to process information!  Be patient!  Give long pauses.  Don’t overload them.  Don’t give them more than one complex task at a time.  Walking is a complex task.

(Some of you know that my father and I communicate by our holding up fingers to designate an answer.  Example, “do you want 1 for coffee, 2 for tea, or 3 for nothing,” and I hold up 1, 2, and 3 fingers.  He answers by holding up fingers.  Long after the fingers come up, he may try to verbalize the answer.)  I asked Marilyn why my father could hold up fingers faster than he could verbalize a response.  Marilyn said she didn’t know why but pointed out that parents of small children teach their children sign language long before the children can verbalize.

Dementia is rare in PD.  (It’s definitely common in the Atypical Parkinsonism diseases.)  PD folks may lose their keys but they still remember what keys are and how to use them.  (I thought that was a good story for remembering what dementia is.  My dad, for example, cannot remember how to use an ATM card.  I see the dementia very clearly.)

A patch for Sinemet is in the works.  (Some of your loved ones take Sinemet.)

The head of TPI thinks that PD is the most curable of all the neurodegenerative diseases.  (Let’s hope he’s right because hopefully those diseases related to PD can be cured quickly too.)


Theoretical benefit of DBS with PSP and MSA

For those with not enough reading materials(!), neurologyreviews.com is an interesting website.  In the January 2006 News Roundup section of the website, there’s an article about how deep brain stimulation in specific areas could help those with multiple system atrophy or progressive supranuclear palsy.

A short blurb is copied below.




Two studies in the November 28, 2005, NeuroReport demonstrated that the pedunculopontine nucleus can be targeted safely and effectively with deep brain stimulation without major surgical risks in patients with Parkinson’s disease. Low frequency (20 to 25 Hz) stimulation of the pedunculopontine nucleus improves postural stability and gait disturbance, including “on-medication” freezing. Furthermore, combined stimulation of the subthalamic nucleus and the pedunculopontine nucleus appears to be more valuable than stimulation of the pedunculopontine nucleus alone. “In theory, even patients with multiple system atrophy or progressive supranuclear palsy could benefit [from this treatment]­in fact, any patient with intractable locomotive and postural akinesia [could benefit],” reported the investigators.

PSP and MSA can occasionally co-exist

An article was published earlier this week in a medical journal for neuropathologists.  Here’s the key point of this abstract:

“Based upon the findings in this case, the neuropathologic changes of PSP and MSA are distinct and independent processes, but they can occasionally coexist.”

Obviously these things can ONLY be known through brain donation.  I hope everyone in our group will consider that.

I’ve copied the full abstract below.


Acta Neuropathologica (Berlin).  2006 Feb 3; 1-7.

Coexistence of PSP and MSA: a case report and review of the literature.

Uchikado H, Delledonne A, Uitti R, Dickson DW

Department of Neuroscience, Neuropathology Laboratory, Mayo Clinic, 4500 San
Pablo Road, Jacksonville, FL, 32224, USA,  [email protected]

Progressive supranuclear palsy (PSP) is a neurodegenerative tauopathy characterized by Parkinsonism, vertical gaze palsy,  and early falls. The neuropathology is characterized by neurofibrillary tangles, tufted astrocytes, and
coiled bodies, but some brains show other pathologic processes. To investigate the frequency of alpha-synuclein pathology in PSP with immunohistochemistry and to report the clinical and pathological features of a case of PSP with
concomitant Multiple system atrophy (MSA) (PSP/MSA), 290 cases of PSP were screened for alpha-synuclein pathology withi mmunohistochemistry.  Double-labeling
immunohistochemistry was performed on a case of PSP/MSA. Among the PSP cases screened for alpha-synuclein pathology, a single case of PSP/MSA  was detected. The patient was an 86-year-old woman with clinical features consistent with PSP. She had no documented dysautonomia or cerebellar signs, and imaging studies were not diagnostic of MSA. Pathological examination showed tau-immunoreactive neuronal and glial lesions consistent with PSP as well as alpha-synuclein immunoreactive glial cytoplasmic inclusions diagnostic of MSA. Double-immunolabeling studies showed no co-localization of alpha-synuclein and tau in
most neuronal and glial lesions. Based upon the findings in this case, the neuropathologic changes of PSP and MSA are distinct and independent processes, but they can occasionally coexist.


Two distinct types of PSP – RS and PSP-parkinsonism

Here’s the citation to a very important paper published recently on progressive supranuclear palsy (PSP):

Brain. 2005 Jun;128(Pt 6):1247-58. Epub 2005 Mar 23. 
Characteristics of two distinct clinical phenotypes in pathologically proven progressive supranuclear palsy: Richardson’s syndrome and PSP-parkinsonism.
Williams DR, de Silva R, Paviour DC, Pittman A, Watt HC, Kilford L, Holton JL, Revesz T, Lees AJ.
The Queen Square Brain Bank for Neurological Disorders, University College London, UK.

Dr. David Williams and others from The Queen Square Brain Bank in London examined the brains and clinical records of 103 people with autopsy-confirmed PSP.  They discovered two key clinical types of PSP:  Richardson’s Syndrome and PSP-parkinsonism.

The authors described Richardson’s Syndrome (RS) as follows:

“The core clinical features of PSP appears to be bradykinesia, rigidity and postural instability, and are almost always present later in the disease.  Together with the supranuclear vertical ophthalmoplegia, dementia, dysarthria and pseudobulbar palsy, they form the classic features of PSP.  When these features appear in the first 2 years, a diagnosis of RS is most likely.”

The authors described the PSP-parkinsonism type as follows:

“The features which most clearly differentiate this syndrome from RS appear to be an asymmetric onset, extra-axial dystonia, tremor and benefit from levodopa.  Early bradykinesia appears to be essential for the diagnosis, but does not adequately differentiate it from RS, especially later in the disease course.  Disease duration in PSP-P is significantly longer than in RS, and to our knowledge exceeds median survival in all clinicopathological PSP case series.”

Here’s the abstract to this important paper:  (broken into paragraphs)

“The clinical diagnosis of progressive supranuclear palsy (PSP) relies on the identification of characteristic signs and symptoms. A proportion of pathologically diagnosed cases do not develop these classic features, prove difficult to diagnose during life and are considered as atypical PSP. The aim of this study was to examine the apparent clinical dichotomy between typical and atypical PSP, and to compare the biochemical and genetic characteristics of these groups.

In 103 consecutive cases of pathologically confirmed PSP, we have identified two clinical phenotypes by factor analysis which we have named Richardson’s syndrome (RS) and PSP-parkinsonism (PSP-P). Cases of RS syndrome made up 54% of all cases, and were characterized by the early onset of postural instability and falls, supranuclear vertical gaze palsy and cognitive dysfunction. A second group of 33 (32%) were characterized by asymmetric onset, tremor, a moderate initial therapeutic response to levodopa and were frequently confused with Parkinson’s disease (PSP-P). Fourteen cases (14%) could not be separated according to these criteria. In RS, two-thirds of cases were men, whereas the sex distribution in PSP-P was even. Disease duration in RS was significantly shorter (5.9 versus 9.1 years, P < 0.001) and age at death earlier (72.1 versus 75.5 years, P = 0.01) than in PSP-P.

The isoform composition of insoluble tangle-tau isolated from the basal pons also differed significantly. In RS, the mean four-repeat:three-repeat tau ratio was 2.84 and in PSP-P it was 1.63 (P < 0.003). The effect of the H1,H1 PSP susceptibility genotype appeared stronger in RS than in PSP-P (odds ratio 13.2 versus 4.5). The difference in genotype frequencies between the clinical subgroups was not significant. There were no differences in apolipoprotein E genotypes.

The classic clinical description of PSP, which includes supranuclear gaze palsy, early falls and dementia, does not adequately describe one-third of cases in this series of pathologically confirmed cases. We propose that PSP-P represents a second discrete clinical phenotype that needs to be clinically distinguished from classical PSP (RS). The different tau isoform deposition in the basal pons suggests that this may ultimately prove to be a discrete nosological entity.”

From my reading, the PSP-parkinsonism type of PSP looks like Parkinson’s Disease and may look like MSA, specifically the parkinsonism type (MSA-P).

According to the full article, some people with PSP actually had a response to levodopa therapy!  Do the diagnostic criteria need to be changed to accommodate this finding?


Update from 2007:

This important paper is now available online at no cost.

Here’s the direct link to the Brain ’05 article:


And I think the commentary is worth reading too: