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.)

Regards,
Robin

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.

Robin

——————–

www.neurologyreviews.com/jan06/newsroundup.html

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.

Differentiating CBD syndrome from PSP using brain atrophy patterns

Sharon, one of our group members, sent this to me today.  It’s an article about a study done at UCSF that shows that the patterns of brain atrophy are different in progressive supranuclear palsy and corticobasal degeneration.

Many of your loved ones see neurologists at UCSF. In fact, Sharon’s husband is one of the PSP patients in the study.

The abstract is copied below.

Robin


Archives of Neurology, January 2006, Vol. 63 No. 1

Patterns of brain atrophy that differentiate corticobasal degeneration syndrome from progressive supranuclear palsy.

Boxer AL, Geschwind MD, Belfor N, Gorno-Tempini ML, Schauer GF, Miller BL, Weiner MW, Rosen HJ
Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA 94143-1207, USA. [email protected]

BACKGROUND: Progressive brain atrophy is associated with the corticobasal degeneration syndrome (CBDS) and progressive supranuclear palsy (PSP). Regional differences in brain atrophy may reflect the clinical features of disease.

OBJECTIVE: To quantify the structural neuroanatomical differences between CBDS and PSP.

DESIGN: A survey of neurologic deficits was conducted in all patients. Voxel-based morphometry was used to quantify structural neuroanatomical differences on magnetic resonance images in each subject group. SETTING: University hospital dementia clinic.

PARTICIPANTS: Fourteen patients who met clinical research criteria for CBD and 15 patients who met clinical research criteria for PSP, who were matched for severity of disease, age, and functional status, and 80 age-matched control subjects.

MAIN OUTCOME MEASURES: Statistically significant differences in regional gray and white matter volume, after multiple comparisons correction, between groups of subjects.

RESULTS: The patients with CBDS displayed an asymmetric (left > right) pattern of brain atrophy that involved the bilateral premotor cortex, superior parietal lobules, and striatum. Progressive supranuclear palsy was associated with atrophy of the midbrain, pons, thalamus, and striatum, with minimal involvement of the frontal cortex. Midbrain structures were more atrophied in PSP than in CBD, whereas dorsal frontal and parietal cortices were more atrophied in CBD than in PSP. The degree of atrophy of the midbrain and pontine tegmentum and the left frontal eye field differentiated the 2 patient groups with 93% accuracy.

CONCLUSIONS: Distinct patterns of brain atrophy exist in CBDS and PSP that can be used to differentiate the 2 diseases. Assessments of brain atrophy in these disorders should be focused on cortical and brainstem ocular motor control areas.

 

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.

Robin


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.

 

Advance Notice: 4/8/06 PSP Family Conference

I just got word this morning that there will be a PSP Family Conference in the SF Bay Area on Saturday 4/8/06.  It is being put on by the Society for PSP.  It will be held either in SF or somewhere near SFO.  We are being asked to offer suggestions on location and speakers, so let me know if you have any thoughts.  The ’04 conference was attended by 100 people.  The expectation is that this year’s conference will have even more attendees as there is a chance an announcement will be made about a Hollywood personality becoming a spokesperson for the Society for PSP.  I thought the location of the ’04 conference was good (UCSF conference center) and suggested that again.  Hotels, in general, will be more expensive unless we have an “in.”  I thought the UCSF speaker last time on swallowing issues did a great job.  In particular, the Society for PSP is looking for practically-oriented speakers (like speech therapists, swallowing specialists, OTs, and PTs).  I’ll keep you posted as I learn more.
Robin

 

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?

Robin


Update from 2007:

This important paper is now available online at no cost.

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

brain.oxfordjournals.org/cgi/reprint/128/6/1247

And I think the commentary is worth reading too:

brain.oxfordjournals.org/cgi/reprint/128/6/1235

 

Large display clock

This is in the category of a small tip….

My dad (with PSP) had been getting up in the middle of the night, thinking it was morning.  Probably most of the time this happened he fell because he’s very tired and unsteady on his feet at the wee hours.  Over half of his falls used to occur at 3am or 4am.  I had been addressing the “cause” of the falls.  For example, he would often fall at 3am while putting on his robe in the bathroom.  I moved the robe to right next to his bed so he can put it on while sitting down.  But then I addressed the larger issue of why he gets up in the middle of the night.  I learned that he could not read the time on his alarm clock any more.  The display was too small.

I went to the Peninsula Center for the Blind and Vision Impaired (PCBVI) in Palo Alto, CA and found a large display clock for $26.75.  Their supplier is MaxiAids (www.maxiaids.com or 800-522-6294), who sells the clock for the same price.  It’s item #74852 – AM-FM Clock Radio with Extra Large LED Display.  The numbers are green.  Turns out that some low-vision people can see green better than they can white or red.  Anyway, this clock solved the problem of not knowing what time it was in the middle of the night.  Dad no longer gets up at 3am or 4am so those falls have been eliminated.  (Unfortunately there’s still lots of other falling!)

The PCBVI and MaxiAids also have clocks that talk (say the time).  We might have to go that route if Dad’s vision problems worsen.

Robin

 

PSP Overview – Parkinson’s Australia (2002)

This is the description of progressive supranuclear palsy (PSP) written by Parkinson’s Australia in 2002.

Finally I’ve found a definition of pseudobulbar palsy:

“pseudobulbar palsy [nerve problems that affect the muscles of the palate, tongue and throat, causing problems with swallowing, gagging and speech];”

Overall, I think this resource is pretty good. It is published on an Australian health website called mydr.com.

Robin
————————–

https://web.archive.org/web/20060427145721/http://www.mydr.com.au/default.asp?article=3307

PROGRESSIVE SUPRANUCLEAR PALSY
Parkinson’s Australia, 2002

Progressive Supranuclear Palsy, or Steele-Richardson-Olszewski’s Syndrome
Progressive Supranuclear Palsy (PSP), also known sometimes as the Mona Lisa disease, is a distinctive and not uncommon cerebral degenerative disease of late adulthood, the cause of which is unknown at present.

It was first observed by Dr J. Clifford Richardson during the 1950s in Toronto. He recognised a few patients who exhibited an unusual neurological syndrome of supranuclear ophthalmoplegia [nerve problems that affect the eye muscles], pseudobulbar palsy [nerve problems that affect the muscles of the palate, tongue and throat, causing problems with swallowing, gagging and speech], dystonia [problems with the muscles], rigidity of the limbs, dementia and other less typical symptoms, and invited Dr John Steele and Dr J. Olszewski to study the pathological changes in the central nervous system.

They found that neuronal cell loss, neurofibrillary degeneration and gliosis [conditions in which the nerve fibres in the brain can become dense and tangled] were extensive in the brain stem, diencephalic and cerebellar nuclei. Damage to pontomedullary reticular nuclei was also likely. Changes in the metabolism of glucose were found in the prefrontal, premotor ungulate cortex and thalamus parts of the brain.

Analysis of protein in the cerebrospinal fluid (CSF) may provide a useful tool in differential diagnosis (i.e. between cortico-basilar degeneration and supranuclear palsy).

Through considerable observations it has been found that the illness is not caused by noxious or toxic substances, is not restricted to a specific geographic or climatic region and is not related to race, occupation, social or economic circumstance or diet. There seems to be a familial background in some cases.

Diagnosis
Symptoms begin in the fifth to eighth decade (the range of age of onset of PSP is 45-73). Early indications are variable and indefinite, and include symptoms such as :

* unsteady gait;
* abrupt falls;
* slowness (akinesia and rigidity);
* cervical dystonia (problems with the neck muscles);
* blurred vision;
* difficulty maintaining eye contact;
* disturbed vertical gaze;
* altered speech;
* dysphagia [difficulty in swallowing];
* forgetfulness;
* short temper and irritability;
* abnormally aggressive behaviour and subtle changes in personality which may be noticed by family members;
* depression; and
* impaired concentration.

As the early symptoms are common to many cerebral illnesses (such as cerebellar degeneration or dementia), accurate diagnosis is difficult and often not possible until further symptoms develop; in fact, the disease is often initially mistaken for Parkinson’s.

As the disease progresses however, symptoms become more defined and characteristic of PSP, so that accurate diagnosis becomes easier. Progression is also more rapid than in Parkinson’s.

Definition
Owing to the difficulty previously experienced by doctors in diagnosing PSP, the following diagnostic criteria have recently been produced. PSP is a progressive disorder (familial examples are rare), beginning in middle or old age with supranuclear ophthalmoplegia including down gaze abnormalities and at least 2 or more of the following 5 cardinal features:

* axial dystonia and rigidity (a broad-based sailor’s walk);
* pseudobulbar palsy [nerve problems that affect the muscles of the palate, tongue and throat, causing problems with swallowing, gagging and speech];
* bradykinesia [slowness of movement] and rigidity;
* frontal lobe signs; and
* postural instability with falls backwards.

Other features which may be present include:
* resting tremor;
* chorea [loss of function of the neurones in the brain];
* dystonia [muscle problems] of the limbs and face;
* cerebellar ataxia [loss of muscle co-ordination caused by disorders in the brain];
* muscle wasting, fasciculation [brief, irregular twitching of muscles that can be seen under the skin] and weakness;
* dysphagia and dyspraxia [difficulty and pain when swallowing];
* respiratory dyskinesias (inspiratory gasps);
* depression;
* sleep disturbances;
* schizophreniform psychoses;
* echolalia and palilalia [involuntary repetition of the same word or phrase when speaking];
* myoclonus [muscle spasms or twitching];
* perceptive deafness;
* other ocular abnormalities such as slowness of blink or difficulty opening the eyes; and
* emotional incontinence.

Symptoms

Gaze palsy
This is the most evident symptom of this condition, along with walking difficulties. This is so apparent that PSP is often referred to as the ‘can’t look up and can’t look down’ syndrome. This symptom, technically known as ophthalmoparesis, is first noticed as a slowness and limited vertical movement of the eyes. By contrast, full reflex eye movement is possible with passive head movement. This symptom progresses through a loss of eye reflex to a complete failure to control eye movements up or down, with some loss of control over horizontal movements, making focusing a problem. Driving and reading also become difficult.

Facial stiffness
The face becomes stiff, immobile and furrowed. Facial and jaw jerks are exaggerated, though more often than not the mouth gapes open, and drooling is common. These symptoms are also signs of pseudobulbar palsy.

Gait and muscles
The head is usually hyperextended and the neck becomes stiff and extended and will resist forward and backward movement, making going up and down stairs difficult. Rigidity and bradykinesia of the limbs develop slowly. The combination of these symptoms (inability to look down, rigidity and stiffness) causes an increasing awkwardness, disturbance of gait and hesitancy. Unsteadiness and falls are common problems (often the first symptoms) and the person can often totter backwards and fall without knowing why. Walking becomes more and more hesitant and awkward as the tendency to fall backwards continues. The cause of this phenomenon is unknown and is often mistaken for the gait disturbance typical of early Parkinson’s.

Swallowing problems
There are speech and swallowing difficulties, with repetitive swallowing of saliva, explosive coughing and heightened palate and throat reflexes.

Common signs that a person is having difficulty swallowing might include:
* frequent coughing while eating or drinking;
* multiple swallows on a single mouthful;
* the sensation of food ‘sticking’ in the back of the throat;
* weight loss; and
* chest congestion after eating or drinking.

Mental changes
Mental changes are often limited to personality alteration and forgetfulness. However, more recent studies have shown dementia is more common than first thought. A study done in 1986 found that while cognitive impairment did not parallel motor impairment it did correlate with visual impairment. There is evidence of some impairment of judgement and loss of abstract thinking.

Late stages
In the late stages of PSP, the eyes are fixed centrally, and reflex movement may be totally absent. Bradykinesia is prominent and the person assumes a rigid and double hemiplegic-type posture. That is, the body becomes totally rigid and unable to be moved voluntarily. There is particular difficulty with trunk movements when turning from side to side and sitting up. Because of these symptoms and the inability to control one’s movements, the person becomes immobile and bedridden. In extreme cases of poor swallowing a tube may be inserted into the stomach for feeding.

The average length of illness, from diagnosis to death, is 5 to 6 years, with the range being 2 to 11 years. Men seem to be more affected by the disease than women. There are an estimated 20,000 cases in the USA, 6,000 in the UK and up to 1,500 in Australia. Misdiagnosis is frequent and it is most commonly mistaken for Parkinson’s, although it is only about 3 per cent as common.

Management

Medication
Most people with PSP are resistant to dopaminergic medications, probably because they have lesions in non dopaminergic neurotransmitter systems more profound than those in Parkinson’s. Though limb rigidity and bradykinesia and balance improve in patients treated with levodopa, ophthalmoplegia and axial dystonia are unaffected. Other treatments which seem to show some effect are tricyclic antidepressants (e.g. amitryptiline), bromocriptine, pergolide, idazoxan and lisuride. Medication needs to be individualised and doctors should work with the patient to establish a suitable drug regimen. Surgery has been tried without success.

Eating
* Check that the person is sitting up as straight as possible.
* Minimise distractions such as TV.
* Concentrate on the task, considering speed and quantity, as well as how well the person is chewing.
* A teaspoonful of food at a time is ample.
* Allow enough time for the person to eat so that they don’t feel rushed.
* Be sure they have completed the swallow before offering another spoonful.

Walking
* An aid to walking may need to be weighted in front.
* Raising heels of shoes may reduce the tendency to tip backwards.
* Rails in the bathroom may be helpful.
* Remove low objects to prevent the patient falling over them.
* Prismatic glasses have been of limited assistance.

Other exercises
* Exercises can help retain some joint mobility.
* Breathing exercises may be needed to prevent complications of bed rest.

Carers and coping strategies
* It is important to understand changes that are part of the disease process and are therefore out of voluntary control.
* Fluctuation in function and personality are to be expected.
* Lists can help with memory loss.
* Include the individual in all discussion and normal decision-making.
* Carers should not blame themselves but blame the disease.
* If irritability is a problem, distraction is better than argument.
* Reserving time for carers’ own interests is important.

Consultants
Physiotherapists, occupational therapists, speech pathologists, psychologists and social workers all have important roles in assisting in the management of PSP.

myDr, 2002. Reproduced with kind permission from Parkinson’s Australia.
Reviewed : 19/7/2002

PSP Stages/Phases, by two caregivers

This August 8, 2000 document on the phases/stages of progressive supranuclear palsy (PSP) was written by two caregivers who were members of the now-defunct Johns Hopkins PSP Listserv. Many neurological diseases, such as Alzheimer’s and Parkinson’s, have “stages.” So this was an attempt by two PSP caregivers to have the same guide posts for the PSP community.

The guide is copied below. (I’ve fixed a few typos.)

Robin

————————-

www.pspinformation.com/disease/psp/stages.shtml
[Editor’s note, 2013: This website is no longer active]

Caregiver’s Guide to the Phases/Stages of Progressive Supranuclear Palsy
Compiled by Patricia Lake of Texas and Mary Holeman of Indiana
August 8, 2000

In 1999 several members of the Johns Hopkins PSP Listserv decided to pool their collective wisdom to try to see if they couldn’t categorize the symptoms associated with the normal progression of progressive supranuclear palsy enabling the defining of phases or stages of the disease.

This is the result of these efforts. It was originally posted as a message on the PSPInformation mailing list. Visitors to the PSPInformation website often tried to find the information on the website and couldn’t – so, “by popular demand” we are also publishing it here. PSPInformation.com does not claim any credit nor does it assume any responsibility for the statements made in this article. It is solely the viewpoint of the writers.

This categorizing of the symptoms of progressive supranuclear palsy is not meant to be scientific. If you are caring for someone with PSP you should realize the disease follows its own “timetable”. The progress of the disease may be different in your case. The purpose of the article is to serve as a generalized caregiver’s guideline to what to expect as the disease progresses.

We must also note that progressive supranuclear palsy is often misdiagnosed because the diagnosis is based on symptoms. Many symptoms can apply to more than one of the many diseases and conditions that are very similar and determining their real association can be very difficult if not impossible. Most patients may also be on medication and very susceptible to possible medication caused side-effects. Thus, they may develop symptoms that may be thought to be from progressive supranuclear palsy but are not.

The Phases/Stages of PSP

Phase 1 – Deterioration of handwriting and difficulty writing. Speech problems, difficulty being understood by others, slurring, etc. Coordination problems leading to unexpected falls and stumbling; change in walking rhythms/patterns. Vision problems; some complain of ‘blurred’ vision; some try prisms, but examinations by eye Dr. generally will only find normal vision physically. Lethargy, apathy, no desire to do anything; changes in sleep patterns. Cognitive problems; decrease of sound judgement, decrease in modesty; increase in impatience and irritability.

Phase 2 – Problems sitting down or getting up; cannot lower self into chair gently; just ‘plops’ down. Increased difficulty walking; begins using a cane for balance; will progress to a walker; increased number of falls. Stooped posture because of vision problems; can’t see downward easily. Problems opening or closing eyes; some patients get ‘dry eye’ because their eyes do not close all the way. Difficulty dressing; cannot do buttons or zippers; hands and fingers do not work as they used to. Almost impossible to write anything legibly. Eating problems; coughing and choking; loss of eating etiquette; fills mouth too full; lots of spills; begins wearing a bib to save clothes. Bathroom problems; difficulty voiding/unable to get to bathroom in time; constipation or diarrhea; may need help with personal hygiene. Needs help bathing; may need hand rails/bathing bench, etc. A mobile shower head is a good idea, if possible. Weakness or neglect on one side of body; one side more dominant; ie: drags left or right foot, etc. (ShyDrager Syndrome) Subject to infections; urinary tract, respiratory tract (pneumonia) etc. Alien hand; sometimes holds on to things and cannot let go or takes the hand a long time to release. Difficulty concentrating; sometimes seems ‘out of it’.

Phase 3 – Some obsessive-compulsive behavior: ie: fingers “pill rolling”, hands smoothing out imaginary wrinkles on table, etc. Increased irritability; increased impatience. May become incontinent of urine and bowel. Increased speech problems; often very difficult to understand; cannot articulate proper speech sounds. Increased eating problems; more coughing/choking. Increased cognitive problems; cannot follow stories on TV; cannot read much, due to vision; will watch game shows, some news. In Theater movies are not recommended, as some suffer from ‘sensory overload’; loud sounds and many colors, lots of movement on screen make patient ‘nervous’. sleeps much of the day, and all night, too. Instances of ‘restless leg’ syndrome. Limbs and neck may become rigid; may loose ability to support self on legs. Increased falls; some falls may be close to geing described as ‘seizures’; complete loss of control of arms and legs, with resultant fall. After fall, will sleep for an hour or so; may not always know whether is injured or not; may not ‘feel’ the injury. Increased coughing and choking; drooling becomes common; often does not close mouth; Infections may be more frequent. Requires much more help in dressing and with all activities of daily living. Does not speak much, but does enjoy seeing friends and relatives, even though patient may not respond much to them. May have pain in arms or legs; non-specific pain for no apparent reason; application of ‘heat’ rubs may help; Tylenol may also help.

Phase 4 – Unintelligible speech/mumbling; cannot say words; may go days with out saying anything. constant drooling; coughing and choking may become so severe that eating normally is impossible; Dr. may recommend feeding tube, which requires a surgical procedure to install. May have trouble opening mouth, even for meds. Increased incontinence/constipation problems. Loosing interest in daily activities; sleeps most of the time; uncomfortable sitting for any length of time; prefers bed. Cannot support self on legs; ‘spaghetti legs’; body rigid, especially neck area. Little eye movement; cannot ‘look’ at something; slow to focus on things in view. delusions, hallucinations at times; may be disoriented and not know where they are. Pain, but cannot identify the area. Withdrawn, but remains aware of people; cannot move on own; needs extensive help for all activities of daily living.

Note: These phases or categories often overlap and are not the same for all patients. Some may have two or three phase 1 problems and one phase 3 problem. Some may never have all of the problems, but most will need extensive help to live out their lives and will need to be made as comfortable as possible for the duration of their illness. It is wise to gain from the patient, specific information as to feeding tubes, restorative therapies, etc. before the disease is well advanced; a living will is a good idea, so that loved ones will know how the patient wishes to be treated, should life threatening acute problems occur. Long term care will probably be needed and plans should be made before the patient becomes unable to participate in the planning.