Transcript Living-with-Parkinsons-Tidmanx

Functional
Implications in
Living with
Parkinson’s
Melanie M. Tidman DHSC,
MA, OTR/L
[email protected]
Goals for Presentation
 Provide
suggestions for living with
Parkinson’s for maintaining mobility and
strength
 Provide information regarding functional
implications for common Parkinson’s
medications
 Provide simple and practical home
exercises and activities to maintain
mobility and balance
Basic Neurology Review

The function of the deep structures of the brain
•
•

Dopamine uptake implications
Influence of the Cerebellum on movement
Influence of the deeper structures: The Substantia
Nigra: The dopamine-producing cells of the
substantia nigra send their projections (axons)
upward into the bottom portion of the brain
(cerebrum), connecting with dopamine receptors in
the next part of the circuit, the striatum(apda,2010)
•
The Motor strip
Precentral Guyrus
 Postcentral Gyrus

Parkinson’s Brief Review
 Second
most common degenerative disease of
the nervous system (second to Alzheimer’s)
 Progressive
 Abnormal neuronal cytoplasmic filaments
appear in the substantia nigra of the Basal
Ganglia
 Loss of dopaminergic neurons
 Loss of balance between dopamine (which is
inhibitory) and acetylcholine (which is excitatory)
 Without dopamine, acetylcholine ramps up
producing hypokinetic rigidity. (AOTA, 2006)
Systems Affected

Respiratory function


Autoimmune function
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
Encourage return to “trip training” (Q 2hours)
Motor function


Pt may need medications to counteract slow bowel.
Chronic constipation can lead to a bowel obstruction
Bladder function


Advise pt not to be around toxins such as smoke
Gastro-intestinal functions
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Inability to fight off infections
Sensitivity to environmental toxins


Remember to test and treat this system
Weighted cuffs and vests help to stabilize
Central balance
Use of COM/BOS training
Complications
A lack of Dopamine can cause:
 Inhibition of breathing responses with hypoxia
 Inhibition of bowel motility causing bowel
blockages
 Inhibition of timing and coordination causing Falls
 Inhibition of swallowing responses causing
aspiration pneumonia
Timing of Meds is Critical for all PD patients in Stages
III, IV and V.
Basic Brain Functions
Basic Review of Systems

Somatosensory (Includes visual)Parietal Lobe


Touch, pressure, sensation
Vestibular- Deep Nuclei of the brainstem

Balance and Equilibrium

Motor/Kinesthetic -Parietal Lobe

The Cerebellum (Mr. Gatekeeper)
Balance and Falls Prevention
 Falls:
The startling fact is that the deaths
due to falls in the 5O+ population is almost
as high as the MVA deaths in the
accident-prone l5-29-year group.
 50%
of the falls occur during some form of
locomotion (Winter, 1995)
The Balance Connection
“Quick and Dirty” Neuro
Overview
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Spinal Cord -the incoming highway of
sensation
Brain Stem – all the Nuclei that “gate keep”
incoming sensations
Basal Ganglia- The Conductor
The Cortex – The motor strip for movement
activation
The Cerebellum – Timing, intensity,
coordination of motor output (a feedback
loop)
“Vision is the system primarily involved in
planning our locomotion and in avoiding
obstacles along the way.
The vestibular system is our ‘gyro’, which senses
linear and angular accelerations.
The somatosensory system is a multitude of
sensors that sense the position and velocity of
all body segments, their contact (impact) with
external objects (including the ground), and
the orientation of gravity.” (Winter, 1995)
Cerebellum Responsibilities
 The
biggest challenges to the locomotor
system:
 to initiate and terminate walking,
 ability to turn and change directions
quickly,
 avoiding obstacles either by quick
avoidance maneuvers or stepping up
or over,
 altering the length of steps,
 bumping into people or objects due to
the inability to start/stop quickly.
How Many patients with Parkinson’s would
say these are their biggest challenges??
Stages of Parkinson’s


Stage one: During this initial phase of the disease, a
person usually experiences mild symptoms, such as
tremors or shaking in a limb. During this stage, friends
and family can usually detect changes such as poor
posture, loss of balance, and abnormal facial
expressions
Stage two: In the second stage of Parkinson's disease,
the person's symptoms are bilateral, affecting both
limbs and both sides of the body. The person usually
encounters problems walking or maintaining balance,
and the inability to complete normal physical tasks
becomes more apparent.
Cont’d
 Stage
three: Stage three can be rather severe
and include the inability to walk straight or to
stand. There is a noticeable slowing of physical
movements in stage three.
 Stage four: This stage of the disease is
accompanied by severe symptoms . Walking
may still occur, but it is often limited, and rigidity
and bradykinesia -- a slowing of movement -- are
often visible. During this stage, most patients are
unable to complete day-to-day tasks, and
usually cannot live on their own. The tremors or
shakiness of the earlier stages of the disease,
however, may lessen or become non-existent for
unknown reasons during this time.
Cont’d
 Stage
five: In the last or final stage of Parkinson's
disease, the person is usually unable to take care
of himself or herself and may not be able to stand
or walk. A person at stage five usually requires
constant one-on-one nursing care, critical
medication scheduling, prevention for aspiration
and other respiratory issues, monitoring of bowel
and bladder function.
Resources for Patients/Families
 One
of the best handbooks for either
clinicians or patients/families is the
Parkinson’s Disease Handbook by the
American Parkinson’s Disease Association.
Find this free resource at
http://www.apdaparkinson.org/
Patient Education
Techniques:
So What are you???
(COM/BOS)
The Leaning Tower
The Egyptian Pyramids
Mantra for Falls Prevention
All together now:
 Posture
 Flexibility
 Balance
 Strength
This is the continuum that is the foundation
of treatment (in my opinion) in order of
importance.
Falls Prevention
Relevant Studies
Morberg BM1, Jensen J1, Bode M1, Wermuth L1.
((2014). The impact of high
intensity physical training on motor and nonmotor symptoms in patients with Parkinson's
disease (PIP): a preliminary study.
NeuroRehabilitation. 35(2):291-8. doi:
10.3233/NRE-141119.
 The
results suggest that a personal high intensity
exercise program may favorably influence both
motor and non-motor symptoms and reduce Falls in
patients with mild to moderate PD
Gillespie, et al., (2012) Interventions for
preventing falls in older people living in
the community

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Group and home-based exercise programs,
and home safety interventions reduce rate
of falls and risk of falling.
Multifactorial assessment and intervention
programs reduce rate of falls but not risk of
falling;
Tai Chi reduces risk of falling.
Overall, vitamin D supplementation does not
appear to reduce falls but may be effective in
people who have lower vitamin D levels before
treatment.
Chase;Mann; Wasek;
Arbesman (2012).
 This
systematic review explored the impact of fall
prevention programs and home modifications for
falls and the performance of community-dwelling
older adults.


33 articles analyzed
Strong evidence for multifaceted programs that
included
 home
evaluations and home modifications,
 physical activity or exercise, education,
 vision and medication checks
 assistive technology to prevent falls.
Chase;Mann; Wasek;
Arbesman (2012).

Positive outcomes included
 a decreased rate of functional
decline
 a decrease in fear of falling
(what do patient who are afraid
of falling do? They Fall!)
 an increase in physical factors
such as balance and strength.
Quick Review of Meds:
 Carbidopa/Levodopa
therapy (Sinemet)
most popular as it is well tolerated.
Carbidopa allows for more Dopamine to
be absorbed by the brain. Half life is
crucial!
 Side effects:

Nausea, vomiting, falling blood pressure
upon standing, worsening of glaucoma,
dyskinesia, hallucination, psychosis, low
blood pressure, confusion, dyskinesia, dry
mouth, dizziness
Cont’d
 Dopamine

Agonists
Side Effects:

Nausea, vomiting, low blood pressure, sleepiness,
dyskinesias, hallucinations, chest pain
 Anticholinergics

Side Effects: ACS
 Confusion,
hallucinations, nausea, blurred
vision, dry mouth, urinary retention,
nervousness; not used long-term due to side
effects
Med Schedules and Half-life


Medication half-life is the time it takes the body to reduce the medication by
half. The amount of medication in the system is directly proportional to the
amount of medication being eliminated. For example.
Medication half life is the time it takes the body to reduce the medication by
half. The amount of Medication with a half life of 4 hours being eliminated in
the following way:

8:00 AM Amount of drug in body initially = 100%


12:00 noon Amount remaining in body after 4 hours = 50%
(50% has been eliminated)

4:00 PM Amount remaining in body after 8 hours = 25% (~75% eliminated)

8:00 PM Amount remaining in body after 12 hours = 12.5% (~87.5% eliminated)

12:00 midnight Amount remaining in body after 16 hours = 6.25% (~93.75%
eliminated)
Other Med Influences
Protein and the uptake of Carbo/Levadopa

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It is not only the timing of the intake of protein that
interferes with the uptake of dopamine, it is the timing
as well.
End-of-dose failure and the on-off phenomenon
Dyskinesias: seen as a peak dose phenomena or an
over-medicated phenomena.
Bottom Line: Ask for Parkinson’s medications to be given
to the patient 1 hour prior to your session. Variability in
patient performance and function is greatly influenced
by the half-life of these medications. It is more crucial to
administer these meds on a schedule than insulin meds
for diabetics!
Demo Time!
My Sincere Thanks to My Friend
Ric Pfarrer
It’s an Impulsion Problem!
The
best way to describe it is the
Drive behind the movement.
Push
off in Gait
Forward Momentum
The Driving force (The “Rear-wheel
Drive”
COM/BOS (demo)
Impulsion: The “desire” to move
forward
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
The ability of the body to drive forward with
good push-off from the trailing leg and a
total forward movement of the trunk/torso
as if pushing through water.
PD causes a decrease in the “impulse” to
move forward. Movement becomes more
up/down than forward with shortened
stride length
Impulsion: The impulse to
move forward
 https://www.youtube.com/watch?v=GT6
Yn7SLkmQ
 Evaluation
of balance reactions,
impulsion, movement fatigue,
gait, COM/BOS
 Quality of forward impulsioncrucial for gate
 Rhythm of step
 Step length/stride length
 Change of direction
 Up/down
Techniques to Improve Gait
and Balance
 Repetitive
Forward Reach in sitting
 Repetitive Sit to stand
 Repetitive step forward and back
VS Resistance-theraband demo
(creates impulsion)
 Flexibility Training-BLE flexibility
important for stride length
The Sequel!
Families
in the Rehab
Center and Beyond.
Xlibris publishing. Pending
Publication Fall 2016!
Questions?
My Sincere Thanks to Ric
and Julie Pfarrer for their
enduring friendship and
assistance!
References
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The American Parkinson Disease Association, Inc. (2010). Parkinson’s
Disease Handbook. The Richard E. Heikkila APDA Advanced Center for
Parkinson’s Disease Research, Department of Neurology, Division of
Movement Disorders. Robert Wood Johnson Medical School, New
Brunswick, New Jersey
AOTA (2006) The role of occupational therapy with the elderly. 2nd ed.
AOTA press. Baltimore.
Carla A. Chase; Kathryn Mann; Sarah Wasek; Marian
Arbesman (2012). Systematic Review of the Effect of Home
Modification and Fall Prevention Programs on Falls and the
Performance of Community-Dwelling Older Adults. American
Journal of Occupational Therapy, May/June 2012, Vol. 66,
284-291. doi:10.5014/ajot.2012.005017

Gillespie LD1, Robertson MC, Gillespie WJ, Sherrington
C, Gates S, Clemson LM, Lamb SE.(2012). Interventions
for preventing falls in older people living in the
community. Cochrane Database Syst Rev. 2012 Sep
12.9:CD007146. doi: 10.1002/14651858.CD007146.pub3.

Morberg BM1, Jensen J1, Bode M1, Wermuth L1. (2014).
The impact of high intensity physical training on motor
and non-motor symptoms in patients with Parkinson's
disease (PIP): a preliminary study. NeuroRehabilitation.
35(2):291-8. doi: 10.3233/NRE-141119.

Winter, D, A., (1995). Human balance and posture
control during standing and walking. Gait & Posture. 3,
193-214.
YouTube Videos
Qi Gong:
 https://www.youtube.com/watch?v=sMZLdu5ngVg

Tai Chi
https://www.youtube.com/watch?v=ApS1CLWO0BQ

Movement Exercises (Balance)

https://www.youtube.com/watch?v=hiTZl-m_xPQ

YouTube Videos cont’d
 Think
Big Program
 https://www.youtube.com/watch?v=uoLI
JZbSK1A
Online Course on PD
 https://www.homeceuconnection.com/pl
ay/3752?mobile_alert=no&template=non
e
 The
best course I’ve taken for 6CEUs on
Evaluation and Tx of Pts with PD