Download San Diego OT session Three updated Wed Oct 22 2014

Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
ALLIED TEAM
TRAINING FOR
PARKINSON
2014 –San Diego
Session Three
Occupational Therapy in Early Stage Parkinson’s Disease
Rick VandenDolder, OTR/L
Linda Tickle-Degnen, PhD, OTR/L, FAOTA
Disclosures for
Rick VandenDolder, OTR/L:
Linda Tickle-Degnen, Phd, OTR/L,
FAOTA
None
I will not be discussing the off-label use of various
medications.
1
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Objectives:
•
Describe PD symptoms as they limit function
in specific tasks and cause disability
•
Develop Intervention plans based on client’s
goals and evidenced based desired
treatment outcomes, using the PEO model
•
Participate effectively as an interdisciplinary
or inter-professional team member
•
Describe the unique and complementary role
of each discipline in your care team
•
Identify strategies for building interprofessional networks and community
partnerships
OT in PD -Best Practice
Guidelines
-Deane (2003)
• Cueing
• Cog mvmt strategies
• Education
• Provision of equipment/environmental adapt
• Techniques for managing meds, on/off
• Fatigue, anxiety
• Involvement of carer (teaching, handling
techniques)
2
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Cueing Strategies in PD
• Rescue Project
•
•
•
Consortium of Universities in Europe
collaborating in research about cueing in
PD as a method to improve mobility
Clinical trial confirmed use of cueing as
effective treatment in home setting
Cues: prompts that give information on
how an action should be carried out
Allied Team Training for Parkinson II
15-18 years after onset of PD:
Falls occur in 81% of patients (23% sustained fractures)
Cognitive decline is present in 84%
48% fulfill criteria for dementia
Hallucinations and depression in 50%
Choking in 50%
Symptomatic postural hypotension in 35%
Urinary incontinence in 41%
40% live in aged care facilities
-Hely, et al. Movement Disorders (2005)
3
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
PD Symptoms affecting visual function
• Visual loss of contrast
sensitivity and altered ocular
movement affecting
functioning within the home
and community
Visual Deficits
• Decreased scanning speed
interferes with reading
• Defective occulomotor
function gives blurring of
vision
4
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Visual Deficits
Adaptations
• Ensure adequate lighting
• Eliminate clutter
• Ultra Optix line magnifier
• Gathers light, magnifies, eye on
line
• Large print books
• Books on tape.
Visual Deficits
Adaptations
5
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
PD and Eating
•
•
•
•
Dexterity
Wrist rigidity
Bradykinesia
Tremor
PD and Eating
• Appetite may be diminished
• Medications-nausea
• Olfactory changes
• Gastroparesis slowed
• Rigidity increases caloric expenditure
• Fatigue
• Participation for self esteem, swallow reflex,
socialization
6
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
PD and Eating
• Swallowing problems can
affect adequate nutrition and
have an impact on
physiological functioning
OT Intervention Strategies
for PD
• Modify with client and carepartner
the routines in meals:
• Time of meals
• Texture
• Amount
• Environment
7
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
OT Intervention Strategies
for PD
•
•
•
•
•
Only needed items on table
Small portions
Posture, proximity to table
Contrasting colors
Adaptive equipment
• Plate guard
• Offset spoon, fork, universal knife
Swallowing
• Warm / cold food and liquid are
easier to track and swallow
• Posture
• Chin tuck
• Double swallow
• May need to have mechanical
soft diet
• Thickened liquids
8
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Swallowing: Adaptations
• “Nosey” cup
• Straw
• Head position
neutral
Foods Hard to Chew and
Swallow
• Long
spaghetti
• Stringy,
tough meat
• Wild rice
• Popcorn
• Peanut
butter
• Fried eggs
• Coarse, dry
cereal
• White bread
• Course grainy
bread
• Hard, raw fruits
and vegetables
9
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Foods Easy to Chew and
Swallow
•
Turkey
•
Chicken
•
Ground meat
•
Casseroles
•
Boneless fish
•
Soft pasta
•
Moist rice
•
Mashed potatoes
and gravy
•
Medium white
bread
•
Creamed soups
•
Mashed or cooked
vegetables and
fruit
•
Custard, yogurt,
ice cream
•
(Will increase
phlegm and saliva)
Offset Fork, Color Contrast
10
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
PD and Eating
Raise level, Non-slip liner
11
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Offset Spoon
Oriental Soup Spoon
12
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Universal Knife
PD and Eating
Mobility
13
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Mobility and Transfers
Services and Support
• Teach carepartner optimal
body mechanics and safe
methods to assist client with
transfers, bed mobility,
toileting, bathing, lifting
wheelchair and lifting client
from floor.
Carepartner Instruction
Chair Transfers
• Body Mechanics
• Client positioning in
chair
• Transfer Belt
• Cue patient (less is more)
14
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Adaptations
• Satin/flannel over fabric
surface
• Raise seat height
• Foam cushion
• Folded blanket or quilt
• Blocks or platform
• Electric lift chair
15
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
16
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
17
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Impact of Advanced
Parkinson’s on Posture
Education/Positioning
•
Increased muscle rigidity and
progressing balance changes
result in:
Loss of automatic position
change or inability to
independently change position
Reduced activity levels
Potential skin changes
Seating Systems
•
•
•
Correction for asymmetries
ie: trunk lean/pelvic obliquity
Reclining back to compensate
for fixed forward lean
Cushion to maintain integrity
of integumentary system
18
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Wheelchairs
•
Hemi-height
•
Seat dimensions
specific to patient
•
Removable leg
rests
•
Extended brake
levers –marked
for visibility
•
Pelvic belt
•
Anti-tip bars
•
Pressure relief
cushion
19
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
20
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
OT Intervention Strategies
for PD
Services & Support
• Teach carepartner to help
maintain abilities of client,
through cueing, assisting
client with exercise,
recognizing medication
fluctuations and side effects.
OT Intervention Strategies
for PD
Services & Support
• Incorporate low vision techniques
and other techniques to promote task
accomplishment within living
environment
21
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
OT Intervention Strategies
for PD
Services & Support
• Simplify sensory input
within the environment
to decrease confusion,
increase attention span
and concentration for
task accomplishment
OT Intervention Strategies
for PD
Services & Support
• Simplify cognitive demands
within living environment;
instructions, directions, and
cautions. Incorporate voice
and auditory input
22
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
OT Intervention Strategies for PD
– Simplifying Demands
•
•
•
•
•
•
•
•
Familiar routine
Gradual transitions
Decrease clutter
Activity box
Things in predictable place
Pictures/labels
Calendar on refrigerator
Frequent reorientation
OT Intervention Strategies
for PD
Services & Support
• Educate client and significant
others to recognize changes that
may affect performance but are
not secondary to PD.
23
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
OT Intervention Strategies
for PD
Services & Support
•Involve individual in simple goal
directed task to make use of
cognitive, motor, and perceptual
abilities
OT Intervention Strategies
for PD
•Involve individual in simple goal
directed task to make use of
cognitive, motor, and perceptual
abilities
24
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
OT Intervention Strategies
for PD
Services & Support
• Incorporate challenges to
promote motivation and
interest at present and
past intellectual levels
OT Intervention Strategies
for PD
25
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
OT Intervention Strategies
for PD
Services & Support
• Focus on client and
carepartner’s adaptation to
changes in self-image; teach
to identify and validate
actual reality; provide
sources of respite and
support
Bed Mobility
• Axial Rigidity, decreased spinal
and pelvic ROM
• Teach principles of leverage –
log roll with knees bent,
generate momentum with head
and top arm, use
counterweight of legs to bring
trunk up
26
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Bed Mobility
•
•
•
•
•
•
•
•
Chair or bed rail or bed pole
Adapt bed height
Satin draw sheet
Bed cradle (blanket support)
Comforter vs. blanket and sheet
Visual cues/verbal cues
Twin bed
Firm mattress
27
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Bed Rail/Satin drawsheet
28
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Floor Transfer
• Cue and assist to assume 4
point crawl; use furniture to
support to assume half
kneeling to sitting before
standing
• Assess carepartner ability to
assist
• Ski poles, shovels for outdoor
support
Tub/Shower
• Shower curtain vs sliding glass
door
• Bathmat
• Grab bars
• Tub bench
• Large movements
• Terry robe
29
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Tub/Shower
Tub/Shower
• Shower curtain vs sliding glass
door
• Bathmat
• Grab bars
• Tub bench
• Large movements
• Terry robe
30
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Tub bench with back
Toileting/Incontinence
• Strategies
• Timing of fluid intake
• Timing regular trips to toilet
• Medications
• Adaptations
31
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Toileting/Incontinence
Adaptations
•
Velcro closure
pants
•
Incontinence
pads
•
Condom
catheter
•
Commode at
bedside
•
Non-spill urinal
Multidomain Approach to
Predicting Driver Safety
Wood (2008)
-J.
•
Vision: Useful Field of Vision, Dot
Motion
•
Motor: Knee extension strength, sway
path length
•
Cognitive: Trail making, Part B, Color
choice reaction time
•
91% sensitivity, 70% specificity in
identifying safe and unsafe drivers.
32
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Toileting/Incontinence
Adaptations
Balance Changes in
Parkinson’s disease
One of the four primary symptoms of PD
Least responsive to dopaminergic
replacement therapy
Rarely seen as first symptom; typically seen
later
(Early balance changes may be “red flag”
for Parkinson’s Plus).
33
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Parkinson’s Symptoms
Influencing Changes in
Balance
Rigidity in axial and lower extremity
musculature
Reduction/loss of postural righting
reflexes
Narrow base of support
Postural changes-center of gravity not
aligned over base of support
Parkinson’s Symptoms
Influencing Changes in
Balance
Propulsion/Festination
Retropulsion
Freezing
Dyskinesia
Dystonia
Fatigue
34
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Potential Contributing Factors
Unrelated to Parkinson’s
Disease
•
Structural foot deformities
(hammertoes, bunions, etc)
•
Sensory changes, i.e. peripheral
neuropathy
•
Proprioceptive changes
•
Vestibular dysfunction
•
Other medical conditions
Propulsion/Festination
Compensation Strategies
•
Self monitoring – complete stop if
stride length shortens. Restart with
longer step.
•
Wheeled walker with resistance may
be helpful
•
Use of rhythm to maintain speed and
pace may be helpful
35
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
U-Step Walker
•
Consult with
physical therapy
•
May be more
effective for for
person with PSP
to deter
backwards or
lateral falling.
Retropulsion Triggers
•
Carrying things in both hands.
•
Stepping backwards while turning.
•
Pulling/dragging items backward
while gardening, yard work, farm
chores, vacuuming
•
Sudden displacement backward
(being jostled in a crowd,
pets/children jumping up , etc.
36
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Falls Prevention
•
Home evaluation
•
Rails (both sides)
•
Barrier at top of
steps
•
Grab bars at doors
•
Remove clutter
•
Adequate lighting
•
Mark corners,
edges thresholds
with contrasting
colored tape
•
Impulsivity may be
risk factor
Stairway Gate
37
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Retropulsion: Compensation
Strategies
•
Carry objects in bag with handles at your
side rather than in front
•
Use vertical grab bar near door
•
Reduce tension on automatic closing doors
•
Sit when dressing
•
Re-arrange cupboards/shelves to place
frequently used items within easy reach.
Retropulsion: Compensation
Strategies
•
Tai Chi stance
•
Move forward in
wide circle rather
than backing up
•
Marching to pivot
•
Clock turn
38
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Retropulsion: Compensation
Strategies
Retropulsion: Compensation
Strategies
39
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Retropulsion: Compensation
Strategies
Retropulsion: Compensation
Strategies
•
In kitchen slide dish along counter top
when possible rather than carrying items
•
Use walker to carry object on walker tray
or use rolling kitchen/laundry/garden carts
to transport items
•
Avoid stepstools and ladders
•
Delegate higher risk activities
40
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Freezing compensation
Strategies
•
Remove floor clutter (plant stands,
magazine racks, foot stools) and throw
rugs
•
Move furniture or arrange environment to
widen walking paths
•
Teach visualization techniques (stepping
over or kicking through an imaginary
object
•
Estimate steps to a target and count aloud
Freezing compensation
Strategies
•
Look for frequent freeze
locations in the home
environment and
provide visual cue (e.g.
lines across path in
doorway, “x” in front of
chair or toilet)
•
Divert attention from
feet/legs; practice deep
breathing, unrelated
arm movements, or
centering activity
•
Educate family/staff
re: triggers and cues
41
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Postural Changes
in Parkinson’s Disease
Forward
head
Increased
thoracic
kyphosis
Decreased
lumbar
lordosis
Increased
hip and
knee flexion
Forward
trunk lean
Narrow
base of
support
Changes in Postural
Awareness
•
Decreased self
awareness of posture
is evident in those
with Parkinson’s
•
Posture often appears
to decline even
further when engaged
in activity or when
fatigued
42
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Posture Enhancement Exercises
•
•
Stretching,
including neck,
trunk, pectorals,
hip flexors, heel
cords, and
hamstrings.
Strengthening of
core muscle
groups: scapular
muscles, trunk,
abdominals and
legs
Posture
Enhancement/Exercises
•
Activities emphasizing
pelvic mobility/weight
shift/LE weight bearing
•
Spinal
lengthening/supine
chin tucks
•
Therapy ball or Tai chi
•
Increase self
awareness through use
of mirror, photos or
video
43
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Posture Education/Positioning:
Sitting Posture
•
Assess home environment, car
and workplace postures
•
Instruct in proper ergonomics
•
Use of lumbar roll/cushion to
enhance lumbar curve
•
Emphasis on lengthening spine,
not “leaning backward”
Posture
Education/Positioning:
Sleeping Posture
•
•
•
Minimize use of excessive
pillows/cushions for sleeping
Use of cervical roll/cushion to
enhance cervical curve
Instruct in techniques to allow
position changes during the
night
44
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
OT and ADL’s in PD
• Toileting
• Dressing
• Hygiene
Personal Hygiene
•
Sit if balance deficit
or low endurance
•
Wide based stance
•
Electric toothbrush
•
Electric razor
•
Suction denture
brush
45
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Personal Hygiene and
Grooming
•
•
•
•
Sit to apply makeup
Support arms on table or vanity
Build up handles on brush or comb
If possible, wait until meds take
effect to decrease difficulty of
task.
Toilet hygiene
•
•
•
•
•
•
•
Toilet rails
Moist wipes
Step stool
Bidet
Men sit or use urinal
Velcro pants
Trunk rotation
exercises
46
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Dressing
Affected by:
Rigidity
Bradykinesia
Posture
Balance
Multi-tasking
Visual/Perception
Organizing
Coordination
Dressing
Set up clothing the night before in order it
will be put on
Allow adequate time to avoid need to
hurry
Wait 45 min after taking morning meds
before dressing
Sit to dress – sit on chair not bed
Focus on each part of sequence
47
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Dressing
Loose-fitting, stretchy clothes- eliminate
impractical clothing from wardrobe
Slippery underclothes
Velcro collar, cuff, or whole shirt
Snap closures
Polo shirt
Button hook if no perceptual deficits
(Buttoning is therapeutic if not frustrating)
Dressing
Over the head shirt
48
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Dressing
Button down shirt/jacket
Dressing
Put more involved arm into sleeve first
Flipping shirt/jacket over head is risky
Button lowest buttons and pull shirt over
head
Front closure or velcro closure bra
49
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
Pants
•
Urgency, stress
complicates
closures
•
Velcro fly
•
Elastic
waistband
•
Suspenders
Dressing
Adaptations
Footstool
Elastic laces/velcro
closures
Slip on shoes
Sock aid
Reacher
Long shoe horn
50
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
OT Intervention Strategies
for PD
Services & Support
Simplify and adapt methods and
instructions for safe and
independent use of instruments
to promote personal hygiene,
dressing, functional mobility,
home management, work, and
leisure tasks
OT Intervention Strategies for
PD
Services & Support
Increase client skill with clientspecific compensatory methods
and adaptive equipment for IADL
and ADL task accomplishment
51
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
OT Intervention Strategies for
PD
Services & Support
Teach client and carepartner to
make changes in the environment
that will provide visual cues for
safety and independent task
performance.
OT Intervention Strategies
for PD
Services & Support
Teach client and carepartner
home exercise program for
client to deter losses due to
increases in sedentary
lifestyle.
52
Allied Team Training for Parkinson's
Presentation
NameParkinson's Disease
OT in Early Stage
Arlington , VA March 15, 2012
11/3/2014
OT Goals for PD
Services and Support
Increase client and carepartner
understanding of the fluctuations
of PD symptoms and in the
client’s need for assistance.
Teach coping skills for these
fluctuations.
Discussion
• What is involved in being an
effective interdisciplinary or interprofessional team member?
• Who are the critical disciplines in
your care team?
• What are your and their unique and
complementary roles?
• What are strategies for building
inter-professional networks and
community partnerships?
53