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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 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 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 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 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 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 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 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
