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parkinson's disease

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by

Josie Logue

on 8 September 2014

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Transcript of parkinson's disease

parkinson's
disease

case-based strategies
for
life with parkinson's

case 6: 67 year old female with Stage III Parkinson's disease
What is Parkinson's Disease?
A progressive, degenerative neurological disease primarily affecting the basal ganglia resulting in common motor impairments
Physical Decline
Impaired mood
loss of function
depression
sedentary behaviour cycle
dance for pd ©
LSVT BIG
Management
evidence
clinically proven to aid in falls prevention
falls management plan
allied health professionals
medication
surgery
physiotherapy interventions
community nurses
social workers
cueing strategies
cognitive movement strategies
exercise
gait
balance
falls
primary motor
impairments
bradykinesia/hypokinesia
tremor
rigidity
postural instability
freezing/akinesia
Pathology
Results from pathological process beginning in the substantia nigra of the basal ganglia
Degeneration: dorsal motor nucelus -> vagal nerve -> olfactory nucleus -> lower brain stem -> basal ganglia -> forebrain -> cortex
Loss of dopaminergic neurones ---> motor symptoms of PD
Apparent after ~80% nerve cells degenerated (occurs over years)
Some impairments (motor & non-motor) --> degeneration of other parts of the brain
Signs & symptoms
slow, shuffling walking
reduced/absent arm-swing during walking
soft unemotional speech
lack of facial expression
difficulty moving around in bed
gradual decrease in size & speed of repetitive movements
motor
cognitive
impairments
attention
memory
dementia
30%
depression
anxiety
apathy
psychosis
Incidence & Prevalence
3 in 1000 in general population
1 in 100 over 60 years
In 2014 80,000 Austrlians with PD
2nd most common neurodegenrative disorder
Average age 65+
1 in 7 diagnosed under age 40 (early-onset)
Men > women
Prognosis
Normal life expectancy!
Progression
Hoehn & Yahr Scale
Stage III
impaired righting reflexes
loss of balance
inability to make rapid, automatic & involuntary movements
increased risk of falls
Ms Nyugen
Memory impairment
Recent falls
Fast progressing
Social issues
Lives alone
Younger sister 15km away (bi-weeky visits)
Difficulty dressing/bathing
Identified safety issues with cooking
Dreads having "to go into a home"
primary concerns for prevention
falls
disease progression
Most people with PD will develop a problem with falls
Increase awareness & avoidance of circumstances predisposing to falls
Environmental modifications to prevent falls
Training/exercise to prevent falls
Develop a management plan for dealing with falls
"stepping on"
Falls Prevention Program
Carande-Kulis et al (2010)
Clemson et al (2004)
Gillespie et al (Review)
why?
Preserve & promote independence & QOL
how?
health promotion programs
tai chi for PD
long-term mx
mid-term mx
short-term mx
Target modifiable factors through:
Specific motor assessment & goal setting
An individualised exercise program
Cueing strategies
Cognitive movement strategies
Home assessment (for home-based exercise & identification of falls risks)
Education (patient & family)
Link/refer to other health professionals

Regular review for change in condition
Modify program/strategies as appropriate
Working in conjunction with other AHP to manage
developments/fluctuations

Develop long-term plan for eventual disease progression
(mutual decision-making with patient, physio & family)
prevention strategies
Drug management = highly effective
in managing symptoms
Most effective during
initial years (3-8years)

positives
negatives
The progressing nature of PD symptoms along with side-effects of
medication make management of movement problems
increasingly difficult as time progresses.
The balancing of medication (multiple) is very individualised &
symptom-dependent making management difficult - regular
medication review is vital.
Levodopa
Combats:
Hypokinesia
Akinesia
Tremor & rigidity
comt inhibitors
Reduces breakdown of L-dopa before it reaches the brain
Not effective on their own - need to be combined with L-dopa
= the chemical precursor of dopamine
dopamine agonists
Mimic actions of dopamine
Addition to L-dopa therapy
---> reduces fluctuations in motor performance
role of dopamine
side effects
confusion
hallucinations
postural hypotension
mao inhibitors
Reduce breakdown of dopamine in the brain
Used with L-dopa
side effects
nausea
vomiting
postural
hypotension
dyskinesia
pulmonary/peritoneal
fibrosis
neuropsychiatric disturbances
confusion
mood swings
hallucinations
medication-related
management factors
end-of-dose slowing
peak dose dyskinesia
on-off phenomenon
Pallidotomy
Thalamic surgery
Subthalamic surgery
Deep brain stimulation
Reduce tremors, rigidity & bradykinesia
Can provoke dyskinesias
Effective method of controlling tremor
No effect on bradykinesia
Indicated for unilateral dyskinesias, on-off fluctuations & drug failure
Can improve motor examinations & ADLs
High incidence of adverse effects
Surgical procedure of choice for PD because:
Does not involve destruction of brain tissue
It is reversible
It can be adjusted as the disease progresses or adverse events occur
Bilateral procedures can be performed without a sig. increase in adverse events
occupational therapist
home assessment
home & environmental modifications
strategies for:
self-care
eating & drinking
washing & dressing
cognitive assessment & intervention
Liftware "smart" spoon
speech pathologist
vocal loudness & pitch range
(LSVT LOUD)
promoting effective
communication
swallowing
assist personal hygiene & self-care
assist with medication
administration
identify home-needs
& refer appropriately
liaise with family
& patient
cleaning/assisted living services
meals on wheels
discuss care facilities
& requirements
neuropsychologist
assess & treat cognition
e.g. depression/anxiety
GP
medication review (3-6months)
community transport
dietician
assist with optimum weight
management
constipation
vitamin insufficiency
(vit D)
adapt diet to medication
interaction
inpatient rehab
why?
what?
Promote independence & safety
Following adverse events e.g. sudden deterioration
or episode of falls
Restore patient confidence
Offer family temporary respite
Allow time for home modifications
Initial/specific diagnosis
Identification of new/existing impairments
Intensive & comprehensive treatment - benefit of inpatient MDT
24hr medical management & nursing-care
Daily physiotherapy & OT Rx
Education for patient & family
Falls prevention
Outpatient management plans developed

How to get up from a fall
Emergency response device/alarm
Portable phone use
Education on immediate management:
Post-fall management:
Tell your doctor
Referral to other AHPs
Identify cause of fall
Address fear of falling
Fear of falling increases likelihood of falling
Improve balance & strength to increase walking confidence
Socialisation (PD specific exercise classes)
pd warrior
reversed using the "theory of reasoned action/planned behaviour"
behavioural model
inactivity
what?
LSVT BIG: Big movements for BIG living.
standardised, supervised intensive training course
high effort, repetitive and empowering with a focus on amplitude i.e. "bigness‟ of movement"
why?
LSVT BIG is appropriate for people with Parkinson's Disease by counteracting hypo/bradykinesia
yields measurable results within first hour of treatment
PLUS improves movement & self-confidence over-time
repetitive, exaggerated movements increase dopamine production in the brain & recalibrate muscle function
how?
4 week training program
attend the centre four times a week for an hour
in addition to a home exercise program daily throughout the program (tailored to her needs as assessed by a certified physiotherapist that has completed the LSVT BIG training)
evidence
LSVT BIG v Nordic walking v Home-ex program -- LSVT significantly improved UPDRS scores, function & gait speed over a 4week program of 1hr x4/wk - Ebersbach et al (2010)
exercise-based behavioural treatments may improve function & slow progression of motor symptoms in PD due to it's neuroprotective effect - Ahlskog 2011 <----- this is an active area of research
by training patients to use bigger movements "automatically"‟ in everyday living, LSVT BIG training has shown significant improvements for over two years following participation in the individual training program
weaknesses of LSVT BIG ALONE
general program
doesn't target freezing of gait specific
one-to-one
lacks socialisation benefits
strengths of the centre (advancecare rehab)
sets basis for PD exercise training
options for referral to specific gait/freezing training & group exercise for PD (PD warrior)
available as home-based if unable to come to clinic
assumes that people behave in rational manner & have control
behavioural intention - likelihood of changing the behaviour
attitudes to behaviour & subjected norms
By increasing her sense of personal control over aspects of her disease (the progression), she is lead to an increase in intention to perform these large amplitude movements, encouraging her to actually adopt high amplitude movement as part of her daily life.
limited in that not all behaviours are simply a matter of choice
therefore...
develop a plan & problem-solving skills
walking aids
pros
increase independence & safety
use of wheeled-walker to compensate for postural instabilty
cons
increase attentional demands
can make walking more complex & difficult (particularly w/sticks)
do not improve speed or freezing
Cubo et al (2003)
walking speed = slower with walkers compared to walk alone
standard walker increased freezing
wheeled walker = no different from walk alone
The unique aspects of the LSVT Programs include the combination of:
an exclusive target on increasing amplitude (bigger movements in the limb motor system)
a focus on sensory recalibration to help patients recognise that movements with increased amplitude are within normal limits, even if they feel "too big"
training self-cueing and attention to action to facilitate long-term maintenance of treatment outcomes.

In addition, the intensive mode of delivery is consistent with principles that drive activity-dependent neuroplasticity and motor learning.

exercise and parkinson's disease
presented by
sumaiya rahman, mengjie liu
& josephine logue
Full transcript