An Evidenced-Based Interdisciplinary Approach for Self-Management of Idiopathic Parkinson s Disease

Transcription

1 An Evidenced-Based Interdisciplinary Approach for Self-Management of Idiopathic Parkinson s Disease Elizabeth Hoover, MS-CCC-SLP Theresa Ellis, Ph.D., PT, NCS Melanie Matthies, Ph.D., CCC-A Linda Tickle-Degnen, Ph.D., OTR/L

2 Is Rehabilitation Effective in PD? g Physical Therapy Occupational Therapy.00 Walk Speed Stride Length ADL Neurologic Signs ADL Fine Motor Speed De Goede, CJT (2001); Murphy, S & Tickle-Degnen, L (2001).

3 Clinical Implications of the Syntheses People with PD effectively learn new tasks and improve functional performance through focused practice of tasks during rehabilitation therapy.

4 Efficacy of a Physical Therapy Program in patients with PD: A Randomized Controlled Trial Ellis et al. Arch Phys Med Rehabil 2005;86:626-32

5 1.1 Comfortable Walking Speed 1.0 Mean Scores.9.8 Group A B TIME

6 14.0 UPDRS II (ADL's) Mean Scores Group A B 24 TIME

7 Conclusion Individuals with PD benefit from PT group treatment in addition to their MT with regard to: function as it relates to ADL s and walking speed quality of life as it relates to physical mobility

8 Next Step Sustain gains over longer period of time Self-management approach Increase impact on quality of life Interdisciplinary Home visit Interventions Intensity manipulation

9 Self-Management Study Does rehabilitation that focuses on selfmanagement of health help to improve day-today functioning and quality of life of communitydwelling people living with PD, beyond the effects of medication alone? Determine if increasing doses of selfmanagement rehabilitation results in increasingly positive self-management outcomes: specifically healthy, competent and satisfying participation in life activities.

10 Emergence of Movement and Action Task Person Environment Shumway-Cook & Woollacott, 2001

11 Self-Efficacy Definition of Self Efficacy: An individual's estimate or personal judgment of his or her own ability to succeed in reaching a specific goal Ways to Increase Self-Efficacy: Mastery Experiences Vicarious Experiences provided by social models Verbal Persuasion Bandura, A. (1994). Self-efficacy. In V. S. Ramachaudran (Ed.), Encyclopedia of human behavior (Vol. 4, pp ). New York: Academic Press. (Reprinted in H. Friedman [Ed.], Encyclopedia of mental health. San Diego: Academic Press, 1998).

12 Self-Management Study Randomized Controlled Trial: Condition I: medications only (no rehab) Condition II: 2 days in clinic + 1 day in social session (3.0 hours rehab per week = 18 hours in total) Condition III: 2 days in clinic + 1 day in home / community (4.5 hours rehab / week = 27 hours in total)

13 Inclusion Criteria Diagnosis of idiopathic, typical PD Hoehn & Yahr stages II and III years of age > 26 MMSE < 20 Geriatric Depression Scale Walk without physical assistance Stable dose of PD meds for > 2 weeks prior to and during the study No rehab services for > 2 months prior to the start of the study Living in the community (not institutionalized) No other severe medical disorders (neurological, cardiovascular, orthopedic) Able to understand, communicate with and be understood by recruitment personnel Interested in participating and able to provide informed consent

14 Self-Management Program Group Format (4-6 participants) Led by a licensed PT, OT, SLP 6 weeks; 1.5 hours per session

15 Health Condition Parkinson s Disease Body Functions & Structures (Directly Related to PD) Tremor, Bradykinesia, Rigidity, Akinesia Body Functions & Structures (Indirectly Related to PD) Flexibility, Endurance, Strength Environmental Factors Home and community settings Activities Walking, Dressing, Speaking Participation Ability to work, to interact socially, to perform self-care Personal Factors Resources, personal attitudes, emotions & feelings

16 Spinal Flexibility, Postural Alignment, & Balance

17 Axial Mobility

18 Thoracic Alignment & Reaching

19 Evidence for Relationship Between Flexibility/Posture and Function Spinal flexibility is associated with: balance (functional reach) in communitydwelling adults with and without PD (Schenkman, et al., 2000) daily activities (e.g., reaching shoes, getting onto a bus) (Bergstrom et al., 1985) vital capacity necessary for speech (Porter et al., 1995)

20 Evidence-Based Intervention Individuals with PD can improve spinal range of motion (Schenkman, 2000 &1998; Ryan, 1997; Bergstrom, 1985) Individuals with PD can improve strength (Hirsch, 2003; Scandalis, 2001; Reuter, 1999; Bridgewater, 1997) Individuals with PD can improve cardiorespiratory fitness (Inzelberg, 2005; Koseoglu, 2001; Bridgewater, 1996)

21 Evidence-based Intervention People with PD effectively learn new tasks and improve functional performance through focused practice of tasks during rehabilitation therapy. (Ellis, 2005; DeGoede, 2001; Murphy, 2001; Nieuwboer, 2001; Muller, 1997; Mohr, 1996; Patti, 1996; Kamsma, 1995; Gauthier, 1987)

22 Evidence-based Intervention People with PD can improve their walking ability by directing their attention to external cues (Rochester, 2005; del Olmo, 2005; Suteerawattananon, 2004; Dibble, 2004; Cubo 2004; Howe, 2003; Freedland, 2002; McCoy, 2002; Thaut, 2001&1996, Marchese, 2000; Lewis, 2000; Ebersbach, 1999; Zijlstra, 1998; McIntosh, 1997; Morris, 1996)

23 Clinic Sessions Mobility Exercises 25 minutes Communication activities 10 minutes Functional training 15 minutes Gait training 10 minutes Group discussion 30 minutes

24 Trunk rotation Purpose: To increase chest and trunk range of motion, decreasing stiffness and allowing for improved turning as well as mobility in bed Starting Position Lying on your back, knees bent, feet flat on floor Arms out at 90 degrees (like a T ) with palms facing upward Towel beneath your head (not your neck) Action With knees together, allow both legs to fall slowly down to the left and hold for 3 seconds Do not move your head, neck or shoulders Return to the starting position and repeat the motion to the right For positioning of the towel roll under your head: This Not This

25 Functional Training Moving in bed Rising from a chair Getting up from the floor Dressing Swallowing Handwriting Social communication

26 Gait Training with Cues

27 Discussion Topics Barriers to exercise, self-care, leisure activities, communication and mobility; benefits of exercise; strategies to increase participation Mastering moving in bed and rising from a chair Getting up from the floor Social Communication Handwriting Self-management for life: moving forward Managing tremor and rigidity Preventing falls Dressing Talking on the phone Walking Self-management for life: staying on track

28 Home Sessions Practice functional tasks at home Practice solving problems related to mobility, leisure, communication & ADL s in the home or community Reinforce the exercises and their relationship to function and quality of life

29 Summary Key Components of the Intervention: Interdisciplinary approach Patient centered Self-management strategies Task based practice at the functional level Minimize secondary impairments (flexibility, strength, fitness) Use of external cues Intensity is an important factor

30 Communication Components of the Self-Management Program Focuses on strengthening and relaxing key muscle groups for communication: Speech/voice Social aspects of communication (facial expression, gestures) Bridges discrete skill to conversational speech Promotes self-management Addresses quality of life issues through education and peer group support.

31 Self-Management Program Communication tasks are based on: principles of exercise-based therapy: Stathopoulos & Duchan, 2006 Ramig et al., 2001 Robbins et al, 2005 Social/quality of life benefits of group therapy: Holland et al, (1991) Elman (1999) Kagan, (2007)

32 Communication Components Communication Exercises (speech, voice, facial expressivity) Functional Training (social communication, swallowing, goal setting) Formal discussion sessions. Social Communication, Talking on the Telephone *Chanting during gait training. *Spontaneous conversation throughout the 90- minutes treatment sessions.

33 Communication Exercises O Exercise Lip Press Cheek puff/lip purse Smile Exercise Rapid Repeating Pitch Glide Hard Attack Ah Brace

34 Buccal-Facial Exercises O Exercise Lip Press Cheek puff/lip purse Smile Exercise Stretches and strengthens muscles of the lips and face Functional outcome: Increased clarity of speech. Increased facial expression. Increased saliva and food management

35 Rapid Repeating Improves coordination across articulation, phonation, prosody, resonance and respiration. Train repetitive motion rates with single syllables Train alternating motion rates with groups of varying syllables Functional outcome: Increased clarity of speech and loudness levels. Increased respiratory support

36 Voice Exercises Pitch Glide Hard Attack Bracing (Isometrics) Improves respiratory control, phonation and pitch variability Functional outcome: Increased loudness Increased prosody (inflection in the voice) Increased length of utterance*

37 Functional Training: Speech Topics All tasks are speech related because they involve discourse. The following topics were facilitated by the SLP: Social communication Goal setting Performance review Dysphagia

38 Discussion topics dedicated to communication Social Communication Talking on the Telephone

39 Discussion Topics Change something about yourself Change the strategy you use Change something about the environment.

40 Social Communication Change something about yourself: Rigidity across muscle groups can subdue and alter facial expressions. Maintain the flexibility and strength in these muscles by doing the exercises practiced in group. Voice/speech exercises Trunk exercises to increase respiratory support. Change the strategy you use Your face may not always convey the emotions you are feeling. Use words with greater emotional meaning. Be animated. Exaggerate your facial expressions Use speech clarity strategies, i.e. loud voice, over-articulate, reduce rate of speech Etc., etc. Change something about the environment Conduct conversations in a quiet environment. Minimize competing distractions Be comfortable physically Use of adaptive devices to increase amplification. Etc., Etc.

41 Talking on the Telephone Change something about yourself Exercises for trunk extension, respiratory support Vocal and speech exercises Change the strategy you use Talk loudly, try to project your voice Slow down, over articulate Keep your sentences brief check in with your listener every few minutes Use repetition and redundancy Discuss your communication concerns with your listener Etc., etc., Change something about the environment Communicate in a quiet environment, so that your voice is not competing with ambient noise Consider using an adaptive telephone (built in amplifier or enlarged key pad) Consider physical comfort and fatigue

42 Generalization Goal is to individualize strategies for each client and reinforce those strategies in all communication environments Discourse during mobility exercise Discourse during functional training Discourse during discussion Any and all spontaneous discourse

43 Voice production methods Participants were asked to produce the vowel /a/ at a comfortable pitch and loudness. They sustained the vowel for as long as possible. Analysis was completed with the Multidimensional Voice Program (MDVP) software from KayPentax The preliminary analysis includes 86 subjects who provided data in all four assessment periods. There were 25 women and 61 men in the analyzed sample with a mean age of 65.4 years (sd=9.1). The 344 vocalizations had acceptably periodic vibration which allowed them to be analyzed with MDVP.

44 Voice production was evaluated across sessions with MDVP. A strong vocal source has strength with steady pitch and amplitude. Pitch period perturbation quotient (PPQ) was used to measure pitch variability and amplitude perturbation quotient (APQ) was used to measure loudness variability. Noise-to-harmonics ratio (NHR) evaluated voice quality. The measure compares spectral energy of inharmonic to harmonic components and includes noise due to jitter, shimmer, and turbulence.

45 Results One-way analysis of variance of the baseline data indicated no significant effects of RCT group on any of the MDVP variables prior to treatment. Raw data were converted to Z-scores using the standardization data provided by KayPentax. At baseline, most speakers showed significant deviations from normal voice Repeated-measures analysis of variance of the Z- scores was used with RCT as a between-groups factor and session as a within-subjects factor.

46 APQ decreased (moved closer to normal values) for treatment groups 2 and 3 15 Amplitude perturbation quotient RCT= base 6wk 2mo

47 PPQ also decreased for both treatment groups, RCT=2 and 3 15 Pitch perturbation quotient 10 5 base 6wk 2mo 0 RCT= 1 2 3

48 Many individuals improved Baseline results 6-week results Amplitude perturbation quotient Normal PPQ-high Normal APQ and PPQ are both high Pitch perturbation quotient, baseline Pitch perturbation quotient, 6 weeks RCT=1( ), 2 ( )) and 3( )

49 Treatment groups ( ) improvement compared to RCT=1( ) at 2 months 12 Baseline results 2-month results 12 Amplitude perturbation quotient Normal Pitch perturbation quotient, baseline Pitch perturbation quotient, two months

50 Noise-to-harmonic ratio also improved for treatment groups, RCT=2 and 3 Noise-to-harmonic ratio base 6wk 2mo -5 RCT= 1 2 3

51 Voice production had greater clarity and less variability after treatment for RCT groups 2 and 3. A significant main effect for RCT was found for pitch period perturbation quotient [F=5.38, p=.006], amplitude perturbation quotient [F=8.76, p<.001 and noise-to-harmonics ratio [F=5.03, p=.007]. Planned comparisons indicated that the treatment groups (RCT 2,3) showed improvement which brought them closer to normative values while the medicationonly group (RCT 1) displayed generally stable or declining performance over the six months of testing.

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53 Change from baseline to post in quality of life domains Condition III (rehab + home) & Condition II (rehab + social) ** ** ** * * * * Rehab effect Effect beyond size medication d (effect size d) Co mmunication Bodily Discomfort Mobility ADL Socia l S upp ort Stigma Emotional Well-being Co gnition ---- Physical Psycho-social ----

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55 Condition II Social Session Get to know one another for who you are as individuals. Parkinson s s disease is not discussed here. Content Ice-breaker activity Conversation about topics of mutual interest General socializing directed by the participants Often talk and activities focused on family, work, favorite activities Facilitators 2 friendly students Directed conversation away from PD No therapeutic guidance / strategies

56 Adaptation and PD People with PD who maintain active participation in life activities, regardless of disease severity, have less depression and experience more well-being, than those who do not maintain participation. (Herrmann, et al., 1997; Livneh & Antonak, 1994; Pinquart and Sörensen, 2000).

57 Spoiled Identity The posture of Parkinson s disease is an attitude related to hostility and the defense against it, comparable to the stealthy approach of the boxer or wrestler to his opponent or the expectant creeping posture of so many primitive religious dancing rituals. Jellife, S. E. (1940). The parkinsonian body posture: Some considerations on unconscious hostility. Psychoanalyst Review, 27,

58 The Social Consequences of Spoiled Identity Stigmatizing impressions Difficulty sustaining rapport Barrier to active social participation (Goffman, 1963)

59 Interpersonal Communication Rating Protocol (Tickle-Degnen, Lyons, Huang & Takahashi) FACIAL: VIDEO ONLY 1 Active expressivity in face 2 Eyebrows raising 3 Eyebrows pulling together 4 Blinking 5 Cheek raising 6 Lip corners up 7 Active mouth closure during speech BODY: VIDEO ONLY 8 Movement in trunk & head 9 Forward slouching 10 Tremors 11 Gesturing with arms VOICE: AUDIO ONLY 12 Client talkativeness 13 Vocal inflection 14 Articulation 15 Loudness 16 Vocal speed 17 Laughing SPEECH CONTENT: VIDEO + AUDIO 18 Positive content 19 Negative content 20 Topic control

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61 RCT Effects for Interpersonal Behavior (ICRP) Condition III (rehab + home) Condition II (rehab + social) More control over vocal and facial mechanism More worries related to problems More expression of adequate ability to handle problems Less control over vocal and facial mechanism Less emotional reactivity to problems More expression of inadequate ability to handle problems Expresses worries but feels able to act on problems Alternative: Decreased apathy/resignation/acceptance Expresses emotional stability but not as able to act on problems Alternative: Increased apathy/resignation/acceptance

62 Does self-management rehabilitation have positive quality of life outcomes for PD? Specificity of intervention response Transfer of functional skills (Condition III) V Managing physical function Repaired identity & social acceptance (Condition II) V Regulating psycho-social function

63 Summary Study results indicate that this approach is beneficial for individuals with PD Interdisciplinary approach is a tool in rehabilitation of PD Important to note that this approach has not been contrasted with another type of treatment, only with medication treated control group.

64 Moving Forward Community Wellness group Runs in 11 sites 22 Programs Served 168 participants

65 Questions, comments?