Welcome and Introductions

Transcription

1 Spotlight on Parkinson s Disease Staying on Your Feet Balance Matters Tuesday, October 18, 2016 Welcome and Introductions Stephanie Paul Vice President Development and Marketing American Parkinson Disease Association 2 1

2 Presenters Tami Rork DeAngelis, PT, DPT, GCS Anna DePold Hohler, MD, FAAN 3 Presentation Anna DePold Hohler, MD, FAAN Assistant Dean, Office of Clinical and Strategic Affiliations Director of the Center for Military and Post Deployment Health Associate Professor of Neurology Boston University School of Medicine Boston, MA 4 2

3 Balance Matters Medication Side Effects PD Motor Symptoms Blood Pressure Interventions Physical Therapy Medication Treatments Conservative Treatments 5 PD Motor Symptoms 6 3

4 Parkinson s Disease Motor Symptoms Patients with PD can have difficulties with posture and walking which can affect balance. Posture can be stooped affecting balance Walking can be slowed with scuffing which increases the risk of tripping 7 Complications of Therapy Wearing off On off Dyskinesias 8 4

5 Wearing off 9 Over time there is a progressive loss of dopamine in the brain. More medication is needed for symptom control. Patients may experience a drop in their dopamine levels when their pills are wearing off during which time their PD symptoms worsen. This can affect their balance. This is often managed with increasing dosing or pill frequency. On Off Over time, patients may develop symptom fluctuations. The ON period is when a person notices that their medications are working. The OFF period is when the medications are not working. In more advanced disease there is less on time, more off time, and more on off fluctuations. This may be improved by increasing the dose of the medication, more frequent dosing, or adding on medications Off Chart.jpg 5

6 Dyskinesias Dyskinesias are dancing movements that patients may experience after they have been on dopaminergic medications often for 5 years or more Dyskinesias may affect balance and increase risk of falls. They may be managed by spreading out medications or adding on a 11 particular medication for dyskinesias. /cdcd243057a dfdd546bd253f_f37.png Blood Pressure 12 6

7 Parkinson s Disease Non Motor Symptoms Parkinson s Disease is associated with a number of nonmotor difficulties. Blood pressure fluctuations are common Regulation of Blood Pressure 14 Fluctuations in blood pressure is commonly seen in PD Orthostatic hypotension is a drop in the systolic blood pressure (top number)of 20 points or a drop in the diastolic blood pressure (bottom number)of 10 points after changing position Blood pressure is frequently worsened by medications used in PD 7

8 Symptoms of Low Blood Pressure Fainting Falls Confusion Balance difficulties Lightheadedness Weakness 15 All symptoms of low blood pressure are worse with standing. Medication Side Effects 16 8

9 Medication Side Effects Dopamine medications can often drop blood pressure Some patients are also on blood pressure medications that lower blood pressure Some bladder medications also lower blood pressure 17 Correcting Orthostatic Hypotension Improves Function Patients with Parkinson s disease frequently have orthostatic hypotension They may not be symptomatic The only way to know for sure is by doing orthostatic blood pressure monitoring. Patients showed significant improvement in their motor function, walking, balance and cognitive function with treatment of orthostatic hypotension 18 Hohler AD, Amariei DE, Katz DI, et al. Treating Orthostatic Hypotension in Patients with 'Parkinson s Disease Improves Function. Journal of Parkinson's Disease Issue Volume 2, Number 3,

10 Conservative Treatments 19 Blood Pressure Conservative Treatment Slow position changes Hydration ounces per day Electrolyte rich fluids Add salt to the diet Compression stockings 20 Abdominal binder Spring Bottled Water 169 oz Bottles 24 Case/product_

11 Medication Treatments 21 Medications Used to Treat Low Blood Pressure 22 Fludrocortisone can be used to expand blood volume. Side Effects include: swelling, headaches, weight gain, and high blood pressure Midodrine can constrict blood vessels. Side Effects include high blood pressure, vision changes, numbness, and itching Droxidopa chemically stimulates the autonomic system and increases blood pressure. Side effects include high blood pressure, headaches. 11

12 Presentation Tami Rork DeAngelis, PT, DPT, GCS Senior Physical Therapist Center for Neurorehabilitation Sargent College of Health and Rehabilitation Sciences Boston University Boston, MA 23 Physical Therapy 24 12

13 What Do We Need to Do to Keep Our Balance? Maintain quiet standing Walk without tripping or stumbling Anticipate challenges to balance Tolerate unexpected challenges to balance 25 What Systems Are Involved in Balance? Strength, Flexibility and Posture Unexpected postural changes Stability during walking Balance Control Expected postural changes Sensory System (sight, inner ear, etc) 26 Stability Limits Adapted from Horak FB, et al. The Balance evaluation Systems Test (BESTest) to differentiate Balance Deficits. Physical Therapy 2009;Vol 89, 5:

14 How Can These Systems Be Affected in People With PD? Strength, Flexibility and Posture Decreased hip strength Decreased ankle flexibility Forward flexed and stiff spine Stability during walking Catching toe when walking Trunk stiffness/rigidity Sensory System Changes in processing of information Impaired vision 27 Adapted from Horak FB, et al. The Balance evaluation Systems Test (BESTest) to differentiate Balance Deficits. Physical Therapy 2009;Vol 89, 5: How Can These Systems Be Affected In People With PD? (cont.) Expected Postural Changes Unexpected Postural Changes Stability Limits Delayed muscle on Abnormal muscle coordination Too big or too little of a response Ankle stiffness 28 14

15 Can Physical Therapy Interventions Improve Balance and Decrease Falls? Case 1: Bob 63 years old. PD for 5 years. Reports tripping when walking his dog. Daily near falls, one fall in the last year

16 Case 1: Bob Primary Problems Decreased balance reactions Stiffness Slowness Secondary Problems Maintain quiet standing Walk without tripping or stumbling Anticipate challenges to balance Tolerate unexpected challenges to balance Muscle weakness Decreased flexibility Decreased posture 31 Case 1: Bob s Physical Therapy 32 Physical Therapy Treatment Plan Strengthening program for legs and trunk Gait training on treadmill and over ground with a metronome beat Balance training Stretching program for ankle and hip muscles Physical activity plan 6 month follow up appointment 16

17 Case 2: Shirley 68 years old. PD for 12 years. Loses balance daily, falls weekly. Loss of balance/falls mostly in evenings, when turning and while carrying grocery bags or reaching for phone. Experiences ON/OFF times and dyskinesias. 33 Case 2: Shirley Primary Problems Decreased postural reactions Stiffness Slowness 34 Maintain quiet standing Walk without tripping or stumbling Anticipate challenges to balance Tolerate unexpected challenges to balance Secondary Problems Maintain quiet standing Walk without tripping or stumbling Anticipate challenges to balance Tolerate unexpected challenges to balance Muscle weakness Decreased flexibility Decreased posture 17

18 Case 2: Shirley s Physical Therapy Physical Therapy Treatment Plan 35 Check in with Neurologist for medication adjustment. Complete Fall log Balance training activities Gait Training activities (with dual task) Strategy Training to maximize safety Exercises for strength and flexibility. Discharge to Tai Chi 2X per week class AND Follow up in 3 months for balance assessment Conclusions A team approach is key when it comes to managing balance. Prevention and early treatment is ideal. Balance can be improved throughout your lifespan with PD (It s never too late!). Keep moving your feet to stay on your feet! Call the APDA Rehab Resource Center Helpline to find a PT with expertise in Parkinson s disease near you! (888)

19 Question & Answer Tami Rork DeAngelis, PT, DPT, GCS Anna DePold Hohler, MD, FAAN 37 Closing Remarks Stephanie Paul Vice President Development and Marketing American Parkinson Disease Association 38 19

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