Exercise as Medicine The Role of Rehabilitation Professionals in Helping to Treat Parkinson's Disease Rehabilitation Services

Transcription

1 Exercise as Medicine The Role of Rehabilitation Professionals in Helping to Treat Parkinson's Disease Katie Parafinczuk PT, DPT, NCS Redwood City, CA Rehabilitation Services

2 My Background Student Experience Emory University, Bachelor s Science Arcadia University, Doctor of Physical Therapy Student internship at Dan Aaron Parkinson Foundation (Philadelphia, PA) Professional Experience Kaiser Permanente Neurological Clinical Specialist Outpatient and Acute hospital care (including post DBS surgery) Parkinson Education and group exercise classes Community class instructor 2 November 12, 2017 Kaiser Permanente All Rights Reserved.

3 Objectives Parkinson s Disease : possible symptoms Your Rehabilitation Team: Who we are, what we do Exercise as Medicine: Role of Rehabilitation providers What can you do? Question & Answer Session 3 November 12, 2017 Kaiser Permanente All Rights Reserved.

4 Parkinson s Disease What is Parkinson s Disease? Progressive, neuro-degenerative disease affecting the brain Deficiency of dopamine (neuro-transmitter) Characterized by 4 symptoms Bradykinesia (slow movement) Rigidity (stiffness) Tremor (at rest) Postural Instability (poor balance) 4 November 12, 2017 Kaiser Permanente All Rights Reserved.

5 Parkinson s Disease What are the Signs and Symptoms? Primary motor symptoms Bradykinesia: slowness of movement Rigidity: stiffness, limited flexibility Tremor: RESTING Postural instability: off balance when standing Secondary motor symptoms Freezing: my feet are glued to the floor Micrographia: small handwriting Mask-like expressions: lack of facial expressions Unwanted acceleration with walking 5 November 12, 2017 Kaiser Permanente All Rights Reserved.

6 Parkinson s Disease What are the Signs and Symptoms? Non-motor symptoms Loss of smell Vision (dry eyes due to limited blinking) Excessive saliva (swallowing issues, drooling) Bladder issues (trouble with control) Constipation REM sleep behavior disorder Mood disorder, depression Fatigue, lack of energy/motivation Cognitive issues: slowed thinking, memory loss, confusion Medication side effects 6 November 12, 2017 Kaiser Permanente All Rights Reserved.

7 Parkinson s Disease Types of Parkinson s Disease Idiopathic Parkinson s Disease Atypical Parkinsonism: ~15% of PD diagnoses Corticobasal Degeneration Lewy Body Dementia Multi-System Atrophy Progressive Supranuclear Palsy 7 November 12, 2017 Kaiser Permanente All Rights Reserved.

8 Parkinson s Disease Stages of Parkinson s Disease Stage 1: Initial onset, one limb affected, mild postural changes Stage 2: Bilateral symptoms, balance and activities of daily living more difficult Stage 3: Slowing of movement, more prominent symptoms Stage 4: Increased rigidity, decreased walking abilities, bradykinesia (slow movement) Stage 5: Loss of walking or standing abilities, requires assistance with activities of daily living 8 November 12, 2017 Kaiser Permanente All Rights Reserved.

9 Neuroplasticity Adapted from Ellis T. Barriers to Exercise in People with Parkinson Disease. PTJ 2013 Disability Diagnosis Compensation Neurorepair Neuroprotection Window of Disease Modification Time Disease progression

10 Parkinson s Disease: Exercise as Medicine Typical treatment options Medication Exercise Deep Brain Stimulation Individualizing dopamine management Changes through the disease process MUST be taken on schedule to maximize benefits Side effects Neurologist PM&R doctor 10 November 12, 2017 Kaiser Permanente All Rights Reserved. Address/improve function Neuroprotective Neurorepair Start early in disease process PT/OT/SLP Appropriate for some people May increase fall risk Complications may occur Movement Disorder Specialist and Neuro surgeon

11 Parkinson s Disease: Your Rehabilitation Team Who we are and what we do Neurologist Physical Medicine and Rehabilitation doctor Physical Therapy Occupational Therapy Speech Therapy Social Worker Psychiatry/psychologist 11 November 12, 2017 Kaiser Permanente All Rights Reserved.

12 Team Approach for PD Care: 12 November 12, 2017 Kaiser Permanente All Rights Reserved.

13 Parkinson Net: The Inspiration and the proof that a Team care approach is beneficial for people with PD Keus SH, Bloem BR, Hendriks EJ, et al. Evidence-based analysis of physical therapy in Parkinson's disease with recommendations for practice and research. Mov Disord 2007; 22(4): Kalf JG, de Swart BJM, Bloem BR, et al. Guidelines for speech-language therapy in Parkinson's disease. Parkinsonism Relat Disord 2007; 13(S3):414. Nijkrake MJ, Keus SH, Ewalds H, et al. Quality indicators for physiotherapy in Parkinson's disease. Eur J Phys Rehabil Med 2009; 45(2): Nijkrake MJ, Keus SH, Overeem S, et al. The ParkinsonNet concept: development, implementation and initial experience. Mov Disord 2010; 25(7): Van der Eijk M, Faber MJ, Al SS, et al. Moving towards patient-centered healthcare for patients with Parkinson's disease. Parkinsonism Relat Disord 2011; 17(5): November 12, 2017 Kaiser Permanente All Rights Reserved.

14 Kaiser Permanente Parkinson s Care: A Resource Guide for Patients and Providers Our Mission is to Bring Members with Parkinson s Together Your place to find resources, support, and our clinical network. Resources for Clinician education, networking and new information 14 November 12, 2017 Kaiser Permanente All Rights Reserved.

15 Role of Neurologist Clinical Evaluation and diagnosis Medication Recommendation and management Symptom management and referrals 15 November 12, 2017 Kaiser Permanente All Rights Reserved.

16 Role of Physical Medicine and Rehab Doctor Overlook and organize therapy services (determine which therapists need referral) Help to order equipment and braces Management of certain symptoms (spasticitybotox injections or medications) Leads medical rounds with rehab team 16 November 12, 2017 Kaiser Permanente All Rights Reserved.

17 Indications for a referral to a Speech Language Pathologist: People don t hear what you say. You choke on your food. You have too much saliva. Every movement seems smaller. Your brain doesn t give you the feedback it once did. 17

18 -Speaking difficulties: Who we are and what we do Decreased intelligibility Decreased loudness Cognitive problems -Difficulty swallowing: Choking Loss of appetite -Problems with drooling: How to minimize it With atypical Parkinson s, results may be different because other parts of the brain are involved. 18

19 During your visit with a Speech Language Pathologist Come prepared with a list of questions/concerns and priorities. Be open and honest about any difficulty with Speaking/Cognition, Swallowing, and/or Drooling. Areas we assess: Difficulty with speech: Difficulty with chewing and swallowing Difficulty with controlling saliva Bring a caregiver, family member, or friend. 19

20 What to expect in Speech Therapy The Speech Language Pathologist also trains the main conversational partners/caregivers in taking over cueing of patient necessary to allow for carry-over outside of therapy. 20

21 Parkinson s Disease: Your Kaiser Permanente Team What is Occupational Therapy (OT)? Helps people participate in the things they need and want to do through therapeutic everyday activities (occupations) 1 Self-care activities (grooming/hygiene, dressing, bathing, etc.) Everyday activities (hobbies, cooking, housework, etc.) Fine motor skill coordination training and adaptation strategies 21 November 12, 2017 Kaiser Permanente All Rights Reserved.

22 Parkinson s Disease: Your Kaiser Permanente Team What to expect in occupational therapy Organize your priorities, needs and strengths in activities (and of caregiver) Information and coaching Training tasks Training compensatory strategies in tasks Simplifying tasks and breaking down your tasks to fit with your abilities 22 November 12, 2017 Kaiser Permanente All Rights Reserved.

23 Parkinson s Disease: Your Kaiser Permanente Team What to expect in occupational therapy cont. Building and writing of a daily schedule to manage fatigue, exercise and medication Adaptation suggestions for the home environment For caregiver: information, coaching and training skills 23 November 12, 2017 Kaiser Permanente All Rights Reserved.

24 Parkinson s Disease: Your Kaiser Permanente Team Meaningful Tasks Participating in your meaningful activities is a form of EXERCISE Important to continue with engaging in your daily activities and find strategies to maintain independence Contact your local OT if you find that 1 or more of your activities has been affected. 24 November 12, 2017 Kaiser Permanente All Rights Reserved.

25 Parkinson s Disease: Your Kaiser Permanente Team PHYSICAL THERAPIST Areas we assess Walking form Balance Physical Capacity (endurance) Functional Ability, dual task Bring a family member, friend or caregiver 25 November 12, 2017 Kaiser Permanente All Rights Reserved.

26 Parkinson s Disease: Your Kaiser Permanente Team Role of PHYSICAL THERAPIST Skilled assessment and guided interventions Integrate evidence based exercise approach Its not just exercise but HOW you exercise Targeting PD specific deficits Intensity training with skill acquisition Dosage of training Dual task 26 November 12, 2017 Kaiser Permanente All Rights Reserved.

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28 Parkinson s Disease What to expect in Physical Therapy Cues to assist with movement Motor-cognitive training (freezing strategies, fall prevention) Balance training: anticipatory, reactive, dynamic Strength training Practice activities of daily living and collaborate on modifications Initiate exercise routine with specific dosage Exercise groups Post-surgery Re-assessment and modifications (DBS) 28 November 12, 2017 Kaiser Permanente All Rights Reserved.

29 Parkinson s Disease Exercise Principles for Neuroplasticity Trunk Rotation Large Amplitude Movement Focused Movement High Intensity Movement Dual Task Activity Balance challenge 29 November 12, 2017 Kaiser Permanente All Rights Reserved.

30 Role of Physical therapist: Research King LA et al. Effects of Group, Individual, and Home Exercise in Persons with PD: A Randomized Clinical Trial. J of Neurol Phys Ther. 2015; 39: sessions with home program OR group program OR individualized physical therapy 58 participants, average age 64 Agility exercises, postural balance training, coordination and gait Moderate-somewhat hard level of exertion Results: Only the individual PT group significantly improved in the Physical Performance Test (specifically in function and balance measures) Individual and group exercise showed improvement in gait 30 November 12, 2017 Kaiser Permanente All Rights Reserved.

31 Physical Therapy: Research Dibble LE et al. Exercise and Medication effects on Persons with Parkinson disease across the domains of disability: a randomized control trial. J of Neurol Phys Ther. 2015; 39: Significant improvement seen despite type of exercise (strength versus balance training) Exercise and Medicine together resulted in improved scores on: Muscle force production UPDRS Functional gait assessment 6 min walk test Proves preserved motor adaptability and neural recruitment in PD 31 November 12, 2017 Kaiser Permanente All Rights Reserved.

32 Parkinson s Disease: Exercise as Medicine How to Start Exercising? DATE: ACTIVITY: MINUTES: INTENSITY: (0-10) (Borg scale) MEDICATION ON/OFF Good Bad Activity Log: 32 November 12, 2017 Kaiser Permanente All Rights Reserved.

33 Parkinson s Disease: Exercise as Medicine Options for Exercising: PT makes it patient specific Parkinson s Exercise Class (PWR!, LSVT, PD background instructor) Tai Chi Yoga/Pilates Walking Cycling Dancing Boxing Chair Classes Gym (cycling, mat classes, cardio machines, etc.) 33 November 12, 2017 Kaiser Permanente All Rights Reserved.

34 Social Worker Mental Health Sexual Health Caregiver Stress Relaxation Techniques Planning Ahead Resources

35 Psychiatrist/Psychologist: Mental Health and Behavior Depression Anxiety Apathy Sleep Disturbance Fatigue

36 Depression and Anxiety in Parkinson s Rates of depression and anxiety are much higher in Parkinson s patients Why? Researchers believe that depression and anxiety in Parkinson s disease may be due to the underlying changes in brain chemistry and circuitry that are caused by the disease itself Depression is a part of PD and not just a reaction to it

37 What will help anxiety and depression? Newer antidepressants have been shown to be effective in treating depression in people with PD The following have been shown to be effective in treating depression: Exercise Behavioral Activation: Planned pleasant activities have been shown to be effective in treating depression Problem Solving Treatment: identifying problems and setting realistic achievable goals Cognitive Behavioral Therapy: help to change negative thought patterns

38 Parkinson s Disease: Exercise as Medicine What can I do today? Think about what exercise you enjoy>write it down Think about what daily challenges you have>write it down Meet with a rehab provider to help get started (bring your list): Tips and ideas to implement at home Update your list annually Meet with your Rehab team annually> Re-measure and Refresh you exercise routine! 38 November 12, 2017 Kaiser Permanente All Rights Reserved.

39 Parkinson s Disease: Exercise as Medicine Challenges in the Home: Fall Prevention Let s be proactive! Clear hallways of clutter Remove throw rugs Hand rails if needed (in bathroom, stairs etc.) Sticky tape for visual cues Use assistive device if appropriate 39 November 12, 2017 Kaiser Permanente All Rights Reserved.

40 Parkinson s Disease : Exercise as Medicine Challenges at Night Medication (off phase) Decreased visual support WHAT to DO? Add night lights Remove throw rugs Avoid slippers 40 November 12, 2017 Kaiser Permanente All Rights Reserved.

41 Parkinson s Disease: Exercise as Medicine What can I do today, as a caregiver? Encourage exercising Attend rehab appointment to learn ways to help Help make changes to the home environment Be an exercise partner! 41 November 12, 2017 Kaiser Permanente All Rights Reserved.

42 Parkinson s Disease What s the Take Home Message? Parkinson s disease progresses slowly Effects of Parkinson s disease are individual Exercise is a form of medication: Improves symptoms of PD and can slow PD progression Your Rehab provider is the expert for the right dosage of exercise: Intensity, Quality, skill, and specificity See your rehab provider as soon after diagnosis as possible and follow-up annually (Neuro specialty is recommended) Monitor any changes and tell your doctor or rehab team 42 November 12, 2017 Kaiser Permanente All Rights Reserved.

43 My Plan: MRN My Goals: What is important to me? I have concerns about: My Diagnosis: Date of Diagnosis: Family history of PD or other neurological disorder?: Exposure to heavy metals or pesticides? Yes/No History of repetitive head trauma? Yes/No Neurology Appointment Date(s): Where? Who is my Neurologist? PD Medications: Possible short term and long term symptoms to expect: What else do I need to know: Next Steps: Physical Therapy (PT) **** Start Date: End Date: Where? Who is my Physical Therapist? Recommended physical activity What else do I need to know?: Classes: Dates and times of class(es) PD Education Class: No referral needed Call: Date: PD Exercise Class: Your therapist can enroll you. Speech Therapy (ST) or Occupational Therapy (OT) Start Date: End Date: Where? Who is my Speech Therapist? Who is my Occupational Therapist? What else do I need to know: Dates and times of appointment(s) Information I need to know Support Groups (When? Where? Phone #): My Care Coordinator / Navigator (name / phone #): Neurologist (name / department phone #): Physical Therapist(name / department phone #): Speech Therapist (name / department phone #): Occupational Therapist (name / department phone #) Pharmacy (phone #): 24-hr Advice Nurse (for weekends or evenings): Resources for my caregivers: ****How do I access PT, ST or OT? Answer: PCP or Neurologist may refer. KP online resources: parkinsonscare.kaiserpermanente.org KP/Community Resources: (customized by area) Revised Dec 2015

44 Thank YOU! Any Questions??? 44 November 12, 2017 Kaiser Permanente All Rights Reserved.