disclosures for rick vandendolder, otr/l: linda tickle ... · 2014 –san diego session three...

Allied Team Training for Parkinson's OT in Early Stage Parkinson's Disease Arlington , VA March 15, 2012

11/3/2014Presentation Name

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Occupational Therapy in Early Stage Parkinson’s DiseaseRick VandenDolder, OTR/L

Linda Tickle-Degnen, PhD, OTR/L, FAOTA

ALLIED TEAM

TRAINING FOR

PARKINSON

2014 –San DiegoSession Three

Disclosures for

Rick VandenDolder, OTR/L:

Linda Tickle-Degnen, Phd, OTR/L, FAOTA

None

I will not be discussing the off-label use of various medications.



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Objectives:

• Describe PD symptoms as they limit function in specific tasks and cause disability

• Develop Intervention plans based on client’s goals and evidenced based desired treatment outcomes, using the PEO model

• Participate effectively as an interdisciplinary or inter-professional team member

• Describe the unique and complementary role of each discipline in your care team

• Identify strategies for building inter-professional networks and community partnerships

OT in PD -Best Practice Guidelines-Deane (2003)

• Cueing

• Cog mvmt strategies

• Education

• Provision of equipment/environmental adapt

• Techniques for managing meds, on/off

• Fatigue, anxiety

• Involvement of carer (teaching, handling techniques)



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Cueing Strategies in PD

• Rescue Project

• Consortium of Universities in Europe collaborating in research about cueing in PD as a method to improve mobility

• Clinical trial confirmed use of cueing as effective treatment in home setting

• Cues: prompts that give information on how an action should be carried out

15-18 years after onset of PD:

Falls occur in 81% of patients (23% sustained fractures)Cognitive decline is present in 84%

48% fulfill criteria for dementiaHallucinations and depression in 50%

Choking in 50%Symptomatic postural hypotension in 35%

Urinary incontinence in 41%40% live in aged care facilities

-Hely, et al. Movement Disorders (2005)

15-18 years after onset of PD:

Falls occur in 81% of patients (23% sustained fractures)Cognitive decline is present in 84%

48% fulfill criteria for dementiaHallucinations and depression in 50%

Choking in 50%Symptomatic postural hypotension in 35%

Urinary incontinence in 41%40% live in aged care facilities

-Hely, et al. Movement Disorders (2005)

Allied Team Training for Parkinson IIAllied Team Training for Parkinson II



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• Visual loss of contrast sensitivity and altered ocular movement affecting functioning within the home and community

PD Symptoms affecting visual functionPD Symptoms affecting visual function

Visual Deficits

• Decreased scanning speed interferes with reading

• Defective occulomotor function gives blurring of vision



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Visual DeficitsAdaptations

• Ensure adequate lighting

• Eliminate clutter

• Ultra Optix line magnifier

• Gathers light, magnifies, eye on line

• Large print books

• Books on tape.

Visual Deficits Adaptations



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• Dexterity

• Wrist rigidity

• Bradykinesia

• Tremor

PD and Eating

• Appetite may be diminished

• Medications-nausea

• Olfactory changes

• Gastroparesis slowed

• Rigidity increases caloric expenditure

• Fatigue

• Participation for self esteem, swallow reflex, socialization

PD and Eating



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• Swallowing problems can affect adequate nutrition and have an impact on physiological functioning

PD and EatingPD and Eating

OT Intervention Strategiesfor PD

• Modify with client and carepartner the routines in meals:

• Time of meals

• Texture

• Amount

• Environment



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OT Intervention Strategiesfor PD

• Only needed items on table

• Small portions

• Posture, proximity to table

• Contrasting colors

• Adaptive equipment

• Plate guard

• Offset spoon, fork, universal knife

Swallowing

• Warm / cold food and liquid are easier to track and swallow

• Posture

• Chin tuck

• Double swallow

• May need to have mechanical soft diet

• Thickened liquids



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Swallowing: Adaptations

• “Nosey” cup

• Straw

• Head position neutral

Foods Hard to Chew and Swallow

• Long spaghetti

• Stringy, tough meat

• Wild rice

• Popcorn

• Peanut butter

• Fried eggs

• Coarse, dry cereal

• White bread

• Course grainy bread

• Hard, raw fruits and vegetables



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Foods Easy to Chew and Swallow

• Turkey

• Chicken

• Ground meat

• Casseroles

• Boneless fish

• Soft pasta

• Moist rice

• Mashed potatoes and gravy

• Medium white bread

• Creamed soups

• Mashed or cooked vegetables and fruit

• Custard, yogurt, ice cream

• (Will increase phlegm and saliva)

Offset Fork, Color Contrast



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PD and Eating

Raise level, Non-slip liner



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Offset Spoon

Oriental Soup Spoon



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Universal Knife

PD and Eating Mobility



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Mobility and Transfers

• Teach carepartner optimal body mechanics and safe methods to assist client with transfers, bed mobility, toileting, bathing, lifting wheelchair and lifting client from floor.

Services and SupportServices and Support

Carepartner Instruction

• Body Mechanics

• Client positioning in chair

• Transfer Belt

• Cue patient (less is more)

Chair TransfersChair Transfers



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Adaptations

• Satin/flannel over fabric surface

• Raise seat height

• Foam cushion

• Folded blanket or quilt

• Blocks or platform

• Electric lift chair



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Impact of Advanced Parkinson’s on Posture Education/Positioning

• Increased muscle rigidity and progressing balance changes result in:

� Loss of automatic position change or inability to independently change position

� Reduced activity levels

� Potential skin changes

Seating Systems

• Correction for asymmetries ie: trunk lean/pelvic obliquity

• Reclining back to compensate for fixed forward lean

• Cushion to maintain integrity of integumentary system



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Wheelchairs• Hemi-height

• Seat dimensions specific to patient

• Removable leg rests

• Extended brake levers –marked for visibility

• Pelvic belt

• Anti-tip bars

• Pressure relief cushion



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OT Intervention Strategies for PD

• Teach carepartner to help maintain abilities of client, through cueing, assisting client with exercise, recognizing medication fluctuations and side effects.

Services & SupportServices & Support

• Incorporate low vision techniques and other techniques to promote task accomplishment within living environment





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• Simplify sensory inputwithin the environment to decrease confusion, increase attention span and concentration for task accomplishment


• Simplify cognitive demands within living environment; instructions, directions, and cautions. Incorporate voice and auditory input





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OT Intervention Strategies for PD – Simplifying Demands

• Familiar routine

• Gradual transitions

• Decrease clutter

• Activity box

• Things in predictable place

• Pictures/labels

• Calendar on refrigerator

• Frequent reorientation

• Educate client and significant others to recognize changes that may affect performance but are not secondary to PD.





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•Involve individual in simple goal directed task to make use of cognitive, motor, and perceptual abilities


•Involve individual in simple goal directed task to make use of cognitive, motor, and perceptual abilities




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• Incorporate challenges to promote motivation and interest at present and past intellectual levels






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• Focus on client and carepartner’s adaptation to changes in self-image; teach to identify and validate actual reality; provide sources of respite and support



Bed Mobility

• Axial Rigidity, decreased spinal and pelvic ROM

• Teach principles of leverage –log roll with knees bent, generate momentum with head and top arm, use counterweight of legs to bring trunk up



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• Chair or bed rail or bed pole

• Adapt bed height

• Satin draw sheet

• Bed cradle (blanket support)

• Comforter vs. blanket and sheet

• Visual cues/verbal cues

• Twin bed

• Firm mattress

Bed Mobility



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Bed Rail/Satin drawsheet



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Floor Transfer

• Cue and assist to assume 4 point crawl; use furniture to support to assume half kneeling to sitting before standing

• Assess carepartner ability to assist

• Ski poles, shovels for outdoor support

Tub/Shower

• Shower curtain vs sliding glass door

• Bathmat

• Grab bars

• Tub bench

• Large movements

• Terry robe



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Tub/Shower

Tub/Shower

• Shower curtain vs sliding glass door

• Bathmat

• Grab bars

• Tub bench

• Large movements

• Terry robe



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Tub bench with back

Toileting/Incontinence

• Strategies

• Timing of fluid intake

• Timing regular trips to toilet

• Medications

• Adaptations



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Toileting/Incontinence Adaptations

• Velcro closure pants

• Incontinence pads

• Condom catheter

• Commode at bedside

• Non-spill urinal

Multidomain Approach to Predicting Driver Safety -J. Wood (2008)

• Vision: Useful Field of Vision, Dot Motion

• Motor: Knee extension strength, sway path length

• Cognitive: Trail making, Part B, Color choice reaction time

• 91% sensitivity, 70% specificity in identifying safe and unsafe drivers.



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Toileting/Incontinence Adaptations

Balance Changes in Parkinson’s disease

One of the four primary symptoms of PD

Least responsive to dopaminergic replacement therapy

Rarely seen as first symptom; typically seen later

(Early balance changes may be “red flag” for Parkinson’s Plus).



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Parkinson’s Symptoms Influencing Changes in Balance

Rigidity in axial and lower extremity musculature

Reduction/loss of postural righting reflexes

Narrow base of support

Postural changes-center of gravity not aligned over base of support

Parkinson’s Symptoms Influencing Changes in Balance

Propulsion/Festination

Retropulsion

Freezing

Dyskinesia

Dystonia

Fatigue



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Potential Contributing Factors Unrelated to Parkinson’s

Disease

• Structural foot deformities (hammertoes, bunions, etc)

• Sensory changes, i.e. peripheral neuropathy

• Proprioceptive changes

• Vestibular dysfunction

• Other medical conditions

Propulsion/Festination Compensation Strategies

• Self monitoring – complete stop if stride length shortens. Restart with longer step.

• Wheeled walker with resistance may be helpful

• Use of rhythm to maintain speed and pace may be helpful



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U-Step Walker

• Consult with physical therapy

• May be more effective for for person with PSP to deter backwards or lateral falling.

Retropulsion Triggers

• Carrying things in both hands.

• Stepping backwards while turning.

• Pulling/dragging items backward while gardening, yard work, farm chores, vacuuming

• Sudden displacement backward (being jostled in a crowd, pets/children jumping up , etc.



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Falls Prevention

• Home evaluation

• Rails (both sides)

• Barrier at top of steps

• Grab bars at doors

• Remove clutter

• Adequate lighting

• Mark corners, edges thresholds with contrasting colored tape

• Impulsivity may be risk factor

Stairway Gate



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Retropulsion: Compensation Strategies

• Carry objects in bag with handles at your side rather than in front

• Use vertical grab bar near door

• Reduce tension on automatic closing doors

• Sit when dressing

• Re-arrange cupboards/shelves to place frequently used items within easy reach.


• Tai Chi stance

• Move forward in wide circle rather than backing up

• Marching to pivot

• Clock turn



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• In kitchen slide dish along counter top when possible rather than carrying items

• Use walker to carry object on walker tray or use rolling kitchen/laundry/garden carts to transport items

• Avoid stepstools and ladders

• Delegate higher risk activities



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Freezing compensation Strategies

• Remove floor clutter (plant stands, magazine racks, foot stools) and throw rugs

• Move furniture or arrange environment to widen walking paths

• Teach visualization techniques (stepping over or kicking through an imaginary object

• Estimate steps to a target and count aloud

Freezing compensation Strategies

• Look for frequent freeze locations in the home environment and provide visual cue (e.g. lines across path in doorway, “x” in front of chair or toilet)

• Divert attention from feet/legs; practice deep breathing, unrelated arm movements, or centering activity

• Educate family/staff re: triggers and cues



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Postural Changes in Parkinson’s Disease

� Forward head

� Increased thoracic kyphosis

� Decreased lumbar lordosis

� Increased hip and knee flexion

� Forward trunk lean

� Narrow base of support

Changes in Postural Awareness

• Decreased self awareness of posture is evident in those with Parkinson’s

• Posture often appears to decline even further when engaged in activity or when fatigued



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Posture Enhancement Exercises

• Stretching, including neck, trunk, pectorals, hip flexors, heel cords, and hamstrings.

• Strengthening of core muscle groups: scapular muscles, trunk, abdominals and legs

Posture Enhancement/Exercises

• Activities emphasizing pelvic mobility/weight shift/LE weight bearing

• Spinal lengthening/supine chin tucks

• Therapy ball or Tai chi

• Increase self awareness through use of mirror, photos or video



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Posture Education/Positioning: Sitting Posture

• Assess home environment, car and workplace postures

• Instruct in proper ergonomics

• Use of lumbar roll/cushion to enhance lumbar curve

• Emphasis on lengthening spine, not “leaning backward”

Posture Education/Positioning:

Sleeping Posture

• Minimize use of excessive pillows/cushions for sleeping

• Use of cervical roll/cushion to enhance cervical curve

• Instruct in techniques to allow position changes during the night



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OT and ADL’s in PD

• Toileting

• Dressing

• Hygiene

Personal Hygiene

• Sit if balance deficit or low endurance

• Wide based stance

• Electric toothbrush

• Electric razor

• Suction denture brush



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Personal Hygiene and Grooming

• Sit to apply makeup

• Support arms on table or vanity

• Build up handles on brush or comb

• If possible, wait until meds take effect to decrease difficulty of task.

Toilet hygiene

• Toilet rails

• Moist wipes

• Step stool

• Bidet

• Men sit or use urinal

• Velcro pants

• Trunk rotation exercises



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Dressing

Affected by:

Rigidity

Bradykinesia

Posture

Balance

Multi-tasking

Visual/Perception

Organizing

Coordination

Dressing

Set up clothing the night before in order it will be put on

Allow adequate time to avoid need to hurry

Wait 45 min after taking morning meds before dressing

Sit to dress – sit on chair not bed

Focus on each part of sequence



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Dressing

Loose-fitting, stretchy clothes- eliminate impractical clothing from wardrobe

Slippery underclothes

Velcro collar, cuff, or whole shirt

Snap closures

Polo shirt

Button hook if no perceptual deficits

(Buttoning is therapeutic if not frustrating)

Dressing Over the head shirt



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DressingButton down shirt/jacket

Dressing

Put more involved arm into sleeve first

Flipping shirt/jacket over head is risky

Button lowest buttons and pull shirt over head

Front closure or velcro closure bra



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Pants

• Urgency, stress complicates closures

• Velcro fly

• Elastic waistband

• Suspenders

Dressing Adaptations

Footstool

Elastic laces/velcro closures

Slip on shoes

Sock aid

Reacher

Long shoe horn



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Simplify and adapt methods and instructions for safe and independent use of instruments to promote personal hygiene, dressing, functional mobility, home management, work, and leisure tasks

Services & SupportServices & SupportServices & SupportServices & SupportServices & SupportServices & SupportServices & SupportServices & Support


Increase client skill with client-specific compensatory methods and adaptive equipment for IADL and ADL task accomplishment




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Teach client and carepartner to make changes in the environment that will provide visual cues for safety and independent task performance.



Teach client and carepartner home exercise program for client to deter losses due to increases in sedentary lifestyle.




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OT Goals for PD

Increase client and carepartner understanding of the fluctuations of PD symptoms and in the client’s need for assistance. Teach coping skills for these fluctuations.

Services and SupportServices and SupportServices and SupportServices and SupportServices and SupportServices and SupportServices and SupportServices and Support

Discussion

• What is involved in being an effective interdisciplinary or inter-professional team member?

• Who are the critical disciplines in your care team?

• What are your and their unique and complementary roles?

• What are strategies for building inter-professional networks and community partnerships?

disclosures for rick vandendolder, otr/l: linda tickle ... · 2014 –san diego session three...

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