Nin Bajaj

Consultant Neurologist, Nottingham

Fiona Lindop,

Specialist Physiotherapist, Derby

Multidisciplinary Team Working in PD

Setting up a PD service

• Nuts and Bolts

• You can’t do this alone

• You need “mates” or at the very least people you can work with on a professional level

• The days of the “solo” practitioner really should be over

The team- the minimum requirement

• A neurologist

• A Care of the Elderly Physician

• A PD specialist nurse

The extended team

• PD physiotherapy

• OT

• SALT

• Community PD nurses

• Neurorehab specialist

The fantasy football team

• Pharmacist

• Dietician

• PD service management

• Psychiatrist

• Palliative Care

• Parkinson’s UK/Care PD patient representative

PD Steering Group

• The Fantasy Football team

• Meet 4x a year

• Allows managed expansion and cohesive lobbying

• Allows access to “pots” from Cancer and Medicine

• Allows unified drug, pharmacovigilance and audit policy

How do you create a profile for the service

• Playing at Home

• Playing Away

• International fixtures

Playing at Home

• The local community with PD has to have a voice in the local service

• This might be best done by co-opting local patient representatives from the charities

• Having a local rep man the information stand at clinics

• Holding education groups and facilitating special groups locally e.g. young persons with PD

Playing Away- National Level

• Endorsement of the service

• Hospital Doctor Award

• Guardian Public Sector Awards

• HS awards

• Research Profiles

Hospital Doctor Award

Research Profiles

• DeNDRoN

• CLRN

• The DeNDRoN PD Director (region)

• Non-portfolio work

• Refereeing

• Working for and with the Charities

Research Profiles- National

• DeNDRoN working parties

• National grants

Co-operative Working with Pharma

• Educational Events

• IIT research grants

• Portfolio Adoption

Playing Away from Home- International

• International Endorsement

• The national Parkinson Foundation Programme

• Research

NPF

NPF Centres of Excellence

Research- International

• Present at conferences

• Lecture

• Faculty Boards

How to build a world class PD service: Business cases in Derby

• Specialist Physiotherapist & OT Posts (appointed 2009, but already working as specialists for several years)

• Dedicated SALT (appointed 2009) – LSVT training 2010 (one patient, 4 weeks / 4 x 40mins at present)

• Dietician – appointed 2010

Impact of Specialist Therapy Posts: in-reach and out-reach

• Potential for reduced length of stay• Specialist support for in-patients• Outpatients reduced waiting list &

improved follow up availability• Provision of emergency therapy

appointments• Specialist MDT may be able to support

patients while waiting longer for consultant/PDNS clinic appointments

Further aspects of the roles

• Education for patient and carer– Including exercise, relaxation

• Education and support for ward staff

• Education for AHP’s on a national level – NCORE courses – annual PD or Parkinson’s Plus courses

• Signposting to other support agencies e.g. Parkinson’s UK

Specialist Physiotherapy Role

• Promote best practice- evidence-based models of therapy

• Assessment and Management

• Outcome measures – including LPAS,

• Importance of exercise

• Teach compensatory cues and strategies

• Ultrasound for Apo-nodules

Lindop Parkinson’s Assessment

Specialist Occupational Therapy Role

• Functional Assessment – all aspects of ADL including self-care, domestic, leisure, work

• Assessment of cognition – ACER, MOCA• Assessment of Mood – HAD Scale, Becks.• Information regarding mood disorders - anxiety

or depression• CBT/Anxiety management group• Relaxation/ fatigue management• Sleep hygiene

Future Dreams

• Second PDNS

• More SALT hours

• Education framework

• Palliative Care

• Training for Care home staff

• Outreach to people with Parkinson's in care homes

Basal Ganglia Dysfunction

• Impaired performance of well-learned motor skills and movement sequences – Preparation, Initiation, Sequencing,Timing

• Difficulty in performing 2 or more well-learned tasks simultaneously

• Difficulty in shifting motor and cognitive sets• Increased time required for mental

processing

Enhancing function in PD – whole team approach

Principles

• Engage conscious attention

• Avoid dual tasking• Use of cues• Use of strategies

CuesInternal• Attention/concentration• Mental rehearsal• Visualisation• Cognitive• Weight transference

External• Facilitation of attention• Visual• Auditory• Sensory

Whole team approach: Freezing of Gait

• “Inability to initiate walking sequences, a sudden cessation of stepping, part-way through a locomotor task, or difficulty igniting subsequent steps in the sequence once the motor block has occurred”

(Morris et al 2008; Bloem at al 2004)

• Reduces activity

Intervention for Freezing

• Freezing: auditory cues to slow step frequency; visual cues to maintain momentum of step

• Gait initiation: visual cue, rhythmic weight transference strategy

• Step length: visual cue, attention cue, strategy

• Relaxation techniques• Training for or avoidance of dual tasking

Turning

Safe turn requires:

• Independent mobility• Ground clearance• Good stability• Continuity of

movement• Good posture

Intervention for turning:

• Avoid dramatic change of direction

• Avoid dual tasking• Cues • Physiotherapy to

improve balance and rigidity

Intervention for falls

• Balance re-education

• Teach to recognise festination in time

• Cues for freezing

• Environment – inside and outside

• Strategies for dyskinesia (compression & resistance) and dystonia (stretches)

• Teach how to get up from the floor - backward chaining

To Summarise...Team Approach!