welcome and introductions - · pdf filewelcome and introductions ... american parkinson...

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Spotlight on Parkinsons Disease
Staying on Your Feet Balance Matters
Tuesday, October 18, 2016
WelcomeandIntroductions
Stephanie PaulVice President Development and MarketingAmerican Parkinson Disease Association
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Presenters
Tami Rork DeAngelis,PT, DPT, GCS
Anna DePold Hohler,MD, FAAN
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Presentation
Anna DePold Hohler, MD, FAANAssistant Dean, Office of Clinical and Strategic Affiliations
Director of the Center for Militaryand Post Deployment Health
Associate Professor of NeurologyBoston University School of Medicine
Boston, MA
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MedicationSideEffects
BloodPressure
MedicationTreatments
ConservativeTreatments
PhysicalTherapy
PD MotorSymptoms
BalanceMatters
Interventions
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PDMotorSymptoms
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ParkinsonsDiseaseMotorSymptoms
PatientswithPDcanhavedifficultieswithpostureandwalkingwhichcanaffectbalance.
Posturecanbestoopedaffectingbalance
Walkingcanbeslowedwithscuffingwhichincreasestheriskoftripping
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ComplicationsofTherapy
Wearingoff
Onoff
Dyskinesias
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Wearingoff
Overtimethereisaprogressivelossofdopamineinthebrain.
Moremedicationisneededforsymptomcontrol.
PatientsmayexperienceadropintheirdopaminelevelswhentheirpillsarewearingoffduringwhichtimetheirPDsymptomsworsen.
Thiscanaffecttheirbalance.
Thisisoftenmanagedwithincreasingdosingorpillfrequency.
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OnOff
Overtime,patientsmaydevelopsymptomfluctuations.
TheONperiodiswhenapersonnoticesthattheirmedicationsareworking.
TheOFFperiodiswhenthemedicationsarenotworking.
Inmoreadvanceddiseasethereislessontime,moreofftime,andmoreonofffluctuations.
Thismaybeimprovedbyincreasingthedoseofthemedication,morefrequentdosing,oraddingonmedications.
http://www.wearingoff.eu/wpcontent/uploads/2013/08/WearingOffChart.jpg
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Dyskinesias
Dyskinesiasaredancingmovementsthatpatientsmayexperienceaftertheyhavebeenondopaminergicmedicationsoftenfor5yearsormore
Dyskinesiasmayaffectbalanceandincreaseriskoffalls.
Theymaybemanagedbyspreadingoutmedicationsoraddingonaparticularmedicationfordyskinesias. http://www.centralneurosurgery.com.au/files/cache/cdcd243057a21728473dfdd546bd253f_f37.png11
BloodPressure
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ParkinsonsDiseaseisassociatedwithanumberofnonmotordifficulties.
Bloodpressurefluctuationsarecommon.
ParkinsonsDiseaseNonMotorSymptoms
http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/A/autonomic.gif13
RegulationofBloodPressure
FluctuationsinbloodpressureiscommonlyseeninPD
Orthostatichypotensionisadropinthesystolicbloodpressure(topnumber)of20pointsoradropinthediastolicbloodpressure(bottomnumber)of10pointsafterchangingposition
BloodpressureisfrequentlyworsenedbymedicationsusedinPD14

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SymptomsofLowBloodPressure
Fainting
Falls
Confusion
Balancedifficulties
Lightheadedness
Weakness
Allsymptomsoflowbloodpressureareworsewithstanding.
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Dopaminemedicationscanoftendropbloodpressure
Somepatientsarealsoonbloodpressuremedicationsthatlowerbloodpressure
Somebladdermedicationsalsolowerbloodpressure
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CorrectingOrthostaticHypotensionImprovesFunction
PatientswithParkinsonsdiseasefrequentlyhaveorthostatichypotension
Theymaynotbesymptomatic
Theonlywaytoknowforsureisbydoingorthostaticbloodpressuremonitoring.
Patientsshowedsignificantimprovementintheirmotorfunction,walking,balanceandcognitivefunctionwithtreatmentoforthostatichypotension
18 HohlerAD,AmarieiDE,KatzDI,etal.TreatingOrthostaticHypotensioninPatientswith'ParkinsonsDiseaseImprovesFunction.JournalofParkinson'sDiseaseIssueVolume2,Number3,2012.

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ConservativeTreatments
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BloodPressureConservativeTreatment
Slowpositionchanges
Hydration6080ouncesperdayElectrolyterichfluids
Addsalttothediet
Compressionstockings
Abdominalbinder http://www.staples.com/PolandSpringBottledWater169ozBottles24Case/product_71314020

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MedicationTreatments
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MedicationsUsedtoTreatLowBloodPressure
Fludrocortisonecanbeusedtoexpandbloodvolume.SideEffectsinclude: swelling,headaches,weightgain,andhighbloodpressure
Midodrinecanconstrictbloodvessels.SideEffectsincludehighbloodpressure,visionchanges,numbness,anditching
Droxidopachemicallystimulatestheautonomicsystemandincreasesbloodpressure.Sideeffectsincludehighbloodpressure,headaches.
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Presentation
Tami Rork DeAngelis, PT, DPT, GCSSenior Physical Therapist
Center for NeurorehabilitationSargent College of Health and Rehabilitation Sciences
Boston UniversityBoston, MA
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PhysicalTherapy
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WhatDoWeNeedtoDotoKeepOurBalance?
Maintainquietstanding Walkwithouttrippingorstumbling Anticipatechallengestobalance Tolerateunexpectedchallengestobalance
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WhatSystemsAreInvolvedinBalance?
BalanceControl
Strength, Flexibility
and Posture
Stabilityduringwalking
SensorySystem
(sight,innerear,etc)
StabilityLimits
Expectedposturalchanges
Unexpectedposturalchanges
AdaptedfromHorakFB,etal.TheBalanceevaluationSystemsTest(BESTest)todifferentiateBalanceDeficits.PhysicalTherapy2009;Vol89,5:484498

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HowCanTheseSystemsBeAffectedinPeopleWithPD?
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AdaptedfromHorak FB,etal.TheBalanceevaluationSystemsTest(BESTest)todifferentiateBalanceDeficits.PhysicalTherapy2009;Vol89,5:484498
Decreasedhipstrength Decreasedankleflexibility Forwardflexedandstiffspine
Strength,Flexibilityand
Posture
Catchingtoewhenwalking Trunkstiffness/rigidity
Stability duringwalking
Changesinprocessingofinformation ImpairedvisionSensory System
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HowCanTheseSystemsBeAffectedInPeopleWithPD?(cont.)
Delayedmuscleon Abnormalmusclecoordination
Toobigortoolittleofaresponse
Anklestiffness
ExpectedPosturalChanges
UnexpectedPosturalChanges
StabilityLimits

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CanPhysicalTherapyInterventionsImproveBalanceandDecreaseFalls?
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Case1:Bob
63yearsold.PDfor5years.
Reportstrippingwhenwalkinghisdog.
Dailynearfalls,onefallinthelastyear.
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Case1:Bob
PrimaryProblems
Decreasedbalancereactions
Stiffness Slowness
SecondaryProblems
Muscleweakness Decreasedflexibility Decreasedposture
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Case1:BobsPhysicalTherapy
Strengtheningprogramforlegsandtrunk
Gaittrainingontreadmillandovergroundwithametronomebeat
Balancetraining
Stretchingprogramforankleandhipmuscles
Physicalactivityplan
6monthfollowupappointment
PhysicalTherapyTreatmentPlan
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Case2:Shirley
68yearsold.PDfor12years.
Losesbalancedaily,fallsweekly.
Lossofbalance/fallsmostlyinevenings,whenturningandwhilecarryinggrocerybagsorreachingforphone.
ExperiencesON/OFFtimesanddyskinesias.
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Case2:Shirley
PrimaryProblems
Decreasedposturalreactions
Stiffness Slowness
SecondaryProblems
Muscleweakness Decreasedflexibility Decreasedposture
Maintainquietstanding Walkwithouttrippingorstumbling Anticipatechallengestobalance Tolerateunexpectedchallengesto
balance
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Case2:ShirleysPhysicalTherapy
CheckinwithNeurologistformedicationadjustment.
CompleteFalllog Balancetrainingactivities GaitTrainingactivities(withdual
task) StrategyTrainingtomaximizesafety Exercisesforstrengthandflexibility. DischargetoTaiChi2Xperweek
classANDFollowupin3monthsforbalanceassessment
PhysicalTherapyTreatmentPlan
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Conclusions
Ateamapproachiskeywhenitcomestomanagingbalance.
Preventionandearlytreatmentisideal.
BalancecanbeimprovedthroughoutyourlifespanwithPD(Itsnevertoolate!).
Keepmovingyourfeettostayonyourfeet!
CalltheAPDARehabResourceCenterHelplinetofindaPTwithexpertiseinParkinsonsdiseasenearyou!(888)6061688
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Question&Answer
Tami Rork DeAngelis,PT, DPT, GCS
Anna DePold Hohler,MD, FAAN
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ClosingRemarks
Stephanie PaulVice President Development and MarketingAmerican Parkinson Disease Association
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Foradditionalinformation,answerstoyourquestions,orresources
Pleasevisitourwebsitewww.apdaparkinson.org
Orcallus18002232732
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welcome and introductions - · pdf filewelcome and introductions ... american parkinson...

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