Delivering Care Within the NHS

1. Delivering Care Within the NHS Pat Chapman Clinical Specialist Physiotherapist Heart of Birmingham Teaching Primary Care Trust November 20th 2009

2. Aims of the Session To look at the role of the Physiotherapist in the different stages of Parkinson�s Disease To look at Heart of Birmingham�s population with PD & how we provide a Physiotherapy service for them

3. Classification of disease staging in PD Hoehn & Yahr Scale 1967 Stage 1 � mild unilateral signs & symptoms Stage 2 � Bilateral symptoms with minimal disability Stage 3 � Equilibrium impairment, general dysfunction noted Stage 4 � Severe symptoms, limited mobility, support necessary at home Stage 5 � Cachexia, dependent, immobile

4. Clinical Staging of PD Diagnosis Maintenance Complex Palliative In general early phase - H&Y 1-2.5 Mid phase - H&Y 2-4 (falls risk at this stage) Late phase - H&Y 5

5. When should people with PD be referred for physiotherapy? In all stages of PD but especially at diagnosis as �prevention is better than cure� NICE recommends that Physio should be available for people with PD (NICE 2006) BUT not everyone wants or is ready for Physio! Historically referral was made too late and people had fixed deformities and were less successful with treatment happens within first 2 years. NICE also includes advice re safety in the home. Respect not all want physio or are reday at diagnosis and that there may be issues to do with beliefs and cultures. In Hob very multicultural so can cause difficulties talking to pts where English not a first language. Also some families don�t want their relative to know � not sure how accurate info is even with an interpreter. PD soc produces info in diff languages � not always literate to read and lots of dialects. Historically referral was made too late and people had fixed deformities and were less successful with treatment happens within first 2 years. NICE also includes advice re safety in the home. Respect not all want physio or are reday at diagnosis and that there may be issues to do with beliefs and cultures. In Hob very multicultural so can cause difficulties talking to pts where English not a first language. Also some families don�t want their relative to know � not sure how accurate info is even with an interpreter. PD soc produces info in diff languages � not always literate to read and lots of dialects.

6. Early referral / H&Y 1-2.5 Baseline assessment � especially look at posture Identify any movement problems and introduce strategies to address these Encourage to continue with life as normally as possible Try to increase participation in exercise � something they like!!! Education about PD � may include spouse, friends, workplace colleagues if required Review as necessary Within first 2 years pts develop �poking chin� ie increased cervical lordosis and thoracic kyphosis which quickly becomes fixed and postural instability occurs. Fear avoidance seen a lot � scared to moveWithin first 2 years pts develop �poking chin� ie increased cervical lordosis and thoracic kyphosis which quickly becomes fixed and postural instability occurs. Fear avoidance seen a lot � scared to move

7. Early / Middle / H&Y 2 - 4 Specific intervention for muscular impairment Gait re-education / advice Problems from falls or transfer difficulties Environmental assessment � home, work Provision of aids & equipment Advice to carers re moving & effective handling

8. Late Stage / H&Y 5 For work with formal & informal carers to ensure optimal movement, positioning & handling to prevent falls & promote skin care, chest care & nutrition

9. Quick Reference Cards (UK)based on the Royal Dutch Society Guidelines Available from PD Society website. 4 cards History taking Physical examination Specific treatment goals Treatment strategies Produced by a working party of Physios Bhanu Ramawamy leading the group. Goes into more depth around specific measures eg history of falls questionnaire, phone Fott, tragus to wall measure etc. If unsure what to do look at them, not exclusive but a good help Produced by a working party of Physios Bhanu Ramawamy leading the group. Goes into more depth around specific measures eg history of falls questionnaire, phone Fott, tragus to wall measure etc. If unsure what to do look at them, not exclusive but a good help

10. Hob Physiotherapy ServiceStaffing 2 part time clinical specialists (0.6ea) 1 full time band 7 2 full time band 6 1 rotational band 5 Assistant support

11. Currently have 94 people with PD in Hob Close liaison with Sarah Coyle � PD nurse specialist, regular review meetings to discuss patients as well as regular telephone calls and joint visits. Just embarked on attending Dr Siddique�s PD clinic at City Hospital � runs 2x a month

12. PD Assessment Initial assessments are always carried out at home unless patient does not wish for this. (Ashburn,A. et al.2001) Allows immediate assessment of patient in own surroundings, eases anxiety and can provide a �truer� picture of their issues. Often a good chance to see carer as well and discuss any worries/fears they have. Often don�t complete a full assessment on first visit � better to really discuss their needs and not overtire them. Can easily be there 1 hour plus. Return visit � pt more relaxed as already met and may be completely different. Remember time of day you visit, record it ? Fluctuation due to meds Ann Ashburns recommendations as able to identify pts problems more accuratelyAnn Ashburns recommendations as able to identify pts problems more accurately

13. Physio Assessment Demographic details (age , sex, marital status etc) PMH Drug history How long have they had PD symptoms & when were they diagnosed? Presenting problems (with prompts for areas which may not be apparent at time of assessment such as fatigue, sleep disturbance, dystonias, motor fluctuations)

14. Physio Assessment cont Current medication / treatment / investigations Involvement of other professionals & agencies Contraindications / precautions in relation to physiotherapy Carer issues Social network Housing Lifestyle

15. Assessment should include: Posture sitting & standing Walking (inc. outdoors) Turning & changing direction Standing up Sitting down Turning in bed Stairs Car transfers Reaching, grasping & manipulating objects Writing Respiration Posture � tendency to flex, Simian posture, poking chin, hips flexed, knees flexed, pelvis post tilt, arms increase in flex and are at waist level, imp to see what they sit on at home when assessing sit posture. Bear in mind postural hypotension � side effect of drugs that may influence ability to stand Walking � dec confidence, fear of falling leads to dec stride length Trunk rigidity inc leading to dec trunk rot. 54% sit to stand compromised Turning in bed � probs with rolling due to trunk rot having inc rigidty Gait � dec toe clearance during swing phaseis a result of dec hip flex, dec stride length with short shuffly steps, dec arm swing and dec trunk rot Rescue CD rom � extensive ref list on gait disturbance in Pd If pt v dyskinetic can make gait pattern v erratic 50 -60 %fall Bloem et alPosture � tendency to flex, Simian posture, poking chin, hips flexed, knees flexed, pelvis post tilt, arms increase in flex and are at waist level, imp to see what they sit on at home when assessing sit posture. Bear in mind postural hypotension � side effect of drugs that may influence ability to stand Walking � dec confidence, fear of falling leads to dec stride length Trunk rigidity inc leading to dec trunk rot. 54% sit to stand compromised Turning in bed � probs with rolling due to trunk rot having inc rigidty Gait � dec toe clearance during swing phaseis a result of dec hip flex, dec stride length with short shuffly steps, dec arm swing and dec trunk rot Rescue CD rom � extensive ref list on gait disturbance in Pd If pt v dyskinetic can make gait pattern v erratic 50 -60 %fall Bloem et al

16. Assessment Continued:- Condition of feet & footwear Muscle strength Joint range Pain � musculoskeletal, dystonic, neurogenic,neuropathic On/off toilet, use of shower/bath Onward ref to social services OT for larger adaptations if appropriate Often onward referral to many other agencies if required e.g. OT, PD Nurse Specialist, SALT, continence team, DN etc Neuropathic- pain in nerve root distribution � pain in 40% of pwpd Nice guidelines Neurogenic- burning, central may be paraesthesia Musculoskeletal � joint stiffness, may also have arthritis in joints/other premorbid conditions mention pt with MS & PD Dystonic off period seveve cramp like pain Feet � look at general condition, appropriate shoes and ankle mobility Muscle strength & power � need to have enough power i.e explosive force to get up from low chair can prob mange high one OT assessment useful Neuropathic- pain in nerve root distribution � pain in 40% of pwpd Nice guidelines Neurogenic- burning, central may be paraesthesia Musculoskeletal � joint stiffness, may also have arthritis in joints/other premorbid conditions mention pt with MS & PD Dystonic off period seveve cramp like pain Feet � look at general condition, appropriate shoes and ankle mobility Muscle strength & power � need to have enough power i.e explosive force to get up from low chair can prob mange high one OT assessment useful

17. Treatment Agree with patient what they wish to improve/maintain Agree goals � can be many things but try to keep it simple and allows room to build Focus on one or two key areas Provide support, our pts encouraged to telephone us with any problems, not wait till we next visit Establish exercise programme � could be them going to their local gym, pool etc Once achieved this can move onto thatOnce achieved this can move onto that

18. Exercise continued Home ex plan- use of pictures to support Offer ex class � basic/advanced Tai Chi Strength & balance class Go to local leisure centre with patient to set up a programme Exercise on prescription Inclusive Fitness Initiative Conductive Education

19. Exercise class � 8 sessions Warm up Exs to strengthen upper and lower limbs with weights Balance exs- use of parallel bars, wobble boards, balance beam Rotational exs including turning strategies Breathing exs Correction of posture in sitting/standing � background to all mvts Cueing strategies for gait� auditory, visual, mental rehearsal, etc Challenge balance by doing more in the advanced class in standing e.g. hockey, badminton, basic more in sitting Bed mobility On/off floor Outdoor mobility Sit to stand strategy Cool down with stretches Intrinsic cues � early/middle stages of PD when can generate own cues. Attention � turn off tv, emotional set �be in the right frame of mind to do it, mental rehearsal, internal dialogue (talks thro it as doing it), visualisation (visualise a door step & how good it feels to get over it) Extrinsic cues- unclutter space if poss where people freeze going thro doors try to get flooring all the same, if not brigth markers on the carpet, Rescue trial use of somatosensory cuesuse of vibration to indicate a rhythm Sit to stand strategy � breaking down task into component parts Visual � tape on floor Auditory � metronome Proprioceptive � step back before stepping fward Cognitive � memorising parts of a mvt sequence & rehearsing them mentally Intrinsic cues � early/middle stages of PD when can generate own cues. Attention � turn off tv, emotional set �be in the right frame of mind to do it, mental rehearsal, internal dialogue (talks thro it as doing it), visualisation (visualise a door step & how good it feels to get over it) Extrinsic cues- unclutter space if poss where people freeze going thro doors try to get flooring all the same, if not brigth markers on the carpet, Rescue trial use of somatosensory cuesuse of vibration to indicate a rhythm Sit to stand strategy � breaking down task into component parts Visual � tape on floor Auditory � metronome Proprioceptive � step back before stepping fward Cognitive � memorising parts of a mvt sequence & rehearsing them mentally

20. Outcome Measures Many! Functional Independence measure (FIM) Unified Parkinson�s Disease rating scale (UPDRS) Berg balance scale Problem-orientated assessment of mobility Timed walks Falls diary Lindop scale Timed up and go test Elderly mobility scale Freezing of gait questionnaire SF-36 Goal Attainment scale PDQ�39 PDS non-motor symptom questionnaire Use what works best in your clinical setting. Remember does it have value for your patient � they may not appreciate or be able to concentrate to answer lots of questions, may also be cognitively impaired. We use Berg and Timed Get Up and Go Test (TUAG) in our ex class CSP Core Standards of Physiotherapy (CSP,2005) state that an outcome measure must be used to evaluate a change in a patient�s status CSP Core Standards of Physiotherapy (CSP,2005) state that an outcome measure must be used to evaluate a change in a patient�s status

21. Results of our ex class2008 Berg � increased by av 3.7 (range of increase 1-13), 1 unchanged and one decreased by 4 TUAG � time reduced on av by 8.3 secs, number of steps decreased by 2.2 Number of steps increased by 6 on worst one. 1 big anomaly pt probably �off� and next time �on� to explain such big change Initial berg pre class = 39.52 Post class = 43.2 a difference of 3.7 Number of steps increased by 6 on worst one. 1 big anomaly pt probably �off� and next time �on� to explain such big change Initial berg pre class = 39.52 Post class = 43.2 a difference of 3.7

22. Results 2008 Patient Satisfaction Survey Results from 24 patients Did you enjoy the class? 24 Do you feel you have improved 24 following the classes? Which areas do you feel you have improved in? Walking mobility 18 Coping strategies 8 Balance 14 Strength 14 Self Esteem 15 Knowledge of PD 11 Posture 17 Bed mobility 18 Other 1 falls, 2 confidence

23. Useful websites ACPIN; Association of Chartered Physiotherapists Interested in Neurology www.acpin.net AGILE;Chartered Physiotherapist Interested in Older People www.agile-uk.org APPDE; Association of Physiotherapists in Parkinson�s Disease � Europe appde.unn.ac.uk

24. References / Suggested reading The Professional�s Guide to Parkinson�s Disease, The Parkinson�s Disease Society 2007 Practical Guidelines for Physiotherapy in Parkinson�s Disease � DVD produced by APPDE KNGF Guidelines for Physical Therapy in Patients with Parkinson�s Disease,Keus et al, 2005 NICE � Parkinson�s Disease � Diagnosis and Management in Primary & Secondary Care. June 2006 Quick Reference Cards (UK) and Guidance Notes for Physiotherapists working with people with PD (2009)

25. Any Questions?