Rehabilitation of Parkinson’s Disease

1. Rehabilitation of Parkinson’s Disease Dr. Padma S Gunaratne MD(SL), FRCP(Lond),FRCP(Glasg), FRCP(Edin), FCCP, Hon FRACP

3. Progression of PD

4. Parkinsonism Syndrome T R A

5. Parkinsonian Disorders DLB Metabolic ET Drugs MSA Toxics PSP PD TREMOR MSD Trauma CBD PD PIGD PD - ALS Enchephalitis Vascular Tumour Dementia

6. Diagnosis of Parkinson’s Disease • Rest tremor of a limb • Presence of olfactory loss or cardiac sympathetic denervation • Dramatic response to dopamine therapy • Predictable wearing off or unequivocal on off fluctuations • Levodopa induced dyskinesia Two supportive criteria Absence of absolute exclusion criteria and red flags Diagnosis is more challenging in elderly – Co-morbidity Polypharmacy in elderly – more drug interactions

7. Symptoms and signs of PD Motor Non motor Behavioural Depression, apathy, anhedonia, fatigue, psychosis, hallucinations Cognitive Bradyphrenia, tip of the tongue, dementia Sensory Anosmia, ageusia (Loss of taste), impaired colour sensitivity, paresthesia, pain Gstro intestinal Nausea, drooling, dysphagia, constipation Dysautonomia Orthostatic hypotension,, urinary and sexual dysfunction, abnormal sweating, seborrhea Sleep disorders Insomnia, Excessive Day time Sleepiness, nocturnal akinesia, Restless leg syndrome, Periodic limb movements of sleep, REM behavioural disorder • Tremor, rigidity, bradykinesia, postural instability • Hypomimia, Dysarthria • Micrographia, difficulties in ADL • Diminished arm swinging, shuffling gait, freezing, festination, difficulty arising from chair, turning in bed • Glabella reflex, Blepharospasm, dystonia, skeletal deformities

8. Multidisciplinary care clinics With net work Protocols • Multi pronged, Individualized, prolonged care given by a multidisciplinary Team at a multidisciplinary clinic with a common data base • Other facilities • Availability of a PD Nurse • Day Hospital • Rehabilitation and long term care • Focus on modifiable factors • with a realistic achievable goals

9. Assessment tools • Unified Parkinson’s Disease Rating Scale (UPDRS) • PD NMS Quest (Non motor symptoms) • Depression – Geriatric Depression scale (GDS15) • Mini mental state examination (Cognitive assessment) • PDQ39 for QoL

10. Staging the disease • Hoehn & Yahr scale (1 -5) • 1 - Unilateral involvement only • 5 - Wheel chair bound or bedridden • More practical staging • Diagnosis • Maintenance • Complex • Palliative

11. Concepts • Normal movements are possible and what requires is suitable activation. • Any complex movement needs to be broken down into smaller components prior to execution • Each little segment of movement should be preferment at a conscious level. • Use an external clue to initiate and maintain movements. • Avoid simultaneous motor or cognitive tasks.

12. Multidisciplinary care clinics With net work Protocols

13. Assessment (physical, mental (cognitive functions & mood) and social domains) (QoL) • Communicating the diagnosis CASE HISTORY • 66 years , PD for 3 yrs, • Curling up of toes of feet on waking up and mild “off” in midafternoon • On carbidopa/levodopa 25/100 4 times per day + selegiline + citalopram • O/E 2 hours post medication – Good ”on” response, mild dyskinesia of neck • Rx • Drugs before 30 mins meals • Night dose was replace with CR • Dopa agonist was introduced • 4 months later patient developed impulse control disorder (On line gambling) • Dopa agonist was tapered and stopped, Increased carbidopa/levodopa 5 time with night dose CR

14. Impulse Control Disorders • Develop with dopaminergic therapy (DA) • Punding, pathological gambling, hypersexuality, compulsory buying & binge eating • H/o previous impulse behavior, smoking, alcoholism increases the risk • Rx: Withdraw DA & replace with levodopa

15. Multidisciplinary care clinics With net work Protocols

16. Behavioural & Cognitive Issues • Apathy, anxiety, anhedonia • Depression (37%) • Rx: CBT, SSRI, Mirtazapine, Venlafaxine, Pramipexole, ECT • Psychosis : Visual hallucinations, delusions, illusions • Reduce anticholinergics, MAO –BI, amantadine, DA, COMT I and levodopa • Low dose quetiapine, Rivastigmine or clozapine • Cognitive impairment & Dementia • Differentiate from LBD • Reduce anticholinergics and amantadine, DA, MAO BI, COMT I • Rx: Choline esterase inhibitors (Riverstigmine) & Memantine

17. Sleep disturbances • Thorough history for sleep disorders is mandatory • Polysomnography and multiple sleep latency test SOS • Excessive day time sleepiness & Sudden onset of sleep • Management • Improve quality of nocturnal sleep • Treat other causes, depression, OSA and review medication • Avoid driving, swimming, climbing ladders etc. • Drug treatment: Modafinil – 200-400mg/day especially for ‘sudden onset of sleep’ • RLS • Periodic limb movements of sleep • REM behavioural disorder • Enact dreams in the form of vocalization and abnormal movements • Clonazepam 0.25-0.5mg or Melatonin 3-6mg at bed time

18. Multidisciplinary care clinics With net work Protocols

19. Physiotherapist’s Role • There is evidence supporting physiotherapy, especially in the form of exercises as a viable supplementary intervention in treating PD. • Exercise improves release of Dopamine from unaffected cerebral cells and improve motor and also cognitive functions

20. Types of physiotherapy • Resistance training • Strengthening leg muscles • Aerobic Training • Bicycle, treadmill, walking with music improves bradykinesia, CV fitness and QoL • Balance • By self destabilization of the center of body mass improves confidence and reduce falls • Gait training • Improves walking speed and stride length • Cued training • Cueing (using external stimuli to facilitate movement initiation and continuation. ) • Visual, rhythmic auditory, somatosensory cues minimizes freezing & festination • Visual cueing device fixed to shoes • Dance - Is an alternative way to improve mobility, gait, balance and QoL

21. Multidisciplinary care clinics With net work Protocols

22. Role of Occupational Therapists • Improve or maintain the level of meaningful activities and provide support to increase social participation by modifying occupation (task) or the environment • Approaches • Learning • Advice on time and anxiety management • Compensatory • Behaviour and environment modification • Use of assistive devices

23. Occupational Therapy • Individual or group activities for motor activities • Activities to maintain personal care • Activities to maintain ADL, work , leisure • Mobility • Safe and comfortable home environment, toilet, • Selection of wheel chair and walker

24. Multidisciplinary care clinics With net work Protocols

25. Speech and Language Therapy-Removes barriers in participation- Mrs. Seetha , 72 Yrs Affects Swallowing and weight loss Chewing and keeping in mouth too long FEES done Therapy Techniques Swallow in conscious steps by using cues Modification of food consistency Diet plan Discuss on alternative feeding methods Mr. Jamal 62 Yrs Speech was affected Voice quality, articulation, volume, pitch and intelligibility Lead to social isolation, restricted participation Therapy techniques • Lee Silverman approach (based on intentionally using in higher volume with clarity ) • Articulatory kinematic approaches • Subsystems approach • Alternative and augmentative communication (AAC) support • Electronic • Low tech Speech Therapy

26. Multidisciplinary care clinics With net work Protocols

27. Nurses Role • Nursing is needed mainly in complex and palliative stages of PD • Nursing interventions include • symptom management using pharmacological and non-pharmacological methods • Implement care plan to meet the individual needs of the patients, with an understanding of their physical, cognitive and behavioural potential. • Should display patience and empathy and ommunicate with care team and educate the patient and the family • Optimizing nutrition, balanced diet • Assist eating, drinking, washing, incontinence, constipations • Provide information about available support services • Safety of the patient (Prevention of falls and bed sore) • Planning and providing palliative and advanced nursing care • Support in bereavement in palliative care settings • Provide services in the community

28. Nurse • Constipation • Improve mobility and exercises • Increase fiber intake in diet (>15 g/d) • At least 1.5L of fluid intake a day • Macrogols may be more effective than lactulose • Dopaminergic medication • Defecation training, puborectalisbotox, sacral nerve stimulation and abdominal massage

29. Multidisciplinary care clinics With net work Protocols

30. Contributors for Falls • Rigidity, akinesia, tremor Poor mobility • Postural hypotension • Depression • Dementia • Underline visual impairment • Rheumatological & cardiological issues • Environmental barriers • Drugs

31. Other important areas • Autonomic involvement • Orthostatic Hypotension • Excessive sweating • Urinary symptoms • DOPA disregulation syndrome • Fatigue, pain • Pain of dystonia and dyskinesia • Coat hanger pain in neck and shoulders • Osteoporosis, arthritic, contractures • Burning mouth syndrome • Pain in genitalia

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35. Gastro intestinal • Drooling • Speech therapy • Pharmacological: only if non-pharmacological treatment is not available. • glycopyrronium bromide (anticholinergic) 1mg - 2mg TDS • Other topical anticholinergics ( 1% atropine) sublingually and (Hyoscine) – if risk of cognitive impairment is minimal • Botulinum toxin A – injection of salivary glands (If above treatments are not effective or contraindicated • Dysphagia • Speech therapist’s input along with video fluoroscopy and upper gastrointestinal endoscopy, endoscopic evaluation of swallowing and oesophageal manometry are used. • Interventions • Exercises to promote tongue strengthening, tongue control and voice exercises • Alteration of the consistency of food and drink • Advice on the organisation of the bolus of food within the mouth and frequency of swallowing • Lee Silverman method

36. Sleep disturbances • Thorough history for sleep disorders is mandatory • Many validated tools are available to asses sleep • Polysomnography and multiple sleep latency test are gold standard • Insomnia • Excessive day time sleepiness • May affect up to 50% • Leads to poor concentration and memory • Some develop ‘Sudden onset of sleep’ similar to narcolepsy • Management • Improve quality of nocturnal sleep • Treat other causes of EDS such as depression, OSA and review medication • Drug treatment: Modafinil – 200-400mg/day especially for ‘sudden onset of sleep’ • Avoid driving, swimming, climbing ladders etc. • Nocturnal akinesia • Restless leg syndrome • Periodic limb movements of sleep • REM behavioural disorder • Enact dreams in the form of vocalization and abnormal movements • Clonazepam 0.25-0.5mg or Melatonin 3-6mg at bed time

37. Autonomic • Orthostatic Hypotension • Presentations are dizziness, falls, syncope and visual disturbances • Check for postural blood pressure drop routinely • Adjust existing medications • Precautions with changing posture • Avoid large meals and alcohol • Ensure adequate fluid and salt intake • Avoid excessive heat • Elevate bed head by 20-30 degrees • Consider elastic stockings • Drug Treatment: • Midodrine – first line –(Alpha adrenergic agonist) May cause supine hypertension and warrants regular check-ups and periodic 24h BP monitoring. If it happens consider night time GTN patch or a short acting vasodilator antihypertensive • Fludrocortisone - maximum 400 μg • Domperidone • L-DOPS (Doxidopa) - a pro-drug of noradrenaline and adrenaline. • Pyridostigmine for mild to moderate orthostatic hypotension • Excessive sweating • Urinary symptoms • Exclude UTIs • Urodynamic studies • Overactive bladder syndrome- Antimuscarinics (oxybutinin, propiverine, solifenacin and tolterodine). Adrug that does not cross the blood brain barrier (tolterodine and trospium) is better than oxybutynin. • Mirabegron, a 3-adrenoceptor agonist, for detrusor over-activity with no anticholinergic activity and cognitive effects, and hence may be useful in PD but no convincing evidence available. • Detrusor botulinum toxin injections may be used. • Retention may need catheterization.

38. DOPA dysregulation syndrome • Tend to develop when Levodopa dose is too much escalated • Treatment – reduce levodopa if possible • Atypical anti Psychotics, Psychiatry referral • DAs

39. Misscellaneous • Fatigue • Pain • Pain of dystonia and dyskinesia • Coat hanger pain in neck and shoulders • Osteoporosis, arthritic, contractures • Burning mouth syndrome • Pain in genitalia

40. Pre-motor Non Motor Symptoms • Impaired olfaction • RBD • Episodic major depression • Constipation • Excessive day time somnolence • Fatigue • Abnormal colour vision/visual perception • Erectile dysfunction • Pain (often unilateral) Pain often evident on side first affected

41. Psychiatrists Role in managing PD • Managing severe depression, Psychotic symptoms & dementia • Screen for depression, cognitive decline, REM sleep behaviour disorders and psychotic symptoms

42. Absolute exclusion criteria • Unequivocal cerebellar signs • Gaze evoked nystagmus • Square wave jerks • Downward gaze palsy • Behavioural variant fronto-temporal dementia or primary progressive aphasia within first 5 years • Parkinson's restricted to lower limbs more than 3 years • Treatment with dopamine receptor blocker and drug induced PD • Absence of a reasonable response to Levodopa • Cortical sensory loss • Normal DaTscan

43. Red Flags • Rapid progression of symptoms (Wheel chair bound within 5 years) • A complete absence of progression over 5 years • Severe bulbar dysfunction within first five years • Inspiratory respiratory dysfunction • Autonomic dysfunction within first five years • Sphincter dysfunction or orthostatic hypotension • Recurrent falls within first three years • Anterocollis or contractures • Absence of non- motor features despite the patient has passed five years of illness [Eg REM Behavioural disorder, autonomic (Constipation & urgency) and neuropsychiatric symptoms and hyposmia] • Pyramidal tract symptoms • Bilateral symmetric parkinsonism

44. Clinically Established PD Clinically probable PD Absence of absolute exclusion criteria Presence of red flags counter balanced by supportive criterion • Absence of absolute exclusion criteria • No red flags • At least two supportive criteria

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