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KEY ISSUES

COMPREHENSIVE APPROACH TO PARKINSON DISEASE. KEY ISSUES. Temporal profile of comprehensive approach management of patients with PD Education: aims and experience (reports) Counseling & Support: identification of patient’s needs Diagnosis and Treatment of non-motor symptoms

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KEY ISSUES

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  1. COMPREHENSIVE APPROACH TO PARKINSON DISEASE KEY ISSUES • Temporal profile of comprehensive approach management of patients with PD • Education: aims and experience (reports) • Counseling & Support: identification of patient’s needs • Diagnosis and Treatment of non-motor symptoms • Exercise: rehabilitation and motor impairment • Gait disorders: problem-oriented approach • Role of diet in PD • Standardized vs Eclectic approach

  2. ON BEING A PATIENTMark Twain’s CatGeorge M. AndesAnn. Int. Med. 1998 My cat and I have had 14 years of forced companionship but certainly not 14 years of friendship. My unhappy kitten has grown into a large, angry cat. For 14 years, he has hissed at me, spit at me, clawed me, and bitten me. He has slowed my step and stooped my back. He has slurred my speech and caused me to shake. He has stolen my balance and disturbed my sleep. He gives no quarter. When I get angry and give him a good shaking, he becomes furious and spits and lashes out with his claws. When I try to placate him, he bites me. He demands my full attention. If I turn my face away, he claws my ear. My companion's anger is unrelenting, and the damage he does is both progressive and irreversible.

  3. NON – PHARMACHOLOGICAL APPROACH TO PARKINSON DISEASE (Olanow & Koller 1998) SUPPORT EDUCATION PROGRESSION of DISABILITY REHABILITATION DIET CHANGE and HOME READAPTATION

  4. FUNCTIONAL IMPAIRMENT RELATED TO PROGRESSION OF PD (community-based study: Peto et al. 1997) Self-evaluation Scale PDQ-39

  5. Neuroprotection Symptomatic Therapy Patient and Caregiver’s Education Counseling and Support Clinical Onset Diagnosis Middle Stage Late stage PD Advanced stage PD Functional Prognosis Prevention TEMPORAL PROFILE OF MANAGEMENT AFTER PD ONSET Functional Impairment Physioterapy/Occupational Therapy/Speech Therapy Psychological and Social Support Physioterapy/Occupational Therapy/Speech Therapy Skilled Nursing Symptoms Appearance Lowering medical needs Worsening prevention Focal disability management and QoL Worsening Management (ADL, QoL)

  6. FROM GUIDELINES TO INDIVIDUAL APPROACH 2001: INTERNATIONAL GUIDE-LINES (Olanow, Watts & Koller) 2002: ITALIAN GUIDE-LINES(LIMPE) FOUR INSTRUMENTS FOR THE NON PHARMACOLOGICAL MANAGEMENT OF INDIVIDUALS WITH PD • EDUCATION • PSYCHOLOGICAL AND SOCIAL SUPPORT • PHYSICAL THERAPY • DIETARY DISEASE MANAGEMENT: MULTIPROFESSIONAL CARE • CARE PLANNING • PROBLEM-ORIENTED APPROACH • MULTIPROFESSIONAL TEAM • SHORT TERM OBJECTIVES • CAREGIVER INVOLVEMENT

  7. PLANNING THE INTERDISCIPLINARY APPROACH • DETECTION OF CARE • 2. CHOICE OF THERAPEUTIC OPPORTUNITIES • ASSESSMENT OF AVAILABLE RESOURCES • 4. EVALUATION OF COSTS • 5. PROVIDING CLINICAL ASSISTANCE • 6. MEASUREMENT OF OUTCOMES

  8. EDUCATION: CONTENTS • COMMUNICATION OF PD EVOLUTION • 2. INFORMATION ABOUT COMORBIDITY • DEFINITION OF PROGNOSIS • HEALTH PROMOTION

  9. ESSENTIALS STEPS OF CLINICAL PATHWAY Multimodal functional evaluation Prevention of increasing disability Goal-oriented rehabilitation Diagnosis I-II Complication prevention Falls prevention Dysfagia-dyspnea management Middle stage I-II Decrease physical and psychological dyscomfort Promotion ADL and IADL Advanced stage III-IV PALLIATIVE CARE Late stage V

  10. Comorbid disorders and hospitalisation in Parkinson disease: a prospective study Martignoni et al , Neurol Sci 2004 Relative incidence of comorbid events prompting the hospitalisation in patients with PD (Italian observational community-based study) Parkinson’s Disease Comorbidity Study Group

  11. Survival Time, Mortality and Cause of Death in Elderly Patients With Parkinson’s Disease: A 9-year Follow-up Fall et al , Movement Disorders 2003 Mortality rate ratio (after 9 years) when comparing 170 PD with 510 controls (mean age 74 years) * * *

  12. PROGNOSTIC FACTORS OF DISABILITY Univariate analysis Multivariate analysis Multivariate analysis

  13. PROGNOSTIC FACTOR OF QUALITY OF LIFE IMPAIRMENT Karlsen et al JRehabResDev2001 Hobson et al 1999 Kuopio et al 2000 Schrag et al 2000 Karlsen et al JNNP 1999 Schrag et al 2000 Cubo et al 2000

  14. EDUCATIONAL PROGRAMS IN PD: EXPERIENCES ACTIONS AUTHORS STUDY DESIGN OUTCOME MEASURES Mercer ‘96 • Perception of general health and psychological well-being • Satisfaction with medical care randomizzed controlled trial PROPATH Diffusion of video and infomation randomizzed controlled trial Montgomery ‘94 PROPATH: Patient education and health promotion program • Quality of life • Time of • ADL execution Stallibrass ‘97 observational Alexander’s technique • Beck, ADL,

  15. COUNSELING & SUPPORT DURING PD PROGRESSION Schawab &England scale 100% PSYCOLOGICAL INTERVENTION/EDUCATION MOTOR ACTIVATION COUNSELING 70% PROBLEM-ORIENTED EDUCATION PHYSICAL TRAINING AND SPEECH THERAPY 50% OCCUPATIONAL THERAPY EMOTIONAL SUPPORT DIETARY SUPPORT 30% CAREGIVER EDUCATION HOME READAPTATION SUPPORT 0%

  16. PSYCHOSOCIAL COUNSELING IN PD ACTIONS AUTHORS STUDY DESIGN OUTCOME MEASURES observational Ellgring ‘93 Application of techniques to every day life Skills for coping in difficult situations controlled Muller ‘97 Hoehn & Yahr UPDRS ADL Muscle relaxation + sequential movements

  17. NON MOTOR SYMPTOMS AUTONOMIC COMPLAINTS Orthostatic hypotension Constipation Bladder instability Hyperidrosis Erectile dysfunction PAIN DYSPHAGIA DEPRESSION COGNITIVE IMPAIRMENT Periodic limb movements in sleep Restless legs syndrome REM sleep behavior disorder SLEEP DISORDERS ECCESSIVE DAYTIME SLEEPNESS PSYCHOSIS SPEECH DISORDERS

  18. OCCURRENCE OF AUTONOMIC DYSFUNCTION RELATED TO MOTOR FLUCTUATION Non motor fluctuations in Parkinson’s disease Witjas et al , Neurology 2002 Prevalence of AUTONOMIC COMPLAINTS in 50 PD with motor fluctuations

  19. CARDIOVASCULAR DYSFUNCTION IN IDIOPATHIC PD Autonomic dysfunction in idiopathic Parkinson’s disease Jost WH , J Neurol 2003

  20. PAIN & MOTOR DISTURBANCES IN PD Non motor fluctuations in Parkinson’s disease Witjas et al , Neurology 2002 Prevalenceof sensory symptoms in 50 PD with motor fluctuations

  21. PSYCHIC DISTURBANCES Non motor fluctuations in Parkinson’s disease Witjas et al , Neurology 2002 Prevalence of psychosis in 50 PD with motor fluctuations

  22. DEPRESSION IN PD Psychiatric aspects of Parkinson’s disease Schrag A. , J Neurol 2004

  23. DEPRESSION IN PD Movement Disorder Society Task Force on Evidence-Based Medicine Mov Disord 2002 • Only NORTRIPTYLINE is “likely efficacious” for the treatment of depression in PD. • There is “insufficient evidence” for the efficacy and safety of other TCAs, MAO-A e MAO-B inhibitors, SSRIs and ECT. • The combination of MAO-A inhibitors and TCAs or SSRIs poses an “unacceptable risk” (Serotonin syndrome), whereas this risk is considered to be low for the combination of selegiline with other antidepressant.

  24. PSYCHOTIC SYMPTOMS IN PD Psychiatric aspects of Parkinson’s disease Schrag A, J Neurol 2004

  25. PHARMACOLOGICAL OPTIONS in PSYCHIC DISORDERS Movement Disorder Society Task Force on Evidence-Based Medicine – Mov Disord 2002 CLOZAPINE CAN BE CONSIDERED “EFFICACIOUS” IN THE SHORT TERM (< 4 weeks) BUT HAVING INSUFFICIENT EVIDENCE ON THE LONG TERM EFFICACY

  26. PHARMACOLOGICAL OPTIONS in AUTONOMIC andPSYCHIC DISORDERS Limitations of Current Parkinson’s Disease Therapy Rascol et al , Ann Neurol 2003

  27. PISA SYNDROME: MOTOR DISORDERS FOLLOWING ANTYPSICHOTIC TREATMENT Tonic truncal flexion (pleurothotonus), usually asimmetric, after exposure to conventional antipsychotics imbalance in the cholinergic-dopaminergic central pathway RISK FACTORS: Combined pharmacological treatment Old age Female gender Brain atrophy on neuroimaging Organic brain disorder Reports of atypical antipsychotics-associated PISA Syndrome (CLOZAPINE: 75-150 mg)

  28. IS PHYSICAL EXERCISE BENEFICIAL FOR PERSONS WITH PD? • Lack of evidence of benefit is not a proof of a lack of effect Deane et al., Cochrane Review ’02 • PD patients improve their physical performances and ADL through exercise Crizzle et al.’06, Trend ’03, Wade ’03

  29. EFNS TASK FORCE ADJUNCTIVE THERAPY OF PARKINSONISM Horstink M. et al, Eur J Neurol 2006 EVIDENCE TREATMENT EXERCISE + PHYSIOTHERAPY + SPECIFIC TRAINING STRATEGIES + SENSORY CUES STRATEGIES ++ SPEECH THERAPY DYSARTRIA - HYPOPHONIA + DYSPHAGIA +

  30. NEUROREHABILITATION in PD: WHERE and HOW Chard S.E., NeuroRx 2006 • SETTING: OUT PATIENTS • EFFECT DURATION: SIX MONTHS • WHEN: III-IV H.&Y. • HOW: SKILL-ORIENTED

  31. PHYSIOTHERAPY & PD: EXPERIENCED TREATMENTS 1) KINESIS THERAPY 2) MULTIMODAL STIMULATION 3) GROUP EXERCISE 4) SKILL ORIENTED

  32. KINESIS THERAPY ACTIVITY AUTHORS OUTCOME MEASURES STUDY DESIGN randomized controlled trial Gait training Functional indipendence (FIM, UPDRS, WRS, NUDS, B.I.) Patti ‘96 Gaittraining and motor dexterity Comella ‘94 UPDRS and ADL randomized controlled trial

  33. VISUAL STIMULATION OUTCOME MEASURES STUDY DESIGN STIMULI AUTHORS High level Weissenborn ‘93 Gait controlled Low level Azulay ‘99 controlled Gait Spatial and temporal parameters of the walking pattern controlled Morris ‘96 Dynamic stimuli Dunne et al. ‘87 Gait observational Worm ‘88 Gait observational Static stimuli Bagley et al. ‘91 Gait controlled Martin ‘67 Gait observational

  34. AUDITORY OR PROPRIOCEPTIVE STIMULATION OUTCOME MEASURES STUDY DESIGN STIMULI AUTHORS controlled Auditory stimuli Enzensberger ‘96 Walking performance Thaut ‘96 randomized controlled trial Stride length and patterns EMG Proprioceptive stimuli Waterson ‘93 controlled Postural control controlled Mc Intosh ‘97 Velocity of walking, cadence and stride length Gait analysis randomized controlled trial Azulay ‘99 randomized controlled trial Abbruzzese ‘99 UPDRS, ADL

  35. EXERCISES CARRIED OUT IN PATIENTS GROUPS ACTIVITY AUTHORS OUTCOME MEASURES STUDY DESIGN ADL training Davis ‘77 Social interaction observational Gauthier ‘87 randomized controlled trial Physical activity, ADL, education B.I. and Psychological well-being Index Use of stimuli Stern et al. ‘80 Gait features, UPDRS III observational Formisano‘92 controlled Passive and active mobilization exercises for postural control and equilibrium, walking Walking test, Fitting Cube Test Pacchetti ‘98 Music therapy observational UPDRS, QoL

  36. SKILL-ORIENTED APPROACH in REHABILITATION of PD PATIENTS ACTIVITY AUTHORS OUTCOME MEASURES STUDY DESIGN controlled Soliveri ‘92 Execution of skilled motor task Performance on a skilled motor task Yekutiel ‘93 Decreased risk of falls controlled Postural and gait training Arm mobilization exercises Postural exercises Tamara ‘99 UPDRS, Webster Schwab-England ADL

  37. SPEECH THERAPY IMPROVED ABILITIES STUDY DESIGN ACTIVITY AUTHORS Prosodic exercises Scott ‘83 controlled Scores for prosodic abnormality and intelligibility Vocal intensity and intelligibility exercises randomized controlled Ramig ‘96 Vocal intensity, communication Vocal intensity and intelligibility exercises De Angelis ‘97 controlled Vocal intensity, communication

  38. GAIT DISORDERS in PD • FESTINATION and DECREASED STRIDE LENGTH DURING WALKING • FREEZING ANDRETROPULSION • FOOT DYSTONIA • DYSKINESIA • POSTURAL INSTABILITY • ORTHOSTATIC HYPOTENSION

  39. CLINICAL FEATURES OF GAIT REHABILITATION A FLUCTUATING CLINICAL EXPRESSION TIMING “Relaxed/Worried” “Morning/Afternoon” “Warm /Cold season” “ON /OFF medication” PHYSIOPATHOLOGY “Impaired internal cueing of SMA set-related activity by the basal ganglia” (Morris et al, ’94, ’96, ’01, ’05) “Impaired activity of the locomotor pattern generator (Pedunculopontine nucleus)” (Ebersbach et al 99; Koozekanani et al ’87; Van Emmerick et al ’99, Pahapill & Lozano 2000) SETTING “Walking on a straight line outdoors/ in an experimental context/ in a complex community setting/ WITH / WITHOUT cues”

  40. Rhythmic Auditory Stimulation: PD patients are able to match their cadence to a beat set at 10% faster than their baseline values. MILESTONES OF GAIT TRAINING IN PD Martin JP 1967 Placement of visual cue floor markers improves gait in PD patients. Transverse lines work, whereas zig zag lines do not; parallel lines may even worsen gait. Lines must be separated by appropriate width and have a colour contrasting with the floor. Mc Intosh et al, 1994 Verbal instructions: PD patients are able to increase their walking speed if they are asked to walk with long strides. Behrman et al. 1998

  41. CLINICAL TRIALS IN GAIT TRAINING OF PD PATIENTS CTs on Rehabilitation efficacy in PD patients

  42. CLINICAL TRIALS IN GAIT TRAINING CTs on Rehabilitation efficacy in PD patients

  43. CLINICAL TRIALS IN GAIT TRAINING CTs on Rehabilitation efficacy in PD patients

  44. OCCUPATIONAL THERAPY STUDY DESIGN ACTIVITY AUTHORS IMPROVED ABILITIES randomized controlled trial General mobilization activities and dexteriry, functional and educational activities Gauthier ‘87 B.I. Quality of life randomized controlled trial Hurwitz ’89 Mobilization exercises, nursing at domicile Clinical evaluation Handicrafts, picture, drawing, basketry, folk singing, dancing and games Fiorani et al. ‘97 UPDRS, NHP, Brown ADL score controlled

  45. FEEDINGS AND NUTRITION IN PD Feeding Dysphagia Nutrition Competitive transport of L-Dopa and Large Neutral Amino Acids in movement into the brain

  46. DIETARY APPROACH IN PD • Changes of consistency, volume, temperature of food. Control the head position during swallowing • Protein distribution diet according to Pincus & Barry scheme: elimination of protein from breakfast or lunch, addition of dopamine-agonist trial & error to determine the interference with L-Dopa absorption

  47. PLANNING THE COMPREHENSIVE APPROACH TO PD PATIENTS STANDARD REHABILITATION “PATIENT-ORIENTED” NEUROREHABILITATION Or PRAGMATIC APPROACH ECLECTIC APPROACH To prevent disabiliy onset To manage disability MULTIMODAL STIMULATION EDUCATION EXERCISE PROMOTION MOTORSKILL-ORIENTED LEARNING GROUP THERAPY OCCUPATIONAL THERAPY SPEECH THERAPY SOCIAL INTEGRATION COUNSELING

  48. DIFFERENCES BETWEEN PROCESS AND SKILL ORIENTED APPROACH PROCESS APPROACH SKILL-ORIENTED APPROACH Or ORIENTED TO ENHANCE PERFORMACE OF GLOBAL MOTOR ACTIVITY ORIENTED TO ENHANCE PERFORMANCE OF SELECTIVE MOTOR TASKS BASED ON CURRENT KNOWLEDGE OF THE PATHOGENESIS PROBLEM SOLVING-ORIENTED APPROACH ENVIRONMENTAL RESTRUCTURING LEARNING IS NECESSARY

  49. SELECTION OF ACTION IN PROCESS OR SKILL ORIENTED APPROACH PROCESS APPROACH SKILL-ORIENTED APPROACH Or JANSEK: global motor activity YEKUTIEL: falls at home Activation before movement Time and Location of every fall Movement sequences should be broken down into smaller components Change objects’ position ADL performance evaluation Attention processes should be used to think each movement component through consciously Cues should be used to initiate and maintain movements Teaching new motor tasks for ADL Simultaneous tasks should be avoided Automatization of new motor skills

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