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Tags >> Treatment

by Michelle Elmo, Physical Therapist

Good posture is important for everyone. In the general population, many back and neck problems stem from poor posture. In addition to this, poor posture decreases a person's ability to weight shift appropriately to maintain balance. Patients with Parkinson's disease are often already set forward due to poor posture and have minimal ability get to neutral let alone shift weight backward without falling. Therefore it is even more important that these patients be diligent about fighting bad posture. So how do you do that?

First, by stretching tight muscles: Pectoral muscles (the front of the chest) Ilipsoas muscle (front of the hip) Hamstrings (back of the upper leg) Gastrocnemius and Soleus (back of the lower leg)

Second, by strengthening the muscles that tend to get weak: Gluteus maximus- buttocks Erector spinae- on either side of the vertebrae of the back Posterior scapular retractors-between the shoulder blades Cervical extensors- in the neck and keep the head from falling forward.

Thirdly, correct positioning at all times: Get rid of extra pillows, only use one pillow to support the small of the neck when you sleep. Sit back against the chair and pull head back- "chin tucks". Walk tall- always think shoulders back, head up, chest out and lead with your heels.

We know exercise works! Many research articles document improvement in balance, confidence, quality of life and reduced fall rates with persons with Parkinson's disease when they are participating in an exercise program. Studies have looked at community verses home based programs and have found improvement with either. Improvement is usually noted in first 3-4 weeks of exercise, with exercise occurring 3-5 times per week. Exercise needs to be a lifelong habit and the benefit fades if exercise stops.

There are many publications with exercises especially for persons with Parkinson's. Many persons not familiar with exercise or anatomy of muscles may have a hard time simply following written instructions for exercises. Don't be overwhelmed! Please ask your physician for a physical therapy referral so that you can be confident and performing exercises that will benefit you maximally. If you are able to safely leave home you can go to an outpatient clinic. If you are rarely and not routinely leaving home you may receive services in your home.

Michelle Elmo is a Physical Therapist, graduate of Grand Valley State with a Masters in the Science of Physical Therapy. She currently works at Gentiva Home Health in Jackson. This article is a portion of her presentation to the Jackson Parkinson Support Group.

 

 

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The Messenger - Fall 2010 Issue. Comments by Brian Cooper, OTR, Residential Home Health, Member, MPF Professional Advisory Board.

Preliminary studies show that patients with Parkinson's disease who regularly do certain exaggerated movement exercises are seeing reductions in their symptoms. In an article published in MedPage Today, www.medpagetoday.com/MeetingCoverage/AAN/19593, the senior editor reported on a study of 20 patients who underwent a supervised program called LSVT BIG for eight weeks and then worked with the Nintendo Wii video gaming system in the final four weeks.

The patients participated in a supervised open-floor series of exercises, which stresses large extensions and movements of the arms and legs. The Wii activities encouraged patients to swing their arms and move vigorously. At the end of the study, all patients showed measurable improvements.

Locally, Brian Cooper, an occupational therapist with Residential Home Health, explained that BIG is based on a successful speech therapy program for PD patients, called LSVT (Lee Silverman Voice Treatment). That therapy helps participants enhance sound and articulation by speaking at an exaggerated volume.

"LSVT BIG teaches patients how to move better, focusing on high amplitude movements to overcome perceptual deficits," said Cooper. "It shows patients, through modeling, how to make bigger movements, then reinforces through practice how to perform high intensity, high amplitude exercises."

Cooper said that patients are taught to take "great big" steps with arms extended and swinging forcefully. They are encouraged to overcome the typical shuffling steps of PD. The concept behind the program is to increase awareness of how movements are made and, by exaggerating the way they are performed, learn more effective techniques. In addition to improving walking, BIG therapy sessions can help patients work on other daily functions such as dressing.

In Michigan, certain physical and occupational therapists have been trained in BIG therapy. Typically, the therapy is conducted in one-hour sessions four times a week on an outpa¬tient basis and is customized when appropriate. After about three or four weeks, patients can practice on their own. Contact your physician for a referral. For more information, call your physician, or (866)902-4000.

 

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by John Argue

A proactive Parkinson's Support Group in the Detroit Metro area contacted us for our professional input on the book titled Parkinson's Disease and the Art of Moving, written by John Argue. We also reviewed the companion videos that incorporate the theories found in this text, which assists in the performance of the exercise program.

John Argue is a gifted teacher with a movement/theatre/ drama therapy background who really understands the various challenges of the Parkinson's patient. Most recently, he has focused his talents toward teaching movement and voice classes for people with Parkinson's disease. I was impressed by the book and videos for many reasons. I appreciated the team approach between the family/ caregiver/client with his instructions and insights. Safety is encouraged with step-by-step exercises to be mastered before continuing to the more progressive advanced standing and floor work. The exercises begin with seated warmup activities and progress to motor planning, coordination, functional weight shift, body awareness and mobility training.

The book is helpful not only for caregivers and clients, but also for any therapist working with clients with Parkinson's disease and/or movement challenges. I particularly appreciate the yoga and Tai Chi influence within the program, which stress quality of movement, grace, and promotion of improved quality of life, an increased sense of well being, alignment, and relaxation. His emphasis on timing and rhythm also assists quite well with ambulation. I am now utilizing many of his techniques with my current patients with increased success.

People at all levels can perform many of these exercises. He also encourages caregivers to care for themselves and stay physically fit. This is a great place to begin an exercise program and I highly recommend using the book and/or video in a safe and supervised (if needed) environment. Remember to do something everyday for your health and fitness...and never give up!

The website for these resources and to learn more about John Argue is: www.parkinsonsexercise.com, video@parkinsonsexercise.com or phone 510-985-2645. The book is also available locally at Borders Booksellers.

Note: St. John Health System, in Detroit, recently started a weekly exercise program, in which we are also utilizing his philosophy. It meets every Tuesday at 3:00pm. Feel free to contact us if you have questions or are interested in participating in this exercise group at 313-343-3744. At home, the equipment is minimal to start. All you need is a chair with arms and a tennis ball.

 

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Symptoms of Parkinson's Disease (PD) may interfere with people's ability to function effectively on a daily basis. Occupational Therapy, Physical Therapy, and Speech and Language Pathology are health disciplines that help people to prevent problems from occurring and to treat difficulties people are having. They can offer you strategies to improve your function or adapt to changes that are imposed by Parkinson's symptoms. Family members can also be involved in learning techniques to make life easier. Typically, a referral by a physician is needed in order to have these services covered by health insurance. It is also necessary to see under what circumstances your health plan provides coverage.

Communication Impairment in PD: Speech and Language Pathology

Speech, language, voice and swallowing disorders are common problems in patient's with moderate to significant PD. Very often the first sign of significant PD is reduced voice power and increased rate of utterance. As the duration of PD increases communication impairment also becomes more complex. Additional communication problems may include poor precision and strength of speech sound pronunciation and reductions in expressive language complexity. Further some patients will experience slowing of mental functioning and memory loss that will also impact language formulation and expression. If these communication impairments become dominant in everyday activities then the patient will begin to withdraw from necessary daily communication activities . Patients may decide to refrain from answering the phone or initiating telephone calls or maintaining conversations. This communication disability can seriously isolate patients and make it difficult for them to function in their families and with caregivers.

The speech and voice communication impairment symptoms in PD are identified by speech-language pathologists as a stereotypic cluster identified as "hypokinetic dysarthria". In general, PD patients will eventually exhibit:

  • Weak and diminishing voice power.
  • Sudden increased rate of utterance.
  • Reduced range of motion of the speech gesture.
  • Monotone and monoloud speech intonation.
  • Poor initiation in speech utterance.
  • Stuttering-like fluency symptoms.

These symptoms of communication impairment can be treated by speech-language pathologists to provide exercises that will allow the patient to reduce the negative effects on overall speech intelligibility. PD patients can improve their communication with treatment, practice and a willingness to work hard to compensate for the neuromuscular impairment in PD.

Swallowing disorders in PD can be significant and should also be evaluated and treated by speech-language pathologists. Because the neuromuscular deficits in PD also affect the muscles of swallowing, patient precautions, x-ray evaluation procedures and treatment may be necessary. Patients may experience difficulty in chewing certain foods sufficiently, choking on liquids or poor passage of food into the esophagus. These swallowing difficulties can also be remedied with exercises and diet recommendations provided by the speech-language pathologist.

Finally, the possible reduction in mental functioning in PD patients has become an increasing concern. These cognitive difficulties include slowing of mental response, short-term memory limitations, slowing word retrieval, time and space disorientation, reductions in expressive language complexity and length, and diminished emotional affect. These problems should also be addressed by the speech-language pathologist in concert with social workers and caregivers.

Evaluating and treating the communication impairment of PD patients while complex, it is rewarding, because improved functioning is possible with speech-voice-language and cognitive rehabilitation.

Contributed by Richard Merson, Ph.D., Speech and Language Pathologist, Beaumont Hospital, Royal Oak Michigan
Chairman, MPF Professional Advisory Board, Member MPF Board of Directors

Occupational Therapy

Occupational therapists (OT) - Occupational therapy is a health care/rehabilitation profession. OT's work with people of all ages, who are experiencing difficulties with leading independent, productive, and satisfying lives. The goal of an occupational therapist is to assist individuals with performing their activities of daily living. People with Parkinson's Disease may need the help of an occupational therapist for many different reasons. While one person may need help learning various strategies to manage their tremors, another may need help with feeding skills, and yet another may need to learn various coordination exercises to maintain functional use of their hands, and someone else may need a home evaluation so the therapist can make recommendations on equipment needs and home safety, the list is endless. The treatment is individualized to your needs which is based on your goals for therapy as well as the therapists evaluation. If you have lost some independence due to your Parkinson's Disease consult your physician regarding occupational therapy.

Contributed by:
Sue Vergilio, O.T.R., St. John Macomb Hospital
Past Member, MPF Professional Advisory Board

Physical Therapy

Some symptoms of Parkinson's disease may include tremors, rigidity or muscular stiffness, and bradykinesia or slowness of movement. These symptoms can cause you pain, a decrease in range of motion in your joints, neck and back, a change in your posture and difficulty moving.

When you experience these problems, your balance and mobility may be affected. You may have difficulty walking and may even start to fall. If any of these occur, you may benefit from visiting a physical therapist. First you need to see your physician for a referral.

When you see a physical therapist, you will have a thorough evaluation. The P.T. will examine your range of motion, strength, coordination, balance, posture, functional mobility skills and your gait, or ability to walk.

One the evaluation is completed, recommendations may include assistive devices such as a cane or walker and a comprehensive exercise program designed especially for your needs. You will also be instructed on the importance of daily exercise or activity to help maintain or improve your quality of life.

Contributed by: Stacey Turner, R.P.T., St. John Macomb Hospital, Warren, MI
Past Member, MPF Professional Advisory Board

Mental Health Issues

The recognition and management of mental health issues is an important part of maintaining a high quality of life for all people. Common issues experience by people with Parkinson's and their families include depression, anxiety, acute confusional states, and dementia. Depression may cause sadness, loss of interest, guilt, lack of energy, insomnia and the inability to experience pleasure. Anxiety may be due to medical problems, pain, or be an understandable reaction to life's circumstances. Medical illness and medications are common causes of acute confusion. Finally, chronic confusion (or dementia) can be seen in some people with later stage Parkinson's Disease. Proper diagnosis of each of these conditions is important because treatment will improve the quality of life.

If you are experiencing any difficulties such as a change in mood or thinking, or anxiety, please discuss this with your physician. It is possible that medications prescribed for P.D. or other illnesses can cause some of these symptoms. You may need to have your medications adjusted. After exploring if there are any physical issues or medications that contribute to your mental health changes, you may receive a referral for further consultation.

Contributed by:

Mark Ensberg, M.D., Michigan State University School of Human Medicine, East Lansing, MI
Member, MPF Professional Advisory Board

 

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Deep Brain Stimulation

The United States Food and Drug Administration approved the use of deep brain stimulation (DBS) in the subthalamic nucleus (STN) and globus pallidum (Gpi) in March of 2002 for the treatment of medically refractory Parkinson's disease (PD). In contrast to the thalamic DBS, which controls only the tremor of PD, both STN and Gpi DBS stimulation are able to ameliorate all cardinal symptoms (tremor, bradykinesia, and rigidity) of PD. There is an impression that the STN stimulation appears to be superior to the Gpi stimulation, but thus far, no prospective randomized data exist for comparison of the two sites.

Not all people with P.D. require surgery. In fact, the vast majority do not require surgical intervention. Prospective candidates must have a diagnosis of P.D., have undergone optimization of medication regimen or who are intolerant to medications due to side effects, not experience significant disability or who have moderate to severe dementia..

Improvements are seen in disabilities related to either "off" period symptoms (tremor, rigidity, bradykinesia, muscle cramps associated with off-dystonia etc) that are responsive to Sinemet, or "on" period symptoms (e.g., dyskinesia) that are induced by dopaminergic drugs. When such symptoms threaten one's independence or livelihood, the risks associated with surgical interventions are often justified.

DBS surgery is a time consuming and tedious procedure that requires extensive cooperation from an awake patient during the surgery. Often the benefits of surgery are delayed and require more frequent postoperative visits for stimulator adjustments. Thus, prospective patients should be in good medical, physical, and mental condition to tolerate the surgery and postoperative care.. Optimal outcome requires significant effort from the patients. Therefore those patients with untreated or under-treated mental illnesses (e.g., depression, schizophrenia, etc.) are excluded from the surgery.

Surgery

STN DBS surgery is often performed bilaterally. Both sides are usually implanted at the same time. In somewhat frail patients, each side is performed separately often months apart for recovery from the initial surgery.

On the day of surgery, a stereotactic frame is placed on the patient's head under local anesthesia. The patient then undergoes MRI and CT examination of the head with the frame in place. The surgeon will use the information obtained from the imaging studies to plan a surgical target. This imaging step takes approximately 1 hour (it may be variable depending on the surgeon). Following the studies, the patient will be moved to the operating room. The patient will be placed in lounge chair position in the operating room. Hair will be shaved and under a heavy sedation, two small burr holes will be placed on the skull. Microrecording system will be mounted to the head frame and the surgeon will perform mapping of the brain to accurately localize the brain target. This process may take 2 to 3 hours. During this part, patient is awake and will be asked to report various sensations and movements. Once the localization is completed, then permanent electrodes are placed into the brain targets. The electrodes are then anchored to the skull and the wounds are closed. The frame is then removed and the patient discharged from the operating room. The patient usually spends 1 or 2 days in hospital for test stimulation and postoperative MRI imaging. The patient is readmitted after 1 week and under general anesthesia, battery packs will be placed under the collarbones. After an overnight stay, the patient will be discharged for convalescence. Programming of the DBS will begin 1 month after the surgery. Adjustments of electrical stimulation and medications are usually made on a monthly basis until optimum setting is achieved. The implanted batteries usually last 5 years depending on stimulation parameters.

Outcomes from STN DBS

The surgery has been shown to be effective for all of the "off" symptoms of PD that were responsive to preoperative Sinemet. Rigidity, bradykinesia, tremor and gait difficulties improve by 40 -60 % in many studies. There is often a marked decline in "on/off" fluctuations, total duration of "off" periods, and "off" dystonia or painful leg spasms. The surgery also decreases the severity of "on" dyskinesia. Most patients experience approximately 50% reduction in PD medication intake. It is generally ineffective in improving "on" state function (i.e., If a patient was wheelchair bound before the surgery even at the best of times, then one would not be walking independently after a successful surgery).

Outcomes from Gpi DBS

The benefits of the surgery are similar to those of STN DBS. The degree of improvement appears to be somewhat less than that of STN. The "off" symptoms have been shown to decrease from 20 - 45%. Improvement in "on" dyskinesia appears to be greater with Gpi than STN DBS. Patients generally require the same amount of medications after the surgery as before the surgery. Also the battery use appears somewhat greater with Gpi stimulation than STN. The only real advantage of Gpi stimulation over STN DBS appears to be in the postoperative DBS programming, which is less problematic with Gpi than STN.

Risks of Surgery

Most DBS procedures are associated with a 1 - 2% chance of devastating intracranial hemorrhages. These hemorrhages are usually lethal or, if one survives, lead to permanent severe neurological deficit including coma, hemiplegia and language impairment. The surgeries are also associated with a 5 - 10% rate of less severe complications including those related to hardware (e.g., infections and breakage). One of the most common transient side effects of surgery is postoperative confusion. This is present in up to 40% of the patients in the immediate postoperative period. It is frightening to unprepared family members, because the patient can be quite agitated, confused and hallucinating. This is short-lived usually lasting 2- 3 days but can last up to weeks. Most patients experience some degree of tingling, numbness, muscle contractions, visual blurring, or lightheadedness associated with stimulation. These stimulation-induced side effects are usually well controlled by adjustments in stimulation parameters. Rarely, a patient will show severe sensitivity to stimulation manifested by violent involuntary movements of extremities, similar to dopa-induced dyskinesia but more severe (hemiballism). Again, this side effect is usually stimulation-induced and can be controlled with alteration in stimulation parameters. These patients will require a slower increase in stimulation parameters than the usual PD patients.

Rarely, DBS stimulation has been shown to worsen existing depression - it is usually associated with stimulation of the electrode in the deeper brain structure and corrected by using an alternate electrode. Permanent cognitive decline is rare except in those with existing dementia or in the most elderly patients. Temporary blunting of affect and a slightly withdrawn personality are often seen in the first 3 months of surgery but permanent changes are rare.

Other Considerations Family and social supports

For the most successful surgical outcome, a strong and committed family and social support is mandatory. Patients are often elderly and frail and require close supervision and assistance postoperatively. Temporary rehabilitation or nursing home facilities may be necessary. Also in contrast to other surgeries, the beneficial effects of surgery are obtained with resumption of electrical stimulation. Optimization of electrical stimulation of DBS requires multiple monthly visits to the physician's office for programming sessions. These sessions are usually very short visits where various electrical stimulation parameters are adjusted but can last several hours especially the very first programming. Medication adjustments are usually made at each programming session. Since the patients are usually debilitated, extensive family or social support are needed to realize the postoperative care.

Economic Considerations

STN and Gpi DBS procedures are approved by the FDA and covered by Medicare and thus by other US insurers. Due to the significant costs associated with the medical devices implanted, in excess of $30,000.00, the insurance co-payments can be significant and should be investigated before the surgery. Also expenses associated with frequent trips to the physician's office associated with programming should be considered before the surgery.

The most important consideration is the patient's expectation of the surgical benefit. It is important to have a realistic expectation of the surgery to avoid postoperative disappointments despite a successful surgery. It is important to recognize that no two patients are the same and therefore postoperative benefits are not the same. Equally important is recognizing the risk associated with surgery. Too often patients are only concerned with the anticipated benefits and ignore the risks. For this reason and others, a frank discussion of surgical benefit and risks should take place with the medical team and the patient and his or her family.

Taken from MPF The Messenger Newsletter, June 2002
Frederick Junn, M.D., Neurosurgeon, Oakwood Hospital - Dearborn, MI
Member, MPF Professional Advisory Board

 

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Contributed by: Michigan Parkinson Foundation and MPF Professional Advisory Board

Overview

Since the 1960s, much research and study has contributed to the development of new treatments for Parkinson's disease. Although there is no cure, a variety of medications are available to control symptoms. Rehabilitation therapies are frequently used to improve function. Mental health consultation may additionally be called into use. For some, if medication management is no longer effective, surgical options are a possibility. Some people opt to enter research studies.

As the symptoms of Parkinson's disease vary from individual to individual, so does the treatment. What works for one individual, may not work for the next. The one constant is that treatment changes over time. Each person with P.D. needs to be individually evaluated with a regimen developed specifically to meet his or her needs. Family involvement is very helpful. Recommendations will change over time, as P.D. is a progressive disorder, and treatment will depend upon the person's symptoms. Finding a physician who is knowledgeable about the treatment of P.D. and with whom you can communicate is essential in effectively managing your Parkinson's disease. Learning how to monitor your responses to medication and other therapies is an important role the person with P.D. and family needs to learn. Dealing with Parkinson's disease requires patience and a good working relationship with the health care team.

Staying Healthy

Your overall health is important in maintaining optimum wellness. A healthy lifestyle contributes to your sense of well-being and is your first line of defense against illness. Managing the symptoms of Parkinson's disease can be a "career" in itself and you may overlook general health concerns. Care partners may also neglect their own health needs when a family member has care needs.

Here are ten healthy living tips:

  • Have routine health check-ups.

  • Exercise regularly.

  • Be on the alert for signs of stress and learn ways to manage them before distress takes over.

  • Eat a well-balanced diet.

  • Get adequate sleep and relaxation.

  • Maintain connections with others and the world around you.

  • Stay as active and involved as you can.

  • Be the "captain of your ship," by finding a competent physician with whom you can relate.

  • Learn to ask for help from others.

  • Educate yourself on your condition - knowledge is power.

  • Keep a sense of humor.

 

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