REHABILITATION IN

PARKINSON’S DISEASE

WHY DOES IT
MATTER
Chronic Illness
Treatment In the Current Paradigm

Their healthcare
treatment is provided “in
a vacuum”

They are struggling to

maintain independence

Their families are strained

due to roles as caregivers
 Occupational Therapy Role

z Address “Occupational Performance”

z “Occupational Performance” includes the

areas of:
- Self care
- Productivity
- Leisure

3
 Assessment Areas

Primary Assessment Areas:

z Activities of Daily Living (ADL)

z Upper limb strength and range of motion
z Tone, rigidity
z Coordination
z Vision
z Writing
4
 Assessment Areas

Secondary Assessment Areas:

z Fatigue
z Sleep
z Cognition
z Depression
z Quality of Life

5
 Challenges in Self Care

z ADLs take increased time

z On and off times affect performance
z Safety is compromised
z Decreased desire or motivation to complete
ADLs

6
 Challenges in Productivity and
Leisure

z Changing roles
z Decreased participation in competitive
activity
z Decreased energy or desire
z Decreased motivation
z Social anxiety

7
 Treatment Overview

z Patient-centered goals
z Make observations
z Environment
z Blocked practice techniques
z Self vocalization techniques
z Energy conservation and work simplification
techniques
8
 Treatment: Managing Tremor
and Rigidity

z Stretching and ROM exercises

z Use of non affected UE
z Positioning Techniques/Splinting
z Energy Conservation/Work Simplification
z Relaxation
z Pain Management

9
 Treatment: Feeding

z Weighted utensils
z Built up utensils
z Scoop plates
z Rocker knives
z Adaptive Strategies

10
 Treatment: Grooming

z Built up toothbrush or
makeup brush
z Electric toothbrush or razor
z Wash mitt or soap on a rope
z Adaptive Strategies

11
 Treatment: Dressing
and Bathing

z Reacher
z Sock Aid
z Long Shoehorn
z Elastic or Velcro
z Long Sponge
z Robe for Drying
z Adaptive Strategies
12
 Treatment: Housekeeping and
Meal Preparation

z Electric gadgets
z Dycem to prevent slipping
z Trolley, cart or walker trays

13
 Treatment Ideas:
Computer Work
z Adapted Keyboards and Mouse
z Hands Free Software
z One Handed Typing
z Seating and Positioning

14
 Treatment: Micrographia

z PRINT
z Use lined paper
z Adaptive writing aids
z Practice

15
Physical Therapy Role

z Gait (walking)
z Postural Instability (balance)

z Functional Mobility

z Rigidity
z Positioning
Challenges in Walking

z Slow, Small, Shuffling Steps

z Festination

z Freezing

z Decreased arm swing

z Narrow base of support
Challenges in Balance
(Postural Instability)

z Increased Fall Risk

z Advanced Disease

z Loss of Postural Reflexes

z Retropulsion
Challenges in Functional
Mobility

z Problem Areas z Contributing Factors

– Bed mobility – Bradykinesia
– Sit to stand – Smaller
– Turning movements
– Stairs – “Freezing”
– Rigidity
– Safety concerns
– Posture instability
Challenges in Rigidity

z Increase in muscle tone

– Cogwheel, Lead Pipe
– Dystonia
z Often increases with
– Active Movement
– Mental Concentration
– Emotional Tension
z Stooped, forward posture
z Pain
Treatment: Overview

z Compensatory Strategies

z Repetition

z Family/Caregiver education
– Cognitive deficits decrease carryover
(Nieuwboer et al, 2002)
Treatment: Walking

z Cues (Rubinstein et al, 2002)

– Lines taped to the floor (Lewis et al, 2000; Sidaway et al,
2006)
– Improve carry over (Marchese et al, 2000)

z Focused Attention
– Think Big (Farley and Koshland, 2005)
– Reduced Distraction

z Auditory and Verbal Cues (Howe et al, 2003)

– Counting steps
– Music
Treatment: Walking

z Straight Cane
z Rolling Walker
– Straight or Swivel Wheels
– Rollator
z USTEP Walking Stabilizer
– Heavy
– Turns smoothly
– Laser Light
Treatment: Walking
z Treadmill Training
– Improvements in gait speed, step length,
and balance
– Safety harness
– Protocols:
z 3x/week, 20-60 minutes, 4-8 weeks
z Progressively increase TM speed
z Directional Stepping
z Stop/Restarts

Cakit et al, 2007; Protas et al, 2005; Toole et al,

2005; Pohl et al, 2003; Miyai et al, 2002; Miyai et al,
2000
Treatment:
Freezing of Gait

z Wheeled walkers
z Combination of balance and walking training
z Sensory cueing (auditory, visual, tactile)
z Compensatory strategies to overcome
freezing
z Individualized treatment

Morris et al, 2008; Niewboer, 2008

Treatment: Balance

z Conventional Static and Dynamic Balance

(Goodwin et al, 2008; Keus et al, 2007; Stankovic, 2004)

z Exercise Groups (Hackney and Earhart, 2008; Hackney et al,

2007)

z Strength Training (Hirsch et al, 2003)

z Perturbation Training (Jobges et al, 2004)
z Treadmill Training (Cakit et al, 2007; Protas et al, 2005)
Treatment: Functional Mobility
z Compensatory Strategies (Kamsma et al, 1995)
– Separating complex movements into components
– Conscious movement control
– Cueing
– Assistive devices
– “Think Big” training program
z Blocked Practice (Lin et al, 2007)
z Parkinson’s Specific Exercise Groups
(Tamir et al, 2007; Viliani et al, 1999)
Treatment: Rigidity

z Relaxation
z Deep Breathing

z Active Range of Motion

z Passive Range of Motion

z Stretching
Treatment: Positioning

z Prevent bed sores and contractures

z Allow interaction with environment
Speech & Language
Pathologist’s Role

z Evaluate and treat changes in the

following areas:

– Swallowing
– Speech and Language
– Cognition
Challenges in Swallowing

z May occur at any stage of the disease

z May worsen and deteriorate rapidly

z PD medications may impact dysphagia

z Chronic aspiration which can lead to

pneumonia
Clinical Signs of Aspiration

z Coughing, choking, throat-clearing;

wet, gurgly voice when eating or drinking
z Difficulty managing saliva, drooling, and
swallowing pills
z Complaints of food “sticking”
z Increased time required for meals
(not related to manual dexterity)
z Unintentional weight loss
Challenges in
Speech/Communication

z Increased time to communicate needs

Hypokinetic dysarthria
z Hypophonia
z Fast rate of speech
z Respiration and speaking
Challenges in
Speech/Communication

z Phonation

z Resonance

z Articulation

z Facial Expression
Challenges with Cognition

z Reduced concentration
z Reduced problem-solving ability
z Impaired processing skills
z Difficulty word finding
z Increased distractibility
z Impaired insight
z Impaired visual-spatial skills
z Decreased memory
Treatment: Overview

z Simplify treatment
z Maximum change with minimal cognitive
effort
z Visual cueing and demonstration
z Repetitive activities
z Focus on increasing functional
communication.
Treatment: Dysphagia

z Strengthening exercises for muscles used for

eating and swallowing

z Compensatory strategies for safe swallowing

z Diet Modifications

z Patient and family education

Treatment: Speech

z Lee Silverman Voice Treatment (LSVT)

focuses on phonation:
– Vocal loudness
– High effort productions with multiple repetitions
– Intensive Practice (motor learning)
– Training individuals to use loud voice in functional
ways
Treatment: Cognition

z Increase awareness
z Compensatory strategies:
-Auditory processing and retention strategies
-Daily planner, routine, schedule
-Take notes or using a tape recorder
-Doing one thing at a time
-Repetition/Rehearsal
-Allowing extra time
Rehabilitation and Parkinson’s
Disease
A Coordinated Approach to Care

1. Collaborative definition of problems

2. Targeting, goal-setting and
planning
3. Continuum of self-
management training
and support services

4. Active and sustained

follow-up
Thank you.