Physical Therapists for Parkinson's

Dual tasking is doing more than one thing at a time. People with Parkinson’s (PwP) often have greater difficulty doing 2 things at the same time. This is in part due to the increased concentration required to perform activities. Disruptions with walking when dual tasking is often used as an example due to potential fall risk involved.

Over the years I have focused interventions on redirecting primary focus on gait with less attention to the secondary task. Patient education regarding increased attention demands on gait helps the individual understand the need for redirected focus. Also, educating PwP to place balance as a priority over the task at hand can be helpful for self-management with balance control. Conditioning exercises and gait training utilizing compensatory strategies to maximize stride length can prepare individuals when there are more distractions. I have found benefits in this comprehensive approach.

Only occasionally have I attempted dual task training with individuals with mild PD : walking + cognitive task or walking + manual or walking + manual + cognitive. I have observed either short term or no improvements but have to admit that perhaps not enough time was spent on these activities (4 sessions for 30 minutes).

I have often wondered if I should work more on dual tasking to prepare an individual for the real world but have felt it would require an inordinate number of treatment sessions to become successful. Dual tasking, I find also requires an individual to have the capability or capacity to learn to filter distractions. So, would exposing an individual to numerous distractions help to desensitize and improve focus in dual tasking conditions? If this is so, I would think community Parkinson’s classes could help an individual in this area more economically. Community classes can be ongoing and definitely distracting! Two community based exercise programs which come to mind which specialize in PD and comprehensively address the needs of PwP are:

1. The PWR (Parkinson’s Wellness Recovery) Exercise classes – founded by Becky Farley PT, PhD . Dr Farley is currently doing work in dual task function in early PD. http://www.pwrgym.org/

2. Delay the Disease http://delaythedisease.com/

It appears there are various sources which are currently investigating interventions and outcomes in the area of dual tasking. I look forward to the completion of these studies!

Recently discovered a website which has a comprehensive listing of tests to measure the status of our patients. It shows the name of the test, how long it takes to perform a particular test, diagnoses appropriate for a particular test. It links you to the instructions of the test and any useful information you need to know. I have added the link to this website for physical therapists. click on outcome measures. Or, you can click here. It also has definitions of statistical terms – bonus!

Getting out of a car is typically harder than getting out of a chair for 2 reasons. First, the car seat slops back and you have to scoot up hill just to swing your legs out. Second, the rim of the car is blocking your feet from sliding back so you can stand up. Here are some options:

A wedge seat cushion can help to level out the slope. Choosing a cushion with a vinyl type of fabric and a dense foam to make sliding in and out easier. Avoid memory foam since it will make scooting more difficult. Sitting higher will also make it easier to stand up unless you have a vehicle with high seating.

I recently found an ideal wedge cushion made with a dense foam and vinyl cover. It’s called a ‘Slant cushion’ by Duro Med Industries item # 513-8062-0323. It is hard to find this cushion in a store but can be ordered through Briggs 1-800-247-2343. It’s about $25.00.

Another device is called the ‘handybar’ which is a handle that slides into the latch of the car door and can be used like an ‘arm rest’ when getting out of the car. Take a look at the link under transfer devices for the handybar to see a video demonstration.

Initially when recommending an orthotic for someone with a drop head syndrome I had mentioned the MND (motor neuron disease) oxford collar click here. Since then I have found 2 other options. One of them is called the ‘Headmaster collar’ from Symmetric designs which was recommended by another physical therapist but the person should make sure to get the right size. Click here for information and sizing. You can get the various sizes through Amazon. The last support system is called a baseball cap orthosis. Briefly, it is a baseball cap with a strap attached to the back of it and anchored to a chest strap.
The reference article for this device is:

Fast, A. and M. A. Thomas (2008). “The “baseball cap orthosis”: a simple solution for dropped head syndrome.” Am J Phys Med Rehabil 87(1): 71-3.

The APDA Information & Referral Centers can offer a wealth of information regarding Parkinson’s, symptoms, where to locate doctors who specialize in Parkinson’s, where to find exercise classes and support groups. They help with any questions you may have and if they don’t have an answer they can guide you to resources who can help you. The APDA Midwest Chapter keeps a listing of exercise classes and support groups in the Illinois and NW Indiana area. You can access this information through the link APDA Illinois on this page or calling 800-223-9776.

A universal problem with walking in PwP is a reduction in stride length. One way to improve this problem is walking to music but the music should have a ‘walking rhythm’ so it can be easy to follow. Music uses different parts of the brain to compensate for deficiencies which allows for longer steps with less effort. Music is also used in dance classes for PwP in a similar manner to improve general movement, weight shifting and last but not least a sense of well being. You could almost think of music as a ‘medicine’ to help you move. It makes E-X-E-R-C-I-S-E more fun! Click here to see a clip on a dance class.

Last month I listed various resources to find physical therapists. There is an additional resource you can call or email. Below is an excerpt explaining this resource center which a partnership between Boston University and the APDA (American Parkinson’s Disease Association) and led to the establishment of this Center.

“Boston University’s Center for Neurorehabilitation has partnered with the American Parkinson’s Disease Association to establish the first-of-its-kind National Resource Center for Rehabilitation of people with Parkinson’s Disease. This National Resource Center is directed by Terry Ellis, PT, PhD, NCS. The center’s toll-free “helpline” allows the caller to speak with a licensed physical therapist who can answer questions about exercise, provide information about programs in the caller’s area and provide educational materials. In just nine short months, more than 500 people with Parkinson’s disease, their family members and health care professionals from across the United States have called 1-888-606-1688 and received free recommendations on exercise from the leaders of one of America’s renowned centers on rehabilitation.
In addition to the helpline, click here to find out their hours or directly email for information.
The center’s Web site can be reached by going to the APDA site’s home page, click here

If you are a person with Parkinson’s how can you track down a physical therapist who specializes in Parkinson’s? The National Parkinson’s Foundation has a website which allows you to search for therapists or other health care professionals by zip code: NPF search for therapists. For someone who doesn’t use a computer very often it can be hard to find the information on this site since you have to click on the ‘up/down’ arrow and then select ‘local resources’ before you can begin your search for health professionals by zip code. Perhaps you can call your local American Parkinson’s Disease Association (APDA) -Information and Referral Center for some names and locations of physical therapists. You can check this blog but how would you know that this blog even exists? You can ask your local physical therapist if they know of other therapists who specialize in PD. The American Physical Therapy Association has a listing of therapists ‘Find a PT‘ with various expertise and you can search under ‘neurologic’ expertise. It will give you a listing of therapists close to you by zip code. Once the names further present themselves on the listing you can see if they specifically specialize in PD. The ‘Find a PT’ listing is comprehensive but is not specific to therapists with Parkinson’s. Probably the most comprehensive listing of therapists who are knowledgeable in PD is through a website who’s clinicians are certified in a specific treatment technique ‘LSVT BIG‘ for people with PD. What about the therapists who are not certified but specialize in PD?

Currently, names of physical therapists…clinicians who specialize in PD are still difficult to find.

Developing an address database is not the hard part. Aquiring names of therapists who specialize in PD, keeping the listing updated and most important, having a listing which is easily accessible to a person with PD seem to be logistical challenges. Other questions to think about: Should there be a central listing only or should there be supplemental local listings? The keepers of the local listings could help maintain the central listing. What incentive would therapists have to update their contact information so that we can offer accurate up to date referrals?

We need to develop better contacts to improve outcomes.

People with PD who have orthostatic hypotension are not always diagnosed which can limit there abilities if left untreated. Here is an individual with PD who is coming to physical therapy for the 1st time to address her PD and is scheduled to undergo DBS(deep brain stimulation) surgery in the near future. It was the patient who requested physical therapy. She was feeling down because over the course of a year she was trying to increase her walking endurance however because of extreme fatigue and legs feeling like they were going to buckle, her walking endurance worsened. She was unable to stand for more than a minute before needing to sit. When asked if she had blood pressure problems, she denied any problems. When asked if she ever had her blood pressure taken while standing or after standing for a few minutes the answer was no. She reportedly drinks a lot – about a gallon of water a day. Her sitting blood pressure was 98/54 Heart rate 60. Initial standing 78/52 heart rate 64. After 3 minutes her blood pressure did rebound somewhat but the systolic was still below the initial sitting blood pressure. She was advised to see a nutritionist since I thought her fluid intake seemed excessive and could potentially act as a diuretic – but wasn’t sure. She contacted her neurologist and communicated the blood pressure readings. She took her blood pressure at home everytime she was symptomatic with systolic readings typically in the 70’s. The neurologist started her on florinef. The nutritionist calculated her recommended fluid intake which was less than the gallon she had been drinking. With these adjustments she is now walking on average 8,000 steps a day. her systolic is in the 120’s

I am currently sharing a physical therapy student with another clinical instructor. The student told me today that she had been reading about PD and exercise. Apparently she read many articles on this topic. She looked at me and said, “it looks like any kind of exercise will help people with PD.” Well I couldn’t disagree although exercise frequency and intensity do play a role in gains.