nin bajaj consultant neurologist, nottingham fiona lindop, specialist physiotherapist, derby...
TRANSCRIPT
Nin Bajaj
Consultant Neurologist, Nottingham
Fiona Lindop,
Specialist Physiotherapist, Derby
Multidisciplinary Team Working in PD
Setting up a PD service
• Nuts and Bolts
• You can’t do this alone
• You need “mates” or at the very least people you can work with on a professional level
• The days of the “solo” practitioner really should be over
The team- the minimum requirement
• A neurologist
• A Care of the Elderly Physician
• A PD specialist nurse
The extended team
• PD physiotherapy
• OT
• SALT
• Community PD nurses
• Neurorehab specialist
The fantasy football team
• Pharmacist
• Dietician
• PD service management
• Psychiatrist
• Palliative Care
• Parkinson’s UK/Care PD patient representative
PD Steering Group
• The Fantasy Football team
• Meet 4x a year
• Allows managed expansion and cohesive lobbying
• Allows access to “pots” from Cancer and Medicine
• Allows unified drug, pharmacovigilance and audit policy
How do you create a profile for the service
• Playing at Home
• Playing Away
• International fixtures
Playing at Home
• The local community with PD has to have a voice in the local service
• This might be best done by co-opting local patient representatives from the charities
• Having a local rep man the information stand at clinics
• Holding education groups and facilitating special groups locally e.g. young persons with PD
Playing Away- National Level
• Endorsement of the service
• Hospital Doctor Award
• Guardian Public Sector Awards
• HS awards
• Research Profiles
Hospital Doctor Award
Research Profiles
• DeNDRoN
• CLRN
• The DeNDRoN PD Director (region)
• Non-portfolio work
• Refereeing
• Working for and with the Charities
Research Profiles- National
• DeNDRoN working parties
• National grants
Co-operative Working with Pharma
• Educational Events
• IIT research grants
• Portfolio Adoption
Playing Away from Home- International
• International Endorsement
• The national Parkinson Foundation Programme
• Research
NPF
NPF Centres of Excellence
Research- International
• Present at conferences
• Lecture
• Faculty Boards
How to build a world class PD service: Business cases in Derby
• Specialist Physiotherapist & OT Posts (appointed 2009, but already working as specialists for several years)
• Dedicated SALT (appointed 2009) – LSVT training 2010 (one patient, 4 weeks / 4 x 40mins at present)
• Dietician – appointed 2010
Impact of Specialist Therapy Posts: in-reach and out-reach
• Potential for reduced length of stay• Specialist support for in-patients• Outpatients reduced waiting list &
improved follow up availability• Provision of emergency therapy
appointments• Specialist MDT may be able to support
patients while waiting longer for consultant/PDNS clinic appointments
Further aspects of the roles
• Education for patient and carer– Including exercise, relaxation
• Education and support for ward staff
• Education for AHP’s on a national level – NCORE courses – annual PD or Parkinson’s Plus courses
• Signposting to other support agencies e.g. Parkinson’s UK
Specialist Physiotherapy Role
• Promote best practice- evidence-based models of therapy
• Assessment and Management
• Outcome measures – including LPAS,
• Importance of exercise
• Teach compensatory cues and strategies
• Ultrasound for Apo-nodules
Lindop Parkinson’s Assessment
Specialist Occupational Therapy Role
• Functional Assessment – all aspects of ADL including self-care, domestic, leisure, work
• Assessment of cognition – ACER, MOCA• Assessment of Mood – HAD Scale, Becks.• Information regarding mood disorders - anxiety
or depression• CBT/Anxiety management group• Relaxation/ fatigue management• Sleep hygiene
Future Dreams
• Second PDNS
• More SALT hours
• Education framework
• Palliative Care
• Training for Care home staff
• Outreach to people with Parkinson's in care homes
Basal Ganglia Dysfunction
• Impaired performance of well-learned motor skills and movement sequences – Preparation, Initiation, Sequencing,Timing
• Difficulty in performing 2 or more well-learned tasks simultaneously
• Difficulty in shifting motor and cognitive sets• Increased time required for mental
processing
Enhancing function in PD – whole team approach
Principles
• Engage conscious attention
• Avoid dual tasking• Use of cues• Use of strategies
CuesInternal• Attention/concentration• Mental rehearsal• Visualisation• Cognitive• Weight transference
External• Facilitation of attention• Visual• Auditory• Sensory
Whole team approach: Freezing of Gait
• “Inability to initiate walking sequences, a sudden cessation of stepping, part-way through a locomotor task, or difficulty igniting subsequent steps in the sequence once the motor block has occurred”
(Morris et al 2008; Bloem at al 2004)
• Reduces activity
Intervention for Freezing
• Freezing: auditory cues to slow step frequency; visual cues to maintain momentum of step
• Gait initiation: visual cue, rhythmic weight transference strategy
• Step length: visual cue, attention cue, strategy
• Relaxation techniques• Training for or avoidance of dual tasking
Turning
Safe turn requires:
• Independent mobility• Ground clearance• Good stability• Continuity of
movement• Good posture
Intervention for turning:
• Avoid dramatic change of direction
• Avoid dual tasking• Cues • Physiotherapy to
improve balance and rigidity
Intervention for falls
• Balance re-education
• Teach to recognise festination in time
• Cues for freezing
• Environment – inside and outside
• Strategies for dyskinesia (compression & resistance) and dystonia (stretches)
• Teach how to get up from the floor - backward chaining
To Summarise...Team Approach!