Julia: Good afternoon everybody and welcome. This topic today is important based on the prevalence of Parkinson's disease. If you are not currently seeing individuals with Parkinson's Disease, I am sure you will at some point in your career. I am really passionate about helping people understand how to approach individuals with this condition and because there is a lot of good we can do in our role as occupational therapists. I am not going to get into the brain science behind Parkinson's as that would be a whole other webinar. We could go all day long into the pathophysiology, but today, I want to get into how this impacts us as clinicians. I want to help you identify and understand outcome measures to help create a very person-centered approach.
PD Symptoms and Functional Impact
Cause and Prevalence
- Brains of people with PD demonstrate loss of dopaminergic neurons in the substantia nigra.
- Nearly one million will be living with Parkinson's disease (PD) in the U.S. by 2020.
- More than 10 million people worldwide are living with PD.
- The incidence of PD increases with age, but an estimated 4% of people with PD are diagnosed before age 50.
(National Parkinson’s Foundation, 2018)
The cause of Parkinson's is a loss of dopaminergic neurons in the substantia nigra, within the basal ganglia. There is a protein that now we know is linked with this cell death. There is less dopamine in the brain, and the activities in the areas of the brain that are fueled by dopamine become impacted. We are going to get more into what that looks like in a moment.
Nearly one million people will be living with Parkinson's in the United States alone by the year 2020, and it is only second to Alzheimer's Disease as neurodegenerative conditions go. If you were to combine ALS, MS, and MD, more people have Parkinson's. This is a lot more common than we think. Worldwide, we see more than 10 million people living with Parkinson's, and it's often considered to be a condition that older adults have. Even though the incidence increases with age, it is estimated that four percent of people are diagnosed before the age of 50. You could see people that are still young with small children and who are still working that are afflicted by this condition. It is also notable that the numbers are expected to double by the year 2040. This is a condition I think that we will be seeing a lot in the future.
Motor Symptoms of PD
There are four loops that are affected in the brain by this condition, and two of them are motor. If you notice the symptoms here, these are what we often think of with Parkinson's. That it is a movement disorder.
- Loss of automatic movement
- Gait changes—
- Decreased dexterity
- Deficits in force generation
- Postural instability occurs later—if early, can be a sign of an Atypical Parkinsonism
(Moustafa et al., 2016)
The first three symptoms, bradykinesia, tremor, and rigidity, are considered to be the cardinal symptoms of Parkinson's as it is a clinically diagnosed condition. When someone comes in for treatment, they have often been seen by a neurologist or a movement disorder specialist who looked at their movement during finger taps, rapid alternating movements of pronation and supination, getting up from a chair, and walking down a hallway. This is how it is diagnosed. People might doubt the diagnosis because in this day and age we really expect some type of a blood test, a brain scan, or something that diagnosis this disorder more definitively, but they are looking for these three symptoms. Bradykinesia is the movement gets slower. Tremor is a familiar term, but many of my students think that everyone with Parkinson's has a tremor, and it is seen a lot less than you would think.
The big one that you do see is the hypokinesia, with their movements getting smaller with less amplitude. We are going to get more into that in a bit. Akinesia is freezing, and this can happen both with gait and with things like bringing a fork to the mouth or getting dressed. They will also have freezing in a lot of different movements. Micrographia is where the handwriting becomes small, and hypomimia is the facial movements become smaller. They will have what is called a masked face and often not have a lot of facial expressions. There is a loss of automatic movement as well. This results in less arm swing, leaning forward to get out of a chair, and a narrow base of support. Things that we do unconsciously, and that we really take for granted day to day, become very difficult.
There are many gait changes that we see. Festination is where the gait becomes like a runaway train. Cognitively, the initiation and the termination of movement become very difficult. Freezing is where you will see people try to initiate moving, either walking or picking up a fork, and they perceive that they are truly stuck, even though they can move.
We see decreased dexterity which impacts fine motor coordination and deficits in force generation, where they often feel weak. They perceive that their hands are weak or that their legs are too weak to get out of a chair. However, it is more of a decrease in amplitude.
Dystonia is where there is cramping in the muscles or posturing, and often, it causes the toes to curl. This and dyskinesia are common side effects of the medication. It is most often seen with over-medication or when somebody has a peak on-time with their dopaminergic medications, but it can also happen in off-times.
Postural instability can occur later. It used to be considered a cardinal feature of Parkinson's. If you see someone newly diagnosed and they are having a lot of falls and their posture is really unstable, it is more of a sign of an atypical Parkinsonism. There is a whole family of conditions that are related to this. George Bush, Sr. had vascular Parkinsonism, but the focus for today is idiopathic Parkinson's disease. These other ones, especially the atypicals, would be an entire webinar all their own.
Non-motor Symptoms of PD
We are now going to move on to the non-motor symptoms.
- Depression/ Anxiety/Apathy
- Obsessive /compulsive symptoms
- Sleep disturbance
- Cognitive changes
- Autonomic Abnormalities-- OH
- Stomach and upper GI disturbance
- Sexual dysfunction
(Bonnet et al., 2012)
There are two loops in the brain then that are involved with the non-motor symptoms. One is a limbic loop, and it relates to mood. You notice on this list that there are depression, anxiety, and apathy as symptoms. The other loop is a cognitive or an associative loop. We also see significant changes in cognition that we are going to get into in a moment.
The most often reported non-motor symptom that is really bothersome for people is fatigue. This is something that we want to check in on any time we assess someone. There can also be behavioral issues like obsessive-compulsive symptoms or impulsivity, especially as the condition progresses. People can have sleep disturbances, and many times, these occur many years prior to the onset of Parkinson's.
Loss of smell is now known to be one of the pre-symptoms before diagnosis. In fact, many do not realize that they have lost their sense of smell. "I thought it was my sinus infections or allergies." We also see a lot of autonomic abnormalities, especially with orthostatic hypotension. This is very common, and with the dopaminergic medications that they are often on, this can further complicate things.
Stomach and upper GI disturbances can become a problem, especially constipation. There are some theories now that Parkinson's actually begins in the gut. We do not have anything concrete, but that is something researchers are looking at a lot.
Last, but not least, is sexual dysfunction. This can be present in both and women.
Mid-stage Parkinson’s Disease
Parkinson's often is referred to in three stages. I did not put up a slide on the early stage to save time. In the early stage, we are really looking at just the diagnosis until mid-stage when someone is either medicated or non-medicated and have symptoms. The symptoms are somewhat managed in the early stage. They might be having some problems, but they are doing pretty well. There are not a set amount of years until a person hits mid-stage, and this is different for everyone as it refers to the expression of symptoms.
In this stage, we start to see that the symptoms are less suppressed with medication. For example, even with medications, they may still have a tremor, be rigid, or demonstrate freezing. The motor fluctuation starts to happen more. There will also be off episodes where the medications can abruptly stop working or there is a delayed on-time and takes them longer to start working. People start to have more difficulty managing their condition.
Clinical Presentation of Late Stage PD
By late-stage Parkinson's, as you can imagine this is usually the presentation (about 15 to 18 years).
- 40% live in aged care facilities
- 81% experience falls (23% sustained fractures)
- 84% demonstrate cognitive decline
- 48% fulfilled criteria for dementia
- 50% experience hallucinations and depression
- 35% present with symptomatic postural hypotension
- 41% demonstrate urinary incontinence
- 50% experience choking
(Hely et al., 2008)
At this point, a large majority (40%) live in a facility of some sort. They start to have falls, and a good number sustain fractures. 84% are going to have cognitive decline. Almost 50% meet the criteria for dementia, and that is one of the most common reasons for someone being put in a facility. Hallucinations and depression are a lot more common. Postural hypotension, urinary incontinence, and choking become issues. Speech-language pathologists may be involved.
Vision Changes in PD
One of the other loops in the brain is an oculomotor loop that relates in with this whole system. There can be changes to vision related to the motor function of the eye.
- Contrast sensitivity
- Depth perception
- Visual processing speed
- Visual acuity
- Convergence insufficiency
- Impaired eye movements
- Impaired recognition motion/emotion/faces
- Peripheral vision impairments
- On/Off fluctuations
- Reduced contrast sensitivity
- Deficits in visual-spatial, visual attention & motion perception
- Impaired visual processing speed
- Correlates with gait disturbances and postural instability
(Davidsdottir et al., 2005; Uc et al., 2005; Weil et al., 2016)
The tiny muscles that control the coordination of the eyes are thus affected. Additionally, dopamine is a part of our color vision, and that can be affected as well. You will notice many issues with contrast sensitivity and depth perception that can cause problems with navigating stairs, curbs, and uneven terrain. Their visual processing speed can also be an issue. Thus, reading can be more difficult. Visual acuity especially becomes a problem. Convergence insufficiency and even diplopia might be seen early on. And, as noted, the movements of the eyes are affected so saccades and visual tracking are often impacted. Another area that I think is really interesting is that they sometimes have trouble recognizing motion. A really dear friend of mine with Parkinson's is going through this. He perceives something to be moving that is not. They also do not recognize facial emotions like anger, frustration, or surprise. They start to have more peripheral vision impairments, and it gets very interesting as all of these vision changes can be exacerbated with on-off and those motor fluctuations. All of these changes can correlate with gait disturbances and postural instability. If someone is having a lot of vision changes, there is going to be more risk and issue for falls.
Cognition in Early PD
Impairments found in early, untreated PD:
- Impaired processing speed
- Attention deficits
- Visuospatial impairments
- Executive dysfunction
- Memory impairments
Functional impact on process skills:
- Impaired problem solving
- Difficulty multi-tasking
- Decreased mental flexibility
- Decision making
- Difficulty planning and organizing
(Weintraub et al., 2015)
This research came from Dr. Weintraub who is a colleague of mine at Penn. He and his colleagues found that even in early Parkinson's, we are seeing decreased processing speed, trouble with attention, and visuospatial impairments. Executive dysfunction and memory impairments are also present. Remember, some of these people are still working. They start to have a lot of problems, especially with the executive dysfunction that affects sequencing, multi-tasking, and dual tasking. It also has an impact on their problem solving and mental flexibility. Often, it is difficult for them to plan and organize tasks. This is where, in my team, I really come into play by helping people stay employed as long as they want by helping them to utilize some cognitive strategies.
Impact of Symptoms on Function: Motor Skills
Now, let's start to look at how these symptoms really impact function. What does this look like in day to day?
Loss of automatic movement
- Impaired motor planning
- Familiar, sequential patterns become impaired
- Decreased weight shift, loss of arm swing
Motor planning becomes impaired. One that I frequently see is that when they get up from a table and go to step away, they will cross over with the foot. They will not lead with that foot in the direction they are going. Familiar sequential patterns become more difficult. These are things like getting on a coat, getting out of the car, and getting out of the bed. You will notice a decreased weight shift with a shuffling gait because they are not reshifting their weight from one foot to the other. This is where the freezing comes in later on. We also see that decreased weight shift during transfers. If you or I go to get up from a chair, we are going to lean forward and stand. They stop leaning forward and cannot figure out why they cannot get up. Finally, we see a loss of arm swing usually on the affected side. The big thing that I want to point out is that with the basal ganglia we are looking at a sensorimotor disorder, so often, they are not aware of these symptoms or these changes. Although, some people are very aware. They will typically say something like, "My husband told me my left arm wasn't swinging when I walk." However, often, they do not perceive it themselves and do not understand where the breakdown is.
- Reduced amplitude of movement
- Slow task performance
- Impaired transfers & bed mobility
It is important to note that they also demonstrate a reduced amplitude. They will perceive themselves as weaker and have a slower task performance. Recently, I taught a course for the Parkinson's Foundation. An occupational therapist said, "Well if they're slow, I'm not going to intervene if they're still independent." But keep in mind, this is a progressive condition with different stages. If someone starts to slow down in their ADL performance, how long until they are going to start asking for help and need more and more assistance. So, it is important that we look at that amplitude and their movement and try to intervene.