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How occupational therapyhelps in Parkinsons disease

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How occupational therapyhelps in Parkinsons disease

throughout the day, as well as over thecourse of the disease, and is manifestedin a highly individualised manner(Gaudet, 2002). The occupationaltherapist working with PD patients needsto focus on facilitating the execution ofmeaningful everyday occupations andaddressing issues that interfere with this.These issues can include the stage ofthe disease, environmental restrictions

both physical and social drug regimes,motivation issues, fatigue, depression,freezing, and other motor and cognitiveimpairments.

The diversity of issues associated with PDand its management affects individualsusual or expected physical, social andmental well-being. By using a top-down,client-centred approach, we focus on thoseoccupational issues that are important toour PD patients. Furthermore, Fisher(2003) argues that this top-down approachbegins with the evaluation of the PDpatients ability to perform daily life tasks

that she or he wants and needs to performin order to be able to fulfil his or her rolecompletely and with satisfaction.

Ljubljana Neurology ClinicI would like here to present my own viewsand describe the practices we carry out inthe Centre for Extrapyramidal Disordersat the Ljubljana Neurology Clinic. Wefollow the Occupational PerformanceProcess Model (OPPM,) described atwww.epda.eu.com/eotn/eotn_projects.shtm.We use the Canadian OccupationalPerformance Measure (COPM) to identifyclients perceptions of their performance in

daily practice over time.

While we are conducting a COPM interview,we ask the patient to identify the activitiesthat are difficult to perform in the domainsof self-care, productivity and leisure(Niestadt, 2000). The therapist listens tothe patients story within the context of hisor her personal environment, and is thenable to individualise the necessaryintervention, resulting in somethingmeaningful for the patient.

It is important to consider the characteristicsof environment in which a person with PD

participates, as it is well known that eventhe perception of an environment beingsupportive can influence well-being.Furthermore, through the use of COPM, thepatient is helped to identify those daily tasks

Jelka Jansa discusses how occupational therapy can help patientswith PD improve their daily quality of life

The World Federation of OccupationalTherapists defined occupational therapy(OT) as a profession concerned with

promoting health and well-being through

occupation. According to Mattingly (1994),OT is concerned with the quality, potentialand empowerment of life through performingnormal and meaningful occupations.

There is currently a trend towards using atop-down and client-centred approach.This approach helps immediately toidentify functional problems in the areas ofwork or daily living tasks of concern to thepatients and thus enables the therapist tofocus quickly on those impairments thatappear problematic for that particularpatient.

Improving daily life with OTParkinsons disease (PD) affects manyaspects of both motor and non-motorperformance; it is influenced byenvironmental conditions, often fluctuates

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that he/she wants to do, needs to do, isexpected to do but finds he/she cannot do,or cannot do to a sufficiently satisfactorylevel (Fearing, 2000). Such an approach mayprovide a stronger sense of control whenliving with PD.

When is the right time to start?The evidence suggests that OTintervention is most often required in theintermediate (maintenance and complex)and later stages (palliative) of the diseasewith Hoehn and Yahr stage 3-5 (Trombly,2002). Although there is as yetinsufficient evidence to fully support thevalue of OT for treatment in PD, this doesnot mean that it is not beneficial (Deane,2003). The Parkinsons Disease Society UKis to start a pilot randomised controlledtrial in Birmingham of OT in PD patientswith a Hoehn and Yahr score of 3-5. Thistrial will examine the effects of OTintervention in terms of mobility, activities

of daily living, mood and health-relatedquality of life.

Occupational therapists working with PD whomet during the EPDA conference in Lisbon allagreed that early referral would be morereasonable, as it may result in betteradaptation to the disease progression. Dueto the progressive nature of the disease weare likely to maintain contact with PDpatients and their carers over many years.This intervention can be given at thepatients home, in the hospital, neurologicalward, Parkinson clinic, or rehabilitationinstitution on an in or outpatient basis.

Early OT interventionEarly OT aims towards establishing rapport,preventing changes in roles andparticipation in environment. It may helpto prevent some functional problemsbefore they arise. Also, we may use OTtargeted towards the restoration ofunderlying impairment, be it motor or non-motor: this is most relevant for the earlystages (diagnosis and maintenance) of PD.

OT at advanced stage PDAs the disease progresses, some changesare required in overall lifestyle. It is

important to organise daily routine in sucha way as to encourage independence,safety and confidence in as many areas ofdaily life for as long as possible. In theintermediate (maintenance and complex)and later (palliative) stage, it is importantto consider wearing-off problems, on-offfluctuations, dyskinesias, falls and freezing.Relatives become important members ofthe rehabilitation team. This is the timewhen adaptive and compensatoryapproaches become relevant. These willinclude introducing equipment aids andenvironmental adaptations, such asprovision of hoists, adapting bathroom

facilities, installation of a stair-lift, adaptingthe kitchen, supply of handwriting devices,adaptation of clothing and so on. Patientand therapist may focus on methods thatwill help patients to perform meaningful

occupations independently and withsatisfaction according to the patientsresidual abilities, and also by usingattentional strategies, visual and auditorycues and multitask training.

Patients with PD have difficulty performingtheir activities of daily living because of thebrains deficit in maintaining the size andcorrect timing of movements. There are alsoproblems in the formulation and maintenanceof cognitive sequences, leading to impairedability with executive, frontal-typefunctioning. The patient can be taughtmovement and cognitive strategies thatutilise conscious attention and avoid multi-tasking. For example, dressing is madeeasier by planning the activity sequence inadvance, gathering and organising thegarments and sitting down to dress.

A study of micrographia (smallhandwriting) by Oliveira et al (1997),

showed that both external visual andauditory cues draw attention to the goal(of writing bigger). This encourages thepatient to write less automatically, with thebeneficial effect of increasing amplitude(and thus legibility) of handwriting.

ConclusionsOccupational therapists should effectivelyprovide ongoing support and treatmentfor the patient with PD in order to help tosustain and/or regain physical, mentaland social well-being. This is moreeffective when having an opportunity towork within a multidisciplinary movement

disorder team.

Jelka Jansa, OT, MSc, University MedicalCentre Ljubljana, Neurology Clinic,Ljubljana, Slovenia

Further reading

1 Deane KHO, Ellis-Hill C, Dekker K, Davies P, Clarke CE. Survey of current

occupational therapy practice for Parkinsons disease in the UK. British Journal

of Occupational Therapy2003; 5: 193.

2 Fearing VG, Clark J. Individuals in Context. A practical guide to Client-Centred

Practice. Thorofare: SLACK, 2000.

3 Fisher A. Assessment of Motor and Process Skills. Volume 1, 5th ed. Colorado:

Three Star Press, 2003: 1-15.

4 Gaudet P. Measuring the impact of Parkinson's disease: an occupational

therapy perspective. Can J Occ Ther2002; 4: 104-113.

5 Mattingly C. Fleming C. Clinical Reasoning Forms of Inquiry in Therapeutic

Practice. Philadelphia, FA DAVIS, 1994.

6 Neistadt ME. Occupational Therapy Evaluation for Adults. Baltimore: Lippincott

Williams & Wilkins, 2000: 1-123.

7 Oliveira RM, Gurd JM, Nixon P, Marshall JC, Passingham RE. Micrographia in

Parkinsons Disease: The effects of providing external cues.J. Neurol

Neurosurg & Psych 1997; 63: 429-433.

8 Parkinsons News. Clinical Trials update.A Quarterly Bulletin for Health and

Social care Professionals: Issue 22, 2005.

9 Trombly CA, Radomski Vining M. Occupational Therapy for Physical

Dysfunction. Baltimore: Lippincott Williams & Wilkins 2002: 885908.

10 www.nice.org.uk/page.aspx?o=267747

11 www.epda.eu.com/eotn/eotn_projects.shtm#

12 www.wfot.org.au/WFOT_information/default.cfm