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Occupational Therapy
Management for
Parkinson's Disease
Phinoj K. Abraham, MOT, EPGDHA
Occupational Therapist
1
2
• Deane KHO, Ellis-Hill C, Dekker K, Davies P, Clarke CE. A Survey of Current Occupational Therapy Practice for Parkinson’s Disease in the United Kingdom. British Journal of Occupational Therapy.
2003;66(5):193-200. doi:10.1177/030802260306600503
• Deane KHO, Ellis-Hill C, Dekker K, Davies P, Clarke CE. A Delphi Survey of Best Practice Occupational Therapy for Parkinson’s Disease in the United Kingdom. British Journal of Occupational Therapy.
2003;66(6):247-254. doi:10.1177/030802260306600603 3
The survey demonstrated that:
1. OTs emphasized self-care over Occupational Performance
2. OTs lacked knowledge in condition-specific interventions for PD and
3. OTs expressed a need for more training to address occupational performance
aspects of Parkinson's care
4
The Gap..
We as OT’s,
sometimes miss out to fully address Occupational Performance,
which is the core part of Occupational Therapy
5
Objectives
• Identify the impact of Parkinson's disease on a client's occupational performance
and quality of life.
• Analyze a framework for occupational therapy intervention in Parkinson's disease
that addresses all aspects of Occupational Performance.
• Explore evidence-based occupational therapy interventions for managing
Parkinson's disease symptoms.
6
Conflict of interest
• None to declare
7
Parkinson’s Disease
8
Parkinson’s Disease
• …is a progressive, neurodegenerative disorder that affects
predominately the dopamine-producing (“dopaminergic”) neurons in
substantia nigra (basal ganglia), characterized by the onset of tremor,
muscle rigidity, slowness in movement (bradykinesia), and
stooped posture (postural instability).
What is Parkinson’s? (n.d.). Parkinson’s Foundation. https://www.parkinson.org/understanding-parkinsons/what-is-parkinsons
9
Symptoms of PD
 Motor Symptoms
 Bradykinesia - Movement starts
but is slow
 Hypokinesia - Movement starts but
is small
 Akinesia - inability to initiate
movement
 Rigidity
 Rest tremor
 Postural instability
 Non-motor Symptoms
 Cognitive Dysfunctions
 Emotional and neuropsychiatric
problems
 Autonomic failure - sweating
 Incontinence
 Sexual health issues
 Fatigue
 Pain
 Sleep disturbance
 Dementia
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
10
Symptoms of PD
 Motor Symptoms
 Akinesia - inability to initiate
movement
 Bradykinesia - Movement starts
but is slow
 Hypokinesia - Movement starts but
is small
 Rigidity
 Rest tremor
 Postural instability
 Non-motor Symptoms
 Autonomic failure - sweating
 Incontinence
 Sexual health issues
 Fatigue
 Pain
 Sleep disturbance
 Cognitive Dysfunctions
 Emotional and neuropsychiatric
problems
 Dementia
 Cincotta, M. C. (2023, May 19). Newly Diagnosed With Parkinson’s Disease? Here’s What You Need to Know. Temple Health. https://www.templehealth.org/about/blog/understanding-
stages-of-parkinsons-disease 11
Prevalence and incidence of PD
• Parkinson's disease affects over 10 million people worldwide, with nearly 1 million in the
U.S. and expected to rise to 1.2 million by 2030.
• Incidence of PD has increased by 50%, with around 90,000 new diagnoses annually in the
U.S.
• Men have a 1.5 times higher incidence and prevalence of PD compared to women, with
prevalence increasing with age.
• In summary, Parkinson's disease is a growing public health concern, with hundreds
of thousands of new diagnoses each year in the U.S. alone.
Statistics (n.d.). Parkinson’s Foundation. https://www.parkinson.org/understanding-parkinsons/statistics
Prevalence & Incidence (n.d) Parkinson’s Foundation. https://www.parkinson.org/understanding-parkinsons/statistics/prevalence-incidence
12
Quick Facts
 Parkinson's disease (PD) is the most common cause of parkinsonism (about 80%)
 Risk Factors: Age, Genetics, Gender & Environmental Factors
 PD remains incurable but treatable.
 The disease progresses in stages, with symptoms gradually worsening over time.
 The disease causes not only motor symptoms, but also cognitive, emotional and
other symptoms impacting quality of life
 PD is often accompanied by social stigma and discrimination.
 Shrimanker, I., Tadi, P., & Sánchez-Manso, J. C. (2022, June 7). Parkinsonism. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK542224/
 Rodriguez-Oroz, M. C., Jahanshahi, M., Krack, P., Litvan, I., Macias, R., Bezard, E., & Obeso, J. A. (2009). Initial clinical manifestations of Parkinson's disease: features and pathophysiological
mechanisms. The Lancet. Neurology, 8(12), 1128–1139. https://doi.org/10.1016/S1474-4422(09)70293-5 13
Parkinsonism Vs. Parkinson’s Disease
Parkinsonism
Primary
Parkinsonism
Parkinson’s
Disease
A Typical
Parkinsonism
(Parkinson+)
Secondary
Parkinsonism
Drug Induced
Parkinsonism
Vascular
Parkinsonism
& more..
References:
• Types of Parkinsonisms. (n.d.). Parkinson’s Foundation. https://www.parkinson.org/understanding-parkinsons/what-is-parkinsons/types-parkinsonisms
• What is Primary and Secondary Parkinsonism. WORLD PARKINSON’S PROGRAM. https://pdprogram.org/primary-and-secondary-parkinsonism/
14
Pathophysiology
 Pathogenesis of PD remains unclear. Degeneration of dopamine-producing neurons in the
basal ganglia is believed to result in PD
 Basal ganglia (‘autopilot’) - controls well-learnt voluntary and semi-automatic motor skills
and movements.
 Dopamine is a major neurochemical messenger that promotes the functions of basal
ganglia.
 Dopamine also contributes to other cognitive processes, such as attention, drive and
motivation, mood, problem-solving, decision-making, visual perception etc.
 Dopamine deficiency in PD disrupts basal ganglia function, leading to PDD symptoms
 Rouaud, T., Corbillé, A. G., Leclair-Visonneau, L., de Guilhem de Lataillade, A., Lionnet, A., Preterre, C., Damier, P., & Derkinderen, P. (2021). Pathophysiology of Parkinson's disease: Mitochondria, alpha-
synuclein and much more…. Revue neurologique, 177(3), 260–271. https://doi.org/10.1016/j.neurol.2020.07.016
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
15
Pathophysiology
 Rodriguez-Oroz, M. C., Jahanshahi, M., Krack, P., Litvan, I., Macias, R., Bezard, E., & Obeso, J. A. (2009). Initial clinical manifestations of Parkinson's disease: features and
pathophysiological mechanisms. The Lancet. Neurology, 8(12), 1128–1139. https://doi.org/10.1016/S1474-4422(09)70293-5 16
Stages of PD (Hoehn and Yahr Staging System)
 Stage 1: Early stage
 Mild motor symptoms, such as tremors unilaterally. Symptoms do not affect daily life
 Stages 2: Early to Mid stage
 More noticeable motor symptoms bilaterally. Daily activities become time consuming due to
difficulty in balance posture and walking. However, the person will be independent in daily
activities
 Stage 3: Mid-Stage
 Increased risk of falls due to balance problems, ADL can become challenging, However, the person
can still be independent in daily activities.
 Stages 4: Late stage
 Assistance required for ambulation. Dysphagia may be present. Full-time help may be required
 Stage 5: Late Stage
 Requires use of a wheelchair or is bedridden. Constant nursing care is necessary. Cognitive and
neuro psychiatric symptoms may also be present
 Modestino EJ, Reinhofer A, Blum K, et al. Hoehn and Yahr staging of Parkinson's disease in relation to neuropsychological measures. Front Biosci (Landmark Ed). 2018;23(7):1370-1379. doi:10.2741/4649
 Greco, P. (2023, April 26). What Are the Stages of Parkinson's Disease? Health. https://www.health.com/condition/parkinsons-disease/parkinsons-disease-stages
 Stages of Parkinson’s. (n.d.). Parkinson’s Foundation. https://www.parkinson.org/understanding-parkinsons/what-is-parkinsons/stages
17
Note:
‘Early, Mid & late
stage’
terminology is
not part of this
classification
 Hoehn and Yahr staging system based solely on observable motor symptoms.
 Pre-Motor Stage of Parkinson's Disease occurs before diagnosis od PD and motor
symptoms.
 May include:
 Loss of sense of smell
 REM sleep behavior disorder (acting out dreams)
 Constipation
 1) Reichmann H. Premotor diagnosis of Parkinson's disease. Neurosci Bull. 2017;33(5):526-534. doi:10.1007/s12264-017-0159-5
 Greco, P. (2023, April 26). What Are the Stages of Parkinson's Disease? Health. https://www.health.com/condition/parkinsons-disease/parkinsons-disease-stages 18
Hoehn and Yahr Staging System & Premotor Stage of PD
Medical Management of PD
Medications
 Levodopa
 first-line drug
 Often given in combination with the drug
carbidopa to reduce nausea
 ‘ON’ and ‘OFF’ times
 Dopamine Agonist
 Amantadine
 Adenosine A2A antagonist
 Anticholinergic Drugs
Surgery
• Deep Brain Stimulation
• mostly addresses the movement
symptoms – tremor, dyskinesia etc.
• benefits lasting at least five years.
• DUOPATM
• Intestinal gel of carbidopa-levodopa to
reduce “off” times
• Other Surgical options
• Thalamotomy
• Pallidotomy
• Sub thalamotomy
Treatment. (n.d.). Parkinson’s Foundation. https://www.parkinson.org/living-with-parkinsons/treatment 19
Section Summary
• Parkinson's disease (PD), the most common form of parkinsonism
affecting about 80% of cases, is a progressive and incurable but
treatable neurodegenerative disorder.
• Parkinson's disease (PD) goes beyond motor symptoms. It can also
affect cognition, emotions, and other areas of life, impacting quality of
life even before motor symptoms appear.
20
Impact of PD on Occupational Profile
21
Jansa, J., & Aragon, A. (2015). Living with Parkinson's and the Emerging Role of Occupational Therapy. Parkinson's disease, 2015, 196303. https://doi.org/10.1155/2015/196303
Need of a conceptual framework
• A conceptual model provides broader structure to understand a concept.
• It can help OTs to:
• Holistic view of occupational performance: This considers the person, task, and environment.
• Plan intervention: Addresses impairment, activity limitations, and participation restrictions.
• Challenge: Occupational therapy's jargon-heavy conceptual models, create
communication barriers for other disciplines unfamiliar with the specific terminology.
• Solution: An interdisciplinary conceptual model, that can Facilitate communication and
collaboration between the OT’s, client, caregivers and other healthcare professionals.
22
 Moradi, G., Gouya, M. M., Eshrati, B., Mohraz, M., & Piroozi, B. (2018). National action plan of the Islamic Republic of Iran for combating antimicrobial resistance during 2016 - 2021. Medical journal of the
Islamic Republic of Iran, 32, 65. https://doi.org/10.14196/mjiri.32.65
 Haglund, L. and Henriksson, C. (2003), Concepts in occupational therapy in relation to the ICF. Occup. Ther. Int., 10: 253-268. https://doi.org/10.1002/oti.189
 Hostettler, C., Hostettler, C., & Hostettler, C. (n.d.). ICF Case Studies - Introduction to the ICF. https://www.icf-casestudies.org/introduction/introduction-to-the-icf
ICF (International Classification of Functioning, Disability and Health)
ICF is a bio-psycho-social model of
functioning, disability and health by
WHO, outlines key component of health
& their relationship across different
context
23
 Parkinson's disease (PD) affects people
differently, so OT’s need to consider each
person's unique situation. ICF helps in this.
Assessment tools
OTs select standardized and non standardized assessments that are relevant to the person's
goals and abilities. Some examples are;
• Disease Severity:
• Hoehn and Yahr Scale:
• Impairment Level:
• Unified Parkinson's Disease Rating Scale
(UPDRS)
• Movement Disorder Society-Unified
Parkinson's Disease Rating Scale (MDS-
UPDRS)
• Activity Limitations and Participation
Restrictions:
• Functional Independence Measure (FIM)
• Patient-Centered Occupational
Performance Measure (COPM)
• Quality of Life:
• Parkinson's Disease Questionnaire (PDQ-
39)
• Short Form-36 Health Survey (SF-36)
24
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
Impact of PD on Activity & Participation
1. Increased Stiffness and Reduced Trunk
Flexibility:
• Impacts: Difficulty turning, moving in bed,
performing daily activities (ADLs),
transferring, driving, socializing, and living
independently.
2. Gait and Balance Problems:
• Symptoms: Start hesitation, shuffling gait,
slowness, festination, freezing episodes,
postural instability.
• Impacts: Difficulty initiating walking,
increased risk of tripping, reduced walking
speed, impaired coordination during
turns, increased risk of falls.
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
25
Impact of PD on Activity & Participation
3. Reduced Manual Dexterity, Poor
Coordination, and Tremor:
• Impacts: Difficulty with daily tasks like eating,
dressing, applying makeup, and writing.
4. Dysarthria:
• Symptoms: Poor breath support, loss of voice
clarity, decreased speech intelligibility, reduced
volume.
• Impacts: Difficulty communicating effectively.
5 Fatigue:
• Impact: Reduced endurance for daily activities.
6. Cognitive Changes:
• Impacts: Slowed thinking (Bradyphrenia),
difficulty with problem-solving and decision-
making, reduced concentration, apathy leading
to social isolation, low mood, difficulty managing
roles at home, work, and socially.
 Radder, D. L. M., Sturkenboom, I. H., van Nimwegen, M., Keus, S. H., Bloem, B. R., & de Vries, N. M. (2017). Physical therapy and occupational therapy in Parkinson’s disease. International Journal of
Neuroscience, 127(10), 930–943. https://doi.org/10.1080/00207454.2016.1275617
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
26
Impact of environmental & personal factors
Environmental Factors:
 Home safety: Poorly lit areas, loose rugs, and
cluttered spaces can increase fall risk.
 Accessibility: Difficulty navigating stairs, narrow
doorways, or a lack of grab bars can limit
mobility and independence.
 Social settings: Noisy environments can worsen
communication difficulties.
Personal Factors:
 Age: Symptoms often worsen with age.
 Severity of disease: The degree of dopamine loss
impacts the severity of symptoms and limitations.
 Cognitive status: Pre-existing cognitive decline can be
exacerbated by Parkinson's, further impacting daily
activities.
 Motivation and coping skills: A person's outlook and
ability to adapt to limitations can significantly affect
their quality of life.
 Radder, D. L. M., Sturkenboom, I. H., van Nimwegen, M., Keus, S. H., Bloem, B. R., & de Vries, N. M. (2017). Physical therapy and occupational therapy in Parkinson’s disease. International Journal of
Neuroscience, 127(10), 930–943. https://doi.org/10.1080/00207454.2016.1275617
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
27
Section Summary
• The ICF is a valuable conceptual model that OTs and other IDT professionals can
use to understand the impact of PD holistically and plan interventions
collaboratively.
• Suggested reading:
28
Radder, D. L. M., Sturkenboom, I. H., van Nimwegen, M., Keus, S. H., Bloem, B. R., & de Vries, N. M. (2017). Physical therapy and occupational therapy in Parkinson’s disease. International Journal
of Neuroscience, 127(10), 930–943. https://doi.org/10.1080/00207454.2016.1275617
OT Management for PD
29
The Role of Occupational Therapist…
‘The role of the occupational therapist is to support individuals with
Parkinson's disease and to enable them to maintain their usual level of
self‐care, work and leisure activities (Occupational Performance) for as
long as possible.’
Dixon, L., Duncan, D., Johnson, P., Kirkby, L., O'Connell, H., Taylor, H., & Deane, K. H. (2007). Occupational therapy for patients with Parkinson's disease. The Cochrane database of systematic
reviews, 2007(3), CD002813. https://doi.org/10.1002/14651858.CD002813.pub2
30
Principles of OT Interventions for PD
 Early and Proactive Approach
 Client-Centered and Evolving intervention
 Holistic Focus and employment of a wide range of interventions
 Collaborative Goal Setting with individual and carer, with regular
review.
 Interdisciplinary Collaboration
31
1. What, when, how?
2. Is there any
guideline?
Aims & dose of therapy across the stages of PD
(What & When)
Early-stage PD Mid-stage PD Late-stage PD
Consultative,
Proactive Therapy
Restorative Therapy Skilled Maintenance
1-4 sessions with 6-12
month re-evaluation
2-4 visits/week
~1 visits every 1-3
months, ongoing
Stage of PD
Aim of
Therapy
Dose of
Therapy
 Adopted from: Rafferty, M. R., Nettnin, E., Goldman, J. G., & MacDonald, J. (2021). Frameworks for Parkinson's Disease Rehabilitation Addressing When, What, and How. Current neurology and
neuroscience reports, 21(3), 12. https://doi.org/10.1007/s11910-021-01096-0
In addition to offering clinical guidance, this framework equips OTs with evidence-based reasoning for prescribing
optimal therapy frequencies for individuals with PD and explain this approach to stakeholders.
32
OT Interventions process (How?)
Jansa, J., & Aragon, A. (2015). Living with Parkinson's and the Emerging Role of Occupational Therapy. Parkinson's disease, 2015, 196303. https://doi.org/10.1155/2015/196303
(1) Enter/Initiate. (2) Set the stage.
(3)
Assess/evaluate.
(4) Agree
objective and
plans.
(5) Implement
plan.
(6)
Monitor/modify.
(7) Evaluate
outcome.
(8)
Conclude/exit.
33
Evidence based OT Interventions for PD
PD & OT: Past to Present
• Early 2000s: Limited research on specific OT
interventions for PD. Focus was on self-care and
daily activities.
• Today: More research supports OT's value in PD
rehab. Studies show positive results for
individual and group interventions.1, 2.
1. Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
2. Guidelines for Occupational Therapy in Parkinson’s Disease Rehabilitation by Dutch Association of Occupational Therapy 2011. Available at
https://www.parkinsonnet.nl/app/uploads/sites/3/2019/11/ot_guidelines_final-npf__3_.pdf
3. Jansa, J., & Aragon, A. (2015). Living with Parkinson's and the Emerging Role of Occupational Therapy. Parkinson's disease, 2015, 196303. https://doi.org/10.1155/2015/196303
34
Four Dimensions of OT Interventions
(Based on PD Guidelines)
1. Promoting Lifelong Well-being: Optimizes overall health, independence, and
quality of life for people with Parkinson's disease.
2. Empowering Movement: Develops strategies to improve initiation,
maintainability, and control of movement for daily activities.
3. Optimizing Activity Participation: Adapts tasks, environments, and routines to
maximize engagement in meaningful occupations.
4. Supporting End-of-Life Care: Provides comfort, dignity, and continued
participation in valued activities throughout the disease course.
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
35
1. Promoting Lifelong Well-being
Key Areas of Focus for Occupational Therapists (OTs) are;
• Self-Efficacy & Resilience
• Roles & Relationships
• Sexual Well-being & Intimacy
• Work
• Social, Recreational & Leisure Activities
• Community Living Skills & Outdoor Mobility
How?
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational
Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 36
2. Empowering Movement
Key Principles for OT Interventions:
• Conscious Attention: Well-learned movements require focused attention for successful execution.
• Limiting Multitasking: Focus on practicing specific multitask activities instead of constant
multitasking.
• Cognitive & Sensory Cues: Utilize cues (visual, verbal, physical) to trigger and guide movement flow.
• Promote Mental well-being: through relaxation techniques, group programs or referral to mental
health services to enhance participation
Strategies for Initiating and Maintaining Movement
• Cueing
• Intrinsic Cues: self initiated cues like counting, self talk, visualization etc.
• Extrinsic Cues: External prompts like visual cues or verbal instructions to initiate movement.
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
37
2. Empowering Movement
How does cueing works?
• Visual, auditory, or written cues draw attention to the desired movement goal,
encouraging patients to perform tasks less automatically and with more control
• Bypassing the underactive basal ganglia and activate alternative neural pathways, allowing
for better movement (i.e, ‘auto pilot system’  ‘Manual Control’) .
• Stimulating Neural Networks: Cues like visual guides or spoken instructions related to a
specific movement (e.g., “write bigger") can activate the brain networks responsible for
that action, leading to larger and more controlled movements (e.g., bigger handwriting)
Jansa, J., & Aragon, A. (2015). Living with Parkinson's and the Emerging Role of Occupational Therapy. Parkinson's disease, 2015, 196303. https://doi.org/10.1155/2015/196303
38
2. Empowering Movement Cont.
Promoting New Learning:
• Timing: Conduct learning sessions when the person with PD is most alert ("on" state).
• Family/Carer Involvement: Educate and involve family/carers for better carry-over into daily life.
• Minimizing Distractions: Optimize focus during assessment and interventions.
• Instructional Techniques:
• Verbal instructions with key words.
• Visual demonstrations.
• Guided mental rehearsal.
• Hands-on guidance.
• Backward chaining approach (breaking down complex tasks).
• Cue cards for reminders.
• Encourage Self-talk: Promote internalization of key movement steps while performing actions.
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
39
3. Optimizing Activity Participation
Aim: Improving participation in
meaningful occupations through:
• Adapting tasks and environments
• Modifying routines
• Utilizing assistive equipment
Key areas of focus:
 Mobility
 Falls Prevention
 Transfers
 Bed Mobility
 Posture and Seating
 Eating and Drinking
 Self-Care
 Domestic Skills
 Fatigue Management
 Handwriting and Communication
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
40
4. Supporting End-of-Life Care
• Focus on Comfort and Quality of Life:
• Manage symptoms to maximize comfort
and dignity.
• Facilitate enjoyable activities (music,
spending time outdoors).
• Address complications of immobility
(positioning, pressure care).
• 24-Hour Posture and Positioning:
• Regularly assess posture in bed, chair,
wheelchair, car.
• Use pressure-relieving cushions and
mattresses.
• Consider splinting to prevent
contractures.
• Minimizing Manual Handling Risks:
• Assess risks for transfers and daily
activities.
• Provide appropriate equipment (lifts,
hoists) and training.
• Consider caregiver support and
limitations.
• Alternative Living Arrangements:
• Respect wishes for end-of-life care
• Discussing alternative living
arrangements like assisted living facilities
if staying home becomes difficult
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
41
Special Considerations..
‘The evidence based on specific
rehabilitation interventions is still very
scarce but should be considerably
improved in the next years.’
42
Section Summary
• Evidence supports OT's role in PD rehab:
• Growing research demonstrate the effectiveness of both individual and group interventions
delivered by occupational therapists.
• Addressing multifaced problem is a challenge
• Current OT practice may not always fully address the multifaceted challenges of PD through an
occupational performance-based approach.
• ICF can act as a ‘Holistic lens’
• The ICF framework provides a comprehensive understanding of how PD impacts individuals.
And it can enhance interdisciplinary collaboration
• Need of ‘client centered & Stage-specific care’
• A therapy framework considering the different stages of Parkinson's disease can guide the
development and delivery of targeted OT interventions specific to each patient's condition.
43
What Next?
44
https://worldparkinsonsday.com/get-informed/
1. Ignite Innovation: Develop a comprehensive PD rehab program
addressing all aspects of occupational performance, tailored to your
local context.
2. Spark Collaboration: Formulate interdisciplinary clinics at your
workplace to offer holistic care for people with PD.
3. Fuel Connection: Foster support groups and peer counseling
interactions to empower social participation and well-being.
4. Share your ‘spark’: Share success stories through publications to inspire
others.
April 11
Share your
Spark &
Help people
with PD
around you
How?
45
Questions?
46
Suggested Readings
• Pathophysiology of PD
• Rodriguez-Oroz, M. C., Jahanshahi, M., Krack, P., Litvan, I., Macias, R., Bezard, E., & Obeso, J. A. (2009). Initial clinical
manifestations of Parkinson's disease: features and pathophysiological mechanisms. The Lancet. Neurology, 8(12), 1128–1139.
https://doi.org/10.1016/S1474-4422(09)70293-5
• ICF (International Classification of Functioning, Disability and Health (ICF) by the World Health Assembly in May 2001)
• Hostettler, C., Hostettler, C., & Hostettler, C. (n.d.). ICF Case Studies - Introduction to the ICF. https://www.icf-
casestudies.org/introduction/introduction-to-the-icf
• OT Evaluation & Interventions
• Sadural, A., MacDonald, J., Johnson, J., Gohil, K., & Rafferty, M. (2022). Occupational Therapy for People with Early Parkinson's
Disease: A Retrospective Program Evaluation. Parkinson's disease, 2022, 1931468. https://doi.org/10.1155/2022/1931468
• Evidence based OT Intervention for PD
• Rafferty, M. R., Nettnin, E., Goldman, J. G., & MacDonald, J. (2021). Frameworks for Parkinson's Disease Rehabilitation
Addressing When, What, and How. Current neurology and neuroscience reports, 21(3), 12. https://doi.org/10.1007/s11910-
021-01096-0
• OT’s Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists
2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
• Jansa, J., & Aragon, A. (2015). Living with Parkinson's and the Emerging Role of Occupational Therapy. Parkinson's disease,
2015, 196303. https://doi.org/10.1155/2015/196303
47
Acknowledgement
Dr. Arun Kumar Malayappan, PhD, OT
Principal
Saveetha College of Occupational Therapy, Chennai.
44th Webinar on 12-04-2024
48
Contact
Email: phinojot@gmail.com
LinkedIn: www.linkedin.com/in/phinoj-k-abraham-9954738
49
Thank You
50
levels of OT interventions for progressive
movement disorders
• PD's variable symptoms and progression challenge OTs.
• Jeen et al.'s framework offers 3 levels of OT interventions for progressive
movement disorders, such as:
1. Skill Enhancement: Improve performance through physical techniques (e.g., transfers).
2. Knowledge Acquisition: Enhance performance with information on modifying tasks,
equipment, and resources.(e.g.
3. Attitude Adjustment: Adapt performance by modifying expectations and promoting
psychological well-being (e.g., using a scooter).
 Jain S, Kings J, Playford ED. Occupational Therapy for People with Progressive Neurological Disorders: Unpacking the Black Box. British Journal of Occupational Therapy. 2005;68(3):125-130.
https://journals.sagepub.com/doi/10.1177/030802260506800305
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
51
levels of OT interventions for progressive
movement disorders
Jeen et al.'s framework 
 Jain S, Kings J, Playford ED. Occupational Therapy for People with Progressive Neurological Disorders: Unpacking the Black Box. British Journal of Occupational Therapy. 2005;68(3):125-130.
https://journals.sagepub.com/doi/10.1177/030802260506800305
 Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
52

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Occupational Therapy Management for Parkinson's Disease - Webinar 2024

  • 1. Occupational Therapy Management for Parkinson's Disease Phinoj K. Abraham, MOT, EPGDHA Occupational Therapist 1
  • 2. 2
  • 3. • Deane KHO, Ellis-Hill C, Dekker K, Davies P, Clarke CE. A Survey of Current Occupational Therapy Practice for Parkinson’s Disease in the United Kingdom. British Journal of Occupational Therapy. 2003;66(5):193-200. doi:10.1177/030802260306600503 • Deane KHO, Ellis-Hill C, Dekker K, Davies P, Clarke CE. A Delphi Survey of Best Practice Occupational Therapy for Parkinson’s Disease in the United Kingdom. British Journal of Occupational Therapy. 2003;66(6):247-254. doi:10.1177/030802260306600603 3
  • 4. The survey demonstrated that: 1. OTs emphasized self-care over Occupational Performance 2. OTs lacked knowledge in condition-specific interventions for PD and 3. OTs expressed a need for more training to address occupational performance aspects of Parkinson's care 4
  • 5. The Gap.. We as OT’s, sometimes miss out to fully address Occupational Performance, which is the core part of Occupational Therapy 5
  • 6. Objectives • Identify the impact of Parkinson's disease on a client's occupational performance and quality of life. • Analyze a framework for occupational therapy intervention in Parkinson's disease that addresses all aspects of Occupational Performance. • Explore evidence-based occupational therapy interventions for managing Parkinson's disease symptoms. 6
  • 7. Conflict of interest • None to declare 7
  • 9. Parkinson’s Disease • …is a progressive, neurodegenerative disorder that affects predominately the dopamine-producing (“dopaminergic”) neurons in substantia nigra (basal ganglia), characterized by the onset of tremor, muscle rigidity, slowness in movement (bradykinesia), and stooped posture (postural instability). What is Parkinson’s? (n.d.). Parkinson’s Foundation. https://www.parkinson.org/understanding-parkinsons/what-is-parkinsons 9
  • 10. Symptoms of PD  Motor Symptoms  Bradykinesia - Movement starts but is slow  Hypokinesia - Movement starts but is small  Akinesia - inability to initiate movement  Rigidity  Rest tremor  Postural instability  Non-motor Symptoms  Cognitive Dysfunctions  Emotional and neuropsychiatric problems  Autonomic failure - sweating  Incontinence  Sexual health issues  Fatigue  Pain  Sleep disturbance  Dementia  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 10
  • 11. Symptoms of PD  Motor Symptoms  Akinesia - inability to initiate movement  Bradykinesia - Movement starts but is slow  Hypokinesia - Movement starts but is small  Rigidity  Rest tremor  Postural instability  Non-motor Symptoms  Autonomic failure - sweating  Incontinence  Sexual health issues  Fatigue  Pain  Sleep disturbance  Cognitive Dysfunctions  Emotional and neuropsychiatric problems  Dementia  Cincotta, M. C. (2023, May 19). Newly Diagnosed With Parkinson’s Disease? Here’s What You Need to Know. Temple Health. https://www.templehealth.org/about/blog/understanding- stages-of-parkinsons-disease 11
  • 12. Prevalence and incidence of PD • Parkinson's disease affects over 10 million people worldwide, with nearly 1 million in the U.S. and expected to rise to 1.2 million by 2030. • Incidence of PD has increased by 50%, with around 90,000 new diagnoses annually in the U.S. • Men have a 1.5 times higher incidence and prevalence of PD compared to women, with prevalence increasing with age. • In summary, Parkinson's disease is a growing public health concern, with hundreds of thousands of new diagnoses each year in the U.S. alone. Statistics (n.d.). Parkinson’s Foundation. https://www.parkinson.org/understanding-parkinsons/statistics Prevalence & Incidence (n.d) Parkinson’s Foundation. https://www.parkinson.org/understanding-parkinsons/statistics/prevalence-incidence 12
  • 13. Quick Facts  Parkinson's disease (PD) is the most common cause of parkinsonism (about 80%)  Risk Factors: Age, Genetics, Gender & Environmental Factors  PD remains incurable but treatable.  The disease progresses in stages, with symptoms gradually worsening over time.  The disease causes not only motor symptoms, but also cognitive, emotional and other symptoms impacting quality of life  PD is often accompanied by social stigma and discrimination.  Shrimanker, I., Tadi, P., & Sánchez-Manso, J. C. (2022, June 7). Parkinsonism. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK542224/  Rodriguez-Oroz, M. C., Jahanshahi, M., Krack, P., Litvan, I., Macias, R., Bezard, E., & Obeso, J. A. (2009). Initial clinical manifestations of Parkinson's disease: features and pathophysiological mechanisms. The Lancet. Neurology, 8(12), 1128–1139. https://doi.org/10.1016/S1474-4422(09)70293-5 13
  • 14. Parkinsonism Vs. Parkinson’s Disease Parkinsonism Primary Parkinsonism Parkinson’s Disease A Typical Parkinsonism (Parkinson+) Secondary Parkinsonism Drug Induced Parkinsonism Vascular Parkinsonism & more.. References: • Types of Parkinsonisms. (n.d.). Parkinson’s Foundation. https://www.parkinson.org/understanding-parkinsons/what-is-parkinsons/types-parkinsonisms • What is Primary and Secondary Parkinsonism. WORLD PARKINSON’S PROGRAM. https://pdprogram.org/primary-and-secondary-parkinsonism/ 14
  • 15. Pathophysiology  Pathogenesis of PD remains unclear. Degeneration of dopamine-producing neurons in the basal ganglia is believed to result in PD  Basal ganglia (‘autopilot’) - controls well-learnt voluntary and semi-automatic motor skills and movements.  Dopamine is a major neurochemical messenger that promotes the functions of basal ganglia.  Dopamine also contributes to other cognitive processes, such as attention, drive and motivation, mood, problem-solving, decision-making, visual perception etc.  Dopamine deficiency in PD disrupts basal ganglia function, leading to PDD symptoms  Rouaud, T., Corbillé, A. G., Leclair-Visonneau, L., de Guilhem de Lataillade, A., Lionnet, A., Preterre, C., Damier, P., & Derkinderen, P. (2021). Pathophysiology of Parkinson's disease: Mitochondria, alpha- synuclein and much more…. Revue neurologique, 177(3), 260–271. https://doi.org/10.1016/j.neurol.2020.07.016  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 15
  • 16. Pathophysiology  Rodriguez-Oroz, M. C., Jahanshahi, M., Krack, P., Litvan, I., Macias, R., Bezard, E., & Obeso, J. A. (2009). Initial clinical manifestations of Parkinson's disease: features and pathophysiological mechanisms. The Lancet. Neurology, 8(12), 1128–1139. https://doi.org/10.1016/S1474-4422(09)70293-5 16
  • 17. Stages of PD (Hoehn and Yahr Staging System)  Stage 1: Early stage  Mild motor symptoms, such as tremors unilaterally. Symptoms do not affect daily life  Stages 2: Early to Mid stage  More noticeable motor symptoms bilaterally. Daily activities become time consuming due to difficulty in balance posture and walking. However, the person will be independent in daily activities  Stage 3: Mid-Stage  Increased risk of falls due to balance problems, ADL can become challenging, However, the person can still be independent in daily activities.  Stages 4: Late stage  Assistance required for ambulation. Dysphagia may be present. Full-time help may be required  Stage 5: Late Stage  Requires use of a wheelchair or is bedridden. Constant nursing care is necessary. Cognitive and neuro psychiatric symptoms may also be present  Modestino EJ, Reinhofer A, Blum K, et al. Hoehn and Yahr staging of Parkinson's disease in relation to neuropsychological measures. Front Biosci (Landmark Ed). 2018;23(7):1370-1379. doi:10.2741/4649  Greco, P. (2023, April 26). What Are the Stages of Parkinson's Disease? Health. https://www.health.com/condition/parkinsons-disease/parkinsons-disease-stages  Stages of Parkinson’s. (n.d.). Parkinson’s Foundation. https://www.parkinson.org/understanding-parkinsons/what-is-parkinsons/stages 17 Note: ‘Early, Mid & late stage’ terminology is not part of this classification
  • 18.  Hoehn and Yahr staging system based solely on observable motor symptoms.  Pre-Motor Stage of Parkinson's Disease occurs before diagnosis od PD and motor symptoms.  May include:  Loss of sense of smell  REM sleep behavior disorder (acting out dreams)  Constipation  1) Reichmann H. Premotor diagnosis of Parkinson's disease. Neurosci Bull. 2017;33(5):526-534. doi:10.1007/s12264-017-0159-5  Greco, P. (2023, April 26). What Are the Stages of Parkinson's Disease? Health. https://www.health.com/condition/parkinsons-disease/parkinsons-disease-stages 18 Hoehn and Yahr Staging System & Premotor Stage of PD
  • 19. Medical Management of PD Medications  Levodopa  first-line drug  Often given in combination with the drug carbidopa to reduce nausea  ‘ON’ and ‘OFF’ times  Dopamine Agonist  Amantadine  Adenosine A2A antagonist  Anticholinergic Drugs Surgery • Deep Brain Stimulation • mostly addresses the movement symptoms – tremor, dyskinesia etc. • benefits lasting at least five years. • DUOPATM • Intestinal gel of carbidopa-levodopa to reduce “off” times • Other Surgical options • Thalamotomy • Pallidotomy • Sub thalamotomy Treatment. (n.d.). Parkinson’s Foundation. https://www.parkinson.org/living-with-parkinsons/treatment 19
  • 20. Section Summary • Parkinson's disease (PD), the most common form of parkinsonism affecting about 80% of cases, is a progressive and incurable but treatable neurodegenerative disorder. • Parkinson's disease (PD) goes beyond motor symptoms. It can also affect cognition, emotions, and other areas of life, impacting quality of life even before motor symptoms appear. 20
  • 21. Impact of PD on Occupational Profile 21
  • 22. Jansa, J., & Aragon, A. (2015). Living with Parkinson's and the Emerging Role of Occupational Therapy. Parkinson's disease, 2015, 196303. https://doi.org/10.1155/2015/196303 Need of a conceptual framework • A conceptual model provides broader structure to understand a concept. • It can help OTs to: • Holistic view of occupational performance: This considers the person, task, and environment. • Plan intervention: Addresses impairment, activity limitations, and participation restrictions. • Challenge: Occupational therapy's jargon-heavy conceptual models, create communication barriers for other disciplines unfamiliar with the specific terminology. • Solution: An interdisciplinary conceptual model, that can Facilitate communication and collaboration between the OT’s, client, caregivers and other healthcare professionals. 22
  • 23.  Moradi, G., Gouya, M. M., Eshrati, B., Mohraz, M., & Piroozi, B. (2018). National action plan of the Islamic Republic of Iran for combating antimicrobial resistance during 2016 - 2021. Medical journal of the Islamic Republic of Iran, 32, 65. https://doi.org/10.14196/mjiri.32.65  Haglund, L. and Henriksson, C. (2003), Concepts in occupational therapy in relation to the ICF. Occup. Ther. Int., 10: 253-268. https://doi.org/10.1002/oti.189  Hostettler, C., Hostettler, C., & Hostettler, C. (n.d.). ICF Case Studies - Introduction to the ICF. https://www.icf-casestudies.org/introduction/introduction-to-the-icf ICF (International Classification of Functioning, Disability and Health) ICF is a bio-psycho-social model of functioning, disability and health by WHO, outlines key component of health & their relationship across different context 23  Parkinson's disease (PD) affects people differently, so OT’s need to consider each person's unique situation. ICF helps in this.
  • 24. Assessment tools OTs select standardized and non standardized assessments that are relevant to the person's goals and abilities. Some examples are; • Disease Severity: • Hoehn and Yahr Scale: • Impairment Level: • Unified Parkinson's Disease Rating Scale (UPDRS) • Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS- UPDRS) • Activity Limitations and Participation Restrictions: • Functional Independence Measure (FIM) • Patient-Centered Occupational Performance Measure (COPM) • Quality of Life: • Parkinson's Disease Questionnaire (PDQ- 39) • Short Form-36 Health Survey (SF-36) 24  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons
  • 25. Impact of PD on Activity & Participation 1. Increased Stiffness and Reduced Trunk Flexibility: • Impacts: Difficulty turning, moving in bed, performing daily activities (ADLs), transferring, driving, socializing, and living independently. 2. Gait and Balance Problems: • Symptoms: Start hesitation, shuffling gait, slowness, festination, freezing episodes, postural instability. • Impacts: Difficulty initiating walking, increased risk of tripping, reduced walking speed, impaired coordination during turns, increased risk of falls.  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 25
  • 26. Impact of PD on Activity & Participation 3. Reduced Manual Dexterity, Poor Coordination, and Tremor: • Impacts: Difficulty with daily tasks like eating, dressing, applying makeup, and writing. 4. Dysarthria: • Symptoms: Poor breath support, loss of voice clarity, decreased speech intelligibility, reduced volume. • Impacts: Difficulty communicating effectively. 5 Fatigue: • Impact: Reduced endurance for daily activities. 6. Cognitive Changes: • Impacts: Slowed thinking (Bradyphrenia), difficulty with problem-solving and decision- making, reduced concentration, apathy leading to social isolation, low mood, difficulty managing roles at home, work, and socially.  Radder, D. L. M., Sturkenboom, I. H., van Nimwegen, M., Keus, S. H., Bloem, B. R., & de Vries, N. M. (2017). Physical therapy and occupational therapy in Parkinson’s disease. International Journal of Neuroscience, 127(10), 930–943. https://doi.org/10.1080/00207454.2016.1275617  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 26
  • 27. Impact of environmental & personal factors Environmental Factors:  Home safety: Poorly lit areas, loose rugs, and cluttered spaces can increase fall risk.  Accessibility: Difficulty navigating stairs, narrow doorways, or a lack of grab bars can limit mobility and independence.  Social settings: Noisy environments can worsen communication difficulties. Personal Factors:  Age: Symptoms often worsen with age.  Severity of disease: The degree of dopamine loss impacts the severity of symptoms and limitations.  Cognitive status: Pre-existing cognitive decline can be exacerbated by Parkinson's, further impacting daily activities.  Motivation and coping skills: A person's outlook and ability to adapt to limitations can significantly affect their quality of life.  Radder, D. L. M., Sturkenboom, I. H., van Nimwegen, M., Keus, S. H., Bloem, B. R., & de Vries, N. M. (2017). Physical therapy and occupational therapy in Parkinson’s disease. International Journal of Neuroscience, 127(10), 930–943. https://doi.org/10.1080/00207454.2016.1275617  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 27
  • 28. Section Summary • The ICF is a valuable conceptual model that OTs and other IDT professionals can use to understand the impact of PD holistically and plan interventions collaboratively. • Suggested reading: 28 Radder, D. L. M., Sturkenboom, I. H., van Nimwegen, M., Keus, S. H., Bloem, B. R., & de Vries, N. M. (2017). Physical therapy and occupational therapy in Parkinson’s disease. International Journal of Neuroscience, 127(10), 930–943. https://doi.org/10.1080/00207454.2016.1275617
  • 30. The Role of Occupational Therapist… ‘The role of the occupational therapist is to support individuals with Parkinson's disease and to enable them to maintain their usual level of self‐care, work and leisure activities (Occupational Performance) for as long as possible.’ Dixon, L., Duncan, D., Johnson, P., Kirkby, L., O'Connell, H., Taylor, H., & Deane, K. H. (2007). Occupational therapy for patients with Parkinson's disease. The Cochrane database of systematic reviews, 2007(3), CD002813. https://doi.org/10.1002/14651858.CD002813.pub2 30
  • 31. Principles of OT Interventions for PD  Early and Proactive Approach  Client-Centered and Evolving intervention  Holistic Focus and employment of a wide range of interventions  Collaborative Goal Setting with individual and carer, with regular review.  Interdisciplinary Collaboration 31 1. What, when, how? 2. Is there any guideline?
  • 32. Aims & dose of therapy across the stages of PD (What & When) Early-stage PD Mid-stage PD Late-stage PD Consultative, Proactive Therapy Restorative Therapy Skilled Maintenance 1-4 sessions with 6-12 month re-evaluation 2-4 visits/week ~1 visits every 1-3 months, ongoing Stage of PD Aim of Therapy Dose of Therapy  Adopted from: Rafferty, M. R., Nettnin, E., Goldman, J. G., & MacDonald, J. (2021). Frameworks for Parkinson's Disease Rehabilitation Addressing When, What, and How. Current neurology and neuroscience reports, 21(3), 12. https://doi.org/10.1007/s11910-021-01096-0 In addition to offering clinical guidance, this framework equips OTs with evidence-based reasoning for prescribing optimal therapy frequencies for individuals with PD and explain this approach to stakeholders. 32
  • 33. OT Interventions process (How?) Jansa, J., & Aragon, A. (2015). Living with Parkinson's and the Emerging Role of Occupational Therapy. Parkinson's disease, 2015, 196303. https://doi.org/10.1155/2015/196303 (1) Enter/Initiate. (2) Set the stage. (3) Assess/evaluate. (4) Agree objective and plans. (5) Implement plan. (6) Monitor/modify. (7) Evaluate outcome. (8) Conclude/exit. 33
  • 34. Evidence based OT Interventions for PD PD & OT: Past to Present • Early 2000s: Limited research on specific OT interventions for PD. Focus was on self-care and daily activities. • Today: More research supports OT's value in PD rehab. Studies show positive results for individual and group interventions.1, 2. 1. Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 2. Guidelines for Occupational Therapy in Parkinson’s Disease Rehabilitation by Dutch Association of Occupational Therapy 2011. Available at https://www.parkinsonnet.nl/app/uploads/sites/3/2019/11/ot_guidelines_final-npf__3_.pdf 3. Jansa, J., & Aragon, A. (2015). Living with Parkinson's and the Emerging Role of Occupational Therapy. Parkinson's disease, 2015, 196303. https://doi.org/10.1155/2015/196303 34
  • 35. Four Dimensions of OT Interventions (Based on PD Guidelines) 1. Promoting Lifelong Well-being: Optimizes overall health, independence, and quality of life for people with Parkinson's disease. 2. Empowering Movement: Develops strategies to improve initiation, maintainability, and control of movement for daily activities. 3. Optimizing Activity Participation: Adapts tasks, environments, and routines to maximize engagement in meaningful occupations. 4. Supporting End-of-Life Care: Provides comfort, dignity, and continued participation in valued activities throughout the disease course.  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 35
  • 36. 1. Promoting Lifelong Well-being Key Areas of Focus for Occupational Therapists (OTs) are; • Self-Efficacy & Resilience • Roles & Relationships • Sexual Well-being & Intimacy • Work • Social, Recreational & Leisure Activities • Community Living Skills & Outdoor Mobility How?  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 36
  • 37. 2. Empowering Movement Key Principles for OT Interventions: • Conscious Attention: Well-learned movements require focused attention for successful execution. • Limiting Multitasking: Focus on practicing specific multitask activities instead of constant multitasking. • Cognitive & Sensory Cues: Utilize cues (visual, verbal, physical) to trigger and guide movement flow. • Promote Mental well-being: through relaxation techniques, group programs or referral to mental health services to enhance participation Strategies for Initiating and Maintaining Movement • Cueing • Intrinsic Cues: self initiated cues like counting, self talk, visualization etc. • Extrinsic Cues: External prompts like visual cues or verbal instructions to initiate movement.  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 37
  • 38. 2. Empowering Movement How does cueing works? • Visual, auditory, or written cues draw attention to the desired movement goal, encouraging patients to perform tasks less automatically and with more control • Bypassing the underactive basal ganglia and activate alternative neural pathways, allowing for better movement (i.e, ‘auto pilot system’  ‘Manual Control’) . • Stimulating Neural Networks: Cues like visual guides or spoken instructions related to a specific movement (e.g., “write bigger") can activate the brain networks responsible for that action, leading to larger and more controlled movements (e.g., bigger handwriting) Jansa, J., & Aragon, A. (2015). Living with Parkinson's and the Emerging Role of Occupational Therapy. Parkinson's disease, 2015, 196303. https://doi.org/10.1155/2015/196303 38
  • 39. 2. Empowering Movement Cont. Promoting New Learning: • Timing: Conduct learning sessions when the person with PD is most alert ("on" state). • Family/Carer Involvement: Educate and involve family/carers for better carry-over into daily life. • Minimizing Distractions: Optimize focus during assessment and interventions. • Instructional Techniques: • Verbal instructions with key words. • Visual demonstrations. • Guided mental rehearsal. • Hands-on guidance. • Backward chaining approach (breaking down complex tasks). • Cue cards for reminders. • Encourage Self-talk: Promote internalization of key movement steps while performing actions.  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 39
  • 40. 3. Optimizing Activity Participation Aim: Improving participation in meaningful occupations through: • Adapting tasks and environments • Modifying routines • Utilizing assistive equipment Key areas of focus:  Mobility  Falls Prevention  Transfers  Bed Mobility  Posture and Seating  Eating and Drinking  Self-Care  Domestic Skills  Fatigue Management  Handwriting and Communication  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 40
  • 41. 4. Supporting End-of-Life Care • Focus on Comfort and Quality of Life: • Manage symptoms to maximize comfort and dignity. • Facilitate enjoyable activities (music, spending time outdoors). • Address complications of immobility (positioning, pressure care). • 24-Hour Posture and Positioning: • Regularly assess posture in bed, chair, wheelchair, car. • Use pressure-relieving cushions and mattresses. • Consider splinting to prevent contractures. • Minimizing Manual Handling Risks: • Assess risks for transfers and daily activities. • Provide appropriate equipment (lifts, hoists) and training. • Consider caregiver support and limitations. • Alternative Living Arrangements: • Respect wishes for end-of-life care • Discussing alternative living arrangements like assisted living facilities if staying home becomes difficult  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 41
  • 42. Special Considerations.. ‘The evidence based on specific rehabilitation interventions is still very scarce but should be considerably improved in the next years.’ 42
  • 43. Section Summary • Evidence supports OT's role in PD rehab: • Growing research demonstrate the effectiveness of both individual and group interventions delivered by occupational therapists. • Addressing multifaced problem is a challenge • Current OT practice may not always fully address the multifaceted challenges of PD through an occupational performance-based approach. • ICF can act as a ‘Holistic lens’ • The ICF framework provides a comprehensive understanding of how PD impacts individuals. And it can enhance interdisciplinary collaboration • Need of ‘client centered & Stage-specific care’ • A therapy framework considering the different stages of Parkinson's disease can guide the development and delivery of targeted OT interventions specific to each patient's condition. 43
  • 45. https://worldparkinsonsday.com/get-informed/ 1. Ignite Innovation: Develop a comprehensive PD rehab program addressing all aspects of occupational performance, tailored to your local context. 2. Spark Collaboration: Formulate interdisciplinary clinics at your workplace to offer holistic care for people with PD. 3. Fuel Connection: Foster support groups and peer counseling interactions to empower social participation and well-being. 4. Share your ‘spark’: Share success stories through publications to inspire others. April 11 Share your Spark & Help people with PD around you How? 45
  • 47. Suggested Readings • Pathophysiology of PD • Rodriguez-Oroz, M. C., Jahanshahi, M., Krack, P., Litvan, I., Macias, R., Bezard, E., & Obeso, J. A. (2009). Initial clinical manifestations of Parkinson's disease: features and pathophysiological mechanisms. The Lancet. Neurology, 8(12), 1128–1139. https://doi.org/10.1016/S1474-4422(09)70293-5 • ICF (International Classification of Functioning, Disability and Health (ICF) by the World Health Assembly in May 2001) • Hostettler, C., Hostettler, C., & Hostettler, C. (n.d.). ICF Case Studies - Introduction to the ICF. https://www.icf- casestudies.org/introduction/introduction-to-the-icf • OT Evaluation & Interventions • Sadural, A., MacDonald, J., Johnson, J., Gohil, K., & Rafferty, M. (2022). Occupational Therapy for People with Early Parkinson's Disease: A Retrospective Program Evaluation. Parkinson's disease, 2022, 1931468. https://doi.org/10.1155/2022/1931468 • Evidence based OT Intervention for PD • Rafferty, M. R., Nettnin, E., Goldman, J. G., & MacDonald, J. (2021). Frameworks for Parkinson's Disease Rehabilitation Addressing When, What, and How. Current neurology and neuroscience reports, 21(3), 12. https://doi.org/10.1007/s11910- 021-01096-0 • OT’s Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons • Jansa, J., & Aragon, A. (2015). Living with Parkinson's and the Emerging Role of Occupational Therapy. Parkinson's disease, 2015, 196303. https://doi.org/10.1155/2015/196303 47
  • 48. Acknowledgement Dr. Arun Kumar Malayappan, PhD, OT Principal Saveetha College of Occupational Therapy, Chennai. 44th Webinar on 12-04-2024 48
  • 51. levels of OT interventions for progressive movement disorders • PD's variable symptoms and progression challenge OTs. • Jeen et al.'s framework offers 3 levels of OT interventions for progressive movement disorders, such as: 1. Skill Enhancement: Improve performance through physical techniques (e.g., transfers). 2. Knowledge Acquisition: Enhance performance with information on modifying tasks, equipment, and resources.(e.g. 3. Attitude Adjustment: Adapt performance by modifying expectations and promoting psychological well-being (e.g., using a scooter).  Jain S, Kings J, Playford ED. Occupational Therapy for People with Progressive Neurological Disorders: Unpacking the Black Box. British Journal of Occupational Therapy. 2005;68(3):125-130. https://journals.sagepub.com/doi/10.1177/030802260506800305  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 51
  • 52. levels of OT interventions for progressive movement disorders Jeen et al.'s framework   Jain S, Kings J, Playford ED. Occupational Therapy for People with Progressive Neurological Disorders: Unpacking the Black Box. British Journal of Occupational Therapy. 2005;68(3):125-130. https://journals.sagepub.com/doi/10.1177/030802260506800305  Occupational therapy for people with Parkinson’s: best practice guidelines by Royal College of Occupational Therapists 2018. available at https://www.rcot.co.uk/occupational-therapy-people-parkinsons 52

Editor's Notes

  1. The traditional definition, like the one above, only identifies the motor symptoms. However, in reality, PD comes with both motor and non motor symptoms and non-motor symptoms often appear before the motor symptoms in individuals with PD.
  2. The traditional definition, like the one above, only identifies the motor symptoms. However, in reality, PD comes with both motor and non motor symptoms and non-motor symptoms often appear before the motor symptoms in individuals with PD.
  3. Conceptual Framework: A conceptual framework provides a broader structure for understanding a concept. It outlines the key components, their relationships, and the overall principles involved. The ICF does this by offering a standardized language and a way to classify functioning, disability, and health across different contexts.
  4. Conceptual Framework: A conceptual framework provides a broader structure for understanding a concept. It outlines the key components, their relationships, and the overall principles involved. The ICF does this by offering a standardized language and a way to classify functioning, disability, and health across different contexts.