Multidisciplinary Team
Working in PD
Nin Bajaj
Consultant Neurologist,
Nottingham
Fiona Lindop,
Specialist Physiotherapist, Derby
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
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PD physiotherapy
OT
SALT
Community PD nurses
Neurorehab specialist
The fantasy football team
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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
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Endorsement of the service
Hospital Doctor Award
Guardian Public Sector Awards
HS awards
Research Profiles
Hospital Doctor Award
Research Profiles
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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 HomeInternational
• 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
Date
Bed mobility
Gait mobility
Time of Ax
Walking aid
Time of last medication
Sit to stand:Unaided with ease
Unaided with effort
Help of one
Help of 2+
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
Timed
unsupported
stand:
60+ sec
49-59 sec
30-44 sec
0-29 sec
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
Timed up & go: 10-20 sec
21-35 sec
36-60 sec
60+ sec
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
180 turn to right: 4-6 steps
7-8 steps
9-10 steps
11+ steps
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
180 turn to left:
4-6 steps
7-8 steps
9-10 steps
11+ steps
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
Walking through doorway:
No freeze/festination
Some festination
Freezes once
Freezes 2+ times
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
TOTAL
Sit to lie (56 cm bed):
Unaided with ease (≤ 5 sec)
Unaided with effort (6+ sec)
Help of 1
Help of 2/unable
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
Turn to left on bed:
Unaided with ease (≤ 5 sec)
Unaided with effort (6+ sec)
Help on 1
Help of 2/unable
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
Turn to right on bed:
Unaided with ease (≤ 5 sec)
Unaided with effort (6+ sec)
Help of 1
Help of 2/unable
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
Lie to sit on bed:
Unaided with ease (≤ 5 sec)
Unaided with effort (6+ sec)
Help of 1
Help of 2/unable
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
3
2
1
0
TOTAL
Signature
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
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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 welllearned 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
Cues
Internal
• Attention/concentration
• Mental rehearsal
• Visualisation
• Cognitive
• Weight transference
External
• Facilitation of attention
• Visual
• Auditory
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:
Intervention for turning:
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• Avoid dramatic
change of direction
• Avoid dual tasking
• Cues
• Physiotherapy to
improve balance and
rigidity
Independent mobility
Ground clearance
Good stability
Continuity of
movement
• Good posture
Intervention for falls
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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!