OCCUPATIONAL THERAPY

How occupational therapy helps in Parkinsons disease

Jelka Jansa discusses how occupational therapy can help patients with PD improve their daily quality of life
throughout the day, as well as over the course of the disease, and is manifested in a highly individualised manner (Gaudet, 2002). The occupational therapist working with PD patients needs to focus on facilitating the execution of meaningful everyday occupations and addressing issues that interfere with this. These issues can include the stage of the disease, environmental restrictions both physical and social drug regimes, motivation issues, fatigue, depression, freezing, and other motor and cognitive impairments. The diversity of issues associated with PD and its management affects individuals usual or expected physical, social and mental well-being. By using a top-down, client-centred approach, we focus on those occupational issues that are important to our PD patients. Furthermore, Fisher (2003) argues that this top-down approach begins with the evaluation of the PD patients ability to perform daily life tasks that she or he wants and needs to perform in order to be able to fulfil his or her role completely and with satisfaction. Ljubljana Neurology Clinic I would like here to present my own views and describe the practices we carry out in the Centre for Extrapyramidal Disorders at the Ljubljana Neurology Clinic. We follow the Occupational Performance Process Model (OPPM,) described at www.epda.eu.com/eotn/eotn_projects.shtm. We use the Canadian Occupational Performance Measure (COPM) to identify clients perceptions of their performance in daily practice over time. While we are conducting a COPM interview, we ask the patient to identify the activities that are difficult to perform in the domains of self-care, productivity and leisure (Niestadt, 2000). The therapist listens to the patients story within the context of his or her personal environment, and is then able to individualise the necessary intervention, resulting in something meaningful for the patient. It is important to consider the characteristics of environment in which a person with PD participates, as it is well known that even the perception of an environment being supportive can influence well-being. Furthermore, through the use of COPM, the patient is helped to identify those daily tasks

he World Federation of Occupational Therapists 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, potential and empowerment of life through performing normal and meaningful occupations. There is currently a trend towards using a top-down and client-centred approach. This approach helps immediately to identify functional problems in the areas of work or daily living tasks of concern to the patients and thus enables the therapist to focus quickly on those impairments that appear problematic for that particular patient. Improving daily life with OT Parkinsons disease (PD) affects many aspects of both motor and non-motor performance; it is influenced by environmental conditions, often fluctuates

14

EPNN JOURNAL SPRING 2006

OCCUPATIONAL THERAPY

that he/she wants to do, needs to do, is expected to do but finds he/she cannot do, or cannot do to a sufficiently satisfactory level (Fearing, 2000). Such an approach may provide a stronger sense of control when living with PD. When is the right time to start? The evidence suggests that OT intervention is most often required in the intermediate (maintenance and complex) and later stages (palliative) of the disease with Hoehn and Yahr stage 3-5 (Trombly, 2002). Although there is as yet insufficient evidence to fully support the value of OT for treatment in PD, this does not mean that it is not beneficial (Deane, 2003). The Parkinsons Disease Society UK is to start a pilot randomised controlled trial in Birmingham of OT in PD patients with a Hoehn and Yahr score of 3-5. This trial will examine the effects of OT intervention in terms of mobility, activities of daily living, mood and health-related quality of life. Occupational therapists working with PD who met during the EPDA conference in Lisbon all agreed that early referral would be more reasonable, as it may result in better adaptation to the disease progression. Due to the progressive nature of the disease we are likely to maintain contact with PD patients and their carers over many years. This intervention can be given at the patients home, in the hospital, neurological ward, Parkinson clinic, or rehabilitation institution on an in or outpatient basis. Early OT intervention Early OT aims towards establishing rapport, preventing changes in roles and participation in environment. It may help to prevent some functional problems before they arise. Also, we may use OT targeted towards the restoration of underlying impairment, be it motor or nonmotor: this is most relevant for the early stages (diagnosis and maintenance) of PD. OT at advanced stage PD As the disease progresses, some changes are required in overall lifestyle. It is important to organise daily routine in such a way as to encourage independence, safety and confidence in as many areas of daily life for as long as possible. In the intermediate (maintenance and complex) and later (palliative) stage, it is important to consider wearing-off problems, on-off fluctuations, dyskinesias, falls and freezing. Relatives become important members of the rehabilitation team. This is the time when adaptive and compensatory approaches become relevant. These will include introducing equipment aids and environmental adaptations, such as provision of hoists, adapting bathroom facilities, installation of a stair-lift, adapting the kitchen, supply of handwriting devices, adaptation of clothing and so on. Patient and therapist may focus on methods that will help patients to perform meaningful

occupations independently and with satisfaction according to the patients residual abilities, and also by using attentional strategies, visual and auditory cues and multitask training. Patients with PD have difficulty performing their activities of daily living because of the brains deficit in maintaining the size and correct timing of movements. There are also problems in the formulation and maintenance of cognitive sequences, leading to impaired ability with executive, frontal-type functioning. The patient can be taught movement and cognitive strategies that utilise conscious attention and avoid multitasking. For example, dressing is made easier by planning the activity sequence in advance, gathering and organising the garments and sitting down to dress. A study of micrographia (small handwriting) by Oliveira et al (1997), showed that both external visual and auditory cues draw attention to the goal (of writing bigger). This encourages the patient to write less automatically, with the beneficial effect of increasing amplitude (and thus legibility) of handwriting. Conclusions Occupational therapists should effectively provide ongoing support and treatment for the patient with PD in order to help to sustain and/or regain physical, mental and social well-being. This is more effective when having an opportunity to work within a multidisciplinary movement disorder team. Jelka Jansa, OT, MSc, University Medical Centre 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 Therapy 2003; 5: 193. Fearing VG, Clark J. Individuals in Context. A practical guide to Client-Centred Practice. Thorofare: SLACK, 2000. Fisher A. Assessment of Motor and Process Skills. Volume 1, 5th ed. Colorado: Three Star Press, 2003: 1-15. Gaudet P. Measuring the impact of Parkinson's disease: an occupational therapy perspective. Can J Occ Ther 2002; 4: 104-113. Mattingly C. Fleming C. Clinical Reasoning Forms of Inquiry in Therapeutic Practice. Philadelphia, FA DAVIS, 1994. Neistadt ME. Occupational Therapy Evaluation for Adults. Baltimore: Lippincott Williams & Wilkins, 2000: 1-123. 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. Parkinsons News. Clinical Trials update. A Quarterly Bulletin for Health and Social care Professionals: Issue 22, 2005. Trombly CA, Radomski Vining M. Occupational Therapy for Physical Dysfunction. Baltimore: Lippincott Williams & Wilkins 2002: 885908.

2 3 4 5 6 7

8 9

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

EPNN JOURNAL SPRING 2006

15