Therapy student develops Parkinson disease program

By Patricia Ann Speelman - pspeelman@sidneydailynews.com

March 25, 2017

Nory Monnier, left, of Sidney, boxes with occupational therapy doctoral student Erica Boerger, of Fort Loramie, at the Sidney-Shelby County YMCA, recently.

SIDNEY — Ninety-one-year-old Norris “Nory” Monnier, of Sidney, straps on boxing gloves and gets ready to meet his opponent.

He doesn’t have dreams of becoming the next Rocky Balboa, but his goals aren’t small. He hopes for stability, balance and a lessening of the effects of Parkinson’s disease.

His opponent knows that by boxing with her, Monnier has a chance of reaching those goals. His opponent is Erica Boerger, of Fort Loramie.

She’s a doctoral student in occupational therapy at Huntington University in Fort Wayne, Indiana. A requirement for her degree was a residency. So Boerger designed a Parkinson therapy program that she has been leading at the Sidney-Shelby County YMCA four days a week since January.

“It’s wildly successful,” said YMCA Operations Director David O’Leary.

Boerger met with YMCA officials for more than a year to get the project in place, but it was her university teachers who first interested Boerger in developing a workout program for Parkinson patients.

“Exercise is awesome for everyone. I saw benefits of exercise for Parkinson disease. It’s amazing how much exercise helps people with Parkinson disease,” she said.

Boerger became certified in Rock Steady, a boxing-based plan for patients, and has built her 15-week program around that. The 50-minute classes, which will meet through April 14, have been offered free of charge to Y members and nonmembers, twice a day, four days a week. Boerger assessed the participants on the first day they attended and then again eight weeks later. The final assessment will come when the project ends.

Participant Bob Schroerlucke, of Sidney, appreciates the camaraderie that has formed among class members.

“Everybody tries to encourage each other. We all know what we’re fighting,” he said. In addition to taking Boerger’s class, he sits on an advisory board convened by the YMCA to evaluate the project.

Monnier is one of two participants who meet with Boerger for private training.

“I’ve been exercising since I was a year old,” the nonagenarian said recently. A Russia native, Nory “walked everywhere,” according to his son, Dave, of Sidney. Nory used to work for Francis Manufacturing, overseeing the furnace area.

“Year round it was 120 degrees in there. Maybe that helped his stamina,” Dave said. When he wasn’t working, Nory was coaching for his beloved Russia schools. He was recognized about five years ago by the Ohio High School Athletic Association as Ohio’s Top Sports Fan. He’s also a big Notre Dame and Cincinnati Reds fan. A driven volunteer, he served as Russia’s assistant mayor and a fire department officer and oversaw the annual church picnic.

“I belonged to everything in Russia except St. Ann’s Sodality,” he joked.

“Everyone who knows him, knows he has a sense of humor,” David noted.

“I was 10th in my class. There were nine students in my class,” Nory said, with a laugh.

The older Monnier grew up on a farm with no electricity or running water. Horses pulled the farm machinery.

“You’d put a glass of water next to the bed and wake up the next morning and it was frozen,” he remembered. But he can’t remember a time when he didn’t exercise. When he was raising his own family, he would get home from work and do push-ups with his children on his back. Even now, he pops in a tape and completes an exercise routine every day.

Boerger’s is not the first Parkinson program he has done. He completed the Big and Loud program at the Versailles Health Care Center. It was run by Gina Boerger — no relation to Erica — who has been Erica’s mentor.

“She makes me work hard,” he said of Erica. Besides boxing, Nory likes using the stationary bikes.

Schroerlucke has found that the combination of strength and flexibility exercises with those for fine motor skills has worked well. He had completed a different Parkinson therapy at Wilson Health, but it lasted just a month.

“This you can do indefinitely,” he noted. “I know that all the people are appreciative of the Y and Wilson for putting (this program) on. There was nothing like this. It’s making a difference in the lives of the people who participated.”

The project has been under the watchful eye of Zach Monnin, director of therapy services at Wilson Health. Wilson and the YMCA will partner to keep a Parkinson program going at the Y after Boerger leaves. It will be somewhat different from Rock Steady.

“The YMCA will have two trainers who have been certified in Delay the Disease,” Monnin said. Wilson will provide a therapist. Participants will be able to choose a morning or afternoon class that will meet Tuesdays and Thursdays instead of four days a week. Patients’ partners and spouses will also be encouraged to join the sessions. Private training, such as Nory has had, will not be available.

“You don’t need to be referred (by a physician to participate), but you have to have a Parkinson’s diagnosis and medical clearance from a physician,” Monnin said. The 50-minute classes will begin April 18 and will comprise interval training, including cardio exercises, core exercises, flexibility and fine motor or brain work.

According to O’Leary, the program will be open to members and nonmembers, but it will not be free. Four-week sessions will cost $10 for members, $40 for nonmembers.

Until then, Nory, Schroerlucke and their classmates will continue with Boerger’s mix of strength training and agility work.

“I try to do something different each day,” she said. She incorporates punching bags, ladders, wall squats and jogging.

“When you have Parkinson’s disease, communication between the brain and muscles breaks down, so exercises are modeled to keep the connections active. You have to connect exercises with cognative thought at the same time,” Schroerlucke said.

“We’re working toward jumping jacks and jump rope,” Boerger added. Her assessments measure how far her students have come.

“How do we show progress? Standing up from a chair without using your hands. There was one lady who said she’d been through all the Parkinson programs (but she couldn’t get up from a chair). We did (in and out of the chair) over and over. She did 11. She said, ‘I could cry. I’m so happy.’ That’s rewarding. A lot of them say they’re more flexible,” Boerger said.

Nory, who was diagnosed with Parkinson disease in 2007, also has made progress. His son thinks the Rock Steady workouts have helped Nory to be able to use a walker. Nory also has enjoyed the social aspect of going to the Y for training. When asked if he planned to continue in Parkinson-based programs, he was quick to respond that he would — for awhile.

“I’ll try for 10 more years,” he said with a twinkle in his 91-year-old eyes.

http://sidneydailynews.com/news/70064/therapy-student-develops-parkinson-disease-program

Bradykinesia or slowness of movement

Bradykinesia or slowness of movement is one of the three main signs of Parkinson’s, along with tremor and rigidity (stiffness). Taken from Greek words meaning ‘slow’ and ‘movement’, the term was first used by Dr James Parkinson in 1817. Bradykinesia describes slowness in carrying out, rather than initiating, movements. Up to 98% of all people with Parkinson’s experience slowness of movement.

Bradykinesia is one of the early signs of illnesses or movement disorders such as Parkinson’s or Parkinsonism. It is caused by reduced levels of dopamine in the brain and is often noticed by family and friends before the subject becomes aware of it.

Reduced quality of movement is a sign of Parkinson’s rather than a symptom brought on by the illness. A doctor or neurologist who observes bradykinesia may well suspect that a person has Parkinson’s.

Bradykinesia can affect one limb, one side of your body, or your whole body, which can make you unnaturally still. The condition often varies from moment to moment. This can be frustrating, as good quality of movement can quickly be followed by poor quality.

As movements become slower and more difficult, you tend to move less. Your mobility decreases, which can make the condition worse. Reduced co-ordination and, surprisingly, increased muscle tone, may contribute to bradykinesia. You may start to take slower steps for example. Your muscles have not become weaker, they are just reacting more slowly.

You may hear the terms akinesia and hypokinesia used in relation to bradykinesia. Akinesia means a loss of movement, for example, lack of facial expression or rarer eye blinks. Hypokinesia refers to movements that are reduced in scale, such as the small handwriting (micrographia) or soft voice (hypophonia) associated with Parkinson’s. It is possible to experience all of these conditions.

Diagnosis and treatment

If you suspect you, or someone you know, is experiencing slowness of movement, it is important to see a doctor. Bradykinesia is a feature of a number of illnesses, so it needs to be accurately diagnosed.

Bradykinesia causes difficulties with rapidly repeated movements. To make an assessment, the doctor will ask you to perform rapid, repetitive hand movements, such as tapping your finger and thumb together, gripping and releasing, or moving your palms up and down. Or you may be asked to rapidly tap your foot up and down.

The doctor will investigate your family history and also your medical history, since certain medications can cause slowness of movement. In a few cases, the assessment may involve a test such as an MRI scan, to exclude the possibility of stroke or tumour.

Bradykinesia generally responds well to medication, especially in the early stages of the illness. As with all Parkinson’s medicines, treatment is very individual. What works for one person may not work for another, so your doctor may try several approaches to see what works best for you.

Who can help?

Your doctor will usually be your first point of contact and can help by adjusting your medication. He or she might also refer you to a doctor who specialises in movement disorders.

In some countries, there are Parkinson’s Disease Nurse Specialists or nurses who specialise in neurology who can help.

Once diagnosed, your doctor will probably refer you to a physiotherapist or occupational therapist who will look at your symptoms and recommend exercises and techniques to help with slowed movement.

                        Physiotherapists can give advice on how to improve the quality of movement during everyday activities, and suggest exercises to maintain or improve muscle tone.

                        Occupational therapists can also help with changes to your routine to help you stay mobile and independent.

                        Both occupational therapists and physiotherapists can advise on devices and aids to help with mobility.

The type of therapist you are referred to will depend on where you live, the resources available and your individual needs. Treatment may or may not be funded through your country’s national health system.

How can I help myself?

It is important to keep active despite slowed movement. These suggestions can help you to maintain your independence and mobility:

                          Continue your usual daily activities as long as you are able.

Avoid reducing your physical activities and maintain mobility as much as possible.

                     Do the daily exercises that have been recommended to keep your muscles strong and flexible.

                        Adjust your daily routine to make it easier to continue on your own. For example, do things that require more effort at the time of day you feel most mobile. Build in rest periods during the day.

                        Make life easier by using helpful devices such as Velcro instead of buttons, elastic waistbands, height-adjusting beds and raised seat cushions, which make it easier to get out of a chair.

                        Remove or firmly secure loose rugs that may trip you, and rearrange furniture to make it easier to move around at home.

                        Maintain a positive attitude – this can be very helpful in overcoming all sorts of difficulties.

http://www.epda.eu.com/about-parkinson-s/symptoms/motor-symptoms/bradykinesia/

Fatigue

Fatigue is more than a feeling of tiredness. It is typically described as extreme tiredness, exhaustion or a complete lack of energy which limits what you are able to do and affects quality of life. Pathological fatigue is that fatigue which interferes with day to day activities, such as work, social life.  It is not relieved by simple rest.  Fatigue and sleepiness are often confused but are separate symptoms. Sleepy people may fall asleep at inappropriate times whereas people with fatigue need to rest but they generally do not fall asleep during the day.

Fatigue can be a normal physical, mental or emotional reaction to working too hard or being under stress but it is also a symptom of many illnesses. It can sometimes be difficult to work out the cause. Whilst fatigue can range from a degree of slight tiredness to exhaustion, it is considered to be indicative of an underlying disease when it disrupts daily activities.

Fatigue and Parkinson's

Fatigue is one of the most common symptoms of Parkinson’s, with various studies confirming that the majority are affected. Each person’s experience will be different; some cope well with it whilst others find it quite disabling. Fatigue can occur at any time, fluctuating in severity from day to day and even hour to hour.

There is no correlation between fatigue and the severity of Parkinson’s, or how long a person has had the condition. People who are newly diagnosed are just as likely to experience fatigue as someone who has had Parkinson’s for a long time, and the severity may be the same in both cases. Fatigue may be accompanied by memory or cognitive difficulties, dementia or muscle weakness.

It is important to recognise fatigue and find strategies to manage it so as to minimise the impact on quality of life. If you experience fatigue you may feel less inclined to pursue your usual hobbies and activities. You may also feel you cannot continue working, particularly as stress is likely to worsen fatigue and it can then be difficult to concentrate for long periods of time. It is important though to continue social activities to avoid becoming withdrawn or losing stamina and fitness. So try to keep as active as possible. Friends and family can also help by encouraging you with this.

What causes fatigue in Parkinson's?

The precise mechanisms that cause fatigue are unclear but research suggests that any neurological disorder which involves the basal ganglia area of the brain is likely to be associated with significant fatigue. This includes Parkinson’s.

In some cases Parkinson’s medication may be a factor, for example dopaminergic medications may affect sleep and so add to fatigue. Dosage and timing of medication may also affect energy levels.

Fatigue may be linked to other Parkinson’s symptoms, for example depression. With depression there is usually also fatigue, as well as loss of motivation, a general lack of interest and difficulty in sleeping. It is important that these symptoms are recognised as they are very treatable, and overcoming them can reduce fatigue.

If you experience tremor, rigidity or dyskinesia your muscles will have to work harder in order to carry out simple movements or tasks which can mean muscles fatigue more quickly and easily. Slowness of movement (bradykinesia) may also increase fatigue by making activities and tasks more prolonged.

You may have sleep problems and poor quality sleep tends to lead to excessive day-time sleepiness and a tendency to ‘nap’. Although sleepiness is a separate symptom to fatigue, it clearly adds to the problem and fatigue is hard to overcome if you are sleepy.

How is fatigue treated?

Although fatigue is common in Parkinson’s, it has often been rather neglected by doctors. There are numerous causes of fatigue that are unrelated to Parkinson’s but these still need to be recognised for treatment to be successful.

You should first talk with your doctor or specialist to let them know how fatigue affects you and what changes you have noticed over recent months. They will then carry out any tests they feel are appropriate.

Medication: If your doctor suspects that your Parkinson’s treatment is a factor they may recommend a change in medication so that symptoms are better managed, which should give you more energy.

Sleep: It is important to understand the reasons for poor sleep and to treat symptoms that disturb your sleep pattern. For example tremor, stiffness or restless legs may interrupt your sleep, or you may need to use the toilet at night. Your doctor will be able to suggest ways to manage these symptoms and so improve your sleep and reduce fatigue.

Depression: If you experience depression your doctor may suggest a course of appropriate antidepressant medication or may recommend counselling, cognitive behavioural therapy or relaxation therapy. It is important to manage anxiety and stress too as these can worsen fatigue. Your doctor may suggest medication to help with this.

Apathy: Fatigue may imitate a condition known as apathy, which is increasingly recognised in Parkinson’s. Apathy can lead to a loss of interest in activities that have been previously enjoyed. Like depression, apathy needs to be diagnosed so it can be treated.

Lifestyle: Advice to improve fitness through regular daily exercise may be useful. Depending on where you live, you may be referred to an occupational therapist or physiotherapist specially trained in the management of fatigue who can suggest a personal programme of activity and relaxation. In some countries your doctor may refer you to specialist community teams who help people manage chronic fatigue syndrome and can advise on fatigue disorders.

Advice on sleep hygiene or weight reduction may also be considered if appropriate.

General physical activities, together with social activities and mental activities, play an important role in overcoming fatigue. So the more energetic you are, both mentally and physically, the less likely it is that fatigue will become intrusive.

How can I help myself?

The general rule is to keep as mentally and physically active as possible. The following suggestions may be helpful:

Daily activities:

                        Plan your most vigorous activities around when your medication is most effective. You may find keeping a symptom or medication diary helpful for timing when you are likely to be more mobile and energetic.

                        Learn how to pace yourself, taking regular short rests and periods in which to relax throughout the day.

                        If tasks are complicated or likely to take time, break them down into smaller stages so that you can rest between each stage, Share tasks if you live with someone and make use of labour saving devices such as a dishwasher or microwave.

                        Recognise your limitations, identify the priorities of the day and get to know your energy reserves.

                        Plan your major activities in advance and ensure that you have time for recovery afterwards. For instance, if you have a big social function such as a wedding, rest more in the days leading up to the event and also plan to have a few restful days afterwards.

Work:

                       If you work, talk with your employer to see if you can take regular short breaks, even if it’s only to make a drink or talk with colleagues

Diet and exercise:

                      If possible, ask a specialist occupational therapist or physiotherapist with experience in managing fatigue to help plan a regime that suits you.

                        Build up stamina slowly. You are more likely to stick to a regime that is sensible and steady

                        Mental exercise is also important so keep hobbies and interests going so that your brain also keeps fit.

                       Eat a healthy diet. Some people find small but frequent snacks improve energy levels. A balanced diet also helps if constipation is a problem. Constipation can make you feel lethargic so it’s important to treat bowel problems. If you are worried or need advice about your diet, ask your doctor if he can refer you to a nutritional therapist or dietician.

Sleep and rest:

                        Keep to strict sleep hygiene principles, that is a regular bedtime, regular hours of sleep and avoid day-time napping. If you must nap, try to keep it under an hour.

                        Caffeine and tobacco are stimulants and should be avoided in the evenings as they can interfere with sleep. You should avoid excessive alcohol but social amounts of alcohol can act as a relaxant.

                        

You may find you feel fatigued after a large lunch. A short nap may help with this, or you could try having a smaller, lighter meal at lunchtime.

General wellbeing:

                        Incorporate time for relaxation into your daily routine and try to manage stress and anxiety as these can affect fatigue. Formal relaxation training can help, as may activities such as yoga, aromatherapy, light massage, long baths, light reading, relaxation tapes etc.

                        Maintain as many of your interests as possible – this helps with morale and wellbeing, which can help with alleviating fatigue.

Remember that fatigue won’t disappear overnight but with time and a considered approach you should be able to recognise your limitations and manage it more effectively. Achieving a good balance between rest and activity will help you handle fatigue in general and so improve your quality of life.

Acknowledgement

Our thanks to Parkinson’s UK for permission to use the following source:

                        Fatigue and Parkinson’s.

http://www.epda.eu.com/about-parkinson-s/symptoms/non-motor-symptoms/fatigue/

LOSS OF L-DOPA EFFECT IN ADVANCED PARKINSON'S DISEASE

March 19, 2017

Late-stage Parkinson's Disease is dominated by the loss of autonomy due to motor and non-motor symptoms which can be marginally corrected by medication adjustments. However, controversy exists on the mechanisms underlying the decrease in benefit from L-dopa. So researchers assessed the response to L-dopa in late-stage Parkinson's Disease.

People with late stage Parkinson's Disease and people who had undergone Deep Brain Stimulation underwent an acute L-dopa challenge test. Those people with late stage Parkinson's Disease improved by only 11%, whereas those people who had undergone Deep Brain Stimulation improved by 37%. Rest tremor showed the largest improvement. However, the magnitude of the response to L-dopa was significantly correlated with the severity of dyskinesias in people with late stage Parkinson's Disease. As the Parkinson's Disease symptoms improved, even though the improvement was mild, the dyskinesia worsened. A decrease in L-dopa response is therefore an indicator of the progression of Parkinson's Disease.

Reference : Parkinsonism and Related Disorders [2016] 26 : 10-16 (M.Fabbri, M.Coelho, D.Abreu, L.C.Guedes, M.M.Rosa, N.Costa, A.Antonini, J.J.Ferreira)

Complete abstract : http://www.ncbi.nlm.nih.gov/pubmed/26972527 

http://www.viartis.net/parkinsons.disease/news/170321.pdf