This is a multi-part message in MIME format. ------=_NextPart_000_00A1_01BD19E2.A876C060 Content-Type: text/plain; charset="iso-8859-1" Content-Transfer-Encoding: 7bit Hi Barb, >Would it be possible for someone to repost the Best Practices piece about >which some folks on the list are talking about? Apparently, it was in the >Graham's keynote speech which I did not see. My computer was down during the >holidays. Here is the speech. Jim ------=_NextPart_000_00A1_01BD19E2.A876C060 Content-Type: text/plain; name="keynote.txt" Content-Transfer-Encoding: 7bit Content-Disposition: attachment; filename="keynote.txt" From: Bob & Joy Graham <[log in to unmask]> To: Multiple recipients of list PARKINSN <[log in to unmask]> Subject: Keynote address as requested Date: Thursday, 1 January, 1998 1:51 pm BEST PRACTICE IN PARKINSON'S DISEASE Dr Robert Iansek, Keynote Addresss Fourth Australian Multi-Disciplinary Conference on Parkinson's Disease, Perth Western Australia September 12 - 14th 1997 This presentation will cover the approach that has been developed at Kingston Centre in Melbourne, Australia, for the management of Parkinson's disease. It will incorporate a description of the multidisciplinary team approach that is utilised as well as the specific knowledge base that all team members require to function together in a cohesive force. The presentation will be presented under the umbrella of Best Practice for Parkinson's disease. This issue was raised by Mary Baker, President of the European Parkinson's Disease Association, at the recent XII International Symposium on Parkinson's disease in London. Mary Baker challenged the Neurologists at the meeting to improve their practice up and above their current level. Although I believe it is important that Neurologists do improve their practice, I think it is also important for all members of the HealthCare team, including the patient and carer, to look at ways at contributing to improving practice to the best possible level. Today I wish to describe the way that we at Kingston Centre have strived to improve the delivery and quality of service that is available to people with Parkinson's disease to the level of Best Practice. At the outset it is important to mention that Parkinson's disease is a multi-dimensional disease. People with PD develop problems with mobility, as you are all aware, because of malfunction of the basal ganglia. The basal ganglia is that part of the brain that malfunctions in Parkinson's disease. However, there is also malfunction of the non-motor component of the basal ganglia resulting in lesser known problems affecting cognition, behaviour and mood. As you are all aware, Parkinson's disease has no cure because the cause is unknown. Therefore we cannot alter its time course. It is also a progressive disease that slowly gets worse over time and over a period of many years. Nerve cell loss continues year after year. The treatment that is available is directed predominantly to the motor disturbance and the non-motor disturbance does not respond to medication. Even in the motor domain after a period of 3-5 years, problems develop in control of movement and considerable disability occurs with motor fluctuations of a variety of types. It is also important to remember that the pathology that occurs in Parkinson's disease is not restricted to the basal ganglia but extends widely to other parts of the brain. The resultant effect over time is the development of other symptoms such as difficulty in blood pressure control, bladder control, bowel control and also with memory. All these factors over time add up and create a large disease debt in an individual and it is this disease debt which creates other problems in areas of domestic relationships, social interaction and financial difficulties. Globally, therefore, all these problems cannot be managed by one single individual. It is impractical for people with Parkinson's disease to be managed by a single Neurologist once every 3 months over a period of 15 minutes. At Kingston Centre we have approached the management of PD from a different perspective. We have combined the Geriatric philosophy and the Geriatric infrastructure with a specialist knowledge base. The Geriatric philosophy treats the patient not the disease. The holistic approach addresses all problems that are present in an individual and their family. In order for Geriatrics to perform this function it requires an infrastructure of multiple experts working together. Multidisciplinary teams consist of numerous experts who work together to help an individual better manage with their complaints. We have added to this approach a specialist knowledge base that deals with the neurological basis of Parkinson's disease, its management, its prognosis and its pathophysiology. Information about drugs, their effects and side-effects are of upmost importance. Furthermore, through our own research we have developed a rehabilitation approach that improves function in people with Parkinson's disease. The knowledge base required to make the rehabilitation approach work has also been added to the specialist knowledge base of the multidisciplinary team. It is this combination that makes the teamwork at its best. The knowledge base provides the team with a cohesive force that joins them together. Each member understands what the other members are doing and can speak to the patient in a common language. The knowledge base associated with the rehabilitation approach enables all team members to utilise the same guidelines to manage people irrespective of their problems. This is of relevance as difficulties in mobility can affect speech, swallowing, balance, walking, turning, manipulative tasks as well as activities of daily living such as washing, showering, toileting, dressing, cooking and shopping. The rehabilitation approach utilises the knowledge of basal ganglia function and how malfunction occurs in Parkinson's disease to provide guidelines for the development of strategies. These strategies are designed by each allied health professional within the team for each patient according to their requirements. However, the guidelines are always the same whether the strategies are generated by the speech therapist, by the physiotherapist, by the occupational therapist, by the neuropsychologist or by the social worker. Each team member knows what strategies other team members have developed and have utilised. They can therefore use these strategies if necessary to help people in need. Our Community Service has taken this interdisciplinary approach one step further and has become intradisciplinary. In this context one allied health professional can undertake the tasks of numerous other allied health professionals in the home situation. I now wish to explain to you briefly the role of each allied health professional within the HealthCare team. The Physiotherapists develop strategies to help people manage with gait, balance, postural change and bed mobility. The strategies that have been developed enable patients to function in a near normal capacity when they are utilising the strategies specific for their problem. The Occupational Therapists translate the use of these strategies to activities of daily living. They concentrate on enabling people to walk better, turn better and function in their home environment in tasks such as dressing, toileting, preparing meals and travelling from one part of the house to another. They also concentrate on trying to enable people to function safely in the community such as in shopping centres. The Occupational Therapists and the Registered Nurses spend considerable time in ensuring that drug compliance occurs. This is very important because patients with Parkinson's disease are on numerous medications taken frequently through the day and the night and, because of their cognitive difficulties, may forget medication or mix up the dosages. This requires considerable education and the use of a number of aids, which facilitate memory and accurate compliance. Speech therapists concentrate on development of appropriate voice volume, voice fluency and voice articulation. Strategies are used which can improve dramatically the responses that people make in regard to their speech. Swallowing is a major issue in Parkinson's disease and this does not usually respond well to medication. It is important, however, for the benefits of medication to be obtained that the tablets are actually swallowed and not left in the mouth. Strategies are used on a consistent basis by the speech therapist to enable people to swallow even when extreme difficulty exists. Successful use of these strategies enables patients to swallow, not only their medication, but also their normal meals in a safer way. Nurses play a very important role in our multidisciplinary team particularly in the areas of drug optimisation. Monitoring of mobility is of upmost importance in designing the drug regime necessary for people with Parkinson's disease. On our Movement Disorder Ward the nurses monitor patients every hour for normal mobility, impaired mobility or extra movements. This enables us to titrate the medication very accurately and precisely. In addition, monitoring occurs of blood pressure lying and standing, bladder function, bowel function and side effects to medication. Nurses educate patients and carers on drugs, the disease and side effects. In addition, nurses provide an environment in which people feel safe and secure and trusting knowing that the people who are looking after them understand them and their disease and will help them when help is required and not help when help is not required. The Social Worker provides tremendous help in the area of marital, domestic and social counselling. There are tremendous difficulties that patients' experience as a result of the disease which disrupts all these relationships and they require guidance so that they are better able to cope and manage with their problems and not disrupt their familial and social relationships. The Neuropsychologist is important in documenting cognitive disturbance and separating this from the problem of dementia, which sometimes occurs in Parkinson's disease. Knowledge of these problems is of utmost importance for all the therapists to be able to apply their strategies to an individual and their carer. The neuropsychologist provides psychological counselling as well as psychological support. I now wish to mention briefly, the rehabilitative approach that we have developed at Kingston Centre. To do so I need to become somewhat technical. The parts of the brain that are involved in Parkinson's disease are called the basal ganglia. Malfunction of the basal ganglia results in the movement disturbance and the associated cognitive disturbance that is documented in Parkinson's disease. In order for us to understand the use of rehabilitation I have to explain to you how the basal ganglia works normally and how it malfunctions in Parkinson's disease. In order to do so I will compare the relationship between the basal ganglia and the cerebral cortex with the relationship that politicians have with the public service. We can consider the politicians as the cerebral cortex. The basal ganglia could then be considered to be the public service. Like any good public service they are divided into a number of departments. These departments in the basal ganglia are given strange Latin names such the substantia nigra, the globus pallidus, the subthalamic nucleus and the striatum. The public service can only function normally if the departments are working and relating to each other in a normal manner. If one department malfunctions the rest of the departments fall down and the public service does not perform its function. This is a situation with the control of movement. The basal ganglia, or the public service, is responsible for performing movements or activities that have been dictated by the cerebral cortex or by the politicians. Once given the instructions on what should be performed, the public service undertakes those tasks automatically without the politicians being aware of the process involved. Sometimes the politicians can take control and perform that particular task themselves but usually they are too lazy and rely on the public service to perform all these tasks. This liberates them to perform other more interesting tasks like attending cocktail parties and going on overseas trips. This is the same relationship that occurs between the basal ganglia and the cerebral cortex. In order for a movement to take place, the politicians need to go to a vast library of movement types and they select out the movement they require by opening the page for the recipe they need. They then hand the book open at the page and give it to the basal ganglia and they kick-start this movement off and they then leave the basal ganglia, or the public service, to complete the movement. The basal ganglia therefore, or the public service's role in movement control is to keep the page open at the appropriate recipe for movement and to read the movement in the correct sequence with the correct timing between one movement and the next so that it is completed rapidly and appropriately. In Parkinson's disease, the basal ganglia, or the public service, cannot keep the page open. The page for the particular recipe continually tends to fall shut and therefore they cannot read the instructions on how to perform the movement and cannot cue the movement one onto the other. If the page is completely shut then the movement cannot start and people experience what is called akinesia, or difficulty in starting movement. If the page is open but the basal ganglia, or the public service, cannot actually see the instructions or the recipe properly then the whole movement is made smaller or miniaturised. Furthermore, the difficulty in reading each component of the recipe results in a slower and slower movement being performed down the sequence. This is what we call the sequence effect in movement. It should be emphasised that the basal ganglia, or the public service, in the context of movement control are concerned purely with running automatic movement skills. The motor cortical regions, or the politicians, can perform movement if they so wish but it takes all their attention and capacity to do so. Therefore they rarely do it themselves and prefer the basal ganglia, or the public service, to undertake the movement. I will subsequently illustrate to you these functions and malfunctions in Parkinson's disease by the example of writing in Parkinson's disease. This information has been used at Kingston Centre to generate guidelines for strategies so that allied health staff can design these strategies according to this information by following the guidelines. The guidelines are as follows. Firstly, movement control is normal in Parkinson's disease it requires activation. It is up to the therapists to devise ways to trick the brain into movement. It is important that movement is broken up into smaller components. This is done so that the motor cortex can initiate the movement and perform a nearly normal movement for the first few repetitions before the problem of the basal ganglia comes into play and the movement tends to stop. We use attention to try and complete movements because this causes the motor cortex to perform the work rather than the basal ganglia. In this case the politicians are controlling movement not the basal ganglia. We use cues to start and to maintain movement. The cues help the basal ganglia, or the public service, read the page or read the recipe and therefore the movement is performed relatively normally. Finally, we ensure that the basal ganglia is not used when doing two movements and therefore we avoid simultaneous tasks. We only use attention or the politicians, or the motor cortex, to perform the movement because we can guarantee that the movement will then be performed normally. I now will illustrate the use of these guidelines by illustrating some strategies that we have developed and used successfully at Kingston Centre by use of a videotape. In summary, I would like to emphasise that it is possible to achieve best practice in Parkinson's disease and that I believe we have done so through our program at Kingston Centre. This has been achieved by combining the Geriatrics philosophy with a specialist knowledge base. This knowledge base concerns the relevant information about management of Parkinson's disease as well as the underlying basis of rehabilitation and how malfunction occurs in Parkinson's disease. However, I believe that we do not necessarily require to spend a million dollars to provide best practice in Parkinson's disease. This is the cost of running our program at Kingston Centre over a period of 12 months. I believe that each of us as individuals within a HealthCare team should try and provide best practice. We can all look at simple ways by which we can improve our practice. Neurologists can provide more information about the disease, the medication and the progression. They can attempt to improve compliance of medication through better education and by the use of allied health professionals. Allied health professionals themselves can improve their knowledge base and expertise so that the overall management of Parkinson's disease is improved. Support organisations such as your own Parkinson's disease Association can promote increased knowledge through meetings such as this that has been arranged today. Patients and carers too can contribute to best practice by asking more questions of their treating physician, or neurologist, by becoming more involved in the documentation of their disease and by trying to optimise their own control through better understanding. I believe that best practice is possible in Parkinson's disease. I have demonstrated this to you today. I believe that each and every one of us can improve practice in Parkinson's disease and that best practice is really up to each one of us. ------=_NextPart_000_00A1_01BD19E2.A876C060--