1. Nin Bajaj Consultant Neurologist, Nottingham Fiona Lindop, Specialist Physiotherapist, Derby Multidisciplinary Team Working in PD

2. 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

3. The team- the minimum requirement A neurologist A Care of the Elderly Physician A PD specialist nurse

4. The extended team PD physiotherapy OT SALT Community PD nurses Neurorehab specialist

5. The fantasy football team Pharmacist Dietician PD service management Psychiatrist Palliative Care Parkinson’s UK/Care PD patient representative

6. 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

7. How do you create a profile for the service Playing at Home Playing Away International fixtures

8. 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

9. Playing Away- National Level Endorsement of the service Hospital Doctor Award Guardian Public Sector Awards HS awards Research Profiles

10. Hospital Doctor Award

11. Research Profiles DeNDRoN CLRN The DeNDRoN PD Director (region) Non-portfolio work Refereeing Working for and with the Charities

12. Research Profiles- National DeNDRoN working parties National grants

13. Co-operative Working with Pharma Educational Events IIT research grants Portfolio Adoption

14. Playing Away from Home- International International Endorsement The national Parkinson Foundation Programme Research

15. NPF

16. NPF Centres of Excellence

17. Research- International Present at conferences Lecture Faculty Boards

18. 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

19. 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

20. 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

21. 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

22. Lindop Parkinson’s Assessment Date Time of Ax Walking aid Time of last medication Gait mobility Sit to stand:Unaided with ease Unaided with effort Help of one Help of 2+ 32103210 32103210 32103210 32103210 32103210 Timed 60+ sec unsupported 49-59 sec stand: 30-44 sec 0-29 sec 32103210 32103210 32103210 32103210 32103210 Timed up & go: 10-20 sec 21-35 sec 36-60 sec 60+ sec 32103210 32103210 32103210 32103210 32103210 180 turn to right: 4-6 steps 7-8 steps 9-10 steps 11+ steps 32103210 32103210 32103210 32103210 32103210 180 turn to left: 4-6 steps 7-8 steps 9-10 steps 11+ steps 32103210 32103210 32103210 32103210 32103210 Walking through doorway: No freeze/festination Some festination Freezes once Freezes 2+ times 32103210 32103210 32103210 32103210 32103210 TOTAL Bed mobility Sit to lie (56 cm bed): Unaided with ease (≤ 5 sec) Unaided with effort (6+ sec) Help of 1 Help of 2/unable 32103210 32103210 32103210 32103210 32103210 Turn to left on bed: Unaided with ease (≤ 5 sec) Unaided with effort (6+ sec) Help on 1 Help of 2/unable 32103210 32103210 32103210 32103210 32103210 Turn to right on bed: Unaided with ease (≤ 5 sec) Unaided with effort (6+ sec) Help of 1 Help of 2/unable 32103210 32103210 32103210 32103210 32103210 Lie to sit on bed: Unaided with ease (≤ 5 sec) Unaided with effort (6+ sec) Help of 1 Help of 2/unable 32103210 32103210 32103210 32103210 32103210 TOTAL Signature

23. 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

24. Future Dreams Second PDNS More SALT hours Education framework Palliative Care Training for Care home staff Outreach to people with Parkinson's in care homes

25. Basal Ganglia Dysfunction Impaired performance of well-learned motor skills and movement sequences –Preparation, Initiation, Sequencing,Timing Difficulty in performing 2 or more well- learned tasks simultaneously Difficulty in shifting motor and cognitive sets Increased time required for mental processing

26. 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 Sensory

27. 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

28. 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

29. Turning Safe turn requires: Independent mobility Ground clearance Good stability Continuity of movement Good posture Intervention for turning: Avoid dramatic change of direction Avoid dual tasking Cues Physiotherapy to improve balance and rigidity

30. Intervention for falls 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

31. To Summarise...Team Approach!