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An OTs Journey through Parkinson Disease and Pelvic Health

An OTs Journey through Parkinson Disease and Pelvic Health

This week for the Pelvic Rehab Report, Holly Tanner sat down to interview faculty member Erica Vitek, MOT, OTR, BCB-PMD, PRPC on her specialty course Parkinson Disease and Pelvic Rehabilitation. If you would like to learn more about working with this patient population join Erica on June 24th-25th for the next course date!

 

This is Holly Tanner with the Herman and Wallace Pelvic Rehab Institute and I'm here with Erica Vitek who's going to tell us about of course that she has created for Herman and Wallace. Erica, will you tell us a little bit about your background?

Yes. Absolutely. Thanks for chatting with me today about my course! So my course is Parkinson Disease and Pelvic Rehabilitation. I'm just so excited to be part of the team and to be sharing all this great information. How I got the idea for the course is that there was a need for more neuro-type topics related to pelvic health, and individuals were reaching out to me because my specialty is in both Parkinson disease, rehabilitation, as well as pelvic health, and I always talked about the connections and wanting to bring that information to more people. So I wanted to plate all that information together in this great course. 

I got started specializing in Parkinson's back in the early 2000s. I was hired at a hospital as an occupational therapist working with people with Parkinson disease. But when I was in college my real interest was pelvic health. So I kind of got thrown into learning a whole lot about Parkinson disease at that time and I got really interested in how it all related to what I really wanted to do, which was pelvic health. I was able to connect that all, really right from the beginning of my career. Even though I started more on the physical rehabilitation side of Parkinson disease, which I continue to this day. I am able to combine those two passions of mine.

I also am an instructor with LSVT Global(1)and so we do LSVT BIG®(2) course training and certification workshops and I work with them a lot. I also have still a physical rehab background, as well as my connection to the public health background, and I bring that all together in my course Parkinson Disease and Pelvic Rehabilitation. We have two packed-full days of information and I think really it does translate well to the virtual environment.


What are the connections between neuro and pelvic health? Can you talk about what some of the big cornerstone pieces are that you get to dive into with your class?

The beginning of the course on the first day is going back to the basics of neuro in general. Really getting our neuro brains on and thinking about terminology, topics related to neurotransmitters and the autonomic nervous system. Individuals with Parkinson’s specifically, their motor system is affected but also their non-motor systems. This includes autonomic function, the limbic system, and all of the different motor functions that also affect the pelvic floor in addition to all of the other muscles in the body.

We have all of this interplay of things going on that affect the bladder, bowel, and sexual health systems in individuals with Parkinson's that is a little bit different than your general population. There are a multitude of bladder issues that are very specific to the PD population, for example, overactive bladder. 

This is just one example of the depths we go into right in the beginning on day one where we get into the neuroanatomy and neurophysiology of why that is actually happening. This then helps us go into day two where we talk about the practicality of what you do in the clinic about the things that are happening neurologically which is causing all of these bladder, bowel, and sexual health issues.

 

What kind of tools do you give to people to help practitioners understand and implement a treatment program?

People with PD are on very complex medication regimens and many of them are elderly, so the medication complexity is much more challenging in this population. At the end of day one, the last lecture, we go through the pharmacology very specifically for people with Parkinson’s in order to have a base of understanding of how that is interplaying with the pelvic health conditions. 

We set the baseline of getting that information from your patient off the bat, then discuss what you want to be looking for when you start off with that patient and the importance of finding out what kind of bladder and bowel medications they have taken thus far and how that can potentially interplay with their Parkinson’s. Individuals with PD can have potentially worse side effects from some of those medications that are used for bladder issues specifically. We dig into what to look for, we talk a lot about practical behavioral modifications using bladder and bowel diaries and things like that to weed out some things in addition to using our other skills as pelvic health practitioners.


How can people prepare themselves to come to Parkinson Disease and Pelvic Rehabilitation, are there required readings or things that would be helpful for people to catch up a little bit on the pelvic health or neuro side?

I feel like, and I hope, that I did a really good job at the basic review right at the beginning so we can talk through these topics together. I prefer to take a course and not have to spend a lot of extra time on the pre-recordings because sometimes that can be overwhelming with busy lifestyles. When I put together this course I really wanted us to focus together as a group as we start the class to dig into those basics at the beginning and not have a lot of required things to do prior.

So what I did at the beginning of the course is to make a lot of tables, a lot of charts, and a lot of drawings, that we can reference (we don’t have to memorize it) and look at as needed. We can look at a chart and a drawing right next to it in the manual. I spent a lot of time just putting it all down in words, what I’m saying, so you don’t have to take a lot of notes. I think this has really helped practitioners as we get into the course and learn about the details of Parkinson’s and pelvic health.


What is it that makes you so passionate about working with these patients and continuing to learn and share your knowledge?

It is so heartwarming and feels so good to help these individuals. The motor symptoms of PD are really the ones recognized by physicians or even outwardly noticed even by other individuals. These private conditions of pelvic health that we are helping with are things that they might not even mention to their physician. Maybe we find out when we are doing other physical rehab or when colleagues refer them to us because they know what we do, and to help them with something of this magnitude that affects their everyday life - when they have trouble just walking, or moving or transferring. 

Their caregiver burden for these individuals is so high because their loved one - now turned caregiver - is helping them do everything. We can make such an impact on these individuals. I mean, we do on other people too, but when you have a progressive neurologic condition and we can make an effect on shaping techniques they can use to improve their day-to-day. It’s just so great to be able to help them. 

Sometimes these patients with PD can have cognitive impairments, they can have difficulties learning, and that can be helpful for the care partner. It can be a significant reduction in their burdon. I do talk a lot in the course about cognitive impairment and I give a lot of tips about how we can train and some ideas. People with Parkinson’s muscles and minds are a little different so there are some great tips that I can provide and lots of clinical experience. 

I’ve been an occupational therapist for over 20 years, so I have a ton of clinical experience with this population. It’s been the population I’ve worked with my entire career. I hope I can provide the passion that I have for working with these individuals as well as the individuals who take my class.


I’m sure you would agree that we need more folks knowledgeable about Parkinson’s and combine that with pelvic health knowledge as well.

There are over a million people in the United States alone that have Parkinson disease. It’s the second most common neuro-degenerative disorder just behind Alzheimer’s disease. So there are so many individuals dealing with this and I think we can really expand our practices. I don’t think a lot of individuals that work in pelvic health market themselves to neurologists. There is an opening there for additional referrals and more people that we can help.


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References:

  1. SVT Global is an organization that develops innovative treatments that improve the speech and movement of people with Parkinson’s disease and other neurological conditions. They train speech, physical and occupational therapists around the world in these treatments so that they can positively impact the lives of their patients.
  2. LSVT BIG®: Physical Therapy for Parkinson’s Disease and Similar Conditions. LSVT BIG trains people with Parkinson disease to use their body more normally.
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Pelvic Floor Dysfunction and Parkinson Disease

Pelvic Floor Dysfunction and Parkinson Disease

Erica Vitek

Erika Vitek is kicking off the new year with her remote course Parkinson Disease and Pelvic Rehabilitationscheduled for January 14-15, 2022. In this course, she explains that akinesia is a term to describe the movement dysfunction observed in people with Parkinson Disease (PD). Akinesia is defined as poverty of movement, impairment or loss of the power to move, and slowness in movement initiation. This is observable in the loss of facial expression, associated nonverbal communicative movements, arm swing with gait, and overall small amplitude movements throughout all skeletal muscles in the body.

The cause of this characteristic profile of movement is due to loss of dopamine production in the brain, which causes a lack of cortical stimulation for movement(1). If the loss of dopamine production in the brain causes this poverty of movement in all skeletal muscles of the body, how does the pelvic floor function in people with PD, and what should the pelvic floor rehabilitation professional know about treating the pelvic floor in this population of patients?

Common pelvic floor dysfunctions often involve functions controlled through reflexes and voluntary actions such as bladder, bowel, and sexual functions. PD-related pelvic floor dysfunctions impact the non-motor portion of the bladder, bowel, and sexual functions. A recent study by Gupta et al. showed that “urinary dysfunction and constipation, manifestations of pelvic floor dysfunction are common sources of disability and impaired quality of life in women with PD(2).” This study concluded that pelvic floor dysfunction is underreported and undertreated in people with Parkinson's Disease.

As there is no cure for PD, the goal for all treatment strategies is to slow the disease progression and achieve neuroprotection while improving quality of life. There are five common strategies in treating this patient demographic: rehabilitation, therapy, restoration, maintenance, and surgery, as found by Frank Church. Rehabilitate follows the diagnosis and treatments and includes physical, occupational, and speech therapy. Therapy refers to the use of levodopa or other dopamine agonists to preserve dopamine. The restorative strategy includes aerobic exercise programs. Maintenance strategy uses complementary and alternative medicine to support and protect the brain microenvironment, while surgery includes deep brain stimulation(3).

Patients with PD can benefit from physical and occupational therapy as part of their rehabilitative management strategy. A trained practitioner can work with the patient to introduce neuromuscular re-education training. In this type of training, reflexive actions are optimized by promoting repetitive firing of the neurons in the circuits to allow the body to adapt to the most efficient path. Practitioners can also introduce strength training for those muscles under voluntary control to reduce muscle strain and improve contract-relax properties. Exercise-based interventions have been shown to promote improvements and allow a better quality of life in pelvic floor function of Parkinson's patients.

As part of the Parkinson Disease and Pelvic Rehabilitation course curriculum, Erica Vitek delves into the characteristic pelvic health dysfunctions that people with PD face. Options for assessment and treatment planning are also provided, including applications for TENS in the neurologic population. Erica shares “There is no pathological evidence that in Parkinson Disease there is any break in the continuity of the motor system. The neurologic pathways are all intact and the ability to produce muscle power is retained. However, a strong base of clinical knowledge of the disease is required to help these patients activate these intact motor pathways.”


  

References:

 

  1. Caligiore D, et al. Different Dopaminergic Dysfunctions Underlying Parkinsonian Akinesia and Tremor. Front. Neurosci., 29 May 2019 | https://doi.org/10.3389/fnins.2019.00550
  2. Gupta, Ankita et al. Pelvic Floor Health in Women with Parkinson’s Disease. Journal of Parkinson's Disease 1 Jan. 2021: 857 – 864. DOI: 10.3233/JPD-202491 | https://content.iospress.com/articles/journal-of-parkinsons-disease/jpd202491
  3. Church FC. Treatment Options for Motor and Non-Motor Symptoms of Parkinson’s Disease. Biomolecules. 2021; 11(4):612  | https://doi.org/10.3390/biom11040612

 

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Parkinson Disease and Constipation

Parkinson Disease and Constipation

vitek erica head shot 2020

Erica Vitek, MOT, OTR, BCB-PMD, PRPC has attended extensive post-graduate rehabilitation education in the area of Parkinson disease and exercise. She is certified in LSVT (Lee Silverman Voice Treatment) BIG and is a trained PWR! (Parkinson Wellness Recovery) provider, both focusing on intensive, amplitude, and neuroplasticity-based exercise programs for people with Parkinson disease. Erica has taken a special interest in the unique pelvic floor, bladder, bowel, and sexual health issues experienced by individuals diagnosed with Parkinson disease. You can learn more about this topic in Erica's course, Parkinson Disease and Pelvic Rehabilitation, scheduled for July 23-24, 2021.

Parkinson disease (PD) non-motor symptoms can be even more impactful on quality of life than the cardinal motor symptoms most are familiar with, bradykinesia, rigidity, tremor, and postural instability. The list of non-motor symptoms is extensive affecting many body systems including cognitive, sensory, and autonomic.

Constipation is one of the most common autonomic non-motor symptoms experienced by people with Parkinson disease with studies showing 20-89% prevalence (1). As the disease progresses, individuals are more likely to experience symptoms that suggest a strong relationship between neurodegeneration and bowel dysfunction, such as, decreased frequency of bowel movements, difficulty expelling stool, and diarrhea (2). Constipation has also been hypothesized to be an early indicator for the development of Parkinson disease, and there is ongoing research in this area. It has yet to be shown that constipation is specific enough to predict the development of PD.  

Developing an understanding of Parkinson disease constipation and how it differs from other individuals with constipation can have a strong impact on our recommended pelvic rehabilitation plans of care. In a study published by Zhang, M. et al., 2021, they looked at the characteristics of Parkinson disease with constipation (PDC) compared to functional constipation (FC). Functional constipation is generally defined as difficult, infrequent, or incomplete defecations (3). One of the main findings in this study was a significant difference between the groups when looking at resting rectal and anal canal pressures. In the PDC group, resting rectal and anal pressures were significantly lower. These resting pressures are mainly controlled by the internal anal sphincter resting tension which is supported by the autonomic nervous system. This leads the researchers to speculate there may be autonomic nervous system neuropathy in people with PD

They then looked at simulated defecation, which also showed that the PDC group had significantly lower rectal defecation pressure and a lower anal relaxation rate. Since rectal pressures during defecation assist in effective anal relaxation, the researchers state, “a coordinated movement disorder results” and that people with PD may have “pelvic floor cooperative motion disorder” (1). Additionally, the researchers noted that abnormal abdominal pressure is another main contributing factor to the low rectal defecatory pressure in PDC. Abdominal pressure is a key factor in driving complete and efficient rectal defecation. This is also a finding in numerous other studies in the literature unique in PDC.  

The results of Zhang, M. et al., 2021 reveal the need for pelvic health practitioners to help train coordinated defecation efforts in people with Parkinson disease. In my course, Parkinson disease and Pelvic Rehab, we will have an in-depth discussion about how training defecatory dynamics is different in people with PD. Muscle training principles in this population are very unique. Understanding the underlying causal factors of dysfunction will have a significant impact when helping patients with Parkinson disease manage constipation.


  1. Zhang, M., Yang, S., Li, X. C., Zhu, H. M., Peng, D., Li, B. Y., ... & Tian, C. (2021). Study on the characteristics of intestinal motility of constipation in patients with Parkinson's disease. World Journal of Gastroenterology, 27(11), 1055.
  2. Sakakibara, R. (2021). Gastrointestinal dysfunction in movement disorders. Neurological Sciences, 1-11.
  3. Lacy, B. E., Mearin, F., Chang, L., Chey, W. D., Lembo, A. J., Simren, M., & Spiller, R. (2016). Bowel disorders.Gastroenterology 150 (6), 1393-1407.
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