Joe: 00:13

Welcome back to another episode of the Freedom Talks podcast, everybody. This is your host, Joe Ogden, again. And this week, we have another interview with another therapist here at Freedom, who's also our marketing director who I work under and work with all the times. I think it's been over a year now that I've been doing the podcast, so we're circling back with Molly Rippert. Molly, welcome.

Molly: 00:36

Good morning.

Joe: 00:36

It's been a long time since we've been on a podcast together, Molly.

Molly: 00:39

I know. No. You've been doing a good job holding down the fort. So

Joe: 00:43

I think it's been over a year now, hasn't it?

Molly: 00:45

I don't know. Close. If if not a year, definitely, we're coming up to it.

Joe: 00:49

I know we're pretty close. Molly's gonna tell we're gonna have a big conversation today. It is April is Parkinson's month. Right, Molly?

Molly: 00:59

Yep. It is Parkinson's awareness month.

Joe: 01:02

So this podcast is really going to be around Parkinson's, some Parkinson's awareness, and Molly will probably get into some of the treatments and, you know, some things that for those who have the condition or have a family member that has that condition, things to kinda watch out for and be mindful of. So Molly, take it away. Let's get us started here.

Molly: 01:27

So basically, you know, let's just start from kind of the beginning as if people were unaware of what Parkinson's is and kind of just give them a little bit of a background there. And then hopefully just make people more aware of some of the symptoms, and what what can be done. Not necessarily to cure the disease, but to, maintain function that they have and improve movement. So Parkinson's disease is a, progressive neurodegenerative disorder, mostly caused by a lack of dopamine in the brain. Dopamine is a neurotransmitter that is involved in almost all of our body's functions.

Molly: 02:16

So movement, motivation, memory, many things that, you know, you just kind of do without having to think about. There's been a lot of talk about is this hereditary, that sort of thing. They're still working on the why it happens, why dopamine cells in your body basically die, but they they're they're believing that there's more and more link to, like, environmental toxins. So in the there's certain areas even within the United States, that have a higher risk of Parkinson's based on your location. So they're thinking, like, the industrial areas, for whatever reason, the chemicals that are produced in it, have a more dopamine cell killing effect.

Molly: 03:17

So it's it's one of those things that more men are affected than women, but that doesn't limit women being affected by Parkinson's disease. And it's estimated that that 1,200,000 people in the United States will be living with Parkinson's disease.

Joe: 03:35

So a relatively high number?

Molly: 03:38

It it's growing. It it continues to grow. Roughly 60,000 people a year are diagnosed with Parkinson's disease, and it's climbing. I mean, it's they're they're anticipating, you know, in the next few years, 90,000 people a year will be diagnosed with Parkinson's disease. So it's it's something that researchers and scientists are still trying to figure out the the why is it growing, why are we seeing more of it, and trying to figure out, you know, what they can do to slow it, slow the progression.

Joe: 04:18

What is a typical age that we're seeing patients be diagnosed or age range of individuals?

Molly: 04:24

So, typically, it's 65 and plus. There are different types of Parkinson's disease. There is an early onset or a young onset of Parkinson's disease. But for the most part, people 65 and above typically are the ones that are diagnosed with Parkinson's.

Joe: 04:47

Molly, I think we kinda brushed over this, but I'll I'll touch on it again just to make sure, that on the podcast we're clear. Molly, here at Freedom in Fox Point, mainly your patient population is Parkinson's, isn't it?

Molly: 05:01

Yep. So, I think it was about 3 or 4 years ago, I decided this was something that was of interest to me. I got LSVT big certified, which is is the the main Parkinson's organization that really works with Parkinson's disease. It's been interesting though because while I do see a lot of people with Parkinson's, there are other forms of Parkinson's that are not tip like, they're they're atypical Parkinson's, and I tend to see I've seen more and more of that over the last few years.

Joe: 05:52

Now your patient population now, because you just said that, you know, a lot of the presentations sometimes with patients are the same, but they're not diagnosed, what are some of the things that you're looking for from a a therapist point of view? Even more so also to give some information and context to individuals who are listening who maybe they they're noticing a certain decline in either a loved one or a family member that hasn't been diagnosed yet? What are some of the things that we should be looking out for or presentations you see in patients?

Molly: 06:20

Yep. So there's there's kind of 2 sets of

Joe: 06:24

of

Molly: 06:24

patients that I see. So the first are the patients that come in that, you know, their their family members, their primary care physician. Someone has noticed a decline or kind of the more well known Parkinson's issues. So, that could be, like, that shuffling gait or just having, like, moments where, like, they almost freeze and they can't move. So those sorts of patients, they end up someone, family member, friend, physician, sees them, experiences it, experiences it, sends them to the doctor.

Molly: 07:08

They see the neurologist. Neurologist says, you need to see a physical therapist that specializes in Parkinson's, and I see them. They come to me after they've been diagnosed. These people tend to have had symptoms for usually 10 years before they were formally diagnosed. So by this point, their symptoms are visible.

Molly: 07:32

They can see them. It's it's very clear that they have Parkinson's. The second set of patients that I see are a lot of times I will have another therapist in the clinic say, something just isn't right. Like, I don't know what it is. Can you just, like, peek your head in or, like, watch them walk?

Molly: 07:53

We're gonna walk in the clinic. Can you just, like, look at them? And I tend to you see, like, altered gait, where you you can't necessarily pinpoint, like, it's not necessarily a shuffling gait. They're not freezing, but something is just off. A lot of times I'll look at their facial expressions because a lot of times with Parkinson's, people we blink so many times a second, and with Parkinson's disease, they they lose, like, that blinking, and so there's just a different facial expression that you can see.

Molly: 08:35

So a lot of times, in that second set of patients that I see, they are I'm looking at them and then we're sometimes saying, hey. You know, we're not sure what's wrong, but I think, you know, you need to see your primary care physician, or potentially, you know, see a a neurologist. This is what we think might be going on, And so we'll actually send them to a neurologist or their primary care physician, to get kind of more of a workup, and and have more of a formal diagnosis given.

Joe: 09:18

So we have a patient, hypothetically, that has just been diagnosed with Parkinson's.

Molly: 09:25

Mhmm.

Joe: 09:26

What can we expect what can a physical therapist do to provide improvement from, you know, their current conditions or just the diagnosis themselves? What's the role that physical therapists play in the, plan of care?

Molly: 09:41

So, well, physical therapists in general are just movement specialists. So, a lot of times, I will have patients Parkinson's patients either newly diagnosed or they've had it forever. We I really focus on function. So I have people come in who if you saw them at the grocery store, you wouldn't know that they have Parkinson's. Their their tremor might be so insignificant or they only get it when they're tired at night.

Molly: 10:13

You wouldn't ever know that they had Parkinson's. And so a lot of times what we work on in those earlier stages of Parkinson's is giving them strategies so that they can maintain their movement and maintain what their work or their hobbies, well into the future. So we work on bed mobility if they have trouble rolling over or we've worked on I've had patients that have trouble getting in and out of the car. Like, it's just something that so we'll work on strategies to get them in and out of the car in those early stages. Basically, just maintaining the large movement patterns.

Molly: 11:00

So with Parkinson's disease, as the dopamine is depleted out of the body, their brain and their body don't connect as well. So their their brain still thinks that they're taking these huge normal steps. In reality though, they are taking these tiny shuffling steps. So it's recalibrating the brain to help maintain that normal movement pattern. So we really I do kind of a a deep down, evaluation as to things that they do.

Molly: 11:38

Do they get up and up down from the ground? Are they still running? All that sort of stuff. And then we kind of together come up with a, plan to keep those big movement patterns happening. With my patients that come in with later stage, Parkinson's, I really like it when either a family member, a spouse, a close friend comes in with them, and we all kinda talk about the issues that they're having.

Molly: 12:15

If it's standing up in the shower, if it's going up and down the stairs, getting out of the car, getting up from a chair, moving around in bed, getting up and down in the garden, and we really I focus on making it task specific so that we work on movement patterns that are going to help them continue to function well.

Joe: 12:42

I feel like that kinda goes with really any physical therapy specialty for that matter.

Molly: 12:48

Yep. And so

Joe: 12:49

today's world, you know, just with social media and there's just so much out there for for patients and providers, there's always I feel like all of a sudden this push to find this magic exercise that fixes everything. When in reality, our job is just to improve your functional capabilities.

Molly: 13:06

Exactly. I mean and that's what we're we're really that's what I work on with all of my patients, but especially my Parkinson's patients, is, like, recalibrating the brain. Like, you know, growing the neurons in the brain into different pathways to strengthen, like, the movement patterns, the cognitive. So we do especially with my Parkinson's patients, we do a lot of, like, opposite arm, opposite leg, like, having that kind of reciprocal movement. We do so much reciprocal movement, in our daily lives, and it's something that the more we reinforce it, the more that we practice it, it carries over into just their regular daily activities.

Molly: 13:55

So, you know, we do a lot of you know, if you think about if you're standing in the kitchen and, you know, weight shifting to be able to grab a dish, you know, up in the in the cabinet or something like that. We just do a lot of, movement patterns to help my Parkinson's patients continue to live a normal daily

Joe: 14:22

life. What is the prognosis once you're diagnosed?

Molly: 14:25

You know, it's kinda all over the board. It depends a lot on what stage of Parkinson's you're in. So there are 5 kind of stages of Parkinson's according to the Hohne and Yarr scale, and one being, like, minimal to no disability all the way up to 5, which is, like, basically wheelchair bound or bed bound. As Parkinson's progresses, you eventually work your way all the way up through the 5 stages. But for the most part and most people, the progression of Parkinson's tends to be fairly slow, where people tend to have a fairly normal lifespan.

Molly: 15:24

They just end up learning to modify what they do. And the sooner that they do physical therapy, they have more techniques stored in their brain of how to, like, negotiate the world, to decrease risk of falls, and other, like, disabilities that go along with it.

Joe: 15:55

Is it possible for patients to move up and down the scale?

Molly: 15:59

Not typically. So, like, it it because it's a slower like, for most of it people, it's a slower progression. You know, you could be in a level 1 or a 2 for most of your life without without moving on to a different stage. Most Parkinson's patients don't pass away because they have Parkinson's. A lot of times, it's, other issues that occur and Parkinson's kind of doesn't help it, and they end up passing away from that.

Molly: 16:38

But you you could live your entire life, you know, with Parkinson's and not it's not necessarily going to be fatal.

Joe: 16:49

What is one thing that whether it's advice or a cue or just a piece of information that you either repeat to patients and their families a lot or something that you really wish that, they would know before coming to see you or even if it's just motivation? Like, what's that one piece of information that you think, is most important to kinda know about?

Molly: 17:12

The the biggest thing I think that people haven't I think it goes across the board is, like, if you don't use it, you lose it. So it's really really important for everybody as you age, but especially for Parkinson's patients, they have to continue moving. It can get scary, like, especially if people have fallen, movement becomes scary. They're afraid to go out and do stuff, but the more you practice it, especially in a safe setting. So, we know we use gait belts.

Molly: 17:53

You're working 1 on 1 with a physical therapist. My goal is you're not gonna fall when you're with me. So the more that we can practice movement and practice movement in a way that continues to help your brain, keep your movements normal, the better off you're gonna continue to be as the Parkinson's may progress.

Joe: 18:19

And what type how long does that progression take? I mean, I'm sure it's different for everybody, but do you see that progression where, you know, people progress through the 5 stages in 5 days, or is it typically 20, 15 years?

Molly: 18:34

For the most part, it's it's, a long time. It's, like I said, though, the problem for a lot of people is that Parkinson's doesn't get diagnosed easily right away. It's more, a diagnosis of exclusion than, like, the they're coming they're working on more diagnostic tests that can say, yep. Like, this is you know, you have Parkinson's. Right now, you know, they're they're working on basically CT scans of your brain that are looking for cells, and they can see that, you know, age related wise, if you have this much like, you should have this much at this age and that, like, the norms are for this.

Molly: 19:30

And if you have less than that, like, you have an increased risk of of Parkinson's or that sort of thing. But a lot of times with, like, the carbidopa or the levodopa medications, the deep brain stimulation, the progression is typically very slow over years. With that said though, if you are a couch potato and you do nothing, your symptoms are gonna look worse than someone who's actively working to keep their movements big, recalibrating their movements, you know, making sure that their their body is, strong and capable.

Joe: 20:22

So, again, I feel like it kinda goes back to the where we started is just improving your functional capabilities, being consistent, trying to maximize your physical abilities and decrease those limitations as much as possible.

Molly: 20:39

Absolutely. I mean, I have a patient. When she came in, she had the the bradykinesia, the the slowness to her movements. She had, like, stiffness, resting tremor. She had a, like, shuffling gait where, you know, her feet just kinda shuffled in front of her.

Molly: 21:01

And I've been working with her on a fairly consistent basis over the last probably 12 to 16 months, and she still has a tremor, but that tremor is more controlled. She tells me that the tremor is, you know, mostly at night, mostly with fatigue. You know, she can she has working with her doc her neurologist, they have timed her medications differently to meet her needs. She still works. She's, you know, she's doing everything she wants.

Molly: 21:42

We have improved her her speed of movement. So, you know, she she can keep up with her husband, when they take a walk. She's not walking with that shuffling gait. She you know, we we've kind of recalibrated those nice big steps where her heels are hitting first. A lot of times too with Parkinson's disease is they get this kind of rigid torso where when they walk, they almost kind of have this robotic looking, gait.

Molly: 22:20

And so, you know, we've worked on thoracic mobility. We've worked on cervical mobility because a lot of times, they're that stiffness through the neck, you know, they're like, I can't you know, I'm still driving and I can't check my blind spot because they're so stiff. You know, all of those things we've worked on kind of helping her recalibrate and realize when she's taking her steps that although it feels like I'm, you know, asking her to to take this huge step, that's actually a normal step. And over time, with her practicing and practicing and practicing, that big step turned back into a normal size step in her brain.

Joe: 23:08

It seems like a lot of this too, which I I would argue is probably the barrier if a lot of and it's not even just physical therapy. I mean, any any physical treatment in itself, it sounds like there has to be a lot of active buy in from both patients and their families both in and outside of the clinic setting?

Molly: 23:30

Mhmm. Yep. You have to have a good support system. Beyond just, like so, you know, I deal a lot with the movement portion of Parkinson's. But Parkinson's disease, it's been shown there's increased depression, increased increased anxiety, cognitive changes, dementia, fatigue, pain, sleep change.

Molly: 24:00

I mean, you it affects all parts of your body and you need to have a core group of physicians, family members, friends as your team to help you because you don't always notice that you're depressed. You don't always notice, Oh, I stopped going out because I was feeling anxious. So having a, good team surrounding you is super important to your success with the disease.

Joe: 24:37

Now when you get someone, who comes in that just recently been diagnosed, let's say, they're coming in with their spouse as well. As a therapist, again, I know it depends on, you know, the patient specific. But in general, what would you say are your biggest goals or something that you communicate with patients that you've been diagnosed? We're not gonna change this diagnosis. It's it's it's going to be there.

Joe: 25:01

But what is your, you know, biggest goal or takeaway that you try and give to patients where you would consider it a success, that physical therapy did work?

Molly: 25:12

Yep. So, you know, especially with the patients that come in that are recently diagnosed, a lot of times, you know, there's like they've said to me, you know, I've had this these these issues. If it was like, oh, I felt I was just clumsy and I was tripping on my feet or, like, for years. So they've they've been feeling this way for a long time. There hasn't been a label put on it.

Molly: 25:37

So this is like the the label is finally there. A lot of times, it's pretty scary just like with any other diagnosis kind of that initial, like, you get you get diagnosed with something and it there's just so much worry and fear, you know, what is going to happen in the future. So usually the first few sessions, especially with caregivers or family, we kinda just work through, you know, like, this is what's normal. These are things that could potentially happen if they haven't already. We try and put together a kind of a plan of, like, you know, this is, you know, a lot of times the medications take a little bit of time to kind of build up in your system.

Molly: 26:27

So, you know, just because you were given the levodopa 2 weeks ago, it's not at its full, potential at working in your body yet. So, you know, just trying to ease a lot of fear or anxiety about this new diagnosis. Along with that, it's a marathon. It's not a sprint. So, you know, things are gonna change.

Molly: 26:57

You're not gonna always like, your your symptoms may change over time. It in each, you know, change, we're gonna be able to work with you, and make sure that you are living the best life you can, and doing as much as everything that you wanna do. And one thing that I do wanna add with Parkinson's is that I, in the 4 years that I've been treating it, have never seen a one Parkinson's patient that symptoms are exactly the same as somebody else's. It manifests itself differently in everybody. Some people have speech or swallowing issues.

Molly: 27:43

Some people have, like, dizziness, low blood pressure changes that they didn't have before their Parkinson's. There's just it it presents itself and everybody slightly differently. So your symptoms are never necessarily the same as somebody else's, but it doesn't mean that what we're doing is gonna like, I have a core set of exercises that everybody gets and then depending on what's going on specifically to you, we work on other things. A lot of times, especially with a newly not, I guess, not just newly diagnosed, but anybody with Parkinson's, I always suggest, there are support groups around pretty much every, big city, even smaller cities. They host support groups both for the patient that has Parkinson's and for their caregivers.

Molly: 28:54

It's a super important thing to be a part of a group or a community that can help you better understand what's happening to you. I don't have Parkinson's. I work with a lot of Parkinson's patients, but I don't I've never experienced myself Parkinson's. So when these my patients are able to connect with others that have Parkinson's, I think it makes a truly huge impact on them because they can say, you know, man, I am having the hardest time doing x, y, and z. And someone else in the group can say, you know what?

Molly: 29:36

I had the same problem, and I did this, and it helped. So, you know, my takeaways for every patient that comes in is that, you know, this is this is a long term thing. Like, we are not not gonna fix you today. You're not gonna fix yourself today. Your medication isn't gonna fix you entirely.

Molly: 29:56

Deep brain stimulation isn't gonna fix you entirely. But everything that we can do together is gonna keep you moving the best you can for as long as we can, you know, keep you going and finding support.

Joe: 30:11

I feel like that's one of the biggest things that personally I've been touching on a lot with people lately, but nothing is gonna happen today, improvement wise. Nothing's gonna significance is gonna happen tomorrow, but you will see significant improvement if you just stick with it next month, 2 months, 3 months, 4 months. The thing this notion that you're gonna improve instantly is just not it's not realistic. We have to be consistent and just that cliche of just stay the course or whatever term you wanna use, just be consistent with with the deal.

Molly: 30:45

Yep. You know? And it's one of those things like, one thing that people don't think about a lot and what I've seen, I would say, in the last for whatever reason, the last, like, 3 or 4 months, I've had a couple of my Parkinson's patients come in, who are typically, like, my go getters. They're super active. You know, any exercise I throw at them, they're at least willing to try.

Molly: 31:12

Sometimes it works. Sometimes they're like, nope. Hated it. Don't wanna do it. But something that is really not frequently talked about is, the the constipation, the dehydration that occurs with Parkinson's disease.

Molly: 31:29

So I actually had in the last 4 months, I've had 2 different Parkinson's patients come in and they're like they've never complained of low back pain, and they said, I have had the worst low back pain for the last, like, 10 days. And, you know, we go through my regular, you know, PT brain of, like, did you did you do it the activity that you didn't, you know, you haven't done? Did you feel it a tweak? Did you you know, all of the normal questions that I ask any patient with or with that just comes into PT. And then, like, a light bulb kind of went off in my brain, and because of some of the medications and because your digestive system also moves slower with Parkinson's disease, constipation is a a risk factor, if you wanna say.

Molly: 32:27

And so we talked about, you know, increasing fiber content, increasing, hydration, and trying to move a little bit more physically. And I saw them about a week later, and they said you were a 100%. You know, I it was something that they hadn't dealt with, but I it's a, something that isn't necessarily always talked about with Parkinson's, but is a huge thing that affects those with Parkinson's.

Joe: 33:05

I think that's oftentimes in general. I mean, we're so focused, as we should be on, you know, orthopedic conditions and musculoskeletal stuff. But there's oftentimes so much overlap between just the total body systems that also shows the importance, whether it's in PT school or continuing ed course. It doesn't matter for, you know, new grads, PT school, and then, you know, those have been out for a while, really diving deep into understanding pharmacology, understanding the, GI system, understanding the cardiac system. I mean, there's just some so much overlap that it may not truly be a true muscular disorder.

Joe: 33:41

There's something else that's the driving force to, pain presentation.

Molly: 33:47

Absolutely. And it was one of those you know, people don't think about it. You know? Like, but your whole body with Parkinson's without those dopamine, receptors, everything slows down. It's not just your movement.

Molly: 34:01

It's cognitively people slow down. You know, and so it's it's just about keeping people moving and building more neuro neurological connections within the brain to offset some of that neurodegeneration that occurs from the dopamine cell death death. You know, and it it's one of those things that we just you know, as we learn more about the why of Parkinson's because we don't understand why some people have their dopamine cells killed off while others don't, You know, it it's one of those things that we just have to keep people moving both cognitively, physically, and keeping them sharp as they age so that even if they have Parkinson's, their other body systems are still functioning normally.

Joe: 35:11

Molly, is there anything else you wanna add in before we finish up?

Molly: 35:16

I don't think so. I'm just I feel really, privileged to be able to work with this population. It is definitely fun. It's it keeps me on my toes because there are days where someone comes in with a symptom that I didn't realize was Parkinson's related and we get to kind of brainstorm and, be creative in how we go about working with it. So, you know, I feel really lucky to be able to help these Parkinson's patients and hope that, you know, I can just keep, help make someone else's life easier.

Joe: 36:00

Molly is a fantastic therapist who right now just treats at Fox Point, and probably in the future, we'll probably just treat at Fox Point. So for those that are have a family member or the the they themselves who's listening has Parkinson's, please come and see us and see Molly here at at Freedom and Fox Point.

Molly: 36:19

So thank you, Joe.

Joe: 36:21

Thanks for joining today, Molly. Molly's doing this from at home because she's not in the office on Thursday, so we're doing a Zoom meeting quick in the middle of her day. So it's a special thank you to Molly for sitting down and talking about Parkinson's.