Transcript Current Concepts in Physical Therapy for People with Parkinson`s

Current Concepts in Physical
Therapy for People with
Parkinson’s Disease
Tim Pazier, MPT
Franciscan Health System
PWR! certified clinician
LSVT BIG certified clinician
“Lack of activity destroys the good condition
of
every human being, while movement and methodical
physical exercise save it and preserve it”
Plato
Overview
The effect of Parkinson’s disease (PD) on
movement
 The role of physical therapy in PD
 Exercise principles to improve function
 Framework for exercise and PD
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The effect of PD on movement
Progressive neurodegenerative disease
 Motor deficits:
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slowness of movement (bradykinesia)
decreased amplitude (hypokinesia)
rigidity, tremor
decreased balance/postural reactions
freezing
postural changes
The effect of PD on movement
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Non-motor deficits that impact
movement:
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altered sensory perception/activation
difficulty changing strategies
difficulty dividing attention
poor self-monitoring
reduced vitality
depression, anxiety elevated
PD and Physical Therapy
Historically: Physical Therapy prescribed
once person is falling
 By then, > 70% loss of dopamine cells
 Ideally, we want people in therapy at the
first signs of the disease
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Physical Therapy (PT)
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Role of the physical therapist:
◦ prescribes therapy based on movement
analysis and patient goals
◦ assesses equipment needs
◦ advise home modifications as needed
◦ help teach caregivers/family ways to assist the
person with PD (cueing as needed)
Goals of PT
Slow sensorimotor deterioration
 Prevent falls
 Establish home exercise program that
challenges the person with PD
 Follow up every 3-6 months
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The science behind exercise
Neuroplasticity – changes in brain
connections that restores or compensates for
lost function.
 Neuroprotection – changes in brain
connections that spares, rejuvenates, or slows
their degeneration.
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Science, exercise, and PD - in the lab
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Exercise may slow, halt, or reverse the
progression of PD in animal studies:
◦ protection of viable dopamine
neurons (neuroprotection)
◦ restoring compromised neural pathways
(neuroplasticity)
◦ increasing reliance on undamaged
systems (neuroplasticity)
Science, exercise, and PD - in the lab
Findings in the lab can be applied in the
clinic
 Changes in brain function can be seen
indirectly:
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◦ Improved balance
◦ Increased speed and amplitude of movement
◦ Decreased freezing
Principles of recovery and improved
function
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Use it or lose it!
◦ inactivity contributes to PD
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Use it AND improve it!
◦ extended training can strengthen neural
connections
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Continuous exercise matters
◦ gains will be lost if exercise stopped
Principles of recovery and improved
function
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Timing matters
◦ starting earlier better
◦ gains can be made even in advanced PD
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Importance of salience
◦ exercise needs to be relevant to the person
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Push the effort!
◦ activity beyond self-selected effort
Principles of recovery and improved
function
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Repetition key for learning
◦ lots of practice needed
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Specificity matters
◦ therapy should focus on what is difficult
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Empower
◦ people with PD CAN get better
Exercise and Physical Therapy
No one exercise program found to be the
best approach
 However, HOW you exercise is the key…
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Parkinson’s Wellness Recovery (PWR!)
(see www.nfnw.org )
Parkinson’s Wellness Recovery
(PWR!)
NOT a specific exercise regimen, BUT a
framework for treatment
 Utilizes the latest research
 Can be incorporated into any exercise
regimen
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PWR! Framework for PD
Prepare!
Activate!
Reflect!
Motivate!
Prepare!
Remove fear of movement
 Simplify movements
 Focus attention
 Movements modeled to enhance
awareness
 Cardio training to “prime the pump”
 Alignment important
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Activate!
Push effort BEYOND self-selected
 Whole body movements via PWR!
MOVES - building blocks for function
 May need cues for completing movement
 Add complexity (dual task), duration
(sustain holds), intensity (effort to 8/10 on
a 0-10 scale)
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Reflect!
Increase awareness of movements
 Help identify normal performance
 Reduce reliance of vision
 Goal is to internalize and self-cue
movements:
“step BIG”
“reach BIG”
“turn BIG”
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Motivate!
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People with PD need external motivation
◦ Dopamine helps drive motivation
Must be salient to the person
“I want to work on moving better so I
can play tennis again”
“I want to walk with my wife/husband”
 Goal is to empower!
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Types of exercises/treatment
approaches for PD
Treadmill
 Tai chi
 Boxing
 Tango
 Tandem cycling (forced spinning)
 Nordic walking
 Sensorimotor agility program
 Auditory cueing - metronome
 LSVT LOUD/BIG
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LSVT LOUD/BIG
LSVT = Lee Silverman Voice Treatment
 LOUD/BIG focuses on:
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high effort
single attentional focus (AMPLITUDE)
overlearned movements
LOTS of repetition
sensory awareness retraining
LSVT LOUD/BIG
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Outcomes:
◦ LOUD participants able to sustain
loudness 2 yrs after training
◦ BIG participants exhibit faster gait and bigger
strides, improved reaching, improved trunk
rotation
PWR! MOVES
concepts that can be incorporated
into any exercise program
PWR! Hands
PWR! Reach
PWR!
Reach
PWR!
Reach
PWR!
Rock
PWR! Rock
PWR!
Twist
PWR! Step
PWR!
Turn
PWR! Voice
Can be added to any PWR! Moves
 Voice adds attentional and physical effort
 Promotes greater activation (as seen in
LSVT LOUD/BIG hybrid)
 Focus on breath with movement
important
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PWR! progression
PWR! Moves are the building blocks for
function
 Functional activities (examples):
- getting in/out of bed
- sitting   standing
- walking
 Progress to sports, hobbies, recreation
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PWR! video
What we want…
HIGH effort
 Awareness of movement
 Work towards whole body movements
 Translate movements into functional
activities
 Self cueing/monitoring
 Support of caregivers/family to reinforce
 NO days off, no excuses!!!
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People with PD CAN get better and
STAY better longer with exercise!!!