Current concepts in physical therapy for people with parkinson s disease
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Current Concepts in Physical Therapy for People with Parkinson’s Disease. Tim Pazier, MPT Franciscan Health System PWR! certified clinician LSVT BIG certified clinician.

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Current Concepts in Physical Therapy for People with Parkinson’s Disease

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Current concepts in physical therapy for people with parkinson s disease

Current Concepts in Physical Therapy for People with Parkinson’s Disease

Tim Pazier, MPT

Franciscan Health System

PWR! certified clinician

LSVT BIG certified clinician


Current concepts in physical therapy for people with parkinson s disease

“Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it”Plato


Overview

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


The effect of pd on movement

The effect of PD on movement

  • Progressive neurodegenerative disease

  • Motor deficits:

    • slowness of movement (bradykinesia)

    • decreased amplitude (hypokinesia)

    • rigidity, tremor

    • decreased balance/postural reactions

    • freezing

    • postural changes


The effect of pd on movement1

The effect of PD on movement

  • Non-motor deficits that impact movement:

    • altered sensory perception/activation

    • difficulty changing strategies

    • difficulty dividing attention

    • poor self-monitoring

    • reduced vitality

    • depression, anxiety elevated


Pd and physical therapy

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


Physical therapy pt

Physical Therapy (PT)

  • 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

Goals of PT

  • Slow sensorimotor deterioration

  • Prevent falls

  • Establish home exercise program that challenges the person with PD

  • Follow up every 3-6 months


The science behind exercise

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.


Science exercise and pd in the lab

Science, exercise, and PD - in the lab

  • 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 lab1

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:

    • Improved balance

    • Increased speed and amplitude of movement

    • Decreased freezing


Principles of recovery and improved function

Principles of recovery and improved function

  • Use it or lose it!

    • inactivity contributes to PD

  • Use it AND improve it!

    • extended training can strengthen neural connections

  • Continuous exercise matters

    • gains will be lost if exercise stopped


Principles of recovery and improved function1

Principles of recovery and improved function

  • Timing matters

    • starting earlier better

    • gains can be made even in advanced PD

  • Importance of salience

    • exercise needs to be relevant to the person

  • Push the effort!

    • activity beyond self-selected effort


Principles of recovery and improved function2

Principles of recovery and improved function

  • Repetition key for learning

    • lots of practice needed

  • Specificity matters

    • therapy should focus on what is difficult

  • Empower

    • people with PD CAN get better


Exercise and physical therapy

Exercise and Physical Therapy

  • No one exercise program found to be the best approach

  • However, HOW you exercise is the key…

    Parkinson’s Wellness Recovery (PWR!)

    (see www.nfnw.org )


Parkinson s wellness recovery pwr

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


Pwr framework for pd

PWR! Framework for PD

Prepare!

Activate!

Reflect!

Motivate!


Prepare

Prepare!

  • Remove fear of movement

  • Simplify movements

  • Focus attention

  • Movements modeled to enhance awareness

  • Cardio training to “prime the pump”

  • Alignment important


Activate

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)


Reflect

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”


Motivate

Motivate!

  • 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!


Types of exercises treatment approaches for pd

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


Lsvt loud big

LSVT LOUD/BIG

  • LSVT = Lee Silverman Voice Treatment

  • LOUD/BIG focuses on:

    • high effort

    • single attentional focus (AMPLITUDE)

    • overlearned movements

    • LOTS of repetition

    • sensory awareness retraining


Lsvt loud big1

LSVT LOUD/BIG

  • 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! MOVESconcepts that can be incorporated into any exercise program


Current concepts in physical therapy for people with parkinson s disease

PWR! Hands


Current concepts in physical therapy for people with parkinson s disease

PWR! Reach


Current concepts in physical therapy for people with parkinson s disease

PWR!

Reach


Current concepts in physical therapy for people with parkinson s disease

PWR!

Reach


Current concepts in physical therapy for people with parkinson s disease

PWR!

Rock


Current concepts in physical therapy for people with parkinson s disease

PWR! Rock


Current concepts in physical therapy for people with parkinson s disease

PWR!

Twist


Current concepts in physical therapy for people with parkinson s disease

PWR! Step


Current concepts in physical therapy for people with parkinson s disease

PWR!

Turn


Pwr voice

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


Pwr progression

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


Pwr video

PWR! video


What we want

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!!!


People with pd can get better and stay better longer with exercise

People with PD CAN get better and STAY better longer with exercise!!!


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