Build Your Parkinson’s Success Box

Presented by

Dr. Meredith Roberts Lo, PT, DPT

Roberts Empowered Movement Center

Meredith@RobertsEmpoweredMovement.com

Getting the Ball Rolling – Social Interaction Intervention

Someone who has lived in another

country.

Someone who has had a pet

other than a dog or cat.

Someone who is really tall. Someone who has a job and

is also studying.

Someone who has broken the same

bone twice.

Someone who has locked themselves

out of their car.

Someone who has an obscure

hobby.

Someone who loves

eating aeroplane food.

Someone who is left

handed.

Someone who has never seen a Harry

Potter film.

Someone who has broken a window.

Someone who has more than

three siblings.

Someone who doesn’t like

chocolate.

Someone who goes on an

annual camping trip.

Someone who likes reading comics.

Someone who loves to dance.

Someone who has ridden a

camel.

Someone has acted in a

movie.

Someone you've never met

before

Someone who has the same birth-

month as you.

Someone who has eaten chicken-feet.

Someone who doesn’t have

Facebook.

Someone who plays

tennis.

Someone who doesn't like

dessert.

Someone has travelled to at least 3

other countries.

Learning Objectives Expand knowledge base and understanding of Parkinson’s

Expand

Identify key components that impact assessment and treatment

Identify

Implement effective assessment tools with positive outcomes

Implement

Understand current research and convert into treatment strategies

Understand

Develop creative interventions that address key components of PD

Develop

Implement interventions with progression and modification

Implement

Understand importance of continuum and community exercise

Understand 3

Todays Goals

• You CAN get people with Parkinson’s better

• You CAN help them stay better

• You NEED creative ideas to put into play on Monday

3 Keys to Success

• Resiliency

• Exercise as Medicine

• Community

What is Your Story of Parkinson’s?

• Does Parkinson’s always win?

John’s Story

• “I may have Parkinson’s but it doesn’t have me!”

He’s Not the Only One

• Many stories like his

• “I may have Parkinson’s but it doesn’t have me!”

• I’m going to fight back

• They are not just born with it!

Resiliency

• You are in control, not the disease

• The ability to pick yourself back up and take a step forward

• To problem solve through barriers and find solutions

• You can learn this!

• At any age

• In any circumstance

“Low Outcome Expectation”

• Number 1 BARRIER to EXERCISE in people with Parkinson’s

• Journal of American Physical Therapy Association • Terry Ellis et al • Published online January 3 2013

• Fear of falling (#2)

• Lack of time (#3)

• Ellis, Terry et al. “Barriers to Exercise in Person’s with

PD” PT Journal Online January 2013

“They are able because they think they are able”. Virgil

How Do You Learn to be Resilient?

• Set goals for yourself

• Work towards them

• Learn along the way

• Acquire a set of skills that help to problem solve and move forward

• Meet your goals and build confidence!

• As the goals grow so does your resiliency level

• The higher the better

Dopamine Release!

• Each time you write a tangible goal

• And meet it

• Check it off your list

• Get a step closer

• You receive a hit of dopamine

• This rewards us and encourages us to keep going

Draw on Your Life Experiences

• What have you tried to change in your life? • Loose weight

• Start exercising

• Quit smoking

• What has worked well for you to find success? • Set goals and action steps

• Find a buddy to do it with you

• Tell someone and have them hold you accountable

• Join a group

• Find a coach or mentor

Creating New Health Habits

• Requires more that dopamine release:

• Coaching and guidance

• Leadership we can look up to

• Serotonin is now released.

• Leadership chemical to help us feel good and want to continue

• We want to make others proud of us

Therapy and Behavior Change

• Bas Bloom and the ParkFit study

• Two year study (n= 586) Netherlands, Bas Bloom

• PD specific therapy vs adding coaching to therapy

• Included: goal setting, overcoming barriers, social support, one on one coaching, activity monitor with daily visual feedback

• Who do you think did better?

• And STAYED BETTER?

PD SELF and Quality of Life

• Diane Cook and University of Colorado

• People with a high level of self-efficacy (AKA resiliency) do better

• People with PD can learn this in a 9 month curriculum

• Their care partner benefits just as much from the program

• Resiliency can be taught at any age and any circumstance

Community and Behavior Change

• Dopamine and Serotonin are good

• If we feel isolated, alone, and like no one else is in this with us…

• It’s not enough

• Oxytocin the community chemical

• Giving to others so they may gain

• Created through shared adversity

• Created through human contact

What Can We Do Different?

• Ask your patient – “What is most important for you to change?”

• How can we get there…

• What are they accomplishing now? • Victories

• What small things can they build on next week? • Action steps

Then review and hold them accountable. Guide them in problem solving if things didn’t go as expected.

The Small Things Matter

• Victories and Goals:

• 3 cups of water -> 4 cups of water

• 1 walk to the mailbox –> 2 walks to the mailbox

• 2 trips up the stairs -> 3 trips up the stairs

• Attended class or support group -> attend again next month

• Do research on a symptom of PD -> determine one action step to try

Use Cues to Help Track and Reward • Tracking for success

• Calendar

• Tracking sheet

• Pennies in a cup

• Empty water bottles

• Fitness monitors

• Smart phone apps

• Find rewards in achievement and by rewarding self with external things (pedicure, ice cream…)

Transition to Community Accountability • Begin to help them find people in their

communities to help with accountability and problem solving when therapy ends

• Friend

• Family

• Class instructor

• Buddy from class or support group

• Ambassador from Parkinson’s Foundation or Davis Phinney Foundation

Why it Works

• Writing it down reinforces memory and our commitment getting close – DOPAMINE RELEASE

• Checking it off the list reinforces the reward center in our brain – DOPAMINE RELEASE

• Getting praise from our coach reinforces the reward center more – SEROTONIN RELEASE

• Connecting with others who are going through what we are, who want to help us, who struggle like we do – OXYTOCIN RELEASE

The Result

• New health habits develop over time

• The patient builds confidence that they can influence their symptoms

• They TRUST that there is a community that has their back, no matter what

• They keep trying each day despite barriers

• We also get a release of these chemicals and remember WHY we LOVE what we do

• Even when we may not like our day

The Resilience Scale

• Move them from low to high

• Change your burnout level from high to low by

• Getting your patients better and help them stay better

“The secret of change is to focus all of your energy not on fighting the old but on

building the new.”

-Socrates

26

Understanding the NEW Parkinson’s

The NEW Parkinson’s

• What is the umbrella of Parkinson’s?

• Why do we get Parkinson’s?

• What is going on in the brain of someone with Parkinson’s?

• How do we diagnose Parkinson’s?

• What are the symptoms of Parkinson’s?

The Umbrella of Parkinson’s

• A spectrum disorder housing many types

• Typical or primary idiopathic Parkinson’s • Tremor dominate vs Bradykinetic or rigid dominate

• Atypical or Parkinson’s Plus Syndrome • PSP, MSA, Corticobasal Degeneration

• Secondary Parkinson’s • Dementia with Lewy bodies, Vascular Parkinson's

When You Have Seen One Person

with Parkinson’s,

You Have Seen One

Person with Parkinson’s

30

Parkinson’s as a Cafeteria Disease

• Long list of symptoms

• Not everyone will have every symptoms

• We can all go through the same cafeteria

• Our trays all look different when we sit down

Who gets Parkinson’s?

• Age – over 62 increased risk

• Race – no difference in risk

• Gender - men only 1.2% higher risk

• Smoking – decreased risk

• Coffee consumption – decreased risk

• High levels of uric acid – decreased risk

• Increased use of NSAIDS – decreased risk

What Causes Parkinson’s?

• Environmental Factors

• Pesticides/herbicides

• Industrial chemicals

• Heavy metal exposure

• Agent orange

• Genetic Factors

• LRRK2

• PARK7

• PINK1

• PRKN

• SNCA

• Parkinson disease - Genetics Home Reference - NIH

• https://ghr.nlm.nih.gov/condition/parkinson-disease

The Perfect Storm

• 85% considered idiopathic

• 15% considered hereditary

• 4-9% increased risk if family member has Parkinson’s (may be exposed to same environment)

• Central Valley of California USC study

• Compared exposure to pesticides and genetic risk

• 10%-25% increased risk alone

• 80-85% risk combined

Pathogenesis of Parkinson’s • Protein accumulation – Lewy bodies

• Oxidative stress

• Mitochondrial dysfunction

• Neuro inflammation

• Apoptosis cascade

35

https://youtu.be/8mvUDiBQbjg Kahn Academy

36

The Importance of the Basal Ganglia • 60-80% of dopamine producing cells have died at

diagnosis

• Basal Ganglia: • Grading movement along with starting and stopping

• Automatic movements and sequences

• Sensory input – internal compass

• Cognition and duel tasking influences

• Dopamine is: • A reward neurotransmitter

• A feel good neurotransmitter

Everything Slows Down • Gait

• Shuffling gait

• Freezing of gait

• Impaired body awareness

• Impaired internal feedback

• Heavy reliance on external feedback

• Emotional expression

• Masked face

• Sexual dysfunction

• Loss of smell

• Speech

• Quiet speech

• Stuttering and stammering,

• Imprecise articulation

• Swallowing

• Extended chew time

• Unintended weight loss

• Loss of appetite

• Difficulty triggering swallow

• Excessive drooling 38

Diagnosing Parkinson’s

• Clinical diagnosis

• Rule out other potential problems

• Try medication and see if it helps

• Watch, wait and see

DAT Scan • Newer technology

• I-123 Ioflupane (DaTscan)

• SPECT scanner

• Intensity of the striatal signal

• Left and right caudate and putamen

• Essential tremor vs PD

• Unable to differentiate PSP or MSA

40

Physicians Use the UPDRS

• Unified Parkinson’s Disease Rating Scale (UPDRS): • Extensive rating scale used universally by clinicians

• 5 sections (3 major and 2 scales)

• Mentation, behavior and mood

• ADLS (self reported)

• Motor Section

• Provides comprehensive score of disability

• Not ideal for identifying specific deficits

• http://rdcu.be/vxQF/

Determining the Severity • Hoehn and Yahr Staging:

• Stage 0 – no signs of disease

• Stage 1 – unilateral disease

• Stage 1.5 – unilateral plus axial involvement

• Stage 2 – bilateral disease with balance impairment

• Stage 2.5 – mild bilateral disease with recovery on pull test

• Stage 3 – mid to moderate disease with some postural instability

• Stage 4 – severe disability still able to walk or stand unassisted

• Stage 5 – wheelchair bound or bedridden unless aided

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Prognosis and Parkinson’s

• Poorer prognosis occurs with: • Older age

• Earlier cognitive problems

• Comorbidities

• Greater level of baseline impairment

• Decreased response to dopaminergics

• Presentation with rigidity and bradykinesia instead of tremor dominant

• DECREASED ACTIVITY LEVEL AND SOCIAL ISOLATION

Motor Symptoms of Typical or Idiopathic Parkinson’s • Bradykinesia

• Rigidity

• Postural control impairments

• Tremor

Parkinson’s Plus Syndromes

• Video Found at: https://youtu.be/Qn4VrJRiBOk By Cure PSP Published September 2016

Progressive Supranuclear Palsy

• Surprised look

• Difficulty controlling eye lids

• Vertical nystagmus

• Cognitive, speech, swallow changes

• Vestibular/visual balance impairment

• Emotional liability and problems with anger and angry outbursts or irritability

• Depression, anxiety and apathy

46

Corticobasal Degeneration

• Asymmetric bradykinesia

• Upper limb dystonia and myoclonus

• Postural instability

• Disturbances of languages (hesitant and halting speech)

• Visual spatial impairment

• Apraxia

• Dysphagia

Multisystem Atrophy

• Two types:

• Parkinsonian type (MSA-P) • Bradykinesia

• Severe postural control impairment - Pisa syndrome

• Autonomic nervous system dysfunction (BP, bladder)

• Cerebellar type (MSA-C) • Cerebellar dysfunction

• Difficulty swallowing

• Speech impairment with quavering voice

• Abnormal eye movements

All Have These Characteristics

• Early balance impairments

• Early cognitive impairments

• Poor response to common PD medications

• Progress much faster

• DBS can accelerate progression

Secondary Parkinson’s

• Parkinson’s caused by something else:

• Medication or drug induced

• Metabolic

• Trauma

• Vascular

• Post encephalopathic

• Brain tumor

Dementia with Lewy Bodies

• Parkinson’s symptoms (slowness, stiffness, tremor)

• AND • Vivid hallucinations

• Behavior rapidly changes and shifts

• Attention and memory declines

DLB and PD – Same Disease?

• Build-up of Lewy bodies

• Accumulated bits of alpha-synuclein protein inside the nuclei of neurons

• Don’t know: why alpha-synuclein accumulates into Lewy bodies or how Lewy bodies cause the symptoms

• Do know: alpha-synuclein accumulation is also linked to Parkinson's disease, multiple system atrophy, and several other disorders called “synucleinopathies”

• Lewy bodies are often also found in the brains of people with Parkinson's and Alzheimer’s diseases.

• Suggests that either DLB is related to these other causes of dementia or that an individual can have both diseases at the same time.

Vascular Parkinson’s

• Caused by a small stroke or lacunar infarcts

• After which Parkinson’s symptoms develop

• Balance and gait dysfunction common

• “Lower limb Parkinson’s symptoms”

• Less likely to have a tremor

• More urinary incontinence

The Laundry List of Symptoms

• Motor symptoms • Bradykinesia • Rigidity • Tremor • Postural control impairments (balance)

• Non-motor symptoms • Autonomic nervous system dysfunction • Sleep dysfunction • Limbic system dysfunction • Gastrointestinal dysfunction • Cognition changes

Assessment and Treatment of Specific Impairments Identifying and improving the laundry list of symptoms

Impaired Sensory Integration

• If my compass is broken how do I know?

• Look outside how I FEEL

• External Cues • Visual – best to keep movement full amplitude

• Auditory – best to maintain timing of movement

• Tactile – ties it all together

Bradykinesia

• Video – looks like slowness of movement

Bradykinesia Assessment

• Assessment tools: Are you timing them?

• PT: Gait speed tests • 10 Meter, 2 min walk, 6 min walk, 20ft timed walk,

• OT: Fine motor and ADLs • 9 hole peg test, Minnesota, timed ADLs

• Both: Mobility and fall risk • 30 sec chair stand, 5 time sit to stand, TUG (tug cognitive

and fine motor)

Decreased Amplitude of Movement Assessment • Assessment: Does it get smaller over time?

• PT: • Step length, steps per minute, stands per min

• OT: • Fine motor finger taps or handwriting over time, ADL

shirt buttons

• Both: • Sit to stand fading and falling back into chair only rising

halfway

Bradykinesia Treatment

• Treatment Strategies: Auditory cues • Sit to stand relay race

• Line Drill

• Caterpillar drill

• ADL dance to fast music with focus on specific new skills • Finger flick

• Towel flick

• Shake out clothes

Decreased Amplitude Treatment

• Treatment Strategies: Visual cues

• Keep it BIG as long as possible • Sit to stand relay race with laser pointer for upright

posture or reach for ball overhead

• Ladder drill and step to targets on floor for big steps

• Handwriting • Use lined paper that provides visual cue for full letters

Case Study

• Group 1: Acute Care

• Group 2: Skilled nursing/inpatient rehab

• Group 3: Home health

• Group 4: Outpatient

• One treatment intervention for your setting

• Progress it to something the PWP can do at home as an HEP

Case Study 1 • 78 y/o male recently diagnosed with idiopathic PD

• Focus on small and slow movement with sit to stands and tendency to fall back into chair

• Presents with self reported worsening balance, gait, thinking

• Findings on exam include: • Lacks 5 degrees of DF bilaterally • Proximal strength 3+/5 • Impaired proprioception, body awareness, perception • Moderate rigidity with significant forward flexed posture • Stands from chair with multiple attempts • Very slow and shuffling gait, stooped posture no arm swing left • Moderate bradykinesia and mod resting tremor left UE • Increased time for processing all commands and questions • Has fallen a couple times this month outside, reaching up into high

closet

63

Rigidity

• Video – looks like stiffness

Rigidity Assessment

• Assessment: What are the function results of rigidity?

• PT: length of hip flexors, hamstrings, and gastrocnemius

• Thomas test, Ober test, adductor and gastroc length

• OT: shoulder flexibility, fine motor • Back scratch test, forward reach test, pinch and grasp

• Both: posture measures • Occiput to wall, Functional Axial Mobility, Modified

Ashworth scale

Rigidity Treatment

• Treatment Strategies:

• Parkinson’s Wellness Recovery – PWR!4life.org

• Big and Loud

• PNF/NDT

• Axial Mobility Program

• Dance for PD with the Mark Morris Dance Company

• Yoga, meditation, mindfulness

Parkinson’s Wellness Recovery

• Power up

• Power rock

• Power twist

• Power step

• Can be done in any position and modified

• Good HEP and movement prep

• Video’s and book available online

• www.PWR!4LIFE.org

Case Study

• Group 1: Skilled nursing/inpatient rehab

• Group 2: Home health

• Group 3: Outpatient

• Group 4: Acute Care

• One treatment intervention for your setting

• Progress it to something the PWP can do at home as an HEP

Case Study 2

• 72 y/o male diagnosed a few years prior

• Pt with severe rigidity focus on reducing tone

• Pt lives with wife at home who works during day

• Decreased length of hamstrings, heel cords, adductors and hip flexors, pt sits most of day

• Decreased lateral flexion and rotation of spine at all levels

• Pt stands with crouched posture

• Demonstrates shuffling, festinating and freezing of gait with rising onto toes as a predictor of a freeze

Postural Control

• Video – looks like a tree in the forest falling forward or back

Postural Control Assessment

• Assessment: • Pull test

• Push test

• Perturbations

• Do they use their strategies and appropriately? • Ankle

• Hip

• Stepping

Postural Control Treatment

• Ankle reactions and hip reactions • Sit to stand with external cues

• Do the “Beyoncé”

• Anterior weight shift off wall

• Look up and reach up

• Stepping strategies • Clock Yourself app – clock stepping

• Balloon tennis in standing – random reactions

Anticipatory Balance Assessment

• Assessment:

• 5 time sit to stand or 30 sec chair stand

• 4 square step

• Forward, backward or lateral reach

• Rise onto toes

Anticipatory Balance Treatment

• Treatment:

• Weight shifting appropriately

• Add visual cue for full movement

• Use music to create rhythmicity • Tapping drum anterior-posterior in prep for stand

• Laterally in prep for stepping or reaching

• Sailors dance in prep for breaking freezing of gait

• Balloon tennis with racket to increase challenge

Somatosensory Balance Assessment • Assessment :

• Standing Romberg

• Standing on foam or incline

• CTSIB

Somatosensory Treatment

• Treatment:

• Foot placement with sensory targets

• Balance MATters – step and connect

• Whoopie cushions

• Hand placement

• Drums, boom whackers, tambourine

• Midline orientation

• Balanced Based Torso Weighting

Vestibular Balance Assessment

• Assessment:

• Dynamic Gait Index

• Vestibular assessment

• Gaze stabilization

• Head shake test

• H – test

Visual and Vestibular Treatment

• Treatment:

• Hitchhiker – VOR gaze stabilization

• Progress seated, standing, Romberg, foam, incline

• Gait with gaze stabilization using targets • Room numbers

• Stroop cards

• Paintings on wall

• Post it notes

Visual Spatial Orientation Treatment • Visual seeking tasks

• Alphabet on floor and wall – spell words

• Scavenger hunt

• Reinforce posture with ball toss up or overhead to wall

• Way finding • Map - can you find…

• Maze on wall

• Body in space awareness • Twister with hiking poles

• Do what I do

Sequential Coordination Treatment • Pattern of movement put into a sequence

• Highlight ending each part of the sequence • Tada!

• Visual target of x on floor for foot placement

• Electric slide or any dance

• Boxing punches 1-6 (jab, cross, hook, hook, up, up)

• Tai chi

• Dance for PD program with Mark Morris Dance Co

Duel Task Assessment

• TUG cognitive and fine motor • Cognitive – count back by 3s, cities in order of alphabet

• Fine motor – carry water, toss scarf, toss ball

• 10% change in speed

• Errors and what do they prioritize? • Fall

• Stop talking

• Stop hand motion or spill

Duel Task Treatment

• Procedural memory – Station activity (3 stations squats, punches, jumping jacks) or ADL stations (brush teeth, wash face, dress)

• Sequencing – 1 through 6 boxing combinations

• Set shifting – given 2 numbers, shadow box first sequence, run to new bag or spot and shadow box second number

• Verbal recall and retention – Mad lips, story telling where each new person builds on the story and then the group recaps at the end what happened

Motor Impersistence - Freezing

• Decreased amplitude

• Poor timing of movement

• Fading or degradation of movement over time

• Gait = Freezing

• Fine motor = Micrographia, inability to manage full shirt of buttons

• Speech = stuttering or stammering

Freezing Triggers - Gait

• Starting

• Stopping

• Turning

• Environment and anxiety

• Assessment:

• Freezing of gait questionnaire

• TUG as a screen

Freezing of Gait Treatment

• Compensation

• 4 S of Freezing • Stop

• Spread

• Sway

• Step

Freezing of Gait Treatment

• Prevention

• Keep the amplitude BIG

• Visual targets

• Maintain the timing of movement

• Auditory targets

• These boots were made for walking with whoopie cushions

Fine Motor Freezing Treatment

• Compensate

• Finger flicks – activate

• Boxing mitts or high fives and thigh slap/clap

• Prevent

• Keep it BIG with visual cues • Lined paper with bumps

• Maintain the timing with auditory cues • ADL dance set to strong beat music

Fine Motor – Tremor Assessment

• Tremor assessment form:

• Identify type of tremor • Resting

• Postural

• Task specific

• Kinetic

• Identify how it affects ADLs

Fine Motor – Tremor Treatment

• Reduce anxiety and stress:

• Progressive Relaxation

• Meditation

• Mindfulness and breathing exercise

• Activate – opposes resting tremor

• Calm the nervous system • Exercise

• Weighted vest or external objects like utensils, pen etc

Freezing of Voice Treatment

• Compensate

• Relaxation therapy, breath control, calm anxiety

• Prevent

• Visual cues for over articulation and oral motor control

• Auditory cues for timing and rate of speech • Drum beat, metronome or cadence meter via music

Voice Assessment and SLP

• Vocal Handicap Index

• S/Z Ratio

• Sustained Phonation

• Pitch Range

• Reading Passage

• Oral motor exam

• Swallowing exam

Voice Therapy

• Lee Silverman Voice Therapy – Speech Therapy

• Music Therapy • Vocal drills to improve sound formation and articulation

• Breathing exercise to enhance volume

• External cues to measure performance

• Volume – decimeter app

• Facial expressions and body language – acting class “making faces”

• I love to laugh song with wicked witch, princess…

Voice Treatment Example

• I love to laugh

• Ha, Ha, Ha, Haaaaa (Disney princess voice)

• Loud and long and clear

• I love to Laugh

• Ha, Ha, Ha, Haaaaa (wicked witch laugh)

• So everybody can hear

• And the more I laugh

• Ha, Ha, Ha, Haaaaa (evil laugh)

• The more I fill with glee

• And the more the glee

• He, he, he, heeee (your choice)

• The more I’m a merrier me!

Balance Standardized Tests

• Are you testing the right things?

• Berg • High floor and low ceiling affect

• Hard to show change unless perfect patient

• Consider the items on the Berg – are they the things that people with PD have trouble with?

• Tinetti • Outdated test – even test creator says use other tests

• They get points for feet together!

Balance Assessment Upgrade

• High level: • Community Balance and Mobility Scale

• HiMAT

• Intermediate: • Mini Best test

• Functional Gait

• Low level: • FIST

Lab Work – Balance Assessments

• Break into groups

• Practice test most appropriate to your setting

• Teach class one to two items on test

Balance Assessments

• Commonly asked questions:

• Yes you can: • Use an assistive device – just document and score

appropriately

• Do pieces of the test – just can’t compare to age matched norms

• Use a calf stretch or incline board or WC ramp, wedge, river stone

Standardized Test Scoring

• AbilityLab.org (rehabmeasures.org)

• Parkinson’s norms (along with other groups)

• MiniBest 22/28 or higher

• FGA 22/30 or higher

• FIST 42/56 or lower less likely to discharge home • https://www.samuelmerritt.edu/fist

• CB&MS 65/96 or higher

• 5x sit to stand 14 sec or less watch for control

• TUG and TUG cognitive 14 sec or less and 10% change in time

Balance Confidence Scales

•Falls Efficacy

•Activities Specific Balance Confidence Scale

•Fear of falling is a predictor of falls

ADL Standardized Tests

• Elderly Mobility Scale

• SLUMS

• Modified Barthal

• Patient specific functional scale

• Activities of Daily Living Index

Case Study – 3

• Focus on Freezing and walking balance for your treatment intervention

• 72 y/o male who walks without AD

• Falling when experiences freezing episodes

• Freezes on eval when: starts to walk, turns, and moves through doorway, onto carpet and with any duel task such as TUG cognitive and fine motor

• Pt with executive function impairment – decreased procedural memory to 2 items at a time on recall

Case Study - 4

• Focus on postural control during mobility and gait

• Pt goal to avoiding falling backwards

• Pt with young onset PD 55 y/o recently stopped working because he was falling frequently

• Difficulty with 5x sit to stand falls backwards into chair on 2nd stand with no ankle, hip reactions

• Delayed response on push test in all directions, pt falls in posterior direction with no stepping responses

• Noted bradyphrenia with instructions, masked face and very soft voice on eval

Case Study – 5

• Focus on body in space awareness, visual vestibular and midline orientation

• Pt is a 66 y/o male who has a possible diagnosis of PD and a history of bleed and seizures

• Pt walks with step to pattern dragging cane along • Pt sits and stands leaning posterior and to right, chin

tucked to chest and rotated right, dec gaze stabilization • Able to reach and orient to left with decreased

awareness, attention, and distance to left vs right side. • Pt with mod difficulty maintaining midline orientation

and on balance testing frequently falls left and posterior in standing, loss of balance with head turns and gait, turning 180 deg and backwards walking

Case Study – 6

• Focus on somatosensory, foot placement, and walking balance for return to hiking

• Pt 64 y/o male with surprised look to face, slurred speech, drooling, droopy eyelids, and difficulty with gaze stabilization, unsmooth pursuits on H test, and LOB with head turns during gait

• Pt with LOB and inc sway with Romberg, standing on foam, and walking with eyes closed

• Pt with poor foot placement tendency to maintain feet close together with either too slow movement or too fast movement and difficulty grading in between.

Non Motor Symptoms

• Sleep: • Fragmented sleep – wake up too early

• REM Sleep behavior disorder – acting out dreams

• Treatment:

• Regular exercise

• Good sleep hygiene habits

• Medication

• Over the counter medication – Melatonin or CBD oil

Non Motor Symptoms

• Gastrointestinal system slows down: • Constipation and poor absorption

• Treatment: • Regular exercise • Drinking enough water • Eating foods high in fiber • Supplementing a home recipe (prune juice, oat bran,

applesauce) • Over the counter fiber, smooth move teas, medications • Use regularly to avoid roller-coaster of diarrhea and

constipation

Non Motor Symptoms

• Autonomic nervous system dysfunction: • Orthostatic hypotension, large swings in blood pressure • Exercise intolerance, temperature intolerance, excessive

sweating

• Treatment: Are they still on HTN medication?

• Electrolyte water and enough of it

• Compression garments

• Prolonged warm up and cool down

• Slow incremental changes to intensity level (pyramid intervals)

Non Motor Symptoms

• Limbic system and mood: • Depression • Anxiety • Apathy

• Treatment: • Regular exercise • Gratitude practice • Counseling, social support, support groups, ambassador

program • Medications • Finding the fun again

Non Motor Symptoms

• Cognition: • Bradyphrenia

• Executive function impairment

• Treatment: • Regular exercise

• Hydration (study regarding hydrated and non hydrated adults MCI)

• Social interaction – face to face conversations # 1 tool

• Use it or loose it

Executive Function Impairment

• New learning – is it possible?

• Medicare cares!

• This is NOT dementia!

• In your assessment tell them why you need more time with them!

• “Pt with executive function impairment. Requires increased time and repetition for new learning. Is demonstrating new learning by…”

Executive Function Impairment

• Assessment • MOCA

• Screen with clock drawing test, 3 word recall

• Treatment – Duel task

• Start where they are successful

• Slowly progress and challenge them

• Help problem solving when duel tasking is safe and when it’s not safe

• Transfer into real life skills

Medical Management Optimizing movement and your ability to create change

Treatment of Symptoms

• Medications help: • Bradykinesia

• Rigidity

• Tremor

• They don’t help balance

• No cure yet!

• Just help the symptoms and OPTIMIZE MOVEMENT

Motor and Key Terms:

“Wearing off” – symptoms appear before the next scheduled dose of medication is due

“On/off phenomenon” – results in unpredictable swings between medication effectiveness and loss of function

“Delayed on” – occurs when medications appear to take longer to improve function after taking scheduled dose

“Dystonia”- muscle twisting, spasm or cramp, often in foot or toes related to too low or too high a dose of Sinemet in system

“Dysmetria” – difficulty timing and scaling movement to meet goal 114

Medication Big Picture

• Dopamine replacing

• Dopamine agonist

• Dopamine extenders

• Anti tremor drugs

Sinemet® Dopamine Replacement • Medication delivery

options: • Oral

• Controlled release

• Extended release

• Sublingual • Patch • G tube gel

• Side Effects • Nausea and

vomiting • Loss of appetite • Lightheadedness • Low blood

pressure • Confusion

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Sinemet® and Medication Timing

• Therapeutic window:

• Fill up the gas tank and go

• Over 6 hours use up all the gas and stop

• Need to refill the tank to go

• As disease progresses brain can’t keep “gas” or dopamine in the system as long

• Need to refill the tank sooner

• Dependent on disease PROGRESSION not amount of total time on medication

Sinemet® and Patterns

• Each time you come to see patient

• Looks like next dose is due before scheduled time

• In an off phase and hard to progress

• WHAT IF?

• Go to team – functionally… Not progressing, can’t return home, needs rehab, high risk for falls

• Could we… review the medications, see the neurologist sooner?

Sinemet® and Patterns

• How is the patient taking their meds?

• 3 times a day can mean:

• Breakfast, lunch, and dinner • Protein absorbed through same channel in gut • Protein wins • Avoid protein 30 min before or after taking Sinemet

• Morning, noon, and night • Outside the 6 hours window by bedtime • Do we need movement medicine at bedtime? • What if we take it when we need it earlier in evening?

Sinemet® and Rescue Dose

• Getting medications on time prevents “off” period

• Barriers include:

• Patient forgets • Memory compensation and tricks

• Nursing does not provide on time

• What if? • Premedicate like pain medicine (ask or set schedule)

• Use Sinemet under tongue or in carbonated beverage 15 min or less in system

Sinemet® and Symptom Awareness Treatment Ideas • Teaching self awareness of symptoms

• Better communication with MD

• Better optimization of movement

• Davis Phinney Foundation • Worksheets and “Every Victory Counts Manual”

• Specific symptom worksheet

• Medication log and symptom tracker

• Prepare for your doctors visit

Dopamine Agonists • Act like dopamine,

fooling the brain

• Taken up by D1, D2, and D3 receptors

• Used as early monotherapy or with dopaminergics

• Fewer dyskinesias especially with Sinemet

• Medication options:

• Mirapex ® (Pramipaxole)

• Requip ® (Ropinirole)

• Side effects:

• Mild nausea

• Lightheadedness

• Dry mouth

• Constipation

• Impulse control disorders

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Drugs that Extend – MAO B Inhibitors

• Prevent the breakdown of levodopa in the brain

• Reuptake inhibitor – keeps more levodopa in the junction longer

• May be used early as monotherapy and later with dopaminergics

• Medication options:

• Eldepryl ® (Selegiline)

• Breaks down into amphetamine byproducts

• Azilect ® (Rasagiline)

• Side effects:

• Mild nausea

• Lightheadedness

• Dry mouth

• Constipation 123

Drugs that Extend – COMT Inhibitors

• Prevent breakdown of levodopa in the system and to a small extent in the brain

• Taken with Sinemet or other dopamine replacing drugs

• Medication options:

• Comtan ® (Entacpone)

• Stalevo ® (Sinemet and Comtan)

• Side effects:

• Red rust colored urine

• May decrease dyskinesia

• Diarrhea

• Possible confusion or hallucinations

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Drugs for Tremor Control – Anticholinergics

• Primarily controls tremors

• Method of action unclear

• Some of the earliest drug treatment for PD – 1900’s

• Medication options:

• Artane® (Trihexyphenidyl)

• Cogentin®(Benztropine)

• Symmetrel ® (Amantadine)

• Side effects:

• Confusion and/or hallucinations

• Decreased short term memory

• Dry mouth

• Blurry vision

• Urinary retention

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Side Effects Theme

• All the things Parkinson’s already causes

• All add up to an…

• INCREASED RISK FOR FALLS!

Medications to Avoid in Parkinson’s • Medications that

block dopamine • Nausea and constipation

medications:

• Prochlorperazine® (Compazine) – gastroparesis

• Promethazine® (Phenergan) – nausea

• Metoclopramide® (Reglan) – nausea

• INSTEAD: Zofran ®

• Antipsychotic medications:

• Risperdal

• Orap

• Zyprexa

• Haldol

• Prolixin

• Stelazine

• Thorazine

• INSTEAD: Seroquil ® 127

Medication Theme

• Optimizing movement is complex

• There are a lot of options

• Very much trial and error

• Every time they see the doctor may change meds

• Very reliant on the patient report of symptoms

• Helpful to: • See an expert (movement disorder specialist)

• Bring a family member or friend

• Prepare and take notes

Make the Patient the Advocate

• Parkinson’s Foundation – Parkinsonsfoundation.org

• “Hospital ready kit”

• Tools to advocate for self

• Free

• You can order and provide to patient and family

• Davis Phinney Foundation website and book

• Prepare for your hospital stay worksheet

Surgery

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DBS Detailed

• Extensive qualifying workup

• Awake vs Asleep surgery

• Neuromotor exam on placement

• Two primary targets: • Globus Pallidus Pars Interna

(GPI) • Subthalamic Nucleus (STN)

• Battery placed post 2 weeks

• Turn on and program • Prolonged fine tuning

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DBS Detailed

Works best for controlling tremor and only as well as medications worked

Side effects vary related to probe placement and programing

• Speech difficulties

• Cognitive changes

• Balance changes or worsening

• If a Parkinson’s plus syndrome may accelerate decline 132

Exercise as Medicine More than managing the symptoms

Research Update

• Exercise is safe

• Exercise improves movement symptoms

• Exercise changes the brain • Does it slow the progression of the disease?

• Exercise needs to be dosed appropriately to work • What does the exercise Rx look like?

• We have to take it to have it work • So how do we create sustainable programs?

Exercise Matters

• 2252 people with PD one year later

• Aerobic exercise of 150 min a week

• Associated with higher: • Quality of life

• Mobility

• Physical function

• Cognition

• And LESS disease progression! • Oguh O et al. Parkinsonism and Related Disorders 2014

(1-5)

Research

Early evidence mostly experiential

Animal studies

RTC People based studies

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Jay Alberts – Starting with

a Observation

• 2003 – Jay and Kathy ride tandem bikes in RAGBRAI, wrote out a birthday card after a ride, handwriting was great…

• 2007 DBS rides tandem with DBS OFF 4 hours and 40 miles later with DBS off looks like it’s on no tremor or bradykinesia

• Aerobic: 65-80% of target HR zone

• “it’s not about the bike, it is about the pedaling… 2011”

• First study: 3x/week for 8 weeks 5-10 min warm up 40 min main set and cool down, 60-80% HR cadence on tandem 80rpm. Check writing improved compared with voluntary exercise group turned back the clock several years: main findings both groups improve vo2 max, only forced exercise improves clinical ratings

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Assisted Cycling

• (N=10, age 45–74y) in Hoehn and Yahr stages 1 to 3

• rapid cadence cycling intervention (active-assisted cycling)

• single session of AAC at a high cadence

• would it promote improvements in tremor and bradykinesia similar to the on medication state?

• Well tolerated, safe

• Most showed improvements in tremor and bradykinesia

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Animal Models – Jay’s Lab

• Mice inject NTPT to create PD

• Run 30 min a day for 4 weeks on a wheel

• Shocked if they don’t keep up

• FORCED EXERCISE

• Findings: • inc release of dopamine, • decreased synaptic clearance, • inc in dopamine D2 receptor, • BDNF, GDNF, IGF-1

neurotrophic factors with inc release

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Boxing

• N = 6, Boxed for 90 min for 12 and 24 weeks

• Attending 24 to 36 sessions

• Found it’s safe and feasible

• Improved balance and gait scores

• Mild PD improved faster

• More time to see improvements in moderate PD

• May prevent progression?

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TANGO

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Dance

• N = 62, twice a week for one year

• community-based Argentine Tango program or a Control group (no intervention)

• assessed off anti-Parkinson medication at baseline, 3, 6, and 12 months

• Groups same at start or baseline

• Tango group improved in gait, balance, duel tasking, fine motor

• long-term participation in tango may modify progression of disability in PD

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RCT: Are you seeing a pattern?

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Treadmill SPARXS

Study

• Not on medication, early stages of PD

• Exercised 4 days a week

• On a treadmill at 60-65% HR max (n = 45) or 80-85% (n = 43)

• Waitlist control group for 6 months

• No adverse events – ITS SAFE

• Improvement in UPDRS-MDS scores

• People got better or stayed the same!

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Exercise Impact on Parkinson’s

Inhibit cell death

Increase synaptic efficiency

Promote behavioral recovery

DISEASE MODIFYING - Slows, halts, of reverses

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Exercise Prescription

• Goal:

• 150 min of high intensity aerobic activity a week

• Strength 2-3 times a week

• Balance 2-3 times a week

• Flexibility daily after aerobic if possible

• Take home:

• Do what you can when you can because inactivity accelerates the progression and decline!

4 Keys to Neuroplasticity

• Intensity – for them with goal above 65% HR max

• Complexity – new learning in functional ways

• Timing – if you don’t take your meds…

• Saliency – instill belief it works and have FUN!

Activity vs Exercise

Activity the place to start if not exercising

Exercise builds on activity

• Uses 4 keys

• Creates neuroplasticity

• Slows progression of disease

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Maximizing Your Session

• Add exercise

• Prime the pump – prepare for new learning

• Teach the skill or task – high repetition and accuracy

• Reflect on performance – guide in problem solving

• Motivate and repeat

Prime the Pump

• Help achieve a high level of intensity

• FOR THEM!

• Without overfatiguing them

• What if…

• Intervals!

Interval Training

• Warm up

• Moderate intensity

• Alternate with higher intensity

• Cool down

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Home health Intervals

Seated or standing

Straight punches

Marching in place

Sit to stands

Lunges

Climb stairs

Casual walking in house

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Putting it ALL Together

Putting in All Together

• What is their resilience level?

• Do they believe they can get better?

• Assess to find their PD tray of symptoms

• Optimize treatment session - begin with a progression into aerobic exercise that becomes HEP over time

• Pick the impairments to focus on and teach the task with external cues to increase performance

• Have FUN to help motivate!

• Create new habits with weekly victories and goals

• Help guide to community resources that keep it up

Your 3 Tools for Success

• Resiliency

• Exercise as Medicine

• Community

• Break the cycle!

Community

• Community exercise

• Community support and relationships

• Community resiliency

• All release • Dopamine

• Serotonin

• Oxytocin

Community Exercise

• Find a class in your network • Share classes you know about with the group

• Create a class – sell it to your boss • Acute care – reduce hospital readmissions for same

things like falls

• SNF – reduce falls in residents and patients with class

• Home health – marketing partner with community referral group like ALF/ILF to increase referrals

• Outpatient – marketing stay top of mind for discharged clients and keep an eye out for changes

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Models for

Delivery

• Partnered with service providers

• Use of sponsor non profit

• Parkinson’s Association of the Rockies (state organizations)

• Partner with community centers

• YMCA

• Jewish Community Center (JCC)

• Partner with adult communities

• ILF, ALF, over 50 communities

• Cash pay or included in facility fees

Grant Money to

Start a Class

• Peddling 4 Parkinson’s

• Davis Phinney foundation

• Parkinson’s Foundation

• Research Grants and patient sign up:

• Fox trial finder at the Fox Foundation

• Home to ongoing research trials

• Webinars for people with PD

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Train the Trainers

Programs

• Dance for PD with Mark Morris Dance Company

• Rock Steady Boxing

• Parkinson’s Wellness Recovery for fitness instructors

• John Argue’s the Art of Moving

• PD SELF learning forum – PDSELF.org

• Allied Team in Training – for the medical team

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Resilience Community Class

• Founded by Diane Cook

• Mission to teach newly diagnosed RESILIENCY

• 9 month course that teaches tools for self efficacy

• Free for participants

• For both care partner and person with Parkinson’s

• Professional (PT) and person with Parkinson’s co-teach

• www.PDSELF.org

• Grant money available to make it no cost

Community Support and Relationships • Support groups

• Exercise classes become mini support groups

• Ambassador program through: • Davis Phinney Foundation

• Parkinson’s Foundation

• Connect patients • In the gym, sit them together at lunch or other activities,

connect them (with permission) via phone or email

Provide With Print Resources

• Davis Phinney Foundation

• Every Victory Counts Manual

• Parkinson’s Exercise Essentials

• More than a Mountain: Our Leap of Faith by Lori Schneider

• Parkinson’s Treatment, 10 Secrets to a Happier Life by Michael Okun

• Optimal Health with Parkinson’s Disease by Monique Giroux

• Parkinson’s Disease & the Art of Moving by John Argue

• Parkinson’s Disease Foundation:

• Hospital Ready Kit

• Parkinson’s Disease Resource List

• Diagnosis Parkinson’s disease: you are not alone

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John’s Story Today

• The true power and meaning behind

• Resiliency

• Exercise as medicine

• Community

• “I may have Parkinson’s but Parkinson’s doesn’t have me!”

Favorite Toys for the Clinic Metronome vibrating watch (Soundbrenner pulse)

Metronome app for smart phone,

Music with fixed cadence between 90-100 bpm (client specific) and Tempo Slow Mo app

Musical instruments: tambourine, drum, boom whackers, boom racquets, shakers,

Nordic/hiking poles, Treadmills, large therapy balls to kick

Safety harness and suspension for safety, Alter G

Balance Matters mat Step and Connect and Move Mor Board

Agility ladders, cones, hurdles, resistance bands, clickers 170

Wrap Up

Post test review

Questions

One take away from the day

• Something you will use Monday

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Thank You Dr. Meredith Roberts, DPT

Roberts Empowered Movement Center

Meredith@RobertsEmpoweredMovement.com

www.linkedin.com/in/meredith-roberts-remcenter

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