current concepts in physical therapy for people with parkinson’s disease tim pazier, mpt...
TRANSCRIPT
Current Concepts in Physical Current Concepts in Physical Therapy for People with Therapy for People with
Parkinson’s DiseaseParkinson’s Disease
Tim Pazier, MPTFranciscan Health System
PWR! certified clinicianLSVT BIG certified clinician
“ “Lack of activity destroys the good condition Lack of activity destroys the good condition of every human being, while movement and of every human being, while movement and methodical physical exercise save it and preserve methodical physical exercise save it and preserve
it”it”
PlatoPlato
Overview Overview The effect of Parkinson’s disease
(PD) on movementThe role of physical therapy in PDExercise principles to improve
functionFramework for exercise and PD
The effect of PD on The effect of PD on movementmovementProgressive neurodegenerative
diseaseMotor deficits:
◦ slowness of movement (bradykinesia)◦ decreased amplitude (hypokinesia)◦ rigidity, tremor◦ decreased balance/postural reactions◦ freezing◦ postural changes
The effect of PD on The effect of PD on movementmovementNon-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 TherapyPD and Physical TherapyHistorically: Physical Therapy
prescribed once person is fallingBy then, > 70% loss of dopamine
cellsIdeally, 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 PTGoals of PTSlow sensorimotor deteriorationPrevent fallsEstablish home exercise program
that challenges the person with PD
Follow up every 3-6 months
The science behind exerciseThe science behind exerciseNeuroplasticity – 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 - Science, exercise, and PD - in the labin the labExercise 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 - Science, exercise, and PD - in the labin the labFindings in the lab can be applied
in the clinicChanges in brain function can be
seen indirectly:◦Improved balance◦Increased speed and amplitude of
movement◦Decreased freezing
Principles of recovery and Principles of recovery and improved functionimproved functionUse it or lose it!
◦inactivity contributes to PDUse it AND improve it!
◦extended training can strengthen neural connections
Continuous exercise matters◦gains will be lost if exercise stopped
Principles of recovery and Principles of recovery and improved functionimproved functionTiming 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 Principles of recovery and improved functionimproved functionRepetition key for learning
◦lots of practice neededSpecificity matters
◦therapy should focus on what is difficult
Empower◦people with PD CAN get better
Exercise and Physical Exercise and Physical TherapyTherapyNo one exercise program found
to be the best approachHowever, HOW you exercise is
the key…
Parkinson’s Wellness Recovery (PWR!)
(see www.nfnw.org )
Parkinson’s Wellness Parkinson’s Wellness Recovery (PWR!)Recovery (PWR!)NOT a specific exercise regimen,
BUT a framework for treatmentUtilizes the latest researchCan be incorporated into any
exercise regimen
Prepare!Prepare!Remove fear of movementSimplify movementsFocus attentionMovements modeled to enhance
awarenessCardio training to “prime the
pump”Alignment important
Activate!Activate!Push effort BEYOND self-selectedWhole 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
movementsHelp identify normal performanceReduce reliance of visionGoal 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 Types of exercises/treatment approaches for PDapproaches for PDTreadmillTai chiBoxingTangoTandem cycling (forced spinning)Nordic walkingSensorimotor agility programAuditory cueing - metronomeLSVT LOUD/BIG
LSVT LOUD/BIGLSVT LOUD/BIGLSVT = Lee Silverman Voice
TreatmentLOUD/BIG focuses on:
◦high effort◦single attentional focus (AMPLITUDE)◦overlearned movements◦LOTS of repetition◦sensory awareness retraining
LSVT LOUD/BIGLSVT LOUD/BIGOutcomes:
◦LOUD participants able to sustain loudness 2 yrs after training
◦BIG participants exhibit faster gait and bigger strides, improved reaching, improved trunk rotation
PWR! MOVESPWR! MOVESconcepts that can be concepts that can be incorporated into any incorporated into any
exercise programexercise program
PWR! VoicePWR! VoiceCan be added to any PWR! MovesVoice adds attentional and
physical effortPromotes greater activation (as
seen in LSVT LOUD/BIG hybrid)Focus on breath with movement
important
PWR! progressionPWR! progressionPWR! Moves are the building
blocks for function Functional activities (examples):
- getting in/out of bed- sitting standing- walking
Progress to sports, hobbies, recreation
What we want…What we want…HIGH effortAwareness of movementWork towards whole body
movementsTranslate movements into functional
activitiesSelf cueing/monitoringSupport of caregivers/family to
reinforceNO days off, no excuses!!!