integrating lifestyle medicine into neurologic...

Integrating Lifestyle Medicine into Neurologic Rehabilitation Promote optimal health

Whole person wellness

Prevention of dis-ease and dis-ability

Montana Physical Therapy Summit 2019 MAPTA Fall Conference September 28th - 29th, 2019 Rita Pascoe, DPT, NCS

Objectives

Describe and defend the physical therapists role in implementing lifestyle medicine into clinical practice

Describe how changes in lifestyle and health behavior may positively effect brain and nervous system health

Develop specific tools and strategies to integrate lifestyle medicine and motivational principles into neurologic rehabilitation

Be able to implement motivational interviewing and health promotion practices into neurologic patient care

Understand resources for referral for patients needing specific, ongoing, or other skilled needs outside of the physical therapy scope of practice

Reflection

What does Lifestyle Medicine mean to you?

Do you implement Lifestyle Medicine or Health Promotion in your practice?

Why is it/would it be important and beneficial to implement?

Lifestyle Medicine Health Promotion and Wellness

Definitions: “Lifestyle medicine is the evidence-based therapeutic approach to prevent, treat and reverse lifestyle-related chronic diseases.” - American College of Preventative Medicine “Lifestyle medicine is the evidence-based practice of helping individuals and families adopt and sustain healthy behaviors that affect health and quality of life. Examples of target patient behaviors include, but are not limited to, eliminating tobacco use, improving diet, increasing physical activity, and moderating alcohol consumption.” - American College of Lifestyle medicine

Health Promotion and Wellness Lifestyle Medicine

Core Definitions (APTA Policy BOD Y03-06-16-39):

Health Promotion: Any effort taken to allow an individual, group or community to achieve awareness of – and empowerment to pursue – prevention and wellness

Health: A state of being associated with freedom from disease, injury, and illness that also includes a positive component (wellness) that is associated with quality of life and positive well-being

Wellness: A state of being that incorporates all facets and dimensions of human existence, including physical health, emotional health, spirituality, and social connectivity

Prevention (Institute for Work and Health)

Primary: Prevent a disease or injury from occurring

Secondary: Reduce the impact of disease/injury through screening and early intervention to prevent long-term problems

Tertiary: Soften the impact of ongoing illness and injury to improve function and quality of life as much as possible

Health Promotion and Wellness

Health Priorities for Populations and Individuals

(APTA HOD P06-15-20-11)

• Physical therapists provide education, behavioral strategies, patient advocacy, referral opportunities and identification of supportive resources after screening for:

• - Stress Management - Smoking cessation

• - Sleep health - Nutrition optimization

• - Weight management - Alcohol moderation

• - Violence-free living - Adherence to health care recommendations

Description of Specialty Practice (Neurologic Physical Therapy)

Professional Roles, Responsibilities and Values

Communication

Education

Consultation

Prevention, Wellness and Health Promotion

Social Responsibility and Advocacy

37-11-101. (7) "Physical therapy" means the evaluation, treatment, and instruction of human beings to detect, assess, prevent, correct, alleviate, and limit physical disability, bodily malfunction and pain, injury, and any bodily or mental conditions by the use of therapeutic exercise, prescribed topical medications, and rehabilitative procedures for the purpose of preventing, correcting, or alleviating a physical or mental disability.

37-11-104. (1) Physical therapy evaluation includes the administration, interpretation, and evaluation of tests and measurements of bodily functions and structures; the development of a plan of treatment; consultative, educational, and other advisory services; and instruction and supervision of supportive personnel. (2) Treatment employs, for therapeutic effects, physical measures, activities and devices, for preventive and therapeutic purposes, exercises, rehabilitative procedures, massage, mobilization, and physical agents including but not limited to mechanical devices, heat, cold, air, light, water, electricity, and sound. (3) The evaluation and treatment procedures listed in subsections (1) and (2) may be performed by a licensed physical therapist without referral.

Scope of Practice: Montana PT Practice Act

In my practice, Lifestyle Medicine and Health Promotion looks like: - Foundational approach to patient care - Strategy and perspective when interacting with patients, starting with the initial evaluation and extending through every interaction - Pairing of traditional rehabilitation with additional focus on health and wellness, in all aspects of the patients life - Empowering patients for long term behavior change - Tapping into intrinsic motivation and personal goals - Promoting a more lasting effect on function and quality of life

Why Is It Important?

6 in 10 adults in the US have at least one chronic disease (related to lifestyle modifiable risk factors)

Lifestyle or chronic diseases (non-communicable diseases) are the major cause of morbidity and mortality. They are strongly associated with risk factors or behaviors, such as physical inactivity, unhealthy diet, and tobacco use, and are thus largely preventable.

Leading cause of death and disability in the US:

Heart Disease - Lung Disease

Stroke - Alzheimer’s Disease

Cancer - Diabetes

Key Lifestyle Risks for Chronic Disease:

Tobacco and Alcohol Use

Poor Nutrition

Lack of Physical Activity

CDC: National Center for Chronic Disease Prevention and Health Promotion, August 2019.

Bezner, PTJ, 2015.

Relevance to the Neurologic Population

Shorter rehab stays and decreased reimbursement - increase the risk of post-rehabilitation health decline and compromising the health of individuals with neurologic disability

Individuals with a disability are less likely to engage in recommended amounts of physical activity

Mobility and other functional limitations can challenge the ability to live a healthy lifestyle

Significant barriers exist that limit exercise and physical activity in the adult neurologic population

Co-morbid conditions/chronic diseases, and lifestyle related behaviors, can exacerbate neurologic symptoms

Quinn L, JNPT, 2017. Morris D, MedBridge Course 2018. Rimmer, JNPT, 2013.

Barriers in PT practice

Time

Lack of interest or awareness (patient, public, and other health care providers)

Lack of education or knowledge

Lack of reimbursement

Lack of resources

Limited counseling skills

Lack of self-efficacy

Decreased focus on secondary and tertiary prevention by physical therapists

Perception that the physical therapy work environment is not suitable for health promotion

Any others?

Bezner, PTJ, 2015

Reflection

What Do We Know About Our Patients Priorities?

Where Do They Want To Go, And How Do They Want To Get There?

How Ready Are They To Make The Necessary Changes?

What Motivates Our Patients? What Drives Them?

What Are Our Own Barriers to Finding Out These Answers?

The Most Important Components for Health and Wellness Promotion?

And the Hardest?

Behavior Change

Motivational Interviewing

Motivational Principles in Rehabilitation

Physical Therapy for Sustained Behavior Change (PT4SBC)

Definition: Physical Therapy for sustainable behavior change aims to optimize movement to improve the human experience by merging the guiding style of motivational interviewing with attitudinal foundations of mindfulness, principles of motor learning, and whole health/well-being.

ANPT Synapse Center, Appendix B

Consider the blending of, and similarities of, neuroplasticity with behavior change and with restorative rehabilitation principles:

motivation, self-confidence, repetition, salience/meaningful tasks, timing and type of feedback, and error tolerance

Behavior Change

Theories

Transtheoretical Model

Health Belief Model

Social Cognitive Theory

Self Determination Theory

Resilience Model

Common Themes

Self-efficacy

Autonomy

Motivation

Readiness

ANPT Synapse Center, 2019

Bezner, PTJ, 2015


Time-based continuum of behavior change

Decisional balance, processes of change, self-efficacy

https://pcna.net/wp-content/uploads/2018/12/16_models_of_behavior.pdf


Preventative Cardiovascular Nurses Association, accessed July 2019






Interventional Strategies

Consider stages of change, attitudes toward exercise, and priorities

Patient-led goal setting

Facilitate patient change – empower self-efficacy, self-management, and resilience

5 A’s and 5 R’s:

Ready to change, use 5 A’s: Ask, advise, assess, assist/arrange

Not yet ready to change, Use 5 R’s: Relevance, Risks, Rewards, Roadblocks, Repetition

Morris D, MedBridge, 2018.

Billinger, S, et al. ANPT Synapse Center, 2019.

Health Belief Model

Health behavior change dependent upon the belief that:

1. There is a risk for a negative health condition

2. There is a positive expectation of avoiding the negative health condition by taking action

3. That you can successfully complete the recommended action to be taken

Perceived benefits >>> perceived barriers to change


Social Cognitive Theory

Inter-personal theory; personal beliefs/factors interacting with environmental factors to influence behavior

Personal Factors: self-efficacy and outcome expectations

Environmental Factors: Physical environment, social context (observed behaviors, opinions of others)


Common Strategies to Implement Behavior Change

Engagement

Open Inquiry

Active Listening, reflective listening

Shared decision making

Goal setting

Action Planning

Accountability


Behavior Change in Neurologic Population

Increased risk for secondary or tertiary consequences of unhealthy lifestyle behavior

Healthy lifestyle behavior can help delay disease progression

Barriers to Health Behavior Change:

Cognitive and communication deficits

Psychosocial and environmental barriers ANPT Synapse Center, 2019

“Findings showed that barriers to physical activity participation arise from personal factors that, coupled with lack of motivational support from the environment, challenge perceptions of safety and confidence to exercise.”

Mulligan, et al. Adapt Phys Activ Q. 2012.

Motivational Interviewing (MI)

Motivational Interviewing: collaborate conversation style for strengthening a person’s own motivation and commitment to change

The addition of motivational interviewing to usual care may lead to modest improvements in physical activity for people with chronic health conditions.

O’Halloran, et al, 2014.

See it in action on YouTube: The Effective Physician Motivational Interviewing https://www.youtube.com/watch?v=URiKA7CKtfc&t=329s

ANPT Synapse Center, Appendix A, 2019.

Collins Medbridge online course, 2019.

https://www.youtube.com/watch?v=URiKA7CKtfc&t=329s



Motivational Interviewing (MI) Guiding Style of conversation

Collaboration: cooperation between patient and clinician

Acceptance: Non-judgement, not trying to sway the patient

Evocation: Evoke from patient’s that which they already have

Compassion: Listen with empathy

Collins T. Medbridge online course, 2019. ANPT Synapse Center, Appendix A, 2019.

Pignataro, 2018

Motivational Interviewing (MI): Importance in Neurorehabilitation Patients are already facing many barriers to activity and lifestyle

changes (mobility, cognition/communication, environmental factors)

Builds Therapeutic Alliance

Empowers participation

Acceptance of deficits

Goal setting, action planning, accountability

Build self-efficacy, self-awareness and sense of control

3 Core Characteristics in PT practice

Clear focus on changing behavior

Use of reflective listening to understand patients perspective about changing their behavior

Emphasis on evoking the patient’s motivation for change


Adapting MI to Cognitive and Behavioral Impairments

MI Standard Principle

Cognitive and Behavioral Challenge

MI Modification

Assumes Intact Cognition

Impaired attention or concentration, disorientation

Repetition, simple verbal and visual materials

Uses open-ended questioning

Aphasia, impaired attention and processing

Clear and concise questions, provide sufficient time, provide acceptable choices

Uses Reflective Listening

Impaired Processing

Simple reflections, sufficient time

Adapted from: Martino et al, Modification of motivational interviewing, Subst Abuse Treat, 2002. ANPT Synapse Center, 2019.

Adapting MI to Cognitive and Behavioral Impairments

Mild Impairment Moderate Impairment

Severe Impairment

Support/manage autonomy of client choices: - Clients

preference for autonomy

- Engage in shared decision making

Uphold autonomy for decisions not impacting safety: - Provide 3 good

choices - Even “trivial”

involvement in decision making

Delegate decision making: - Advise directly

on most appropriate choice of action

- Use family/caregiver to determine choice

Adapted from: The Freedom of Choice Framework, Bhatt et al. Aging & Mental Health, 2018. ANPT Synapse Center, 2019.

Assessment, Tools, and Outcome Measures

Readiness to change ruler, self-efficacy ruler, self efficacy scale

Patient-specific Functional Scale, Goal Attainment Scale

Goal setting work sheets, action planning guides

Activities-Specific Balance Confidence Scale (ABC scale)

Diagnosis Specific Tools: (Participation, QOL)

Academy of Neurologic Physical Therapy -> Practice Resources -> ANPT Outcome Measure Recommendations

https://www.sralab.org/rehabilitation-measures

Shirley Ryan Ability Lab Rehabilitation Measures Database







Reflection

How have you been able to increase patient motivation, autonomy, and self-efficacy in your clinical setting?

How can we promote those attributes during our restorative rehabilitation sessions?

Motivational Principles in Neurorehabilitation

Intrinsic Motivation Factors

Autonomy: Feeling in control of our own actions and lives

Competency: Perceiving self as capable and competent

Social Relatedness: Need to feel included, accepted and connected with others

Self-Efficacy: beliefs about own capabilities to produce desired effects

Lewthwaite, Rebecca. Neuroconsortium, 2015

Building Autonomy in Neurorehab

Studies done by Chiviacowsky, et al: exercise groups that could choose when they would use a tool or strategy during a task would perform better at that task

Controlling language, “you must, you should” can increase a cortisol response (stress response) and inhibit learning

Offering choices, even simple choices, “which task do you want to do first, what color of ball do you want to use?”, helps increase autonomy.

Feeling connected, value, and relaxed creates a dopamine release, which helps with learning

Always give “good choices”, and denote you value their opinion. Choices that are too big or too trivial may be detrimental


Building Competency In Neurorehab Dobkin et al: Group that had feedback and

encouragement during their walking task did better than control group

Feedback types: Positive, normative

Give positive expectations, “lift” negative expectations, give perception of success and progress, connect efforts to desired outcomes/goals

“If you do X, Y, and Z, you will improve”

“Active people like you, with your experience, usually do really well this this task/exercise”


Building Relatedness in Neurorehab

Peer support

Community based support groups

Eagle Mount, Senior Center, Cancer Support Community, Stroke/PD/MS support groups, online support networks

Build comradery in clinic between like patients

Take an interest in patients personal life, and understand what is meaningful to them


Building Self-efficacy in Neurorehab

Sources of self efficacy:

Personal performance/accomplishments

Vicarious experiences

Verbal persuasion

Physiological/mental state

Signs of low self-efficacy:

“I can’t do that” or other direct expressions

Hesitancy to begin an activity, cautious movements

“How confident are you that you can …..”

Low self-efficacy is from 0/10 up to 6/10


Building Self-efficacy in Neurorehab With activities that are successful, ask “how can we make that even

more challenging?”

With activities that aren’t successful, “ok, now we know where to start!”

Create challenging tasks and conditions, but not 100% successful (75-80% success rate is good)

Accomplishments should be attributable to patient, not therapist

Make progress measureable and interpretable by patient

Celebrate! Point out specific, even small, achievements of importance, and how that may impact their goals

Modeling self-efficacy with peer support

Research has supported self-efficacy as a primary correlate of physical activity in PD and MS

Ellis, JNPT, 2013; Lewhwaite, neuroconsortium, 2015

REVIEW

Health Priorities for Populations and Individuals

(APTA HOD P06-15-20-11)

• Physical therapists provide education, behavioral strategies, patient advocacy, referral opportunities and identification of supportive resources after screening for:

• - Stress Management - Smoking cessation

• - Sleep health - Nutrition optimization

• - Weight management - Alcohol moderation

• - Violence-free living - Adherence to health care recommendations

Nutrition: Scope of Practice APTA policy – within scope of PT practice

Montana PT Practice Act – no language limiting us from providing nutrition services, HOWEVER

Montana Code Annotated 2017: TITLE 37. PROFESSIONS AND OCCUPATIONS

CHAPTER 25. NUTRITIONISTS

Part 3. Licensing

Scope Of Dietetic-Nutrition Practice

37-25-301. Scope of dietetic-nutrition practice. Only a nutritionist can provide the following services:

(1) assessing the nutrition needs of individuals and groups and determining resources and constraints in the practice setting;

(2) establishing priorities and objectives that meet nutritive needs and are consistent with available resources and constraints;

(3) providing nutrition counseling for any individual;

(4) developing, implementing, and managing nutrition care systems; and

(5) evaluating, adjusting, and maintaining appropriate standards of quality in food and nutrition services.

Nutrition

Anticipate nutritional issues in our patients

Disease specific, demographic, BMI

Screen: mini-nutritional assessment

Determine readiness for dietary behavior change

Provide general information (nutrition education only)

Recognize need for referral to a registered dietician

Morris, D et al. Physiotherapy Theory and Practice, 2009

Nutrition

Dietary Guidelines for Americans (disease prevention): U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. https://health.gov/dietaryguidelines/2015/guidelines/

Choose My Plate

https://health.gov/dietaryguidelines/2015/guidelines/



Nutrition: Stroke

Malnutrition can be common, associated with worse outcomes

Dysphagia has been shown to be associated with malnutrition and dehydration

Decreased mobility, arm/facial weakness, depression and impaired cognition can all impact nutrition

Nutrition plays a role in all the known metabolic risk factors that can potentially contribute to a second stroke

American Heart Association/American Stroke Association

https://www.stroke.org/en/healthy-living/healthy-eating

Marcel Arnold, et al. PLoS One. 2016; ANPT synapse center, 2019







https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4749248/

Nutrition: Multiple Sclerosis

Diet can increase the inflammatory process (high in SFA’s or TFA’s)

Increase risk of developing MS with diet low in PUFA’s

Low fat diet may reduce rate of relapse and fatigue

High levels of vitamin D slow progression, optimal dose?

Supplementation with B12?

Several diets proposed (Wahls Protocol), no good evidence

Bagur MJ, et al. Adv Nutr. 2017

https://www.ncbi.nlm.nih.gov/pubmed/28507011




Nutrition: Multiple Sclerosis Naturopathic Perspective

Recommend nutrient dense and anti-inflammatory foods

Mediterranean Diet most practical

Gut/Brain link, “leaky gut” or IBS symptoms may be related

Specific foods and supplements recommended, email [email protected] and ask for handouts from presentation, from the National MS Society

Leary-Chang, ND and Vespignani, ND. August 2019.

mailto:[email protected]

Nutrition: Parkinson’s Disease

National Parkinson’s Foundation

https://www.parkinson.org/blog/tips/nutrition

Motor and non-motor symptoms in PD can affect nutrition

Protein and Levadopa interaction (take meds 30-60 minutes prior to eating, or wait 2 hours after eating to take meds)

Foods can be neuroprotective or neurodegenerative

Ruscigno M, 2016



Nutrition: Spinal Cord Injury

Shopping and meal prep difficulties – problem solve with OT

Increased risk of medical complications (DM, obesity, CV disease, osteoporosis, skin health)

BMI cannot be used to accurately assess healthy weight

Specific protein recommendations for wound healing and acute injury (1.2 – 2.0 grams protein / kg of body weight)

HDLs tend to be lower due to decreased activity. C-reactive protein increases with stress/injury, and correlated with increased risk of heart disease

Bone health: decrease caffeine, smoking. Increase Ca, Vit D, and weight bearing

Neurogenic bowel/bladder: Increase fiber and fluid. Cranberry juice for UTI prevention?

Barton, Kim. NW SCI. April 12, 2011.

Nutrition and Brain Health

Naturopathic perspective: Mito Food Plan, Institute for Functional Medicine. Supportive for neurodegenerative disease

MIND diet: Mediterranean-DASH Intervention for Neurodegenerative Delay

Supplements – refer to Pharm D, RD, MD, ND

http://ods.od.nih.gov/ - NIH office of dietary supplements

http://ods.od.nih.gov/

Sleep and Stress Management

Sleep is critical for immune function, tissue healing, pain modulation, cardiovascular health, cognitive function including depression/anxiety, and learning and memory.

Poor sleep quality may also contribute to the development of neurologic conditions:

May play an important role in the accumulation of Beta-amyloid and to the development of Alzheimer's disease

REM disorders have been associated with the development of Parkinson's disease and other neurodegenerative disorders

Sleep is frequently altered in individuals with neurologic conditions such as stroke, Parkinson's disease, Alzheimer's disease, multiple sclerosis, and spinal cord injury. Can impact their ability to learn and potentially influence recovery.

Siengsukon CF, PTJ, 2017


“To integrate sleep health in prevention, health promotion, and wellness interventions, therapists should”:

Assess overall sleep health and screen for risk of sleep disorders – ask general sleep questions

Refer for additional assessment as needed

Provide sleep hygiene education

Provide an appropriate exercise and physical activity program

Consider positioning to promote sleep quality

Address bed mobility issues



Sleep Hygiene Education:

Go to sleep and wake up at the same time each day

Use the bed for only sleep and sex

Develop a relaxing bedtime routine

Adopt an appropriate exercise program

Avoid caffeine 4 hours before bedtime

Avoid alcohol and smoking 3-4 hours before bedtime

Avoid OTC sleeping pills

Avoid day time napping, or keep to 30 minutes

Make sleeping environment comfortable and relaxing

Avoid large meals or spicy foods 2-3 hours before bed



RCT in 2016 found that people with multiple sclerosis who engaged in a moderate-intensity aerobic exercise program, and a low-intensity walking and stretching program, had improved sleep quality. (Siengsukon CF, et al)

Consider type and amount of clothing and sheets/blankets, as well as adapted devices, to help with bed mobility and position changes at night

Consider type and placement of lighting for safety

Help problem solve pain management, positioning, spasticity management at night

Instruct on progressive muscle relaxation, diaphragm breathing, or other forms of meditation and relaxation


Negative stress (distress), or chronic stress, is stress that has a negative impact on health and wellness

Positive stress, or eustress, is stress that is typically motivating, short-term, and within our coping abilities

Stress management refers to the techniques aimed at addressing distress

Signs of distress include: increased fatigue, tension, irritability, elevated BP/HR

Chronic stress contributes to chronic health conditions and can exacerbate neurologic symptoms

Bezner, 2015; ANPT, 2019


Screening for stress, anxiety and depression

Self reported questionnaires – may be limited with cognitive or communication difficulty

Instruct in relaxation techniques (deep breathing, 4-7-8 breathing, progressive muscle relaxation, visualization, meditation, autogenic training, biofeedback, massage)

Physical activity prescription to manage stress, consider t’ai chi and yoga

Time management techniques

Recognize need to refer to another provider

Red flags: suicidal ideation, excessive crying, hopelessness



Stress can contribute to the development and progression of neurodegenerative diseases

Prevalence of depression in SCI, TBI, PD, MS is much higher than that of the average healthy adult population

Decreased mobility -> decreased activity and participation -> depression/anxiety

Involve family, friends, peers, support groups

There’s an app for that - headspace, calm, etc


Smoking Cessation

Employ 5 A’s and 5 R’s

Montana DPHHS

Montana Quit Line: https://dphhs.mt.gov/publichealth/mtupp/quitline.aspx

https://montana.quitlogix.org/en-US/Just-Looking/Health-Professional

https://dphhs.mt.gov/publichealth/mtupp/quitline.aspx








Physical Activity and Exercise

“If exercise could be packaged into a pill it would be the single most widely prescribed and beneficial medicine in the nation.” - Robert Butler, founding director of the National Institutes on Aging

“In adults with neurologic conditions, exercise and physical activity have been shown to have the potential both to decrease risk of disease onset, and to improve motor and cognitive function and quality of life.” - Quinn, JNPT, 2017


Physical Activity:

“movements of the body that use energy, and can encompass a range of everyday activities including walking, gardening, and climbing stairs, but also includes specific forms of sport or exercise, such as playing soccer, running on a treadmill, or doing Pilates or yoga.”

Exercise:

“exercise interventions are programs with a defined prescription of mode, intensity, frequency, and duration.”

FITT Principle – frequency, intensity, time, and type

Aerobic exercise has to potential to help drive neuroplasticity changes

Positive outcomes on motor symptoms, behavior, and quality of life, and cognitive function for individuals with HD, MCI, AD, PD, MS and dementia

Quinn et al, JNPT, 2017


Screening and Testing:

Physical Activity:

Physical Activity Vital Sign – from exerciseismedicine.org

Physical Activity Scale for the Elderly (PASE)

Fitbit, wearable step counters/activity trackers

Exercise:

ACSM’s medical screening and risk stratification, may be warranted for moderate to high intensity exercise

Submaximal exercise testing:

Designing your own sub max test, calculating THR and MHR

6 min walk test.

Recent study in chronic stroke: Woodward, PTJ, 2019

Recumbent Stepper

Billinger et al, Med Sci Spor Exer, 2012, and PTJ 2008.

https://www.youtube.com/watch?v=wZe9TJQVc1Q




Screening and Testing:

Lifestyle Medicine Biomedical Vital Signs:

Body Mass Index: Body Weight (kg) / Height (m2)

Blood Pressure, Heart Rate

Contradictions to starting exercise or stopping exercise

Rate of Perceived Exertion

Lipid Panel, Blood Glucose/A1c


Physical Activity and Exercise Prescription:

Special Considerations in neurorehab

APTA Physical Fitness for Special Populations Pocket Guide

http://www.apta.org/PFSP/

CDC Physical Activity Guidelines:

https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf

http://www.apta.org/PFSP/





Common Barriers:

Access

Time

Mobility Impairments

Cognitive/communication

Co-morbidities

Knowledgeable Trainers

Personal/Social

Newitt et al. Disabil Rehabil, 2016

Quinn et al, JNPT, 2017

Strategies for Implementation:

Personalized programs

Disease pathophysiology

Disease staging

Personal Preference

Integrate behavior change and motivational interviewing

Finding the benefits

Action plans for specific barriers

Models of Care in Physical Therapy for Health and Wellness

Lifespan management of neurodegenerative diseases:

assessment upon diagnosis to establish baseline status and identify key impairments and activity limitations.

ongoing consultation with follow-up visits scheduled regularly, to facilitate exercise adherence, identify changes in functional abilities, and collaborate on setting new goals as needed.

advisory and coaching role over the course of the disease, incorporating behavioral interventions to facilitate exercise adherence and uptake.

Quinn, JNPT, 2017

Models of Care in Physical Therapy for Health and Wellness New exercise program:

PT required for exercise prescription. 1-4 visits every 2-4 weeks. Long term follow ups at 6-1 months for exercise progression, or sooner if change in condition.

Skilled Maintenance Care:

PT required to maintain or progress function and exercise. Set up HEP, gym, caregiver programs. PT every 1-3 months, recheck key outcome measures, exercise progression/modification, functional training.

http://www.apta.org/Payment/Medicare/CoverageIssues/SkilledMaintenance/

Long-term Delivery Model (Dental Model)

PT required every 6-12 months (new episode of care each time) to assess functional status and change in needs

http://www.apta.org/AnnualCheckup/Form/

ANPT, 2019; Ellis, Terry podcast.






Putting it all together

Case Example 1:

30 year old female newly diagnosed with MS. Mother recently passed away from complications due to MS. Single mother. Previously active/regular exercise.

MI employed to assess overall health/wellness goals

Stages of Change/readiness to change

Stress Management

Nutrition

Case Example 2:

18 year old male with AIS B tetraplegia x 2 years. Chronic leg wound, underweight. Not engaging in regular physical activity or exercise.

MI used to understand what is meaningful to patient, assessing barriers to change and barriers to implementing health care recs

Skilled referral needs – nutrition

Physical activity, standing frame use

Collaboration with other healthcare professionals

Case Example 3:

70 year old male with CVA and history of peripheral neuropathy. Spouse reports depression, isolation and sedentary activity. History of falls.

MI used to determine readiness to change, patient preferences, motivation, and overcoming barriers

Behavior change for AD use, activity and safety recs

Engagement in physical activity/exercise

Case Example 4:

75 year old female with PD; co-morbidities include OA, HTN, peripheral neuropathy. Reports falls, anxiety and low self-efficacy regarding her condition.

MI used for assessing self-efficacy, perceptions and goals, motivation

Building self-efficacy in clinic sessions, use of affirmations

Skills for anxiety management, sleep promotion

Involvement of peer support

Questions/Comments/Discussion

References Peer-reviewed Journal Articles:

Rimmer J, Henley K. Building the Crossroad Between Inpatient/Outpatient Rehabilitation and Lifelong Community-Based Fitness for People With Neurologic Disability. JNPT, v37, June 2013.

Bezner, JR. Promoting Health and Wellness: Implications for Physical Therapist Practice. PTJ, v95 n10, October 2015.

Quinn L, Morgan D. From Disease to Health: Physical Therapy Health Promotion Practices for Secondary Prevention in Adult and Pediatric Neurologic Populations. JNPT, v41, July 2017.

Mulligan, Hale, Whitehead, Baxter. Barriers to physical activity for people with long-term neurological conditions: a review study. Adapt Phys Activ Q. 2012 Jul;29(3):243-65.

O’Halloran, et al. 2014. “Motivational Interviewing to Increase Physical Activity in People with Chronic Health Conditions: A Systematic Review and Meta-Analysis.” Clinical Rehabilitation 28 (12): 1159–71. doi:10.1177/0269215514536210.

Ellis T, Motl R. Physical Activity Behavior Change in Persons With Neurologic Disorders: Overview and Examples From Parkinson Disease and Multiple Sclerosis. JNPT, v37, June 2013.

Chiviacowsky S et al. Altering mindset can enhance motor learning in older adults. Psychology and Aging, 2001.

Dobkin B et al. International randomized clinical trial, stroke inpatient rehabilitaiton with reinforcement of walking speed (SIRROWS), improves outcomes. Neurorehabilitation and neural repair. 2010.

Morris, David, et al. Strategies for optimizing nutrition and weight reduction in physical therapy practice: The evidence. Physiotherapy Theory and Practice, 25(5–6):408–423, 2009

References:

Peer-Reviewed Journal Articles:

Marcel Arnold, et al. Dysphagia in Acute Stroke: Incidence, Burden and Impact on Clinical Outcome. PLoS One. 2016; 11(2): e0148424. Published online 2016 Feb 10. doi: 10.1371/journal.pone.0148424

Bagur, MJ, et al. Influence of Diet in Multiple Sclerosis: A Systematic Review. Adv Nutr. 2017 May 15;8(3):463-472.

Siengsukon CF, Al-dughmi M, Stevens S. Sleep health promotion: Practical information for physical therapists. Phys Ther. 2017;97(8):826-836.

Siengsukon C, et al. Randomized controlled trial of exercise interventions to improve sleep quality and daytime sleepiness in individuals with multiple sclerosis: a pilot study. Multiple Sclerosis Journal - Experimental, Translational and Clinical. 2016; 2:1-9.

Woodward J, et al. Cardiopulmonary Responses During Clinical and Laboratory Gait Assessments in People With Chronic Stroke. PTJ, v99 i1, January 2019.

Billinger et al, Modified total-body recumbent stepper exercise test for assessing peak oxygen consumption in people with chronic stroke. PTJ, 88 (10), October 2008.

Billinger et al. Recumbent Stepper Submaximal Exercise Test to Predict Peak Oxygen Uptake. Medicine and Science in Sport and Exercise. August 2012.

Newitt, Rosemarie, Barnett, Fiona, and Crowe, Melissa (2016) Understanding factors that influence participation in physical activity among people with a neuromusculoskeletal condition: a review of qualitative studies. Disability and Rehabilitation, 38 (1). pp. 1-10.













https://academic.oup.com/ptj/article/99/1/86/5210109?searchresult=1

https://academic.oup.com/ptj/article/99/1/86/5210109?searchresult=1

https://researchonline.jcu.edu.au/39101/






References: Online Learning, Expert Opinion, Podcasts, etc:

Billinger S, Bradford E, Gansen J, Fritz S, Hutchnson, K, Miczak K, Rafferty M, Resnick A: Health Promotion and Wellness Strategies Applied to Neurorehabilitation. ANPT Synapse Center and Handout with Resources. Last updated January, 2019.

Morris, D. Prevention, Wellness and Health Promotion: Neurologic Physical Therapy. MedBridge Online Course, October 2018.

Collings, Tracey. Patient-Centered Care; Motivational Interviewing and Health Coaching. Medbridge Online Course, August, 2019.

Pignataro, Rose. Transformative Dialogues: The Use of Motivational Interviewing in Physical Therapy. #PTTransforms blog. July, 2018.

Neuroconsortium: Neurologic Physical Therapy Professional Education Consortium, distance learning through Casa Colina Centers for Rehabilitation, Rancho Los Amigos National Rehabilitation Center and the USC Division of Biokinesiology and Physical Therapy. June – December 2015.

Michelle Leary-Chang, ND and Marco Vespignani, ND. Lifestyle, nutrition and supplement recommendations for optimal MS management. University of Washington, Webinar, August 2019.

Ruscigno, Matt. Nutrition’s Impact on Parkinson’s Disease. www.todaysdietician.com, May 2016.

Northwest Regional SCI System: Everyday nutrition for individuals with SCI. Vickeri Barton, RD, CD and Susie Kim OTR/L. Harborview Medical Center, Seattle, WA. April 12, 2011.

Ellis, Terry. APTA neurology section, degenerative disease SIG, podcast Deep Dive Neurodegenerative Disease, August 2019

Billinger, S. APTA neurology section, stroke SIG, podcast physical activity and exercise in stroke, September 2019.

http://www.todaysdietician.com/

integrating lifestyle medicine into neurologic...

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