Opt imizing Outcomes in Parkinson’s Disease Jaclyn Marangella, M.S., CCC-SLP & Sarah Lopez, PT, DPT, CBIS

Object ives 1. Attendees will be able to define common deficits and functional

impairments resulting from Parkinson’s disease that can be addressed within physical therapy and speech therapy.

2. Attendees will learn about current evidence based interventions indicated for individuals with Parkinson’s disease.

3. Attendees will learn how to optimize clinical practice utilizing evidence based interventions for individuals with Parkinson’s disease.

What is Parkinson’s Disease (PD)? ● Progressive disease of the

nervous system that affects movement

● Associated with lesions in the basal gangl ia, predominantly in the substant ia nigra, and a deficiency of the neurotransmitter dopamine

Tysnes, 2017 Parkinson’s Foundation Website

Prevalence Of PD

● Parkinson’s Foundat ion

○ More than 10 mil l ion people worldwide are living with PD

○ Approx. 60,000 Americans are diagnosed with PD each year ○ PD prevalence increases with age

■ Affects 1% of the population above 60 years ○ Men are 1.5 times more likely to have PD than women

Tysnes, 2017 Parkinson’s Foundation Website

PD Causes

● 85-90% of cases are classified as sporadic ● Only about 10-15% of all cases are genetic forms of the disease

Most experts agree that PD is caused by a combination of genetic and environmental factors (chemicals from occupational exposure or rural

living, head trauma, etc.)

Tysnes, 2017 Parkinson’s Foundation Website

Hoehn and Yahr

Stages

Describes how motor symptoms

progress in PD

Rates symptoms on a scale of 1 to 5

Unif ied Parkinson’s Disease Rat ing Scale (UPDRS)

More comprehensive tool

Progression of motor symptoms AND non-

motor symptoms

Most commonly used scale within the clinical study of PD

The UPDRS sect ions:

● Part I: evaluation of mentation, behavior, & mood ● Part II: self-evaluation of ADLs

○ Speech, swallowing, handwriting, dressing, hygiene, falling, salivating, turning in bed, walking, & cutting food

● Part III: clinician-scored motor evaluation ● Part IV: complications of therapy ● Part V: Hoehn and Yahr staging ● Part VI: Schwab and England ADL scale

Motor Symptoms: Physical & Occupat ional Therapy

Tremor

Bradykinesia

Rigidity

Postural Instability

Micrographia

Shuffling gait

Freezing

Dyskinesia

Festination

Dystonia

Masked face (hypomimia)

Motor Symptoms: Speech Therapy

● Hypokinetic Dysarthria (speech impairment) ○ Reduced vocal intensity ○ Breathy voice quality ○ Short rushes of speech ○ Imprecise articulation

● Drooling (Sialorrhea)

AAAHHHHH!!!!!

“The ability of the brain to encode and learn new be haviors and can be de fine d as change s in

m ole cular and ce llular p roce sse s in re sponse to e nvironm e ntal e xpe rie nce s such as e xe rc ise .”

Pe tzinge r, 2015.

Neuroplast icity

Onset of symptoms

Diagnosis of PD

(pre-disability)

No rehabilitation intervention

Pharmacological Rx

(pre-disability)

Referral PT/OT/SLP

Referral PT/OT/SLP

Onset of overt

disability

Acute event (hip fracture,

aspiration, etc,)

Tradit ional Model of

Rehabil itat ion in PD

Onset of symptoms

Evidenced Based Model of

Rehabil itat ion in PD Diagnosis of

PD (pre-disability)

Referral PT/OT/SLP

f/u PT/OT/SLP

f/u PT/OT/SLP

f/u PT/OT/SLP

f/u PT/OT/SLP

Discrete episodes of care No follow up

Delayed onset of disability Center for Neurorehabilitation

Boston University

Neuroplast icity Treatment Considerat ions

Timing Complexity Intensity Transference/ Generalization Interference Saliency

Specificity Repetition

Age Use it or lose it

Use it and improve it

Current Evidence-Based Intervent ions for Speech/ Voice Individuals with PD often require speech/ voice treatment due to hypokinetic dysarthria, dysphagia treatment due to onset of swallowing impairments, and cognitive-communication therapy due to cognitive decline often associated with PD.

Dysphagia and cognitive deficits in persons with PD are often treated using traditional methods that may not be specific to PD.

For this presentat ion, the focus of current evidence-based intervent ions ut il ized in ST wil l be on speech and voice due to the high prevalence of hypokinet ic dysarthria affect ing individuals w ith PD.

Current Evidence-Based Intervent ions for Speech/ Voice

Intensive t reatment programs requiring high-intensity voice and speech exercises w ith cl inician-guided prompt ing and feedback have been establ ished as effect ive for improving vocal funct ion (Watts, 2016).

High intensity (large number of repet it ions) + cl inician-guided exercise→ promotes adaptat ion in muscles and neurological pathways + increased muscular effort → increases motor unit recruitment + increases ampl itude of motor act ivity. (Watts , 2016)

Increased amplitude of motor activity= increased respiratory effort, louder voice, increased movement of articulators

Lee Silverman Voice Treatment (LSVT LOUD ®) ● Targets vocal effort scaling through increased vocal loudness via intensive, high effort vocalization

and speech exercises ● Designed to improve neuromotor abilities and “recalibrate” the patient’s perception of effort during

speech production. ● Consists of 4, hour- long sessions per week for 4 weeks (total of 16 sessions). ● Speech exercises follow a hierarchy (words--phrases--sentences--paragraph level and spontaneous

speech) ● Home exercise program ● “No junk minutes!” = intensive treatment. ● “Be LOUD”= practice/ repetition using increased amplitude ● Research reflects lasting effects of up to 2 years on average.

(Watts, 2016)

Im age from LSVT Global ®

Fox, 2011

Fox, 2011

SPEAK OUT! ® and LOUD Crowd! ® ● Focus on vocal scaling, targets vocal effort by prompting patients to speak with

“intent” ● Speaking with “intent” = purposeful cognitive focus on increasing vocal loudness and

intonation variability during speech ● 12 intensive individual therapy sessions over 4 weeks (approximately 45 minute

sessions) ● LOUD crowd= continuous therapy component that provides weekly opportunities for

program participants to continue practicing their improved voice productions in natural conversation and social settings without a specified ending point.

● Limited outcome data for larger samples--continued research necessary

(Watts, 2016) (Levit t , 2014)

Phonat ion Resistance Training Exercise (PhoRTE)

● Therapy tasks adapted from LSVT, less intensive than LSVT ● Phonatory-Respiratory exercises ● 1x/ week ● Authors reported significant improvements in participants’

perceptions of QOL and perceived effort of voice production. ● Long-term effects? Patient can utilize a home-exercise program.

(Zeigler, 2014)

Important Considerat ions

Prior to initiating an intensive voice therapy program (such as LSVT Loud), it is considered best-pract ice for the individual to obtain an

examination (laryngoscopy) by an Ear Nose and Throat doctor (ENT) in order to rule out any structural voice disorders (such as nodules or

cysts) for which intensive phonatory exercises can be contraindicated.

Other:

SpeechVive

● Uses the Lombard Effect to facilitate increased vocal intensity in individuals with PD.

(Stathalpolous et. al., 2014)

(speechvive.com)

Speech Therapy-- Equipment

The Evidenced Based Approach: Physical Therapy ● Why perform physical act ivity?

○ Health benefits for individuals of all ages, in healthy & diseased states

○ Protection from a wide range of neurological disorders ■ PD, Alzheimer’s disease, cognitive impairment associated with aging

(Petzinger et al. 2015)

(Conradsson et al. 2015)

The Evidenced Based Approach: Physical Therapy

● Exercise in Parkinson’s Disease (Oguh, et al. 2014) ○ Regular exercise (>2.5 hours/ week) associated with improved:

■ Quality of life ■ Mobility ■ Physical function ■ Cognition

AND ■ Decreased disease progression

Neuroprotect ion & Neuroplast icity ● Exercise → neuroprotective + neuroplasticity → disease

progression ○ Increase in striatal GDNF levels (Cohen et al. 2003)

○ Increases dopamine release in dorsolateral striatum (Akopian et al. 2008)

The Evidenced Based Approach: Physical Therapy

Intervent ion Effects

Cueing st rategies Improve motor performance (especially gait)

Cognit ive movement st rategies

Improve everyday motor tasks (walking, standing up, sitting down, dressing, etc.), and quality of life

Balance t raining Pre ve nt risk of fa lls , im prove postural s tab ility

Aerobic t raining Im prove physical capacity

Strength and f lexibil ity Im prove ge ne ral we ll-be ing and quality of life

Morris et. al (2000) Keus et. al (2007), Borrione et. al (2014)

Essent ial Considerat ions w ithin Physical Therapy

Exercise shown to slow, stop, and reverse disease progression:

Forced movement

High intensity, amplitude based treatment

Cognitive and dual task training

Tandem biking (Ridgel et al. 2009)

● Self selected rate: ~60 rpm; Forced: 80-90 rpm ● 24 session: 3x per week x 8 weeks ● Improved UE coordination via UPDRS:

○ 41% decrease in rigidity ○ 38% decrease in tremor ○ 28% decrease in bradykinesia

● 4 week retention

Forced Movement

Forced Movement Treadmil l t raining + Virtual Real ity (Mirelman et al. 2011) ● Progressive intensive treadmill training with virtual obstacles

○ Speed, orientation, size, frequency of appearance, and shape of the targets were manipulated

● 3x per week x 6 weeks ● Improved comfortable walking speed & stride length ● Improved dual task speed & stride length

Amplitude Specif ic Training ● Lee Silverman Voice Treatment (LSVT BIG ®)

○ Goal LSVT BIG Program: ■ Teach patients to use bigger movements in routine activities --> sustained

training in everyday movements ■ Restore normal movement amplitude by re-calibrating the patient’s

perception of movement execution → sensorimotor processing ○ 4 sessions/ week x 4 weeks (16 sessions total) ○ Daily exercises; hierarchy exercises

■ 8-16 reps/ task; 8-9/ 10 intensity ○ Cue = “Think BIG”

Farley et al. (2008) Fox et al, (2012)

Images from LSVT Global ®

● Farley, et. al, 2005 ○ Improved gait speed ○ Improved balance scores ○ Improved stability during dual walking/ talking tasks ○ 3 month retention

● Ebersbach, et. al, 2010

○ Greater improvement in UPDRS, TUG, and timed 10 meter walking in BIG group compared to walking and home groups

○ No differences seen within quality of life measures

Amplitude Specif ic Training ● Parkinson’s Wellness Recovery (PWR!®)

○ Evolution of LSVT BIG® exercise program ○ Targets multiple symptoms, and allows for adaptation for disease severity ○ Perform movements with with large amplitude, high effort, and attention to

action in multiple postures (floor, all 4’s, sitting, and standing) ○ Targets “4” skills shown by research to interfere with mobility

■ Antigravity extension ■ Weight shifting ■ Axial mobility ■ Transitional movements

http:/ / www.pwr4life.org

http:/ / www.pwr4life.org

Cognit ive & Dual Task Training

● Canning, (2008) ○ Cognitive dual task challenges while walking ○ 1x week (30 minute session) x 3 weeks ○ Improved gait speed in single task and dual task

conditions ○ 3 week retention

Cognit ive and Dual Task Training

● Conradsson, 2015 ○ HiBalance program vs. control (usual care) ○ 10 weeks, 3x/ week ○ Significant improvements in balance and gait performance ○ No significant between group difference was observed regarding gait

performance during dual-tasking ■ Improved performance of the cognitive task while walking

Exercise as a Habit

● Home exercise programs ● Community/ group organizations ● Tune ups

● Utilize neuroplasticity training principles within clinical practice

● Targeting increased amplitude, higher intensity training, and re-calibration of the sensorimotor system improves generalization and long-term maintenance of treatment effects

● Treatment should include:

○ Early intervention, prevention, remediation

● Exercise doesn’t end in the rehab clinic!

Conclusion

References

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● Images taken from Google.com