THINK BIG!EXERCISES FOR

INDIVIDUALS WITH PARKINSON’S

DISEASEBetty MacNeill, PT, DPT

January 2013 SED Meeting

PRESENTATIO

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OBJECTIVES

Identify the symptoms of Parkinson’s disease (PD) that benefit from exercise interventions

Identify both traditional and non-traditional therapeutic models for managing the symptoms of PD

Define and discuss the basic philosophy associated with the LSVT-BIG intervention model

Identify and discuss the 4 fundamental treatment concepts of the LSVT-BIG model

Describe the basic exercise protocols associated with LSVT-BIG and provide a rationale for each

Develop confidence in applying some LSVT-BIG techniques and principles with selected patient populations

PATHOPHYSIOLOGY/ETIOLOGY

Pathophys: Loss of dopanergic cells in the substantia nigra leads to a deficiency in dopamine for use by the communication pathways in the

basal ganglia, which are critical to producing normal movement and postural control, and

neural circuits to the frontal lobe, which are critical for mental processing, motor planning, and personality.

PARKINSON’S DISEASEClassical Clinical Features =

TRAP•Tremor, resting•Rigidity, cogwheel•Akinesia, bradykinesia•Postural Instability

COMPREHENSIVE LIST OF SYMPTOMS IS MUCH MORE HELPFUL FOR

UNDERSTANDING THE FULL SPECTRUM OF THE CHALLENGES FACED BY

INDIVIDUALS WITH IPD See handout for further explanations Motor symptoms (in addition to the 4 Cardinal Signs of PD):

Micrographia, Speech difficulties, Lessened facial expression & smiling, Swallowing difficulties, Decreased blinking and the appearance of staring, Low back pain or ache accompanied by poor posture, Cramps or a burning sensation in thighs or legs, Lack of arm swing on the affected side, Episodes of feeling "stuck in place" when initiating a step (so called "freezing"), Slight foot drag on one or both sides

Non-motor symptoms: Loss of smell, Feelings of hot or cold, excessive sweating, oily skin,

increased dandruff, Sleep Disturbances, Depression and/or anxiety, Decreased “executive function”, Dementia, characterized particularly by decreased memory for recent events

STAGES OF DISEASE PROGRESSION Modified Hoehn and Yahr Staging

Stage 0 = No signs of diseaseStage 1 = Unilateral diseaseStage 1.5 = Unilateral plus axial involvementStage 2 = Bilateral disease without

impairment of balanceStage 2.5 = Mild bilateral disease with

recovery on “pull test”Stage 3 = Mild to moderate bilateral disease;

some postural instability; physically independent

Stage 4 = Moderate to severe bilateral disease; frequent loss of balance; 50% physically dependent

Stage 5 = Non-ambulatory; 80-100% dependent for ADL’s

Who should exercise? How much exercise? Which symptoms and/or movement

challenges are affected by exercise (if any)?

Exercise Considerations

PHYSICAL THERAPY MANAGEMENT – EXERCISE CONSIDERATIONS

General guidelines do not differ much from those applied to other patient diagnoses. Make decisions for treatment interventions based on: Impairments, functional limitations, and disabilities

Also consider for patients with IPD: Timing of optimal effect of medications On/Off phenomena (Clinical fluctuation) Unique characteristics of postural and gait

disturbances Effects of aging Concurrent pathologies

PHYSICAL THERAPY MANAGEMENT – SUMMARY OF HANDOUT RE: EXERCISE MODELS

Many different and effective models are available for helping patients with PD exercise

For best results, the patient must exert an “effort” and be motivated to perform multiple repetitions on a daily basis

Marketing “Exercise as Medicine” is a good way to encourage patient involvement and explain the neuroprotective qualities of adequate exercise

Emphasis for tonight, however, is on the LSVT-BIG Model for Intervention

LSVT – BIG

ONE APPROACH TO

EXERCISE FOR

INDIVIDUALS WITH PD

WHAT IS “LSVT* – BIG”? Definition: Intensive amplitude-based exercise

program for limb motor system Background: Founded upon the principles of LSVT* -

LOUD , which is an intensive amplitude-based exercise program for speech motor system

Main premise: With exaggerated exercise movements, the patient will learn to use their bigger movements automatically in everyday life Better posture Better flexibility Better movements Better balance

*LSVT = Lee Silverman Voice Therapy (www.LSVTglobal.com)

LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS

1. Emphasis on AMPLITUDE is first2. SENSORY Calibration is second aspect3. The exercise program must be INTENSIVE

a. High physical and mental effortb. Dosage/repetition/difficulty

4. Quantification/Empowerment is necessary for follow through

LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTSAMPLITUDE

Defined as the largest range of motion that can be performed with the highest effort with the most

maximally efficient biomechanics every trial / every day

Patients must be approached with high expectations on a regular basis.

Requires vigilance from clinician and patient

LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS

SENSORY CALIBRATION OR RETRAINING

Defined as the process of teaching the patient to self-monitor and to accept that what feels “too big” is really WNL

Important for therapists to give feedback about normalcy

Calibration is at the heart of the matter: Retrain faulty sensory perceptions Establish new associations between effort

and normal movement Create new motor memories (BIGGER plans)

LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS

INTENSIVE EFFORT

Full exercise program has a standardized protocol Prescribed dosage and method of delivery include:

a. Frequency: 16 1-hr individual sessions; 4x/week

b. Duration: 4 weeksc. Strength: High effort

Practice and repetition are essential ingredients to provide the neural protection and up-training benefits

LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS

QUANTIFICATION/EMPOWERMENT

Key is to motivate patient with feedback, because the expectation is that individuals with PD can get better!!!!

REQUIREMENTS: 1) Push the patient to generate high effort2) Reinforce! Motivate!3) Empower with potential4) Document outcomes

LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSIONFEEDBACK GUIDELINES FOR THERAPISTS

DRIVE BIG EFFORT: Best model for teaching – “Do what I do” (minimizes cognitive load)

SHAPE: Optimize alignment first through tactile, visual, auditory, and proprioceptive cues

STABILIZE WITH FEEDBACK: Reinforce, practice and motivate the individual’s own actions. Patients with PD need more reinforcement/motivation than others

CALIBRATE: Retrain sensory perceptions – effort must feel BIG in order to look NORMAL

LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION

SHOULD BE 50-60 MINUTES PER DAY

I. MAXIMAL DAILY EXERCISES1. Multidirectional Sustained Movements (2)2. Multidirectional Repetitive Movements (5)3. Functional Movements (1-5 depending on

patient)

II. HIERARCHY TASKS (Includes ADL’s)

III. CARRYOVER ASSIGNMENTS

LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSIONDEMONSTRATION/PRACTICE ACTIVITIES

I. MAXIMAL DAILY EXERCISES 1. Multidirectional Sustained Movements (2)

Purpose of Exercises: Sustained muscle activation and active stretching.

A. Floor to ceiling stretch in sitting

B. Side to Side stretch in sitting

NOTE: 10-20 secs. would be the average sustained time. A “hand flick” can be added when the patient is able to sustain the position achieved.

EXAMPLES OF “MULTIDIRECTIONAL SUSTAINED MOVEMENTS” WITH AN EXERCISE GROUP

End position for the“floor to ceiling” stretch in sitting

“Side-to-side” stretch with modification

of hand placements

LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSIONDEMONSTRATION/PRACTICE ACTIVITIES

I. MAXIMAL DAILY EXERCISES2. Multidirectional Repetitive Movements (5)

Purpose of these exercises: Differentiating starting and stoppingChanging directionsSequential enduranceBalanceStrengthening

LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSIONDEMONSTRATION/PRACTICE ACTIVITIES

I. MAXIMAL DAILY EXERCISES2. Multidirectional Repetitive Movements

(5) A. Step and Reach (3)

1) Forwards2) Sidewards3) Backwards

B. Rock and Reach (2)4) Forward / Backward5) Side to side

EXAMPLES OF “MULTIDIRECTIONAL REPETITIVE MOVEMENTS” WITH EXERCISE

GROUP

Forward Stepand Reach

Sidewards Step & Reach

LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION

ADDITIONAL DAILY ACTIVITIES

II. HIERARCHY TASKS (Includes ADL’s)Purpose of exercises/tasks:

Overlearn familiar commonly-used and salient everyday movementsReminder for BIG movements at homeEncourages compliance and carryoverRequires task analysis for maximal benefit

Rolling Sit to Stand Walk & Turn

Everyone needs these, but there is some flexibility associated with personal choice

Other Examples:

Floor to StandGetting out of bedSit & reachStand & reach Walk & reachStand & turn

LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSIONADDITIONAL DAILY ACTIVITIESHIERARCHY TASKS:

LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION

ADDITIONAL DAILY ACTIVITIES

III. CARRYOVER ASSIGNMENTSWhat are they? Assignments the PT

man-dates to implement “bigness” into real life. They must fit into the patient’s daily living activities for that day, so they change on a regular basis.

Examples:

BOTTOM LINE

Think and Act BIGBecause if you don’t use

it, then you’ll lose it!