Current Concepts in Physical Therapy for People with Parkinson

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Current Concepts in Physical Therapy for People
with Parkinsons Disease

• Tim Pazier, MPT
• Franciscan Health System
• PWR! certified clinician
• LSVT BIG certified clinician

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Lack of activity destroys the
good condition of every human being,
while movement and methodical physical exercise
save it and preserve it Plato
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Overview

• The effect of Parkinsons disease (PD) on
  movement
• The role of physical therapy in PD
• Exercise principles to improve function
• Framework for exercise and PD

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The effect of PD on movement

• Progressive neurodegenerative disease
• Motor deficits
• slowness of movement (bradykinesia)
• decreased amplitude (hypokinesia)
• rigidity, tremor
• decreased balance/postural reactions
• freezing
• postural changes

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The effect of PD on movement

• Non-motor deficits that impact movement
• altered sensory perception/activation
• difficulty changing strategies
• difficulty dividing attention
• poor self-monitoring
• reduced vitality
• depression, anxiety elevated

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PD and Physical Therapy

• Historically Physical Therapy prescribed once
  person is falling
• By then, gt 70 loss of dopamine cells
• Ideally, we want people in therapy at the first
  signs of the disease

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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)

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Goals of PT

• Slow sensorimotor deterioration
• Prevent falls
• Establish home exercise program that challenges
  the person with PD
• Follow up every 3-6 months

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The science behind exercise

• Neuroplasticity changes in brain connections
  that restores or compensates for lost function.
• Neuroprotection changes in brain connections
  that spares, rejuvenates, or slows their
  degeneration.

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Science, exercise, and PD - in the lab

• Exercise 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)

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Science, exercise, and PD - in the lab

• Findings in the lab can be applied in the clinic
• Changes in brain function can be seen indirectly
• Improved balance
• Increased speed and amplitude of movement
• Decreased freezing

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Principles of recovery and improved function

• Use it or lose it!
• inactivity contributes to PD
• Use it AND improve it!
• extended training can strengthen neural
  connections
• Continuous exercise matters
• gains will be lost if exercise stopped

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Principles of recovery and improved function

• Timing 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

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Principles of recovery and improved function

• Repetition key for learning
• lots of practice needed
• Specificity matters
• therapy should focus on what is difficult
• Empower
• people with PD CAN get better

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Exercise and Physical Therapy

• No one exercise program found to be the best
  approach
• However, HOW you exercise is the key
• Parkinsons Wellness Recovery (PWR!)
• (see www.nfnw.org )

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Parkinsons Wellness Recovery (PWR!)

• NOT a specific exercise regimen, BUT a framework
  for treatment
• Utilizes the latest research
• Can be incorporated into any exercise regimen

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PWR! Framework for PD

• Prepare!
• Activate!
• Reflect!
• Motivate!

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Prepare!

• Remove fear of movement
• Simplify movements
• Focus attention
• Movements modeled to enhance awareness
• Cardio training to prime the pump
• Alignment important

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Activate!

• Push effort BEYOND self-selected
• Whole 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)

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Reflect!

• Increase awareness of movements
• Help identify normal performance
• Reduce reliance of vision
• Goal is to internalize and self-cue movements
• step BIG
• reach BIG
• turn BIG

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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!

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Types of exercises/treatment approaches for PD

• Treadmill
• Tai chi
• Boxing
• Tango
• Tandem cycling (forced spinning)
• Nordic walking
• Sensorimotor agility program
• Auditory cueing - metronome
• LSVT LOUD/BIG

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LSVT LOUD/BIG

• LSVT Lee Silverman Voice Treatment
• LOUD/BIG focuses on
• high effort
• single attentional focus (AMPLITUDE)
• overlearned movements
• LOTS of repetition
• sensory awareness retraining

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LSVT LOUD/BIG

• Outcomes
• LOUD participants able to sustain loudness 2
  yrs after training
• BIG participants exhibit faster gait and bigger
  strides, improved reaching, improved trunk
  rotation

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PWR! MOVESconcepts that can be incorporated
into any exercise program
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PWR! Hands
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PWR! Reach
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PWR! Reach
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PWR! Reach
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PWR! Rock
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PWR! Rock
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PWR! Twist
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PWR! Step
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PWR! Turn
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PWR! Voice

• Can be added to any PWR! Moves
• Voice adds attentional and physical effort
• Promotes greater activation (as seen in LSVT
  LOUD/BIG hybrid)
• Focus on breath with movement important

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PWR! progression

• PWR! Moves are the building blocks for function
• Functional activities (examples)
• - getting in/out of bed
• - sitting ? ? standing
• - walking
• Progress to sports, hobbies, recreation

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PWR! video
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What we want

• HIGH effort
• Awareness of movement
• Work towards whole body movements
• Translate movements into functional activities
• Self cueing/monitoring
• Support of caregivers/family to reinforce
• NO days off, no excuses!!!

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People with PD CAN get better and STAY better
longer with exercise!!!