Parkinson Wellness Recovery (PWR!) Guidelines to Treating People with Parkinson s Disease

Transcription

1 Parkinson Wellness Recovery (PWR!) Guidelines to Treating People with Parkinson s Disease September 14, 2017 Shana Gatschet, OTR/L, CAPS Michelle Drinnen, OTR/L

2 PWR! What is it? Parkinson Wellness Recovery PWR Professionals (FB)

3 Parkinson Wellness Recovery Nonprofit organization founded in 2010 by Dr. Becky Farley PhD, MS, PT Implements cutting edge research on exercise and brain change to real world healthcare paradigms Dr. Farley is also the developer of evidenced based therapy approach of LSVT BIG

4 Framework is founded on clinical research in motor control, motor learning, exercise and physiology. PWR! Dr. Farley s PWR! Center is a Community NeuroFitness Center of Excellence in Tucson, AZ Promotes Exercises as Medicine Her PWR! Gym is offered to people with PD to have access for life to increase longevity and quality of life in hopes that end stage PD is eradicated

5 What is Parkinson s Disease? Neurodegenerative, chronic and progressive movement brain disorder that progresses slowly in most people It involves the malfunction or death of neurons that produce dopamine. Dopamine is a chemical concentrated in the substantia nigra that controls movement to be smooth and coordinated When diagonosed, ~ 60-80%of the dopamine-producing cells are damaged or die, PD symptoms appear At diagnosis, many are already less active than healthy peers. Poor body awareness effects one s perception of true movement quality. Yet, only 12-15% are typically referred to a fitness program or therapy. 6-7 million people worldwide are diagnosed; 2% of the population

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7 6 Primary Features of PD *Resting Tremors *Rigidity *Bradykinesia *Loss of Postural Reflexes *Flexed Posture Definite DX: of at least 2 of these with one as tremor or bradykinesia Probable: Tremor or Bradykinesia present Possible: at least 2 of the last four are present *Freezing

8 PD Symptoms Early Motor Symptoms: decreased arm swing when walking, masked face, stooped posture, micrographia, hypophonia, slow shuffling gait, clumsy hands, falls when fatigued or in a hurry/stressed/distracted Primary Motor Symptoms upon diagnoses: Rigidity, Bradykinesia, Incoordination Non-Motor Symptoms: Emotional: depression, anxiety, apathy Cognitive: attention, executive function Autonomic: sleep, constipation, pain

9 Stages of PD Stage 0 Stage 1 Stage 1.5 Stage 2 Stage 2.5 Stage 3 Stage 4 Stage 5 No signs of disease Unilateral disease Unilateral plexus axial involvement Bilateral disease, without impairment of balance Mild bilateral disease, recovery on Pull Test Mild to Moderate bilateral disease: some postural instability, independent living capacity Severe disability, able to ambulate and stand unassisted Wheelchair bound or bedridden unless assisted

10 Carbon monoxide Causes? Head injury/brain swelling Free radicals High iron and manganese (welding) TIAs, Brain Tumors or Lesions near Brainstem Medications Street drugs Viral infection

11 Research Research advances and clinical science research suggest certain types of exercise may promote brain change (neuroplasticity) in persons with PD This data challenges the assumption that PD as a neurodegenerative disease has no potential for brain change or repair (neuroplasticity) Yet many physicians are unaware of the scientific literature and animal science underlying exercise-induced

12 Neuroplasticity When it comes to Brain Change or neuroplasticity, it s more than just what you do...it s HOW you do it! Exercise for Brain Change helps optimize and repair brain health to address the cognitive, physical and emotional symptoms of PD that interferes with everyday activities.

13 Why is exercise so important? PD is the ONLY chronic neurodegenerative disease for which these are highly effective symptomatic therapies 3 options that reduce motor symptoms and/or disability in PD Medications (that target dopamine) Neurosurgery (DBS)

14 Data from animal models: Research shows Brain Change NeuroProtection (Brain Health) Capable of protecting vulnerable DA neurons from toxic events or rescuing those that are not compromised. NeuroRestoration (Brain Repair) Adaption of compromised signaling pathways within the damage of the basal ganglia circuits Compensation (Brain Adaptation) Produce compensatory strategies occurring outside the CNS (ANS, metabolism, peripheral musculature) or other areas outside the damaged basal ganglia pathways

15 Differences between PWR! and LSVT BIG PWR! LSVT BIG Amplitude training-pd specific functional framework for comprehensive research based programming 4 Functional movements-building blocks of function (UP/ROCK.TWIST/STEP) 5 positions-prone/supine/all4 s/sit/stand May be implemented across all levels of severity Not standard protocol Patient centered protocol, frequency/duration is determined by therapist to produce optimal long term outcomes Offered by therapists or fitness professionals, ratio 1:1 or groups Framework is adaptable, can be integrated with other neuroplasticity-principled approaches or techniques A framework that is continually updated as new research or approaches emerge Amplitude training is a single approach 7 Movement exercises-driven by LOUD protocol 2 positions- Sitting and Standing Protocol is not adaptable It is a standard Protocol Protocol requires frequency of 4xweek/4 weeks as minimal duration Only available 1:1 by certified OT & PT

16 -PD Neuroplasticity- Principles framework to optimize learning and function PREPARE ACTVATE REFLECT MOTIVATE

17 PREPARE- (verbal, mental, physical) Functional readiness: remove inhibitors of fear, stress and pain ROM with target range Sensory stimulation/kinesthetic Awareness Vestibular readiness- weight shift, rock, pivot, rotation Movements- demonstrate and breakdown task, mental imagery/estimate steps, Trial by each person first, deliberate performance, demand readiness prior to movement/pwr! UP. Quality of alignment

18 ACTIVATE-(drive system for maximal motor output and muscle activation) Perform PWR! Moves- high effort for maximal activation (push beyond end point/range) Increase ROM, speed, resistance, reps, time, frequency/duration of high intervals vs sustained efforts Give example of FUNCTION Continuously monitor perceived efforts (+8/10) Remember: motor output is inhibited if fear, stress or pain is present Add external cues: visual (color dots) auditory (metronomes, music, clapping) somatosensory (tactile, vibration, wt bearing, rhythmic movement)

19 REFLECT- (focus intention internally to sustain attention; recognize efforts to move bigger/faster) Hold them accountable to correct movements Remain positive Constant pushing for maximal effort Ask, how did that make you fee?, Reflect with other to improve self monitoring Help them identify what is normal again Remind/Reinforce EFFORT Send home assignments, write down one daily reflection Expect generalization of normal activities

20 MOTIVATION - (exercise=increased dopamine; increased dopamine=internal motivator for brain behaviors) Depression and apathy are part of PD Need to be pushed to participate and engage Share success among peers Remind/promote exercise with function to translate to meaningful activities Continuously educate importance of exercise and effort (reduce falls, better quality of life to be more active with family/friends, decrease freezing, slow down progress of PD/PD fight

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22 PWR! Hands PWR! UP PWR! REACH PWR! ROCK PWR! TWIST PWR! STEP PWR! WALK PWR! TURN PWR! VOICE PWR! MOVES

23 PWR! MOVES PWR! HANDS *Deliberate extension/abduction of fingers/hands and wrists *Addresses flexed posturing of hands, micrographia and temporary relief of tremor *Activity to reduce resting tremor: BIG pronated hands with shoulders in IR, tapping on LE-looks normal in social setting *Sensory input to train ability to focus and divide attention quickly

24 PWR! MOVES PWR! UP Used with any movements that require lifting body against gravity Counteract stooped posture Actively stretches trunk flexors Reinforces good alignment and posture Strengthens extensor antigravity muscles Change in head position and visual field stimulates the sensory system for dynamic stepping/righting responses

25 PWR! MOVES PWR! REACH *Add to all PWR! MOVES to retain normal coordination patterns between trunk and arms *Addresses efficient movements & postural responses *Challenges balance by moving COG outside BOS *Increases overall attention to activation *Requires task switching, increases effort, improves alignment *Weight bearing position mobilizes shoulders, activates postural muscles, strengthen UEs *Crosses midline

26 PWR! MOVES PWR! ROCK Fundamental movements for whole body actions with functional mobility (walking, turning, stopping forward projection, supine to sit) Impaired ability to ROCK or weight shift in lateral or backwards direction is MAJOR contributor to freezing, shuffled gait and falls Rhythmic rocking: may reduce rigidity, trigger stepping, righting response. Promotes wider BOS during ambulation/turning, strengthens abductors, moves COG outside BOS

27 PWR! MOVES PWR! TWIST *Emphasises counter rotation between shoulder and hips * Reduces rigidity to decrease risk of muscular skeletal deformity and back pain * Retains the axial rotation required for dynamic balance

28 PWR! MOVES PWR! STEP Large scale repetitive stepping in a variety of directions Improves strength Improves ability to weight shift for turns Increases ground clearance Moves COG or BOS Increases speed and size of steps to respond to balance

29 PWR! MOVES PWR! WALK Retains perception of effort and amplitude (step size) for normal movement Aerobic endurance First get quality: PWR! UP with long, wide steps Progression: Add arms with elbows bent, then extended Flick fingers with each reach Punch across chest

30 PWR! MOVES PWR! TURNS Reduce/prevent falls and strengthens muscles important for balance Emphasize large BOS Whole body rocking Exaggerated weight shifting to prepare to turn Activities: pivot turns, 45 degree turns, penguin turn, clock turn

31 PWR! MOVES PWR! VOICE *Adds attentional and physical effort, promotes greater activation, challenges physical coordination as a dual task * Target LOUDER but do not strain * Holds Ahhhs with sustained postures * Deliberate articulation * Emphasize gestures

32 PWR! ROUTINES * SITTING * STANDING * WALKING * FLOOR * FLOW

33 PWR! ROUTINES SITTING PWR! UP PWR! TWIST PWR! ROCK/REACH SIDE PWR! REACH DOWN/UP PWR! REACH/TWIST PWR! REACH/TWIST/COMBO PWR! REACH FORWARD AND BACK PWR! UP SIT TO STAND PWR! BREATHE

34 PWR! ROUTINES STANDING PWR! UP PWR! ROCK & REACH SIDE TO SIDE PWR! REACH AND TWIST PWR! REACH AND TWIST COMBO PWR! REACH & TWIST ACROSS & BACK PWR! STEP THROUGH PWR! BREATHE

35 PWR! ROUTINES PWR! WALK PWR! UP FORWARD BACKWARD SIDEWAYS HIGH KNEES TURNS STOPS & STARTS REVERSALS

36 PWR! ROUTINES FLOOR PWR! UP-PRONE PWR! REACH & TWIST-PRONE PWR! UP- SUPINE PWR! REACH-BOTH ARMS PWR! REACH ALTERNATING ARMS PWR! SNOW ANGEL PWR! UPPER BODY REACH & TWIST PWR! STEP UP COMBO PWR! LOWER BODY TWIST PWR! SCOOT PWR! ROLL PWR! BREATHE

37 PWR! ROUTINES FLOW PWR! PRONE CHILD S POSE PWR! STRETCH PWR! UP HANDS & KNEES PWR! REACH ARMS AND LEGS PWR! REACH AND TWIST ARM PWR! REACH AND TWIST LEGS PWR! STEP HANDS & KNEES PWR! UP TALL KNEELING PWR! DOWN PWR! STEP ½ KNEE HALF KNEE REACH AND TWIST PWR! BREATHE

38 Anti-Freezing Tips Staggered wide stance, never with toes lined up. Jump start the first step (march in place, rock, count, sing, etc.) PWR! Up (especially in problem areas or areas that cause anxiety) Visual cues (tape on floor, sticky notes on walls) Treadmill training/pole walking with metronome Walk in sync with beat of music in cluttered/problem areas Add motor/cognitive tasks, perform with high vigor/attention, PWR! Up - Plan - GO Mental imagery, verbalize intention, see the success Complex PWR! Moves, Tai chi, etc Agility drills; build into complex environments Boxing, juggling, rebounder, Bal-a-Vis-X Multi-directional stepping to a complex sequence Train the brain to talk alternative routes

39 PWR! MOVES and ROUTINES ~Videos~ Let s move...

40 Let s collaborate with our TEAM OT - PT - ST Discuss treatment plans Areas of strength/weakness and precautions

41 Exercise to Optimize Brain Repair, Adaptation and Behavioral Recovery Timing Matters -Start today. No excuses. Continued Exercise Matters -A substantial break in motor activity can be degenerative. -See OT/PT/ST for reassessment every 3-6 mo. -Commit -Increase daily activities Intensity Matter -Work harder, Bigger, Faster, Longer

42 Complexity Matters -Change the exercise environment: Physical area: Small spaces, crowded area, uneven surface Add secondary motor components - carry items, visual distractions Add cognitive tasks - speak to others, recite numbers by 2 s Saliency Matters -Keep attentional focus high to keep motivation high (group exercise, goals, positive reinforcement, add leisure activities) -Track progress

43 Specificity Matters -Work on symptom based plan of care -Retrain body awareness (yoga, tai chi, pilates) -Train for strength, balance, agility/coordination -Incorporate external cues - lines, targets, metronome, music, BIG steps, breathing, counting Affirmations Belief --- Action --- Results --- Belief --- Action --- Results

44 PWR! Information Certifications PWR! Therapist (OT/PT) 3-6 mo. Assessments 1:1 intensive Rehab PWR! Instructor (personal trainer, fitness instructor) Optimal PD specific fitness classes Educational empowerment and resource referral *Find a PWR! Professional* Listing on

45 PWR! Information PWR! Moves Videos on website and YouTube PWR! Retreat pwr4life.org 7 day/6 night PD specific exercise retreat in annually in May in Arizona Activities, exercise, seminars for those with PD and their care partners Q&A with physicians and researchers

46 References Coles, M., Muhammed All Parkinson s Center. Living with Chronic Disease. PWR! Retreat 2013, Scottsdale AZ Farley, B. Exercise to Slow/Halt/Reverse Parkinson s Disease? Hirsch, M.A., Farley, B.G. (2009) Exercise and Neuroplasticity in Person s Living with Parkinson s Disease. European Journal of Physical Rehabilitation Medicine 45: Slide and handout copy approval by Dr. Becky Farley