ALLIED TEAM TRAINING FOR PARKINSON Parkinson s Impact on Motor Function: Assessment and Design of Appropriate Interventions In Early Stage PD

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1 ALLIED TEAM TRAINING FOR PARKINSON Parkinson s Impact on Motor Function: Assessment and Design of Appropriate Interventions In Early Stage PD Maria Walde-Douglas, PT Struthers Parkinson s Center Acknowledgements to Rose Wichmann, PT Manager, Struthers Parkinson s Center Session Learning Objectives Identify evidence based, performance-oriented assessment tools for assessing individuals with PD Describe rationale and benefits of exercise for persons with PD Identify the impact of various PD symptoms on motor function Describe evidence-based PT treatment interventions to be considered in treatment of early stage Parkinson s disease 1

2 Patient-Centered Care PT ROLE: Listening to patient needs and concerns Using a motivational style of interview and instruction Ensuring patient understanding Including family carepartner needs and perspectives Developing a partnership throughout a continuum of care Teaching patient advocacy Selection of Best Assessment Tools for PD rehabmeasures.org The rehabilitation clinician's place to find the best instruments to screen patients and monitor their progress PD Edge recommendations: Neurology section of APTA task force on PD: HR: Highly Recommended R: Recommended LS/UR: Reasonable to use, but limited study in target group/unable to recommend NR: Not Recommended 2

3 Performance-Oriented Assessment Tools for PD-PD EDGE Timed Up and Go Dual Task Test 5 Times Sit to Stand Test 10 Meter Walk Test Functional Reach Test Dynamic Gait Index Functional Gait Assessment Berg Balance Scale MiniBESTest 6 Min Walk Test Timed Up and Go Dual Task PD EDGE: HR for H &Y Stages I-IV. NR Stages V Contains balance and gait maneuvers in everyday life Person gets up from chair, walks 3 meters (9.84ft), turns and returns to chair to sit; asked to walk as quickly but safely as possible Test is timed TUG (cognitive): while counting backwards by 3 s from # between or alternating letters of alphabet (a-c-e-g) TUG (manual): while holding a cup filled with water Person may use their customary assistive device Cut-off scores for PD (Maranhao-Filho, et al 2011): difference between TUG and Manual TUG >4.5 sec indicates increased risk for falls *the TUG and cogtugare included on the MiniBESTest: scored lower if the cogtugis 10% more than regular TUG 3

4 5 Times Sit to Stand Test PD EDGE: HR Stages I-IV. NR Stage V cm chair height Arms folded, sitting to back of chair Start and end test on the chair Test is timed Originally designed as a quick LE strength test Significant correlation with other mobility measures (UPDRS, PAS, Mini-BEST and ABC) Cutoff score in PD (Duncan,etal 2011):>16 sec indicated risk of falls & discriminates fallers from non-fallers If unable to perform without use of arms, can test using arms just to record time for retest comparison (cannot apply cutoff score times) 10 Meter Walk Test PD EDGE: HR Stages I-III. NR Stages IV-V Walking time for a set distance: 10 M total but given 2 M acceland deceleration so only middle 6 M timed Collect 3 trials and calculate the average AD can be used Document if fastest or preferred walking speed Not appropriate if person requires assistance to ambulate MDC in PD (Steffen, et al 2008): comfortable gait speed=.18 M/sec fastest gait speed=.25 M/sec 4

5 Functional Reach Test PD EDGE: HR Stages I-III. NR Stages IV-V Patient stands close to a wall with 90 degrees of shoulder flexion and closed fist (yardstick at acromion height) Reach as far as you can forward without taking a step Start and end position of 3 rd metacarpal is recorded for reach distance 3 trials with average of last 2 recorded MDC in PD: 7.32 cm (3.1 in) (Schenkman, et al 1997) Cutoff scores in PD: <31.75 cm (12.7 in) indicates fall risk (Dibble, et al 2006) Dynamic Gait Index PD EDGE: HR Stages I-IV. NR Stage V 20 foot walking course With or without AD 4 point scoring system with total of 24 points Tasks include: steady state walking, changing speeds, head turns, stepping over and around obstacles, pivoting, stairs MDC for PD (Huang, et al, 2011): 2.9 points Cutoff scores for PD (Dibble et al, 2008) : <19 discriminates between fallers and non-fallers 5

6 Functional Gait Assessment PD EDGE: HR Stages I-IV. NR Stage V Modification of Dynamic Gait Index to improve reliability and reduce ceiling effect 10 item test including gait with narrow BOS, backward walking and gait with eyes closed. 30 point total. 4 point scoring system. Cutoff Scores for PD (Leddy, et al 2011): 15/30 indicates predictive ability to identify fallers Berg Balance Scale PD EDGE: HR Stages II-II. NR Stage I, IV, V Static and dynamic activities of varying activity 5 point scale (0-4). Max score of 56 MDC in PD: (Steffanet al, 2008): 5 points 6

7 MiniBESTest Fay Horakto address in Final PD Breakout 6 Minute Walk Test PD EDGE: HR in Stages I-IV. NR Stage V Cover as much distance walking as possible over 6 min Distance measured (measuring wheel) Can use AD; person must ambulate without physical assistance MDC in PD (Steffanet al, 2008): 269 ft(82 meters) 7

8 Changes in Ambulatory Activity in PD Cavanaugh, J, Ellis, t, Dibble, L JNPT June 2012 Step activity monitors on people with PD over one year; measured free-living ambulatory activity (n=33;mild to moderate stage PD) 11% reduction in mean daily steps over course of a year in ambulatory activity (1000 steps/day on average) 40% reduction in daily minutes of moderate intensity activity over course of a year Message of One Year Activity Study Not making an effort to engage in moderate physical activity and exercise can lead to decline in conditioning levels over the course of a year Doing nothing differently or cutting back on activity/exercise can be prodegenerative 8

9 Exercise Behavior and PD Ellis, J PhysTher2011 Stage of PD or degree of disability was NOT the biggest factor that influenced exercise consistency Self-efficacy was most strongly associated with whether community-dwelling persons with PD exercise regularly *Those with high self-efficacy were twice as likely to exercise regularly Self-Efficacy Definition: belief in one s abilities and capabilities to accomplish a task, make a change or attain a goal BELIEVE THAT EXERCISE MAKES A POSITIVE DIFFERENCE People with PD need to BELIEVE they can improve their quality of life and daily function if they exercise and become more physically active *It is vital that we bring this message across to our patients* THE WHY OF EXERCISE 9

10 Is Vigorous Exercise Neuroprotective in PD? Ahlskog, J Eric Neurology July 19, 2011 Vigorous exercise: aerobic physical activity sustained min Prospective evidence suggests midlife, regular exercise reduces subsequent PD risk years later (3 large cohorts) Improved corticomotorexcitability suggests neuroplasticity in human studies (Fisher, et al; Arch Phy Med Rehabil, Jul 2008) May slow disease progression (more evidence needed) Reduces risk of cognitive impairment (short-term cognitive benefits) Protective effect of exercise in animal models of parkinsonism Exercise-Enhanced Neuroplasticity in PD Petizinger, G, Fisher, B et al. Lancet Neurol 2013 NEUROPLASTICITY=more bang for the buck for existing dopamine neurons to do more with less Goal-based motor skill training to engage cognitive circuitry for motor learning PT provides reinforcement and encouragement with instruction to perform beyond self-perceived capability Person with PD becomes more cognitively engaged in activities previously automatic Combination of goal-based with aerobic training can contribute to brain health and repair 10

11 Reprinted from article in Lancet Neurology 2013 Exercise and Neuroplasticity in PD Clinical and basic research studies support the effects of exercise on neuroplasticity in PD. Neuroplasticity is a process by which the brain encodes experiences and learns new behaviors and is defined as the modification of existing neural networks by adding or modifying synapses. Evidence is accumulating that both goal directed and aerobic exercise may strengthen and improve motor circuitry through mechanisms that include but are not limited to alterations in DA and glutamate neurotransmission, as well as structural modifications of synapses. In addition, exercise may promote neuroprotection of substantia nigra neurons and their existing connections. Finally, exerciseinduced alterations in blood flow and general brain health may promote conditions for neuroplasticity important for facilitating motor skill learning, including cognitive and automatic motor control and overall behavioral performance. While more studies are clearly needed, taken together these findings are supportive of a disease modifying effect of exercise in PD. Does Exercise Improve Efficacy of Levodopa? Muhlack, S, Welnic, J, Woitalla D, Muller T Mov Disord 2007 Feb;22(3): Immediate release formulation given followed by exercise near aerobic limit on one day, given the second day in same manner at rest LD plasma behavior did not change significantly Motor response was significantly better on the day with exercise Moderate exercise appears to increase clinical efficacy of levodopa 11

12 Unanswered Questions More Research Is Needed-With human subjects! How much exercise is needed? Frequency? Duration? What is the optimum intensity of exercise? Is one form superior to another? How long does exercise benefit last? What is the mechanism of benefit? What counts as exercise? How much is too much? (increased exercise increases oxidative stress) Theoretical Framework for Intervention Restorative: Change what you can change, return to prior or improved level of function Compensatory: Teach movement strategies Adaptive: Modify the task or environment In PD, we may do a combination of all 3 Depends on disease severity and Stage; as PD progresses, we may focus more on compensatory and adaptive 12

13 Early Stage PD (Hoehnand YahrStage I-II) Asymmetry of symptoms; initially unilateral presentation Axial rigidity may be present; affecting proximal musculature Subtle changes in coordination and balance Gait changes Alteration in perception of movement (sensory mismatch) Loss of automaticity Reduced ability to perform dual tasking Focus on RestorativeIntervention Strategies with some Compensatory techniques mixed in Collaborating with the Interdisciplinary Team In Early Stage PD Workplace assessment/energy conservation techniques/adl compensatory strategies: OT Relaxation/Exercise and Gait Performance: Music Therapy PD Education/Recognizing Patterns : MD and Nursing Integrating Voice/Exercise Activities, Posture Enhancement: Speech Seeking community resources and support services: Social Services Complementary therapy providers (massage, yoga, Tai Chi) 13

14 PD Impact on Motor Function: Hypokinesia Reduced amplitude of movement Affects nearly 80% of PWP Impact on well-learned movement sequences Causes overall reduction in components of gait Decreased step length, resulting in increased cadence/stepping rate Reduced foot clearance Reduced in arm swing, natural rotation of pelvis Intervention aimed at increasing movement amplitude PD Impact on Motor and Sensory Systems Motor disorder: inappropriate scaling of muscle force Sensory disorder: sensory proprioceptive processing problem Mismatch: person with PD feels like their movements are normal or big enough but are not 14

15 Intervention: Large Amplitude Training Farley, BG, Koshland, GF ExpBrain Res 2005 Dec Sensory-Motor Re-training Speed increases with movement amplitude Goal: For patients to self-generate larger amplitude movements 4 week training protocol of daily movements in a hierarchical sequence (4X/week in study). N size was 18 subjects Maximal Daily Tasks: sitting and standing Big effort, repetitive, context specific Multidirectional :sustained and repetitive Functional movements Comparing Exercise: LSVT BIG Berlin Study Ebersbach, G et all MovDisord2010 Oct people with mild to mod PD 3 groups: One-on-one LSVT BIG training ( 16 hours within 4 weeks) Group training of Nordic walking ( 16 hours within 4 weeks) Domestic nonsupervised exercises BIG showed significant differences in UPDRS motor scores; superior TUG and timed 10 m walking scores No significant difference shown on quality of life measure (PDQ 39) 15

16 Additional LSVT Studies Application of LSVT BIG intervention to address gait, balance, bed mobility and dexterity in people with Parkinson Disease; a case series JanssensJ,et al. PhysTher2014 July 3 case studies; mild to mod PD Outcomes: improvement on gait and balance measures (FGA, FRT, TUG, FOGQ, UPDRS motor score). Improved bed mobility (LindopPD Mobility Assessement). No change in dexterity (9 hole peg) Amplitude-oriented exercise in Parkinson s disease: a randomized study comparing LSVT-BIG and a short training protocol Ebersbach, G et al. J Neural Transm2014 May LSVT-Big 4X/wkfor 4 wkcompared with 2 week protocol of 10 sessions with identical exercises. 42 subjects Outcomes: equally improved motor performance (UPDRS III scores) but high-intensity LSVT BIG more effective to obtain patient-perceived benefit HIGH INTENSITY LARGE AMPLITUDE WHOLE BODY EXERCISE 16

17 PD Impact on Motor Function: Loss of Automaticity Loss of the automatic pilot Ability to move is not lost but there s an activation problem Basal ganglia responsible for automatic motion in learned motor tasks Difficulty activating movement sequences Intervention aimed at bypassing the depleted basal ganglia responsible for these automatic movements and to use more conscious frontocortical strategies instead Striding out with Parkinson s disease Morris, ME, Martin CL, Schenkman ML Phy Ther 2010 Feb Evidence-based physical therapy for gait disorders Critiques major PT approaches to gait rehab in PD Comprehensive client- centered PT for people with PD is based on: Compensatory strategies to bypass the defective basal ganglia (external cues, attentional strategies, divided attention training) Strategies to improve motor learning and performance through practice Management of secondary sequelaeaffecting musculoskeletal and cardiorespiratory systems (axial flexibility, strengthening, cardio ex) Promoting lifelong physical activity and exercise habits Fall prevention (safe turns, freezing strategies, AD recommendation) 17

18 Striding Out with Parkinson s Strategies, exercises and health education varied according to age, individual needs and disease progression OVERALL AIM: Enable the person with PD to live well by providing PT interventions at optimal times to promote health and well-being by education the individual regarding long-term self-management strategies Intervention: Gait Training Morris, M PhysTher2006 Oct Vary environment and task Speed, walking surface, turns, path width Encourage activities involving divided attention To retain flexibility/adaptability in locomotor control Instructional sets Cues to move big, long strides 18

19 Intervention: Treadmill Training Journal of Neural Transmission March 2009 Literature Review: 11 long term trials report positive benefits in gait speed, stride length and health related quality of life Long term carryover effects suggest there may be a neuroprotective effect Many studies followed a routine of 3 times a week for 45 min at training heart rate Primate model video on YouTube: Parkinson s: Is Exercise the Answer? Treadmill Training: Increasing Challenges Vary speed, grade, intensity Add secondary cognitive tasks Category naming Reading aloud Backward counting by 3 s Sideways walking Turning: forward>r side>forward>l side Retro-walking Use safety harness if necessary 19

20 Intervention: Nordic Walking Bloehm et al,movement Disorders 2008 Reuters, J Aging Res week Nordic Walking program (Bloehm): Improved 10 m walk, TUG, 6MWT and quality of life (PDQ 39) Benefits persisted 5 months post 3X wk for 6 months program-70 min (Reuters): 3 groups: Nordic (pole) walking, regular walking, flexibility/relaxation NW group superior in improving postural stability, stride length and gait pattern and variability The NW group continued to pole walk even after study was concluded Community-Based Nordic Walking Program Model Maria Walde-Douglas, PT Struthers Parkinson s Center-poster presentation World Parkinson Congress Oct 2013 METHODS An individual with PD sought out a Nordic walking instructor to lead community walks for persons with PD. This lead to collaboration with a physical therapist specializing in PD to develop a program to train others to lead community Nordic walking groups for people with Parkinson s Disease. A comprehensive 4 hour training curriculum was developed with the expertise of an experienced Nordic walking instructor as well as the knowledge of an experienced PT specializing in the treatment of individual with PD. The program contained the following components: Basic Nordic walking technique Group safety/fall prevention PD gait and balance changes Special considerations for PD 20

21 Community-Based Nordic Walking Program RESULTS Eleven persons completed the training curriculum. Following completion of the training, PD Nordic walking groups were formed at area parks and indoors at shopping malls during the winter months. Groups met in a total of 10 locations in the Twin Cities metro area and 1 in northern MN. (Figure 1). Average attendance was people stages I-III PD. Participants reported enjoyment of the activity, reduced fear of falling, improved posture and ability to walk with less pain and fatigue using the poles. Four individuals involved in the original group leader training went on to complete an official Nordic walking instructor training. CONCLUSIONS A community-based Parkinson s Disease walking program offers a practical approach to an evidence-based for of exercise. Education on Nordic walking and PD offer a train the trainer approach to the development of qualified individuals to lead community groups. This offers the opportunity to expand programming to other communities and locations resulting in improved physical abilities and quality of life for persons with Parkinson s Disease Intervention: Parkinson Wellness Recovery (PWR) Treatment Paradigm (not a protocol) developed by Becky Farley, PT, PhD Evidence-based treatment approach following principles for neuroplasticity and neuroprotection NeuroFit Networks (pwrgym.org) Exercise 4 Brain Change TM Program 21

22 PWR Key Constructs Prepare system for Movement Neural priming-aerobic activities Attentional strategies to engage cognition Biomechanical priming-focus on alignment & flexibility Sensory Stimulation-vestibular & kinesthetic awareness Activate the system High effort-borg Scale 8/10 (0-10) Progressive difficulty Cues to trigger movement Power/strength training through whole body movements PWR Key Constructs Reflect Feedback Attention to action: How did that feel? Self-monitoring and correction Emphasize kinesthetic awareness Motivate Group social structure Reinforce effort and success Empowerment and self-efficacy Promote vigor! 22

23 Intervention: Cycling Ridgel Al, Vitek JL, Alberts JL Neurorehabil Neural Repair subjects) 2 groups: Forced and Voluntary 3X wkfor 8 weeks; 10 min warmup and cooldown Voluntary: self-selected speed on stationary bike; averaged rpm Forced group: tandem trainer at rpm (30% faster) *this was later replicated with a motorized Theracycle RESULTS: -Aerobic fitness improved in both groups -Forced exercise group showed 35% improvement in motor function (UPDRS) and bimanual dexterity -UE motor symptom improvements: tremor modification and handwriting improvement (short-term) -Non motor effect: data suggests improved sense of smell (olfaction) -30% improvement in PD symptoms noted even 2 weeks later Practical Application of Cycling Research Instruct in use of a stationary bike with an rpm readout (try and stay at rpms) Use music/metronome at beats/min to stay at consistent pedaling rate Rent/try a tandem bike with a willing partner Consider a 3 wheeled bike if balance is an issue for outdoor cycling Community Spin Classes to motivate and provide guidance 23

24 PD Biking Groups-Pedal and Roll The mission of Pedal and Roll For Parkinson's is to encourage people with PD to live well through education and structured opportunities for exercise. Pedal & Roll For Parkinson'sholds bicycling events, weekly group bike rides, and Nordic walks. We travel to communities in greater Minnesota to share the benefits of exercise. And we have a bike "lending library" at the Williston Fitness Centerin Minnetonka. We are a 501(c)(3) non-profit organization located in Edina, Minnesota. Founder, Liz Ogren Winner of the Davis Phinney Local Hero Award in 2013 Application to PT Practice: What Could This Look Like? Periodic PT assessment and intervention to address impairments especially if new issues/symptoms/functional limitations arise Establish a targeted home exercise program Integration into PD-friendly community-based programs PT provides PD training to exercise trainers and exercise instructors or supervises/leads group exercise programs in area Network of PD exercise groups is established with train the trainer model Person with PD is educated on when to seek referral for more skilled PT intervention in periodic intervals to modify/update recommendations 24

25 Other Interventions Argentine Tango Duncan, et al Neurorehabil 2012 Feb 62 participants assigned to a community-based tango program or a control group for 12 mo. Improved scores OFF MEDICATION on UPDRS, MiniBEST, 6MWT, gait velocity, et al for tango group indicating a modification of disability progression Group Exercise/RockSteady Boxing Method Combs et al: Neurorehabilitation patients with PD assigned to boxing training or traditional exercise groups sessions of 90 min over 12 weeks Boxing group demonstrated significant improvements in gait velocity and endurance Traditional exercise group had significant gains in balance confidence Both groups showed significant improvements in balance, mobility and quality of live In Summary Persons with PD need to believe that consistent exercise will make a difference in their quality of life and not engaging in exercise can be pro-degenerative Exercise can change the brain and leads to neuroplasticity and potentially slow disease progression (neuroprotection) Early intervention and referral to PT can capitalize on these benefits Use of evidence-based assessment tools for the appropriate stage of PD will provide valuable objective data to better quantify impairments and response to intervention Use of evidence-based interventions in PT will yield best outcomes Integration into community-based, PD-friendly programs 25

26 Intervention Summary for Early Stage PD Large amplitude therapy Movement Activation Strategies Axial mobility Cardiovascular training Treadmill Training Nordic walking High intensity, high effort exercise training Dual task training with cognitive challenges+motor activities Cycling (forced exercise training) Involvement in community exercise groups 26