Optimizing Outcomes in Parkinson s Disease. Jaclyn Marangella, M.S., CCC-SLP & Sar ah Lopez, PT, DPT, CBIS

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1 Optimizing Outcomes in Parkinson s Disease Jaclyn Marangella, M.S., CCC-SLP & Sar ah Lopez, PT, DPT, CBIS

2 Objectives 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.

3 What is Parkinson s Disease (PD)? Progressive disease of the nervous system that affects movement Associated with lesions in the basal ganglia, predominantly in the substantia nigra, and a deficiency of the neurotransmitter dopamine Tysnes, 2017 Parkinson s Foundation Website

4 Prevalence Of PD Parkinson s Foundation More than 10 million 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

5 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

6 Hoehn and Yahr St ages Describes how motor symptoms progress in PD Rates symptoms on a scale of 1 to 5

7 Unified Parkinson s Disease Rating Scale (UPDRS) More comprehensive tool Progression of motor symptoms AND nonmotor symptoms Most commonly used scale within the clinical study of PD The UPDRS sections: 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

8 Motor Symptoms: Physical & Occupational Therapy Tremor Bradykinesia Rigidity Postural Instability Micrographia Shuffling gait Freezing Dyskinesia Festination Dystonia Masked face (hypomimia)

9 Motor Symptoms: Speech Therapy Hypokinetic Dysarthria (speech impairment) Reduced vocal intensity Breathy voice quality Short rushes of speech Imprecise articulation Drooling (Sialorrhea)

10 AAAHHHHH!!!!!

11 Neuroplasticity The ability of the brain to encode and learn new behaviors and can be defined as changes in molecular and cellular processes in response to environmental experiences such as exercise. Pe tzing e r,

12 Discrete episodes of care No follow up No rehabilitation intervention Referral PT/OT/SLP Referral PT/OT/SLP Traditional Model of Rehabilitation in PD Onset of symptoms Diagnosis of PD (pre-disability) Pharmacological Rx (pre-disability) Acute event (hip fracture, aspiration, etc,) Onset of overt disability Onset of symptoms Diagnosis of PD (predisability) Referral PT/OT/SLP f/u PT/OT/SLP f/u PT/OT/SLP f/u PT/OT/SLP f/u PT/OT/SLP Evidenced Based Model of Rehabilitation in PD Delayed onset of disability Center for Neurorehabilitation Boston University

13 Neuroplasticity Treatment Considerations Specificity Repetition Age Use it or lose it Use it and improve it Timing Complexity Intensity Transference/ Generalization Interference Saliency

14 Current Evidence-Based Interventions 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 presentation, the focus of current evidence-based interventions utilized in ST will be on speech and voice due to the high prevalence of hypokinetic dysarthria affecting individuals w it h PD.

15 Current Evidence-Based Interventions for Speech/ Voice Intensive treatment programs requiring high-intensity voice and speech exercises with clinician-guided prompting and feedback have been established as effective for improving vocal function (Watts, 2016). High intensity (large number of repetitions) + clinician-guided exercise promotes adaptation in muscles and neurological pathways + increased muscular effort increases motor unit recruitment + increases amplitude of motor activity. (Watts, 2016) Increased amplitude of motor activity= increased respiratory effort, louder voice, increased movement of articulators

16 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.

17 Im age from LSVT Global

18 Fox, 2011

19 Fox, 2011

20 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) (Levitt, 2014)

21 Phonation 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)

22 Important Considerations Prior to initiating an intensive voice therapy program (such as LSVT Loud), it is considered best-practice 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.

23 Other: SpeechVive (speechvive.com) Uses the Lombard Effect to facilitate increased vocal intensity in individuals with PD. (Stathalpolous et. al., 2014)

24 Speech Therapy-- Equipment

25 The Evidenced Based Approach: Physical Therapy Why perform physical activity? 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)

26 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

27 The Evidenced Based Approach: Physical Therapy Neuroprotection & Neuroplasticity Exercise neuroprotective + neuroplasticity disease progression Increase in striatal GDNF levels (Cohen et al. 2003) Increases dopamine release in dorsolateral striatum (Akopian et al. 2008)

28 Essential Considerations within Physical Therapy Intervention Cueing strategies Cognitive movement strategies Balance training Aerobic training Strength and flexibility Effects Improve motor performance (especially gait) Improve everyday motor tasks (walking, standing up, sitting down, dressing, etc.), a nd q ua lity of life Pre ve nt risk of fa lls, im p rove p ostura l sta b ility Improve physical capacity Improve general well-b e ing a nd q ua lity of life Morris et. al (2000) Keus et. al (2007), Borrione et. al (2014)

29 Exercise shown to slow, stop, and reverse disease progression: Forced movement High intensity, amplitude based treatment Cognitive and dual task training

30 Forced Movement Tandem biking (Ridgel et al. 2009) Self selected rate: ~60 rpm; Forced: 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

31 Forced Movement Treadmill training + Virtual Reality (Mirelm an 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

32 Amplitude Specific 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)

33 Images from LSVT Global

34 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

35 Amplitude Specific 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 /

36 /

37 Cognitive & 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

38 Cognitive 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

39 Exercise as a Habit Home exercise programs Community/ group organizations Tune ups

Conclusion Utilize neuroplasticity training principles within clinical practice Targeting increased amplitude, higher intensity training, and recalibration of the sensorimotor system

40 Conclusion Utilize neuroplasticity training principles within clinical practice Targeting increased amplitude, higher intensity training, and recalibration 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!

41 References Ahlskog, J. E., PhD, MD. (2011). Does vigorous exercise have a neuroprotective effect in Parkinson disease? Neurology, 77(3), doi: / wnl.0b013e318225ab66 Asha.org. (2017). Voice Disorders: Treatment. [online] Available at: / PRPSpecificTopic.aspx?folderid= &section=Treatment [Accessed 14 Dec. 2017]. Canning, CG. "Multiple-task walking training in people with mild to moderate Parkinson's disease: a pilot study." Clinical Rehabilitation 22.3 (2008): Conradsson D, Löfgren N, Nero H, et al. The Effects of Highly Challenging Balance Training in Elderly With Parkinson's Disease: A Randomized Controlled Trial. Neurorehabil Neural Repair. 2015;29(9): Ellis, T. Update on Exercise in Parkinson Disease. Research Symposium. Center for Neurorehabilitation Boston University. Available at: / neurorehab/ files/ 2017/ 05/ Reserach-Seminar Final-Handout-Website.pdf Farley, Becky G., et al. Intensive Amplitude-Specific Therapeutic Approaches for Parkinson Disease. Topics in Geriatric Rehabilitation, vol. 24, no. 2, 2008, pp , doi: / 01.tgr d.

42 Farley, BG. "Training BIG to move faster: the application of the speed amplitude relation as a rehabilitation strategy for people with Parkinson s disease." Experimental brain research (2005): Fox,C Georg Ebersbach, Lorraine Ramig, and Shimon Sapir, LSVT LOUD and LSVT BIG: Behavioral Treatment Programs for Speech and Body Movement in Parkinson Disease, Parkinson s Disease, vol. 2012, Article ID , 12 pages, doi: / 2012/ Levitt, J., Chitnis, S. and Walker-Batson, D. (2015). The Effects of the SPEAK OUT! and LOUD Crowd Voice Programs for Parkinson Disease. International Journal of Health Sciences (IJHS), 3(2), pp Levitt, J. (2014). A Case Study: The Effects of the Speak Out! Voice Program for Parkinson s Disease. International Journal of Applied Science and Technology, 4(2), pp Matheron, D., Stathopoulos, E., Huber, J. and Sussman, J. (2017). Laryngeal Aerodynamics in Healthy Older Adults and Adults With Parkinson's Disease. Journal of Speech Language and Hearing Research, 60(3), p.507. Mcdonnell MN, Rischbieth B, Schammer TT, Seaforth C, Shaw AJ, Phillips AC. Lee Silverman Voice Treatment (LSVT)-BIG to improve motor function in people with Parkinson's disease: a systematic review and meta-analysis. Clin Rehabil. 2017;: Mirelman, A, "Virtual reality for gait training: can it induce motor learning to enhance complex walking and reduce fall risk in patients with Parkinson's disease?." The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 66.2 (2011): 234. Neuroskills.com. (2017). Traumatic Brain Injury Resource Guide - Ten Principles of Neuroplasticity. [online] Available at: / w w w.neuroskills.com / brain-injury/ ten-principles-of-neuroplasticity.php [Accessed 14 Dec. 2017]. Oguh O, Eisenstein A, Kwasny M, Simuni T. Back to the basics: regular exercise matters in parkinson's disease:

43 Parkinson s Wellness Recovery. Available at: / Petzinger GM, Holschneider DP, Fisher BE, et al. The Effects of Exercise on Dopamine Neurotransmission in Parkinson s Disease: Targeting Neuroplasticity to Modulate Basal Ganglia Circuitry. Brain plasticity. 2015;1(1): Physical Therapist Guide to Parkinson s Disease Available at: Parkinson s Foundation. Available at: Symptoms. Ramig, L., Countryman, S., Thompson, L. and Horii, Y. (1995). Comparison of Two Forms of Intensive Speech Treatment for Parkinson Disease. Journal of Speech Language and Hearing Research, 38(6), p Ramig, L. (2001). Intensive voice treatment (LSVT(R)) for patients with Parkinson's disease: a 2 year follow up. Journal of Neurology, Neurosurgery & Psychiatry, 71(4), pp Rid g e l AL, Ab d a r HM, Alb e rts JL, Disc e nzo FM, Lop a ro KA. Va ria b ility in c a d e nc e d uring forc e d c ycling p re d ic ts m otor im p rove m e nt in ind ivid ua ls with Pa rkinson's d ise a se. IEEE Tra ns Ne ura l Syst Re ha b il Eng ;21(3): Rid g e l AL, Phillip s RS, W a lte r BL, Disc e nzo FM, Lop a ro KA. Dyna m ic Hig h-cadence Cycling Improves Motor Symptoms in Parkinson's Disease. Front Neurol. 2015;6:194. Sapir, S., Spielman, J., Ramig, L., Story, B. and Fox, C. (2007). Effects of Intensive Voice Treatment (the Lee Silve rm a n Voic e Tre a tm e nt [LSVT]) on Vowe l Artic ula tion in Dysa rthric Ind ivid ua ls W ith Id iop a thic Pa rkinson Disease: Acoustic and Perceptual Findings. Journal of Speech Language and Hearing Research, 50(4), p.899.

44 Sehm B, Taubert M, Conde V, et al. Structural brain plasticity in Parkinson s disease induced by balance training. Neurobiol Aging. 2014;35: Stathopoulos, E. T., Huber, J. E., Richardson, K., Kam phaus, J., Decicco, D., Darling, M.,... Sussm an, J. E. (2014). Increased vocal intensity due to the Lombard effect in speakers with Parkinsons disease: Simultaneous laryngeal and respiratory strategies. Journal of Communication Disorders, 48, doi: / j.jcom dis Tysnes OB, Storstein A. Epidemiology of Parkinson's disease. J Neural Transm (Vienna). 2017;124(8): W atts BMC Ear, Nose, and Throat Disord ers (2016) 16:2 DOI / s Weir-Mayta, P., Spencer, K., Eadie, T., Yorkston, K., Savaglio, S. and W oollcott, C. (2017). Internally Versus Externally Cued Speech in Parkinson's Disease and Cerebellar Disease. American Journal of Speech-Language Pathology, 26(2S), p.583. Whitfield, J. and Goberman, A. (2017). Speech Motor Sequence Learning: Effect of Parkinson Disease and Normal Aging on Dual-Task Performance. Journal of Speech Language and Hearing Research, 60(6S), p.1752 Ziegler, A., Abbott, K. V., Johns, M., Klein, A., & Hapner, E. R. (2014). Preliminary data on two voice therapy interventions in the treatment of presbyphonia. The Laryngoscope, 124(8), doi: / lary Images taken from Google.com

MAXIMIZING FUNCTION IN PARKINSON S DISEASE

1 MAXIMIZING FUNCTION IN PARKINSON S DISEASE September 13, 2016 End Falls This Falls Conference Jan Goldstein Elman One Step Ahead Mobility Toronto, Ontario Outline An overview of Parkinson s disease (PD):