Parkinson s Disease Foundation. Parkinson s Disease Foundation. PD ExpertBriefing: Led By: Ronald F. Pfeiffer, M.D. To hear the session live on:

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1 Parkinson s Disease Foundation Parkinson s Disease Foundation PD ExpertBriefing: Gait, Balance PD and ExpertBriefing: Falls in Parkinson s Disease Understanding Led By: the Terry Progression Ellis, Ph.D., P.T., of Parkinson s N.C.S. Led By: Ronald F. Pfeiffer, M.D. To hear the session live on: To hear Tuesday, the January session 15, live 2013 on: Tuesday, at 1:00 June PM 26, ET at 1:00 PM EDT. DIAL: 1 (888) and DIAL: enter the passcode #. 1 (888) and enter the passcode #. To also view the session live on the computer by visiting: To also view the session live on the computer by visiting: If you have any questions, If you have please any contact questions, please Valerie Holt webcast@pdf.org at vholt@pdf.org or or call call (212) (212)

2 Introduction Robin Anthony Elliott Executive Director Parkinson s Disease Foundation

3 PD ExpertBriefing: Gait, Balance and Falls in Parkinson Disease Terry Ellis, Ph.D., P.T., N.C.S. Director, Center for Neurorehabilitation Boston University College of Health and Rehabilitation Sciences: Sargent College

4 Goals for PD ExpertBriefing Gain a better understanding of the nature of walking and balance problems experienced by people living with Parkinson's disease. Learn about research that demonstrates the benefits of rehabilitation and exercise to improve walking and balance in Parkinson s disease. Learn practical strategies to help improve walking and reduce fall risk as it applies to you, or a loved one or a patient living with Parkinson's disease.

5 Problems with Walking in Parkinson s Disease Slow walking Short, shuffling steps Foot drags or catches Arms swing less Stooped posture Difficulty initiating walking Difficulty turning

6 Why is Walking Problematic in Parkinson s Disease? Hypokinesia (small size of movements) Rigidity (stiffness) Freezing Weakness in the lower extremity muscles Reduced mobility of the joints in the lower extremity and the spine

7 Walking and Disability in Parkinson s Disease: Is There a Link?

8 Walking and Disability in PD Difficulty with ambulation is Clinical Red Flag that marks emerging disability Shulman L. Movement Disorders, 2010; 25 (1):S

9 WALKING DISTANCE: 6 MINUTE WALK TEST

10 Nimwegen MV. Physical Inactivity in Parkinson s disease. J Neurol. 2011;258 (12): Patients Parknet trial N Controls Aging study Men 409 (58.5%) 921 (47.0%) Age 68.6 (±7.7) 65.8 (±7.0) Time since diagnosis 5.3 (±4.7) % 47% 35% 5% People with PD were about 1/3 less active (29%) compared to healthy elders.

11 Changes in Ambulatory Activity in People with PD Over One Year Variable Baseline Mean (SD) [95% confidence interval] One year Mean (SD) [95% confidence interval] Magnitude of Change (% change / Effect size#) Age (years)" (8.75) [ ]" " " Years with PD" 4.44 (4.24) [ ]" " " Hoehn and Yahr Stage (median)" 2.0 (1-3)" 2.0 (1.5-3)" " LEDD (mg)" (294.38) [ ]" (359.66) [ ]" 28 / 0.37" Steps*" 10, (4332) [ ,645]" Moderate intensity minutes*" 22.5 (24.2) [ ]" (3534) [ ,325]" 16.1 (18.7) [ ]" - 12 / 0.28" - 40 / 0.30" MDS- UPDRS Motor subsecyon" (8.56) [ ]" (11.71) [ ]" - 1 / 0.03" MDS- UPDRS Item 3.10 (median)" 1 (0-2)" 1 (0-2)" " 6 minute walk (meters)" (135.61) [ ]" (154.60) [ ]" 3 / 0.11" Maximal Gait Speed (meters/sec)" 1.77 (.50) [ ]" 1.74 (.53) [ ]" - 2 / 0.06" Cavanaugh JT, Ellis T, Earhart GM et al. JNPT;2012:36:51

12 Slow progression of disability Optimize independence and participation in home, work and leisure activities Improve walking Speed Distance Goals for People with Parkinson s Disease Size of movements Turning ability

13 Solutions Practicing walking can improve walking Walking with a metronome or music can help improve coordination, timing, speed and efficiency of walking Using a pedometer can help with setting goals and providing feedback about progress

14 Solutions: Cueing Auditory Visual Tactile Verbal Attention (thinking about the movement) Combination of Above

15 How Does Cueing Work? Replace the lost internal cueing mechanism with an external cueing mechanism Acts as an internal cue or trigger to enable movement sequences to be carried out implicitly, automatically and without attention

16

17 Home Cueing Program Reference Intensity Intervention Nieuwboer (2007) 3x / week Auditory, vibration or visual cue E= mins at preferred frequency 3 weeks Results + step length + velocity decreased freezing no carry over effects at 6 wks PRACTICE TASKS» starting and stopping walking stepping sideways & backward walking dual task walking over uneven surfaces

18 Delivery of Auditory Cues Rhythmic Auditory Stimulus (RAS) Metronome Tone embedded into instrumental music 80 beats / min 100 beats / min 116 beats / min Music with a specific tempo

19 Video Demonstrations NO CUES WITH CUES

20 People with PD can improve their walking ability by using visual cues

21 6 feet 1 foot A B C D E EFFECTIVE CUES INEFFECTIVE CUES Orientation of Lines Adapted from Martin, 1967

22 Can People with Parkinson s Improve Balance? Lessen Risk of Falls?

23 Frequency of Falling One third of healthy older adults over 65 experience a fall Two thirds of people with PD living in the community report falling in the past 12 months Ashburn et al. Age Ageing (2001)

24 When, Where, How Do Falls Happen? N = 124 (age = 72; disease duration = eight years) 639 falls occurred 80% occurred at home Bedrooms Living areas Kitchens Gardens 45% of falls during walking 32% during standing 21% during transferring Ashburn et al. Disabil Rehabil 2008;30(16)

25 Allen et al. Balance & Falls in PD: A Meta-analysis of the Effect of Exercise and Motor Training. Movement Disorders. 26(9):

26 Effects of Tai Chi on Falling in PD 195 persons with Parkinson s disease Assigned to one of three groups: Tai Chi Resistance training stretching Twice a week for 60 minutes over 24 weeks Incidence rate of falls was significantly lower in the Tai Chi group compared to the stretching group No significant difference was found between the Tai Chi and strengthening group Fuzhong Li et al. N Engl J Med 2012;366:511-9

27 N=130 Subjects: PD with history of >2 falls in past year RCT 10 wk group Rx vs usual care Strength and balance training Led by PT Differences in fall rate between groups not stat sig but clin relevant? 32% difference in fall rates between groups during Rx 26% difference 10-wks post Rx Effects of Balance and Strengthening on Falling Goodwin VA et al. J Neurol Neurosurg Psychiatry 2011;82:

28 Example Exercises

29 Recommendations Be Active! Take action to reduce disability and optimize independence and quality of life Treatment focusing on walking and balance can help reduce disability Think prevention: Get treatment for walking and balance even before you notice a problem Consult with a physical therapist who is knowledgeable about Parkinson s disease

30 Things You Can Do Today Walk More: Use a pedometer Keep track of steps: write it down Set goals: # of steps per day Walk better: use a metronome or music to entrain to the beat Improve Balance: Practice balance exercises (visit a physical therapist) Strengthening exercises (practice standing up from a chair) Reduce Fall Risk: When standing still... widen your base of support by standing with your feet apart and not together Avoid multi-tasking this will result in more attention directed at walking and keeping your balance Reduce clutter in your house crowded environments contribute to freezing Fall diary write down the time of day, direction, activity, environment where the fall occurred and look for patterns

31 Questions About Exercise? Resources APDA Rehab Resource Center at Boston University Exercise Helpline (888) or PDF General Helpline (800) or

32 Resources from PDF Fact Sheets Falls Prevention Physical Therapy and Parkinson s Parkinson s Disease Resource List 750 Resources PD ExpertBriefings: Physical Therapy & Parkinson s: What You Need to Know Also available as DVD Professional Education: Online course. PTs, rehab specialists can earn.8 CEUs.

33 Questions & Answers

34 Upcoming PD ExpertBriefings Under-recognized Non-Motor Symptoms of Parkinson's Disease Tuesday, March 12, 1:00 PM 2:00 PM ET K. Ray Chaudhuri, D.Sc., M.D., Kings College London, London, UK Medical Therapies: What's in the Parkinson's Pipeline? Tuesday, April 16, 1:00 PM 2:00 PM ET Kapil D. Sethi, M.D., F.R.C.P., Georgia Health Sciences System, Augusta, GA Improving Communication in Parkinson s: One Voice, Many Listeners Tuesday, June 4, 1:00 PM 2:00 PM ET Angela Roberts-South, M.A., C.C.C.-S.L.P., C.A.S.L.P.O.(Reg.), Ph.D. Candidate, Western University, Ontario, Canada

35 Please complete our SURVEY. Your responses help us to improve the work that we do. Thank you.

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