Neuro without SCI

What are the two physiotherapy guidelines for Parkinson's disease mentioned in the lecture?

The American Physical Therapy Association's Clinical Practice Guideline (2022) and the European Physiotherapy Guideline for Parkinson’s disease (2014).

What neuroprotective effects does exercise have for PD patients?

• having neuroplastic effects

• improve ‘off’ motor symptoms

• decrease in levodopa medication use

What does FITT stand for in the context of exercise prescription?

Frequency, Intensity, Time, and Type.

What are the physical activity guidelines for people living with a disability, including PD?

At least 150-300 mins moderate intensity OR 75-150 mins vigorous intensity aerobic physical activity; Moderate-vigorous intensity strength exercises of all major muscle groups 2 days/week; Moderate-vigorous intensity multicomponent functional balance and strength exercises 3 days/week. Limit sedentary time, Incorporate behaviour change strategies.

According to the Schootemeijer et al systematic review, what did aerobic exercise improve in PD patients?

Physical fitness and “off” motor symptoms.

High intensity aerobic exercise may _ the rate of motor impairments associated with PD.

slow

What does aerobic exercise improve for PD patients?

• VO2 max

• had less progression in motor symotoms

• promote neuroplasticiy

What benefits were found with strength training, according to Braz de Oliveira et al?

Improvements in UL strength, CVS fitness, balance, functional gait outcomes, QOL, No effects in: LL strength, flexibility, gait kinematics

What were the significant improvements found with preogressive resistance training according to Chung et al?

Significant improvements in: muscle strength (maximal voluntary contraction), balance, PD motor symptoms. No improvements in: gait, balance confidence, quality of life

What should strength training be combined with to achieve improved activity performance and participation?

Other forms of intervention.

What does strength training improve for PD patients?

• significant improvements in muscle strength, PD motor impairments

What type of balance exercises is considered to be most effective?

Challenging balance exercises, such as those that reduce base of support, reduce hand support, or involve movement of the COM over the BOS.

Give some examples of highly challenging yet safe balance exercises in a sustainable format

Dancing (especially partnered dance), Tai Chi, Group balance exercises, Use of exergames

Auditory cues improved what gait parameters for people with PD?

Stride length, gait speed, cadence, and UPDRS-II (ADL performance).

Non-freezers may benefit from cueing at a cadence 10% __ baseline.

above, aiming to improve stride length, and walking speed

Freezers may benefit from cueing at a cadence ranging from 0-10% __ baseline.

below, aiming to reduce the frequency and severity of FOG

Treadmill training has been shown to improve what in people with PD?

Walking speed and step length.

Limitations of UL training for people with Parkinson's Disease include which of the following?

Speed-accuracy trade-off, intensity of exercise associated with amount of gain

Need to match exercise to goals, motor and non-motor impairments, enjoyment, safety, environment and response to exercise

individual

What does auditory, visual, or both cues improve in gait?

• Auditory cueing: improved walking speed, stride length and cadence

• Visual cueing: only increase stride length

• Both auditory and visual cue will only increase cadence without the increase in walking speed or stride length

Muscle Weakness in Neurodegenerative Conditions

A feature of many neurodegenerative conditions, including MND, MS, and PD; can be a primary impairment or secondary to disuse/inactivity.

What do patients with mild to moderate PD have redued for lower limbs?

Reduced leg muscle strength (force) and power (force x velocity).

What do the impairments above lead to?

• reduce walking speed

• increase frequency of falls

What does resistance training improve in PD?

Leg muscle strength and leg muscle power.

What does the location of weakness depend on?

Where the lesion is in the CNS

What is the percentage of individuals with MS has the impairment of weakness, and its characteristics?

Muscle weakness, affecting approximately 70% of individuals with MS. Severity tends to increase over time, location depends on CNS lesions, and muscle power is reduced.

Clinical Implications: Strength Training in PD and MS

People will improve muscle strength with standard strength training protocols. Consider muscle power training for beneficial effects on walking speed, balance, and falls.

What will exercise improve for MND patients?

May improve function. No change in muscle strength; mild to moderate intensity strength training is safe.

What does the location of weakness depend on?

Where the lesion is in the CNS

What is DOMS?

• Muscle pain after exercise (typically develpeds 1 to 2 days post exercise

• Occurs after unaccustomed or excessive exercise

• More likely after excessive eccentric strength exercise

• Associated with a short term loss of muscle strength; can lead to difficulty in walking or an inability to walk after exercise

• A: normal walking speed

• B: little decrease in walking speed for 1-2 days

• C: huge decrease in walking speed or unable to walk 1-2 days 

How to prescribe safe resistance exercise for MND patients?

• Begin with low intensity and progress to moderate (avoid high intensity)

• Ensure adequate rest breaks between sets

• Monitor fatigue, exertion, pain, muscle soreness

• Regular re-assessment (every 2-4 weeks)

• Restrict training of each muscle group to 3x per week

• Progress by changin on training parameter at any one time

• Focus on muscle groups that will help with functional activities

• Ensure exercise can be performed safely

What is fatigue in the context of neurodegenerative conditions?

A subjective lack of physical or mental energy that is perceived by the individual or caregiver to interfere with activities of daily living

What are the aims of fitness training?

• Prevent unnecessary secondary impairments

• Promote optimum physical activity

What is fatigue in MS?

• A subjective lack of physical or mental energy that is perceived by the individual or caregiver to interfere with activities of daily living

What are some characteristics of fatigue?

• Fatigue may be physical, mental or both

• Worse later in the day

• Aggravated by heat, depression, pain and excessive exertion

• Interferes with physical and social function

List some potential causes of fatigue in multiple sclerosis.

Anaemia, Thyroid dysfunction, Depression, Sleep disorders and Pain

Why is fatigue important in neurodegenerative conditions?

It interferes with daily activities/concentration, exacerbates other impairments, and is a known risk factor for reduced quality of life

What are the aims of fitness training in managing fatigue?

Prevent unnecessary secondary impairments and promote optimum physical activity

Is there any effect for high intensity interval training compared to continuous aerobic exercise?

no

What are some characteristics of fatigue in MS?

May be physical, mental or both, worse later in the day, aggravated by heat, depression, pain and excessive exertion, and interferes with physical and social function

Name some potential causes of fatigue directly related to MS

Depression, Sleep disorders, Pain, and Bladder dysfunction

Name some primary impairments that can cause fatigue in MS

• CNS dysfunction

  • Demyelination, axonal loss, neural circuti disruption

• Immune dysfunction

  • Higher levels of immune markers

What are some secondary impairments of fatigue in MS?

• Decreases physical activity; weakness and peripheral muscle changes

• Decrease physical activity; decrease cardiorespiratroy fitness

• Heat = increase body temp, causing heat fatigue

• Anti-spasticity medication

How to measure a patient’s fatigue level?

• Fatigue impact scale

• Fatigue severity scale

• Fatigue diary

What type of information could be recorded in a fatigue diary?

Assign a number from 1 to 10 for level of fatigue, the value or importance of the activity, satisfaction with performance, describe physical work, and list MS symptoms

What health professionals/services are involved in a multidisciplinary approach to fatigue management?

Medical practitioners, Psychologist, Physiotherapist, Occupational therapist, Continence advisor, Dietician, Social worker, Sleep clinic, Pain clinic, MS Society resources

What advantages does HIIT training have over moderate intensity continuous training?

May lead to greater improvements in cardiorespiratory fitness in a shorter training time and potential to provide greater benefits for fatigue due to metabolic adaptations

What advantages does moderate intensity continuous training have over HIIT training?

May be better tolerated by people with lower fitness levels or severe MS and may be easier to adhere to for some people

How does physio intervene?

• Addresses some secondary causes of fatigue

  • Improves fitness and strength

  • Reduces deconditioning

  • Promotes better sleep

  • Improves better health/mood

How does telephone counselling and telehealth monitoring of physical activity on fatigue on MS help?

• Decrease depression

• Decrease fatigue

• Increase self-reported physical activity

What exercise guidelines should be followed to Manage fatigue?

• Exercise at cooler time of day

• Exercise early in the day of lower fatigue

• Wear loose, breathable clothing

• Aquatic physiotherapy

• Begin with low-moderate intensity and duration, schedule rests between exercises

• Progress to moderate intensity, aim for a combination of aerobic and resistance exercise

• Include cooling strategies

What cooling strageties are recommended for physiotherapy patients during exercise?

• Pre-exercise cooling (30 mins lower body immersion in 16-17 degree water; to decreaser RPE during exercise, and decrease post-exercise fatigue

• Cooling garments - cap and vest with coolant at 7 degrees for 1 hour; to decrease fatigue

What symptoms may increase temporarily during exercise?

Sensory symptoms (pins and needles, numbness, blurred vision) may increase temporarily, but usually disappear 20-30 mins after exercise

What is community mobility?

The ability to confidently negotiate uneven terrain, private venues, and other public venues.

What does community ambulation refer to?

The ability of a person to walk in their own community, outside of their home and also indoors in private or public locations.

What is the minimum walking speed required to safely cross the road?

1.3 m/s

What walking speed classifies someone as a household ambulator?

Less than 0.4 m/sec

What walking speed classifies someone as a limited community ambulator?

0.4 to 0.8 m/sec

What walking speed classifies someone as a community ambulator?

0.8 to 1.3 m/sec

Name some environmental factors influencing community walking.

Walking distance, temporal demand, ambient conditions, terrains, external physical load, attention demands, postural transitions, crowdedness

List some common gait deviations in people with health conditions.

Reduced walking speed, reduced step length, reduced cadence, increased step width, increased time in double support, reduced distance walked.

How does walking uphill affect walking speed, cadence, and step length?

Decreases walking speed, cadence, and step length

What happens to step length when walking downhill?

Decreases with increasing slope

During stair ascent, what are the phases?

Weight acceptance, pull up, forward continuance, foot clearance, foot placement

During stair descent, what are the phases?

Weight acceptance, forward continuance, controlled lowering, pull through, foot placement

What are some common adaptive strategies used during stair walking by people with health conditions?

Use of rail, 2 feet on one step, wide BOS, circumduction/hitch hip during swing phase

Name some measurements used to assess community walking.

Timed 10m Walk test, 6 min Walk test, Self-report measures

Name a measurement used to assess stair climbing.

Timed ascent/descent of flight stairs

What is the clinical reasoning pathway for community mobility?

1. Background information

2. Observe and measure activity

3. Test for impairment

4. Develop intervention 

What happens when a person walks uphill and downhill respectively? 

Uphill:

• Step length and walking speed decreases

• Increase hip and knee flexion during early stance, and late swing

Downhill:

• Decrease in walking speed

• Increase knee flexion during stance phase

• Increase friction demand increasing slope

• Increase eccentric force knee extensors

What should a patient achieve when passing crubs?

• There should be no hesitation or loss of fluency when crossing the curb

• Accurate and appropriate adjustments to step pattern are made prior to negotiating obstacles

How woud a patient with a stroke react when walking past obstacles?

• The affected limb was positioned closer to the obstacle before crossing

• Affected trail-limb clearance over the obstcle was reduced

• Both affected and unaffected lead and trail limbs landed closer to the obstacle after clearance

What are the three main types of Multiple Sclerosis?

Relapsing-remitting MS (RRMS), Primary progressive MS (PPMS), and Secondary progressive MS (SPMS)

Name three motor impairments associated with MS.

Weakness, Spasticity, and Ataxia

List some non-motor impairments related to MS.

Fatigue, heat sensitivity, sensory issues, pain, bladder dysfunction, cognitive impairment, depression, mood changes

What is the definition of Evidence-Based Practice (EBP)?

The integration of best research evidence with clinical expertise and patient values.

What are the physical activity guidelines for people living with a disability, including MS?

At least 150-300 minutes of moderate-intensity OR 75-150 minutes of vigorous-intensity aerobic physical activity; moderate-vigorous intensity strength exercises of all major muscle groups 2 days/week; moderate-vigorous intensity multicomponent functional balance and strength exercises 3 days/week.

What overall effects on balance, gait, fatigue, and QOL does exercise have on those with MS?

Improved balance, gait, fatigue, and QOL

What domains does balance training improve?

Balance training leads to improved static balance but no effects on TUG, BBS, gait speed / endurance

What are the potential benefits of aquatic exercise?

Buoyancy (reduces body weight), hydrostatic pressure (can reduce swelling), resistance (strength training)

What domains can aquatic exercise improve compared to conventional therapy?

Improvements in fatigue (physical, cognitive, psychosocial), depression, 6MWT, BBS

What effect does exercise have on fatigue in people with MS?

Moderate effect on fatigue

What domains do physiotherapy/exercise improve in ambulatory people with mild-moderate MS?

Strength, walking capacity, fatigue, aerobic fitness, balance, depression, QOL

In people with progressive MS, what interventions have 'positive' evidence?

Positive evidence for physiotherapy as part of a multidisciplinary team and for botox + stretching.

In people with severe MS, what intervention can improve fatigue, 6MWT and BBS?

robotic-assisted gait training appears to improve fatigue, 6MWT, BBS

What are the clinical implications regarding the safety of exercise in MS?

Exercise training is generally safe, begin conservatively, monitor for adverse effects or signs of relapse, and train at a “tolerable” intensity

What domains can telerehabilitation improve in people with MS?

Improvements in impairments (fatigue, pain), activity performance (mobility, balance, PA levels), QOL

List factors to consider when choosing exercise for someone with MS.

All MS are not the same (variations)

All people are not the same (variation in exercise history, life goals, available resources, other medical problems)

one exercise doesn’t fit all (need to match individual goals)

Impairments specific to MS

How can technology be used to provide intervention?

Technology can be used to provide intervention: immediate feedback, enhance enjoyment and motivation

What does aerobic exercise improve for MS patients?

Improved walking endurance, and with gait training, balance is improved

What affects the effects of balance exercise?

The greater the dosage, the greater the benefits

What is the approximate falls rate in older adults?

Around 27% with higher rates in Oceania

What is the fall rate in people with Parkinson's Disease (PD)?

Approximately 60% experience recurrent falls

What is the fall rate in people with Multiple Sclerosis (MS)?

Approximately 60% experience recurrent falls

What is the fall rate in people with Motor Neuron Disease (MND)?

Approximately 30%

In people with PD, when do most falls occur?

While walking or during changes of position, and often 'on' medication

In people with MS, where do most falls occur?

Indoors, during gait-related activities

What are some risk factors for falls in the general older population?

Demographic factors (age, fall history), medical conditions, psychological factors (depression), medications, sensorimotor and balance impairments, environmental factors