Unit 2 - Diagnosis-Specific Considerations (Demyelinating and Basal Ganglia disorders)

MS Review

• Chronic autoimmune disorder affecting CNS

• Demyelination and axonal damage

• Types: RRMS, SPMS, PPMS, PRMS

• Common impairments: fatigue, weakness, spasticity, ataxia, balance/gait deficits

Types of MS

Relapsing-Remitting (RR)

marked by episodes of new or worsening symptoms followed by periods of partial or complete recovery

Types of MS

Secondary Progressive (SP)

often develops from RRMS and involves a steady progression of symptoms over time

Types of MS

Primary Progressive (PP)

characterized by gradual worsening without distinct relapses

Types of MS

Progressive Relapsing (PR)

the rarest form, showing steady progression with occasional acute relapses

Role of PT Across MS Disease Stages

Early Stage

Prevent deconditioning, educate, promote aerobic activity

Role of PT Across MS Disease Stages

Middle Stage

Manage fatigue, address gait and balance deficits

Role of PT Across MS Disease Stages

Late Stage

Prevent contractures, support transfers, maintain quality of life

MS

Fatigue Management Strategies

• Pacing and energy conservation

• Temperature regulation

  • cooling garments, air conditioning, and exercise timing to avoid overheating

• Aerobic conditioning (submaximal, moderate intensity)

  • walking or stationary cycling 

• Activity diaries and fatigue scales (MFIS, FSS)

  • Modified Fatigue Impact Scale

  • Fatigue Severity Scale

MS

Strengthening and Functional Mobility

• Avoid overwork weakness

• Focus on multi-joint, functional exercises

• Closed-chain > open-chain

  • provide joint stability, proprioceptive input, and often mimic the functional demands of upright activities

• Task-specific training: sit-to-stand, stair climbing, transfers

  • improve strength, confidence, and independence

MS

Balance and Gait Training

• Dual-task training

• Static/dynamic balance (foam, perturbations)

• Gait aids and orthotics (AFOs, FES)

• Use of RAS (rhythmic auditory stimulation)

  • uses a metronome or music with a set tempo to improve gait, rhythm, and coordination

  • especially helpful for patients with ataxia or inconsistent stride patterns

MS

Spasticity and Tone Management

• Stretching: slow, prolonged

  • 30-60s

• Positioning and splinting

  • help prevent contractures and minimize abnormal tone

• Modalities: cryotherapy, TENS

• Referral for medical management (baclofen, botox)

MS

Interdisciplinary Care and Patient Education

• Education: pacing, exercise, stress management

• Collaboration: OT, speech, neuropsych, neurology

• Group therapy, support groups, telerehab options

• Goal setting and self-efficacy

Overview of Guillain-Barré Syndrome

• Acute, immune-mediated polyneuropathy

• Rapid-onset muscle weakness, often ascending

• Typically post-infectious (e.g., viral, bacterial)

• Variants: AIDP (most common), Miller Fisher, AMAN/AMSAN

Types of GBS

Miller Fisher syndrome

typically presents with eye movement abnormalities and ataxia

Types of GBS

AMAN or AMSAN

involve axonal damage and often result in a more prolonged or incomplete recovery

Phases of GBS and PT Role

Acute (ICU)

Monitor vitals, positioning, respiratory support, PROM

Phases of GBS and PT Role

Plateau/Subacute

Begin gentle activity, prevent complications (DVT, contractures, skin breakdown), monitor fatigue

Phases of GBS and PT Role

Recovery

Progressive strengthening, mobility, function, community re-entry

GBS

Fatigue & Overwork Prevention

• Monitor closely for overwork weakness

  • phenomenon where excessive or poorly dosed exercise during early recovery actually leads to a decline in strength rather than improvement, especially in partially denervated muscles

• Low-rep, short-duration exercises initially

• Prioritize rest and pacing

• Use of fatigue scales and patient feedback

GBS

Functional Mobility & Strength Training

• Task-specific retraining: transfers, gait, stairs

• Use of ADs and orthoses (AFOs, walkers)

• Progress resistance and reps slowly

• Integrate balance and coordination as recovery allows

GBS

Interdisciplinary Collaboration & Patient Education

• Work with OT, respiratory therapy, neurology, psychology

• Teach energy conservation, joint protection

• Support goal setting and long- term planning

• Prepare for slow, nonlinear recovery trajectory

Orthotic Consideration

• Body function/ structure

• Patient activity

• Environmental factors

• Participation levels

KAFOs

• <3+/5 MMT Quad strength

  • Met Participation criteria

    • If quads <2/5 MMT —> will need RGO

  • Met Completion criteria

KAFOs

Participation Criteria

• No contractures

• straight leg raised to 110 degrees

• floor to wheelchair transfers are independent

• ability to complete 50 dips in the parallel bars

• VO2 max of greater than 20 milliliters

KAFOs

Completion Criteria

• Ability to stand independently

• ability to walk in the parallel bars

• ability to walk 20 steps with supervision

AFOs

• Weakness

• Decreased Motor control

• Can help improve foot drop

• Can help improve knee hyperextension and knee flexion in stance phase

Solid Ankle AFOs

• Foot clearance in swing phase

• Medial and lateral support at the ankle

• triplanar foot support

• may prescribe for people with severe plantar flexor tone

• Indirectly provides knee stability

  • can provide knee flexion in early stance phase

Articulated AFOs

Plantarflexion Stop (PS)

• Allows ankle to be in more DF

• Provide medial lateral support

Articulated AFOs

Dorsiflexion Stop (DS)

• Prevent excessive DF in stance phase

• Provide medial lateral support

Posterior Leaf Spring AFO

• Provides foot clearance in swing phase

• Does NOT provide any medial lateral support

• less effective for people with severe tone or significant foot triplanar challenges

FES

• Common fibular nerve is stimulated to improve dorsiflexion during swing phase

• precautions

  • active cancer, osteomyelitis, epilepsy, pregnancy, skin tolerance, excessive subcutaneous tissue, or a history of implanted electrical devices

SO HOW DO WE CHOOSE TO USE AFOs or FES?

Level and pattern of motor recovery

Does the patient have volitional control of ankle dorsiflexors?

• no active dorsiflexion, then the patient likely needs an AFO to maintain foot clearance during gait

• some dorsiflexion, FES might be used to help activate and strengthen that movement

SO HOW DO WE CHOOSE TO USE AFOs or FES?

Spasticity & Tone

• Moderate to severe spasticity → may favor AFO

• Minimal tone issues → FES may be appropriate

SO HOW DO WE CHOOSE TO USE AFOs or FES?

Volitional Motor Control

• Present but weak DF = FES can facilitate activation

• Absent DF = AFO provides stability & safety

SO HOW DO WE CHOOSE TO USE AFOs or FES?

Fatigue and Endurance

• If fatigue limits function → AFO can reduce energy cost

• FES may be fatiguing for prolonged ambulation

SO HOW DO WE CHOOSE TO USE AFOs or FES?

Skin Integrity & Sensation

Impaired sensation or fragile skin → use caution with FES electrodes

SO HOW DO WE CHOOSE TO USE AFOs or FES?

Cognition & Compliance

• FES requires more active participation, setup, and troubleshooting

• AFO is more passive, easier to don/doff

Short Answer: AFO vs FES

• When AFO’s and FES are directly compared one device is not superior to another in the ability to improve outcomes of QOL, gait speed, other mobility, dynamic balance, endurance, and little in gait kinematics.

• No evidence was found to directly compared muscle activation

Long Answer: AFO vs FES

• AFO

  • Inclusion of an AFO may demonstrate better immediate effects.

  • Increase an individual’s ability to participate at a higher level in the rehabilitation process.

  • AFO more effective in acute phase in individuals walking at slower gait speed or lower baseline mobility.

  • AFO may be most effective at improving balance confidence when compared to FES

• FES

  • ↑ User satisfaction and patient preference may be higher with FES

  • Greater therapeutic effects

  • Better choice for individuals walking at faster speeds or higher baseline mobility.

  • Expensive

Risk of Abandonment

AFO

• Difficult to don and doff

• Not clear on intent or benefits of device

• Too much mobility restriction

• Discomfort

• Cosmesis

• Skin irritation

Risk of Abandonment

FES

• Intolerance to the sensation

• Insufficient DF achieved (recommended ≥ stage 3)

• Skin irritation

• Challenges with electrode placement

AFO vs FES

Body Structure and Function Exam Considerations

Force Production

• Amount of control needed to correct an abnormal movement pattern

• Support needed to assist movement

• Potential to improve active movement

AFO vs FES

Body Structure and Function Exam Considerations

Sensation/Integumentary

• Crude touch/ Nociception: Can the individual perceive discomfort related to skin irritation or breakdown?

• Swelling or edema present

AFO vs FES

Body Structure and Function Exam Considerations

ROM/Alignment

• Does the individual have adequate ROM for the motions allowed by the device?

• Does the individual require support to prevent contractures?

AFO vs FES

Body Structure and Function Exam Considerations

Cognition

Can the individuals and/or caregiver appropriately maintain and don/doff the device?

Quick Summary of AFO Decision Making Algorithm

PD

Gait Training

• Physical therapists should implement gait training

• Evidence Quality = HIGH // Recommendation Strength = STRONG

PD

Gait Training

Benefits

improvements in:

• Reduced motor disease severity

• Step length

• Walking speed

• Walking capacity

• Functional mobility

• Improved balance

PD

Gait Characteristics

• Shuffling

  • Shortened step length, decreased foot clearance and flexed knees and hips

• Rigid trunk and decreased/asymmetrical arm swing

• Bradykinesia, worsens with dual tasking

PD

Gait Characteristics

Festination Anteropulsion

• COM gets to far anterior, “run away train” (leads to falls)

• TRIGGERS: wheeled walkers without hand breaks, forcing through a freeze, being pulled on during a freeze

PD

Gait Characteristics

Festination Retropulsion

• COM gets too far posterior, Under scaled balance reaction, small steps to recover (leads to falls).

• TRIGGERS: backing up, reaching overhead, opening door, carrying items too close to body

PD

Gait Characteristics

Freezing of gait (akinesia)

TRIGGERS: Tight/narrow spaces (doorways, elevators), cluttered areas, crowds, anxiety/stress/rushing, turning/pivoting, change in floor pattern

PD

External Cueing

• Physical therapists should implement external cueing to reduce motor disease severity and freezing of gait, and improve gait outcomes

  • Evidence Quality = HIGH // Recommendation Strength = STRONG

• Cueing including visual, auditory (rhythmic auditory stimuli), or somatosensory cueing superior in comparison to no cueing

• No one mode of cueing is superior to another

PD

External Cueing

Benefits

improvements in:

• Motor disease severity

• Spatiotemporal parameters of gait (gait speed, stride length, cadence)

• Functional gait outcomes (mobility, turning & distance walked)

• Freezing of gait

PD

Visual Cueing

• Most commonly used for gait training

  • Improve Step Length

    • 150% longer than current

    • Target = 40% of patient height (24-28 inches)

  • Improve Turning

  • Improve Initiation of Gait

    

PD

External Accessories

PD

Auditory Cueing

• Rhythmic cueing with use of metronome, music, clapping or snapping

• Used with all exercises

  • PNF patterns – axial rotation

  • Stepping –

    • 25% faster than baseline

    • 100-125 bpm – for higher functioning patients

  • Resistance Exercise

  • Boxing

PD

Freezing of Gait

4 S’s

1. stop

2. stand tall

   1. relax

   2. correct posture

   3. get COM over BOS

3. sway

4. step long/big

PD

FESTINATION of Gait

3 S’s

1. stop

2. stand tall

   1. relax

   2. correct posture

   3. get COM over BOS

3. step long/big

Why Exercise and Movement Matter for Parkinsons Disease

• Neuroplasticity: use it or lose it

• Delays motor decline

• Improves quality of life and ADLs

• Encourages social connection and autonomy

PD

What is LSVT BIG?

• Think Big, Move Big

• = Lee Silverman Voice Treatment

• Expanded from LSVT LOUD to movement-based therapy

• 4-week, 16-session protocol

PD

What is LSVT BIG?

The BIG Approach

• Focus: amplitude (bigness) of movement

• Intensive, repetitive, task-specific practice

• Trains automaticity and recalibrates perception

PD

Evidence Behind LSVT BIG

• Improved gait speed and stride length (decreased shuffling)

• Better balance and reduced fall risk

• Enhanced ADL participation

PD

What is PWR!?

• Parkinson’s Wellness Recovery

• Created by Dr. Becky Farley, LSVT BIG developer

• Builds on BIG principles

  • need for a broader, more adaptable movement system, one that not only trained amplitude, but also incorporated flexibility, balance, and coordination

• Includes 4 foundational “PWR! Moves”

PD

The 4 PWR! Moves: Foundation and Function

• PWR! UP: postural extension

  • helping counteract the stooped posture by activating the extensor muscles

• PWR! ROCK: weight shift

  • provides weight shifting, which is critical for improving balance, initiating movement, and reducing fall risk

• PWR! TWIST: axial mobility

  • works on the axial mobility rotational movements through the spine and trunk that are essential for tasks like rolling in bed or turning while walking

• PWR! STEP: transitional movement

  • emphasizes transitional movements, helping patients move confidently from one position or place to another, like sit to stand, stepping over obstacles, or navigating tight spaces

PD

What is Rock Steady Boxing? Rock Steady Boxing: Fight Back

• Non-contact boxing program for PD

• Combines agility, strength, balance, and coordination

• Group-based, high-intensity

• heavy bag punching, footwork drills, and core strengthening

PD

Rock Steady Boxing

• Warm-up, drills, shadowboxing, mitt work

  • drills and shadowboxing to work on form, coordination, and motor planning

  • Mitt work allows for precision and reaction time

• Voice activation and dual-tasking

  • helps with vocal strength and projection

• Aerobic conditioning

  • boost cardiovascular health and overall endurance

PD

Rock Steady Boxing

Benefits

• Improved balance and coordination

• Increased strength and endurance

• Reduces depression, apathy

PD

LSVT Review

• focus: amplitude

• format: 1:1, 4 weeks

• intensity: high

• use case: early-mid PD

PD

PWR! Review

• focus: function, variety

• format: 1:1, group

• intensity: moderate-high

• use case: lifelong integration

PD

Rock Steady Review

• focus: conditioning

• format: group

• intensity: high

• use case: community-based

PD

How to Choose and Apply Therapy

• Consider stage, goals, and access

• Start with 1:1, move toward group

• Cross-train and re-evaluate quarterly