Adult Neuro- Parkinson's specific PT

Parkinson's disease

second most common neurodegenerative disease; chronic progressive neurodegenerative disease that affects the basal ganglia; loss of dopamine producing brain cells

basal ganglia

parkinson's disease is a chronic progressive neurodegenerative disease that affects the

motor and non motor

parkinson's disease can exhibit what types of symptoms

striatum

fewer neurons in substantia nigra means less dopamine released in the

tremor, rigidity, akinesia, postural instability

what are motor symptoms

cognitive dysfunction, mood disorder, sleep disturbance, fatigue, autonomic dysfunction, urinary disturbance, constipation, sialorrhea, dysarthria, dysphagia, decreased sense of smell, pain/sensory disturbance, psychosis and dementia, eye abnormalities

non motor symptoms

modified hoehn and yahr scale

how is parkinson's disease categorized

stage 1

unilateral disease

stage 1.5

unilateral disease with axial involvement

stage 2

bilateral disease without postural instability

stage 2.5

mild bilateral disease, early signs of postural instability. recovery on pull test

stage 3

mild to moderate bilateral disease with postural instability, physically independent

stage 4

severe disability; still able to stand or walk unassisted

stage 5

confinement to wheelchair or bed

neuroprotection and neuroplasticity

what is used for the management of PD

PD specific exercise + optimal medication

what neuroprotection and neuroplasticity helps to manage PD

prevent progression

PD specific exercise + optimal medication=

regular moderate to vigorous level exercise in midlife

what reduces the risk of developing PD

increases longevity in people with PD, reduces severity of motor/nonmotor symptoms, delay motor progression, higher cognitive scores associated with greater physical fitness

what are the benefits of exercise with PD

quality of life, walking ability/speed, physical function, strength, balance, flexibility, posture, cardiorespiratory function

exercise can improve what aspects of life

decreases depression and apathy, prevention of cardiovascular complications, arrest of osteoporosis, improve cognitive function, improve sleep, decrease constipation, decrease fatigue, improve drug efficacy, optimization of the dopaminergic system

how does exercise affect non motor targets

functional performance, neuroplastic changes, increase efficacy of available dopamine

high intensity aerobic training improves

brain changes

exercise induces

upregulate neurotrophic factors (GDNF/BDNF), reduce oxidative stress, increase efficiency of available dopamine

exercise induces neuroplasticity by

increase DA receptors, increase localized release, stay in synapse longer

how does exercise increase efficiency of available dopamine by

critical

timing of exercise is

prophylactic and capable of protecting dopamine neurons

early exercise can be

high intensity, progressive aerobic training, complex (dual task/cognitive challenge), continuous, salient

exercise should be

initial consult and periodic check up, 1 on 1 skilled physical therapy, home/community exercise

PD specific physical therapy consists of

MOCA, MDS UPDRS part 1 and 3

what are outcome measures for body structure and function

6 MWT, 10 m walk, mini BESTest, FGA, 5 x STS, 9 hole peg test, MDS UPDRS part 2

what outcome measures are for activity

PDQ8, PDQ 39

what outcome measures are used to measure participation

freezing of gait questionnaire, parkinson's fatigue scale, ABC scale, TUG cog

what are specific construct outcome measures

TUG, TUG cog, 10 m walk test, PROMIS

what outcome measures should be performed at the evaluation

mini BESTest, 6 MWT, ABC scale, PDQ 39, FOG questions

what outcome measures should be performed at the first follow up visit

Unified parkinson's disease rating scale

comprehensive assessment designed to monitor the burden and extent of Parkinson's disease; most thoroughly tested instrument, gold standard reference scale, responsive to pharmacological, surgical, rehabilitation intervention

mini BESTest

short version of the balance evaluation system test, target 6 different balance control systems to specify rehabilitation approaches

aerobic exercise, balance training, resistance training, gait training, community based exercise, external cuing, task specific training, integrated care, behavior change approach, flexibility exercise

what are exercise techniques that are components of the PD CPG toolkit

20-60 min, 2-5x/week, 3-8 weeks

what is the dosage for external cueing

external cueing

used to reduce motor disease severity and freezing of gait, also to improve gait outcomes; high evidence quality and strong recommendations

1-4

external cuing is recommended for stages

strategy training

focus attention to enhance motor plan, break down complex movement to discrete sequences

mental rehersal, video feedback, movement amplitude

what are different types of attentional strategies?

cognitive strategies

replaces loss of automaticity with conscious effort

visual cueing

aimed to improve motor function, targeted stepping on/over targets, parallel lines, laser to reduce FOG, clock turn strategy

auditory cueing

sound that is delivered before or during movement to initiate or sustain a motor action

rhythmic auditory stimulation

pulsed rhythmic or musical stimulation aims to improve movement patterns; synching movement with rhythmic auditory beat

cadence

metronome or music set to selected bpm to improve

singing, voice exercises, counting, finger tapping, clapping, metronome, music

what are some ways to perform auditory cueing

somatosensory external cueing

stimuli aimed to heighten afferent input, vibration, tactile cues

amplitude training

high velocity, high amplitude movement training, PWR, LSVT BIG

LSVT programs

administered in an intensive manner to challenge the impaired system; techniques specific to PD deficits (bradykinesia/hypokinesia and kinesthetic awareness)

bigness

what is the target of LSVT BIG

intensive and high effort

what is the mode of LSVT BIG

generalization (sensory, internal cueing, neuropsychological changes)

what is the calibration of LSVT BIG

flexibility exericse

low evidence quality and weak recommendation strength; may implement to improve ROM

daily

what is the dosage of flexibility exercise for optimal effectiveness

ROM restrictions

rigidity can lead to

all stages

what stage should flexibility exercise be used for

home program, part of warm up/cool down

flexibility exercises should be part of the

spinal flexibility, trunk extension, axial rotation

there may be limited flexibility in the

hip and knee flexion, ankle dorsiflexion

there may be decreased flexibility in

chest expansion

may effect pulmonary function

reduce pain, improve efficiency of movement

by maintaining ROM it can help to

resistance training

high evidence and strong recommendation; to reduce motor disease severity, improve strength, power, non motor symptoms, functional outcome and quality of life

1-3

what stages should resistance training be used

2 non consecutive days per week, 30-60 minutes, progress as tolerated with good form, all major muscle goups, target extensors

what are the parameters for resistance training

progress to 80% 1RM

what is the intensity of resistance training to target strength

40-60% 1RM or 1 set of 20-30 reps, progress to 2 sets of 15

what is the intensity of resistance training for beginners

80% 1RM or 3 sets of 10-12 reps

what is the intensity of resistance training for experienced individuals

working at higher speeds, 20-40% 1RM

what is the intensity of resistance training for power

active resistance

when strength training, rigidity may cause

atrophy

strength training aims to maintain muscle force to prevent

standard of care

under dosing strength training is the

postural muscle, expiratory muscle, spinal extensors, scapular retractors, hip extensors and abductors, knee extensors, gastroc/soleus

what muscles should be target with strength training

sit to stand

what should be used for functional strength training

regular aerobic exercise leading to fitness

what is the single strategy with compelling evidence for slowing parkinson disease progression

appropriately optimized levodopa treatment program

engagement in vigorous exercise requires an

ability and motivation to exercise

delayed or underdosed levodopa treatment compromises the

neuroprotection

progressive aerobic exercise shows strong evidence in

increased blood flow, neurotrophic factors, metabolism, immune response, connectivity

what are the mechanisms behind progressive aerobic exercise

motor learning

progressive aerobic exercise has a neural priming effect to enhance

aerobic training

high quality evidence, strong recommendations; to improve oxygen consumption, reduce disease severity, and improve functional outcomes; used in individuals with mild to moderate PD

1-3

what stage is aerobic training used in

3x/week, moderate (60-75% max HR/12-13/20 RPE) to high intensity (75-80% max HR, 14-17/20 RPE), 30-40 minutes, treadmill walking or stationary cycling

what are the parameters for aerobic training

appropriate medical screening, monitor vital sign response, minimize risk for falls with harness system, autonomic dysfunction/orthostatic hypotension

what are some considerations when using aerobic exercise

increasing speed, resistance/load, or incline

how do you progress intensity of aerobic exercise

stationary bike

if patients have balance deficits and/or freezing of gait consider using what foe aerobic exercise

gait training

to reduce motor disease severity, improve stride length, gait speed, mobility, and balance; high quality and strong recommendation

1-3, effect less known in 4-5

gait training should be done in what stages

20-60 mins, 3-5 x week, 4-12 weeks, continuous

what are the parameters for gait training

3-6 months

gait training showed decline after

various walking surfaces, altering environment, addition of dual motor and/or cognitive tasks

what should also be included in gait training

nordic/pole walking

whole body activation, promote upright posture, reciprocal arm movement; retrains stride length, gait symmetry, and walking speed; reduces fear and pain in PD

gait speed and stride length

treadmill training was shown to improve

gait hypokinesia

treadmill training was a beneficial treatment for

treadmill training

task specific, improve gait velocity and step length, more than aerobic and speed training

proper gait mechanic and symmetry, posture, arm swing, progressive intensity and effort

treadmill training focuses on

dual task

affect divided attention, difficulty in shifting from one activity to another, task complexity

dual motor task, dual cognitive task, cognitive and motor task

what are different types of dual tasks