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ALLIED TEAM TRAINING FOR PARKINSONParkinson’s Impact on Motor Function:Assessment and Design of Appropriate

Interventions In Early Stage PD

Maria Walde-Douglas, PT

Struthers Parkinson’s Center

Acknowledgements to Rose Wichmann, PT

Manager, Struthers Parkinson’s Center

Session Learning Objectives

• Identify evidence –based, performance-oriented assessment tools for assessing individuals with PD

• Describe rationale and benefits of exercise for persons with PD

• Identify the impact of various PD symptoms on motor function

• Describe evidence-based PT treatment interventions to be considered in treatment of early stage Parkinson’s disease

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Patient-Centered Care

PT ROLE:

• Listening to patient needs and concerns

• Using a motivational style of interview and instruction

• Ensuring patient understanding

• Including family carepartner needs and perspectives

• Developing a partnership throughout a continuum of care

• Teaching patient advocacy

Selection of Best Assessment Tools for PD

rehabmeasures.orgThe rehabilitation clinician's place to find the best instruments to screen

patients and monitor their progress

PD Edge recommendations: Neurology section of APTA task force on PD:

HR: Highly Recommended

R : Recommended

LS/UR: Reasonable to use, but limited study in target group/Unable to recommend

NR: Not Recommended

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Performance-Oriented Assessment Tools for PD-PD EDGE

• Timed Up and Go Dual Task Test

• 5 Times Sit to Stand Test

• 10 Meter Walk Test

• Functional Reach Test

• Dynamic Gait Index

• Functional Gait Assessment

• Berg Balance Scale

• MiniBESTest

• 6 Min Walk Test

Timed Up and Go Dual TaskPD EDGE: HR for H &Y Stages I-IV. NR Stages V

• Contains balance and gait maneuvers in everyday life

�Person gets up from chair, walks 3 meters (9.84ft), turns and returns to chair to sit; asked to walk as quickly but safely as possible

�Test is timed

�TUG (cognitive): while counting backwards by 3’s from # between 20-100 or alternating letters of alphabet (a-c-e-g)

�TUG (manual): while holding a cup filled with water

• Person may use their customary assistive device

Cut-off scores for PD (Maranhao-Filho, et al 2011): difference between TUG and Manual TUG >4.5 sec indicates increased risk for falls

*the TUG and cogTUG are included on the MiniBESTest: scored lower if the cogTUG is 10% more than regular TUG

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5 Times Sit to Stand TestPD EDGE: HR Stages I-IV. NR Stage V

�43-45 cm chair height�Arms folded, sitting to back of chair�Start and end test on the chair�Test is timed

• Originally designed as a quick LE strength test

• Significant correlation with other mobility measures (UPDRS, PAS, Mini-BEST and ABC)

• Cutoff score in PD (Duncan,et al 2011):>16 sec indicated risk of falls &discriminates fallers from non-fallers

• If unable to perform without use of arms, can test using arms just to record time for retest comparison (cannot apply cutoff score times)

10 Meter Walk TestPD EDGE: HR Stages I-III. NR Stages IV-V

• Walking time for a set distance: 10 M total but given 2 M accel and deceleration so only middle 6 M timed

• Collect 3 trials and calculate the average

• AD can be used

• Document if fastest or preferred walking speed

• Not appropriate if person requires assistance to ambulate

MDC in PD (Steffen, et al 2008): comfortable gait speed=.18 M/sec

fastest gait speed=.25 M/sec

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Functional Reach Test

PD EDGE: HR Stages I-III. NR Stages IV-V

• Patient stands close to a wall with 90 degrees of shoulder flexion and closed fist (yardstick at acromion height)

• “Reach as far as you can forward without taking a step”

• Start and end position of 3rd metacarpal is recorded for reach distance

• 3 trials with average of last 2 recorded

MDC in PD: 7.32 cm (3.1 in) (Schenkman, et al 1997)Cutoff scores in PD: <31.75 cm (12.7 in) indicates fall risk (Dibble, et al 2006)

Dynamic Gait Index

PD EDGE: HR Stages I-IV. NR Stage V

• 20 foot walking course

• With or without AD

• 4 point scoring system with total of 24 points

• Tasks include: steady state walking, changing speeds, head turns, stepping over and around obstacles, pivoting, stairs

MDC for PD (Huang, et al, 2011): 2.9 points

Cutoff scores for PD (Dibble et al, 2008) : <19 discriminates between fallers and non-fallers

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Functional Gait Assessment

PD EDGE: HR Stages I-IV. NR Stage V

• Modification of Dynamic Gait Index to improve reliability and reduce ceiling effect

• 10 item test including gait with narrow BOS, backward walking and gait with eyes closed. 30 point total. 4 point scoring system.

Cutoff Scores for PD (Leddy, et al 2011): 15/30 indicates predictive ability to identify fallers

Berg Balance Scale

PD EDGE: HR Stages II-II. NR Stage I, IV, V

• Static and dynamic activities of varying activity

• 5 point scale (0-4). Max score of 56

MDC in PD: (Steffan et al, 2008): 5 points

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MiniBESTest

Fay Horak to address in Final PD Breakout

6 Minute Walk Test

PD EDGE: HR in Stages I-IV. NR Stage V

• Cover as much distance walking as possible over 6 min

• Distance measured (measuring wheel)

• Can use AD; person must ambulate without physical assistance

MDC in PD (Steffan et al, 2008): 269 ft (82 meters)

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Changes in Ambulatory Activity in PDCavanaugh, J, Ellis, t, Dibble, L JNPT June 2012

�Step activity monitors on people with PD over one year; measured “free-living ambulatory activity”

(n=33;mild to moderate stage PD)

�11% reduction in mean daily steps over course of a year in ambulatory activity (1000 steps/day on average)

�40% reduction in daily minutes of moderate intensity activity over course of a year

Message of One Year Activity Study

�Not making an effort to engage in moderate physical activity and exercise can lead to decline in conditioning levels over the course of a year

�Doing nothing differently or cutting back on activity/exercise can be prodegenerative

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Exercise Behavior and PDEllis, J Phys Ther 2011

�Stage of PD or degree of disability was NOT the biggest factor that influenced exercise consistency

�Self-efficacy was most strongly associated with whether community-dwelling persons with PD exercise regularly

*Those with high self-efficacy were twice as likely to exercise regularly

Self-Efficacy

Definition: belief in one’s abilities and capabilities to accomplish a task, make a change or attain a goal

BELIEVE THAT EXERCISE MAKES A POSITIVE DIFFERENCE

People with PD need to BELIEVE they can improve their quality of life and daily function if they exercise and become more physically active

*It is vital that we bring this message across to our patients*

THE “WHY” OF EXERCISE

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Is Vigorous Exercise Neuroprotective in PD?Ahlskog, J Eric Neurology July 19, 2011

• Vigorous exercise: aerobic physical activity sustained 20-30 min

• Prospective evidence suggests midlife, regular exercise reduces subsequent PD risk years later (3 large cohorts)

• Improved corticomotor excitability suggests neuroplasticity in human studies (Fisher, et al; Arch Phy Med Rehabil, Jul 2008)

• May slow disease progression (more evidence needed)

• Reduces risk of cognitive impairment (short-term cognitive benefits)

• Protective effect of exercise in animal models of parkinsonism

Exercise-Enhanced Neuroplasticity in PDPetizinger, G, Fisher, B et al. Lancet Neurol 2013

NEUROPLASTICITY=more “bang for the buck” for existing dopamine neurons to do more with less

• Goal-based motor skill training to engage cognitive circuitry for motor learning

• PT provides reinforcement and encouragement with instruction to perform beyond self-perceived capability

• Person with PD becomes more cognitively engaged in activities previously automatic

• Combination of goal-based with aerobic training can contribute to brain health and repair

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Reprinted from article in Lancet Neurology 2013

Exercise and Neuroplasticity in PD Clinical and basic research studies support the effects of exercise on neuroplasticity

in PD. Neuroplasticity is a process by which the brain encodes experiences and learns new behaviors and is defined as the

modification of existing neural networks by adding or modifying synapses. Evidence is accumulating that both goal

directed and aerobic exercise may strengthen and improve motor circuitry through mechanisms that include but are not

limited to alterations in DA and glutamate neurotransmission, as well as structural modifications of synapses. In addition,

exercise may promote neuroprotection of substantia nigra neurons and their existing connections. Finally, exercise-

induced alterations in blood flow and general brain health may promote conditions for neuroplasticity important for

facilitating motor skill learning, including cognitive and automatic motor control and overall behavioral performance.

While more studies are clearly needed, taken together these findings are supportive of a disease modifying effect of

exercise in PD.

Does Exercise Improve Efficacy of Levodopa?Muhlack, S, Welnic, J, Woitalla D, Muller T Mov Disord 2007 Feb;22(3):427-30

• Immediate release formulation given followed by exercise near aerobic limit on one day, given the second day in same manner at rest

• LD plasma behavior did not change significantly

• Motor response was significantly better on the day with exercise

• Moderate exercise appears to increase clinical efficacy of levodopa

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Unanswered Questions

More Research Is Needed-With human subjects!

• How much exercise is needed? Frequency? Duration?

• What is the optimum intensity of exercise?

• Is one form superior to another?

• How long does exercise benefit last?

• What is the mechanism of benefit?

• What counts as exercise?

• How much is too much?

(increased exercise increases oxidative stress)

Theoretical Framework for Intervention

�Restorative: Change what you can change, return to prior or improved level of function

�Compensatory: Teach movement strategies

�Adaptive: Modify the task or environment

In PD, we may do a combination of all 3

Depends on disease severity and Stage; as PD progresses, we may focus more on compensatory and adaptive

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Early Stage PD (Hoehn and Yahr Stage I-II)

• Asymmetry of symptoms; initially unilateral presentation

• Axial rigidity may be present; affecting proximal musculature

• Subtle changes in coordination and balance

• Gait changes

• Alteration in perception of movement (sensory mismatch)

• Loss of automaticity

• Reduced ability to perform dual tasking

• Focus on Restorative Intervention Strategies with some Compensatory techniques mixed in

Collaborating with the Interdisciplinary Team In Early Stage PD

• Workplace assessment/energy conservation techniques/ADL compensatory strategies: OT

• Relaxation/Exercise and Gait Performance: Music Therapy

• PD Education/Recognizing Patterns : MD and Nursing

• Integrating Voice/Exercise Activities, Posture Enhancement: Speech

• Seeking community resources and support services: Social Services

• Complementary therapy providers (massage, yoga, Tai Chi)

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PD Impact on Motor Function: Hypokinesia

• Reduced amplitude of movement

• Affects nearly 80% of PWP

• Impact on well-learned movement sequences

• Causes overall reduction in components of gait�Decreased step length, resulting in increased cadence/stepping rate

�Reduced foot clearance

�Reduced in arm swing, natural rotation of pelvis

• Intervention aimed at increasing movement amplitude

PD Impact on Motor and Sensory Systems

Mismatch: person with PD feels like their movements are

“normal” or big enough but are not

• Motor disorder: inappropriate scaling of muscle force

• Sensory disorder: sensory proprioceptive processing problem

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Intervention: Large Amplitude TrainingFarley, BG, Koshland, GF Exp Brain Res 2005 Dec

• Sensory-Motor Re-training

• Speed increases with movement amplitude

• Goal: For patients to self-generate larger amplitude movements

• 4 week training protocol of daily movements in a hierarchical sequence (4X/week in study). N size was 18 subjects

• Maximal Daily Tasks: sitting and standing

• Big effort, repetitive, context specific

• Multidirectional :sustained and repetitive

• Functional movements

Comparing Exercise: LSVT BIG Berlin StudyEbersbach, G et all Mov Disord 2010 Oct 30

• 60 people with mild to mod PD

• 3 groups:�One-on- one LSVT BIG training ( 16 hours within 4 weeks)

�Group training of Nordic walking ( 16 hours within 4 weeks)

�Domestic nonsupervised exercises

• BIG showed significant differences in UPDRS motor scores;superior TUG and timed 10 m walking scores

• No significant difference shown on quality of life measure (PDQ 39)

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Additional LSVT Studies• Application of LSVT BIG intervention to address gait, balance, bed

mobility and dexterity in people with Parkinson Disease; a case series

Janssens J ,et al. Phys Ther 2014 July

�3 case studies; mild to mod PD

�Outcomes: improvement on gait and balance measures (FGA, FRT, TUG, FOGQ, UPDRS motor score). Improved bed mobility (Lindop PD Mobility Assessement). No change in dexterity (9 hole peg)

• Amplitude-oriented exercise in Parkinson’s disease: a randomized study comparing LSVT-BIG and a short training protocol

Ebersbach, G et al. J Neural Transm 2014 May

�LSVT-Big 4X/wk for 4 wk compared with 2 week protocol of 10 sessions with identical exercises. 42 subjects

�Outcomes: equally improved motor performance (UPDRS III scores) but high-intensity LSVT –BIG “more effective to obtain patient-perceived benefit”

HIGH INTENSITY

LARGE AMPLITUDE

WHOLE BODY EXERCISE

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PD Impact on Motor Function: Loss of Automaticity

• Loss of the “automatic pilot”

• Ability to move is not lost but there’s an activation problem

• Basal ganglia responsible for automatic motion in learned motor tasks

• Difficulty activating movement sequences

• Intervention aimed at bypassing the depleted basal ganglia responsible for these automatic movements and to use more conscious frontocortical strategies instead

Striding out with Parkinson’s diseaseMorris, ME, Martin CL, Schenkman ML Phy Ther 2010 Feb

• Evidence-based physical therapy for gait disorders

• Critiques major PT approaches to gait rehab in PD

Comprehensive client- centered PT for people with PD is based on:

� Compensatory strategies to bypass the defective basal ganglia

(external cues, attentional strategies, divided attention training)

�Strategies to improve motor learning and performance through practice

�Management of secondary sequelae affecting musculoskeletal and cardiorespiratory systems (axial flexibility, strengthening, cardio ex)

� Promoting lifelong physical activity and exercise habits

�Fall prevention (safe turns, freezing strategies, AD recommendation)

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Striding Out with Parkinson’s

• Strategies, exercises and health education varied according to age, individual needs and disease progression

OVERALL AIM:

Enable the person with PD to live well by providing PT interventions at optimal times to promote health and well-being by education the individual regarding long-term self-management strategies

Intervention: Gait TrainingMorris, M Phys Ther 2006 Oct

• Vary environment and task�Speed, walking surface, turns, path width

• Encourage activities involving divided attention�To retain flexibility/adaptability in locomotor control

• Instructional sets�Cues to “move big,“long strides”

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Intervention: Treadmill TrainingJournal of Neural Transmission March 2009

Literature Review:

• 11 long term trials report positive benefits in gait speed, stride length and health related quality of life

• Long term carryover effects suggest there may be a neuroprotectiveeffect

• Many studies followed a routine of 3 times a week for 45 min at training heart rate

• Primate model video on YouTube: Parkinson’s: Is Exercise the Answer?

Treadmill Training: Increasing Challenges

• Vary speed, grade, intensity

• Add secondary cognitive tasks �Category naming

�Reading aloud

�Backward counting by 3’s

• Sideways walking

• Turning: forward>R side>forward>L side

• Retro-walking

• Use safety harness if necessary

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Intervention: Nordic WalkingBloehm et al,Movement Disorders 2008Reuters, J Aging Res 2011

6 week Nordic Walking program (Bloehm):

• Improved 10 m walk, TUG, 6MWT and quality of life (PDQ 39)

• Benefits persisted 5 months post

3X wk for 6 months program-70 min (Reuters):

3 groups: Nordic (pole) walking, regular walking , flexibility/relaxation

• NW group superior in improving postural stability, stride length and gait pattern and variability

The NW group continued to pole walk even after study was concluded

Community-Based Nordic Walking Program ModelMaria Walde-Douglas, PT Struthers Parkinson’s Center-poster presentation World Parkinson Congress Oct 2013

METHODS An individual with PD sought out a Nordic walking instructor to lead community walks for persons with PD.

This lead to collaboration with a physical therapist specializing in PD to develop a program to train others to lead

community Nordic walking groups for people with Parkinson’s Disease. A comprehensive 4 hour training curriculum

was developed with the expertise of an experienced Nordic walking instructor as well as the knowledge of an

experienced PT specializing in the treatment of individual with PD. The program contained the following components:

• Basic Nordic walking technique

• Group safety/Fall prevention

• PD gait and balance changes

• Special considerations for PD

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Community-Based Nordic Walking Program

RESULTS

Eleven persons completed the training curriculum. Following completion of the training, PD Nordic walking groups were formed at area parks and indoors at shopping malls during the winter months. Groups met in a total of 10 locations in the Twin Cities metro area and 1 in northern MN. (Figure 1). Average attendance was 10-12 people stages I-III PD. Participants reported enjoyment of the activity, reduced fear of falling, improved posture and ability to walk with less pain and fatigue using the poles. Four individuals involved in the original group leader training went on to complete an official Nordic walking instructor training.

CONCLUSIONS

A community-based Parkinson’s Disease walking program offers a practical approach to an evidence-based form

of exercise. Education on Nordic walking and PD offer a “train the trainer” approach to the development of

qualified individuals to lead community groups. This offers the opportunity to expand programming to other

communities and locations resulting in improved physical abilities and quality of life for persons with

Parkinson’s Disease

Intervention: Parkinson Wellness Recovery (PWR)

• Treatment Paradigm (not a protocol) developed by Becky Farley, PT, PhD

• Evidence-based treatment approach following principles for neuroplasticity and neuroprotection

• NeuroFit Networks (pwrgym.org)

• “Exercise 4 Brain Change”TM Program

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PWR Key Constructs

Prepare system for Movement

• Neural priming-aerobic activities

• Attentional strategies to engage cognition

• Biomechanical priming-focus on alignment & flexibility

• Sensory Stimulation-vestibular & kinesthetic awareness

Activate the system

• High effort-Borg Scale 8/10 (0-10)

• Progressive difficulty

• Cues to trigger movement

• Power/strength training through whole body movements

PWR Key Constructs

Reflect

• Feedback

• Attention to action: “How did that feel?”

• Self-monitoring and correction

• Emphasize kinesthetic awareness

Motivate

• Group social structure

• Reinforce effort and success

• Empowerment and self-efficacy

• Promote vigor!

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Intervention: CyclingRidgel Al, Vitek JL, Alberts JL Neurorehabil Neural Repair 2009

• 10 subjects)� 2 groups: Forced and Voluntary� 3X wk for 8 weeks; 10 min warmup and cooldown� Voluntary: self-selected speed on stationary bike; averaged 50-60 rpm� Forced group: tandem trainer at 80-90 rpm (30% faster)

*this was later replicated with a motorized Theracycle

RESULTS:

-Aerobic fitness improved in both groups-Forced exercise group showed 35% improvement in motor function (UPDRS) and bimanual dexterity

-UE motor symptom improvements: tremor modification and handwriting improvement (short-term)

-Non motor effect: data suggests improved sense of smell (olfaction)

-30% improvement in PD symptoms noted even 2 weeks later

Practical Application of Cycling Research

• Instruct in use of a stationary bike with an rpm readout

(try and stay at 80-90 rpms)

• Use music/metronome at 80-90 beats/min to stay at

consistent pedaling rate

• Rent/try a tandem bike with a willing partner

• Consider a 3 wheeled bike if balance is an issue for

• outdoor cycling

• Community “Spin” Classes to motivate and provide guidance

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PD Biking Groups-Pedal and Rollwww.pedalandroll.org

• The mission of Pedal and Roll For Parkinson's is to encourage people with PD to live well through education and structured opportunities for exercise.

• Pedal & Roll For Parkinson's holds bicycling events, weekly group bike rides, and Nordic walks. We travel to communities in greater Minnesota to share the benefits of exercise. And we have a bike "lending library" at the Williston Fitness Center in Minnetonka.

• We are a 501(c)(3) non-profit organization located in Edina, Minnesota.

Founder, Liz Ogren

Winner of the Davis Phinney

Local Hero Award in 2013

Application to PT Practice: What Could This Look Like?

• Periodic PT assessment and intervention to address impairments especially if new issues/symptoms/functional limitations arise

• Establish a targeted home exercise program

• Integration into PD-friendly community-based programs

• PT provides PD training to exercise trainers and exercise instructors or supervises/leads group exercise programs in area

• Network of PD exercise groups is established with train the trainer model

• Person with PD is educated on when to seek referral for more skilled PT intervention in periodic intervals to modify/update recommendations

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Other InterventionsArgentine Tango

�Duncan, et al Neurorehabil 2012 Feb

�62 participants assigned to a community-based tango program or a control group for 12 mo.

� Improved scores OFF MEDICATION on UPDRS, MiniBEST, 6MWT, gait velocity, et al for tango group indicating a modification of disability progression

Group Exercise/RockSteady Boxing Method�Combs et al: Neurorehabilitation. 2013.

�31 patients with PD assigned to boxing training or traditional exercise groups

�24-36 sessions of 90 min over 12 weeks

�Boxing group demonstrated significant improvements in gait velocity and endurance

�Traditional exercise group had significant gains in balance confidence

�Both groups showed significant improvements in balance, mobility and quality of live

www.rocksteadyboxing.org

In Summary

• Persons with PD need to believe that consistent exercise will make a difference in their quality of life and not engaging in exercise can be pro-degenerative

• Exercise can change the brain and leads to neuroplasticity and potentially slow disease progression (neuroprotection)

• Early intervention and referral to PT can capitalize on these benefits

• Use of evidence-based assessment tools for the appropriate stage of PD will provide valuable objective data to better quantify impairments and response to intervention

• Use of evidence-based interventions in PT will yield best outcomes

• Integration into community-based, “PD-friendly” programs

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Intervention Summary for Early Stage PD

• Large amplitude therapy

• Movement Activation Strategies

• Axial mobility

• Cardiovascular training

• Treadmill Training

• Nordic walking

• High intensity, high effort exercise training

• Dual task training with cognitive challenges+motoractivities

• Cycling (forced exercise training)

• Involvement in community exercise groups