S

Benefit of aquatic exercise for Parkinson’s disease

Jamile Vivas Costa Psychosocial intervention and functional rehabilitation research group,

Department of Physiotherapy

FACULTY OF PHYSIOTHERAPY OF A CORUÑA

Content

S  Overview of Parkinson’s disease

S  Motor and Non-motor symptoms (ICF impairments)

S  Evidence of Aquatic exercise and PD

S  Guidelines recommendations

Parkinson's disease (PD)

S  Parkinson’s disease is an idiopathic, slowly progressive degenerative CNS disorder

Pathophysiology PD

Clinical Features = TRAP

S  Tremor at rest

S  Rigidity

S  Akinesia (or bradykinesia)

S  Postural Instability

S  Flexed posture and freezing

Jankovic, J Neurol Neurosurg Psychiatry 2008

Tremor

S  RESTING TREMOR

S  Unilateral

S  Frequency 4 and 6 Hz,

S  Prominent in the distal part of an extremity

“pill-rolling’’

Rigidity

S  Rigidity is characterized by increased resistance, usually accompanied by the ‘‘cogwheel’’ phenomenon.

S  It may occur proximally and distally

S  Involves both flexor and extensor muscles

S  Small muscles of face, tongue, larynx

Rohkamm, Color Atlas of Neurology © 2004 Thieme

Rigidity

Postural deformities

Bradykinesia

S  Slowness of movement

S  Slowness of initiation of voluntary movement with progressive reduction in speed and amplitude of repetitive actions

S  Reaction time is also increased

MICROGRAPHIA

Postural Instability

S  Normally it doesn't appear early in PD gait and balance disorders

S  PIGD Type

S  Anticipatory and compensatory righting reflexes are impaired

S  Inability to make appropriate postural adjustments

Postural Instability

S  Hesitation in starting to walk

S  Steps are short, lacking heel strike and toe off

S  COG falls anteriorly

S  Festination

S  Freezing briefly

S  Turning in block

S  Diminished or reduced arm swing and pelvic rotation.

Parkinson’s gait

Postural Instability

https://www.youtube.com/watch?v=ITv2SJjuAB8

ICF for Parkinson's disease

ICF for Parkinson's disease

Body functioning and structure

Impairments in Motor functions:

S  Neuromusculoskeletal and movement-related functions

S  Cardiovascular and respiration

S  Digestive system

S  Voice and Speech

S  Postural deformities: Kyphosis and flexed hip and knees

ICF for Parkinson's disease

Body functioning and structure

Impairments in Non Motor functions

ü  Autonomic dysfunction: orthostatic hypotension

ü  Cognitive decline: dementia

ü  Neurobehavioral disorders: depression, anxiety, psychosis

ü  Sleep abnormalities: excessive sleepiness, sleep attacks

ü  Sensory: olfactory dysfunction, pain, paraesthesia, akathisia

S  Executive dysfunction: attention, set shifting and concentration such as planning, decision-making.

•  Up to 70% of pwp experience non-motor symptoms and they may even be present in the early stage of the disease.

ICF for Parkinson's disease

Activities S  Transfers

S  Dexterity

S  Self-care

S  Communication

S  Eating

S  Gait

Participation S  Domestic life

S  Interpersonal relationships

S  Major areas: work

S  Community, social and civic life

Course of Parkinson's disease

S  The natural progression of PD is variable (high and unpredictable)

S  The number of impairments in functions, activity limitations and restrictions in participation will increase.

S  Pwp are likely to become inactive.

S  Increase their risk of co-morbidities.

S  The loss in QOL increases with disease progression.

Parkinson's disease

No cure for PD TREATMENT OPTIONS

Pharmacological Therapy Surgical Rehabilitative care

Levodopa and other dopaminergic drugs

Deep brain stimulation (DBS)

Multidisciplinary approach

Parkinson's disease

Rehabilitative care

Neuropsychologist Speech Therapy Occupational Therapy Physiotherapy

The role of physiotherapy in objectively decreasing the severity of signs of the disease has not been fully addressed.

Effects of Aquatic exercise for PD 20

references found

3 RCT

Volpe et al 2016

Volpe et al 2015

Vivas et al 2011

9 pre-post

Pérez-de la Cruz et al 2016 Ayan & Cancela 2012a Ayan & Cancela 2012b Brugghemans 2011 Jacobs et al 2012 Pellechia et al 2004 Pospisil et al 2007 Queiróz et al 2007 Morini et al 2002

4 case studies

Coelho et al 2012 Hartley et al 2010 Lopez & Ferreira 2008

1 economic

Brefel et al 2002

3 reviews

Methajarunon et al (2016) SR Swarovsky et al (2015) SR Figueiredo (2008)

�  To provide methodological information regarding progression within the program for a future larger trial.

�  To assess and compare 2 different protocols of physiotherapy (land or water therapy) for people with Parkinson’s disease (PD)

Objectives

�  Idiopatic Parkinson’s disease �  15 participants (8 ♂ y 4 ♀)

�  67.7 ± 5.5 years

Inclusion criteria Exclusion criteria-  ≥ 24 no MMSE -  Hoehn & Yahr II-III

-  To follow a stable medication schedule

-  Unable to walk independently -  Surgical treatment for PD

Participants

Trial Flowchart

design

•  Ferrol Parkinson’s Association - Spain •  Performed in OFF-dose •  Aquatic intervention - city spa. •  Pool: 3.55m x 7.75m,1.30m deep; T 32ºC (89.6ºF).

First baseline assessment

(PRETest)

LAND-BASED PROGRAM

(Active control) 4w

WATER-BASED PROGRAM

(Experimental) 4w

Assessment

after intervention

(POSTtest)

Follow-up assessment

after 17 days

(POSTtest-2)

Study design

�  Functional Reach Test (FRT)

�  Berg Balance Scale (BBS)

�  Timed Up and Go (TUG) �  Gait: normal, preferred walking pattern.

Photocells and recorded by a video camera.

3m

�  Unified Parkinson’s Disease Rating Scale (UPDRS)

Assessments

4 weeks, twice a week, nonconsecutive days

Experimental group - Water-based therapy Active control group – land-based therapy

1. Warm-up exercises 2. Trunk mobility exercises (Rotations from Halliwick concept) 3. Postural stability training 4. Task-oriented training

(n = 6) (n = 6)

Interventions

1. Warm-up exercises

Interventions

- Sagittal rotation (SR)

-  Transversal rotation (RT)

2. Trunk mobility exercises

Interventions

-  Balance control on standing -  Balance control with 1 leg resting on a step

3. Postural stability training

Interventions

-  Reaching forward, right and left directions -  Sit to Stand training

4. Task oriented training

Interventions

Therapies significantly improved the functional reach in the same way. Only the group receiving AT improved the BBS and UPDRS

Results - Effect of the Therapies

Results - Effect of the Therapies

Considerations

S  This pilot study shows the impact of an aquatic physiotherapy protocol on postural stability in PD

S  Study Limitations: placebo group; duration of interventions; drug state of participants…

S  Aquatic therapy in this protocol seems to be more effective than land-based protocol

S  The preliminary positive results suggested that the intervention protocols seem suitable for PD

Study interventions and outcomes

Study interventions and outcomes

Evidence of Benefits of AT for PD

Conclusions

S  Specific RCT using exclusively water-based therapy for people with PD are scarce

S  Aquatic future CT should be aimed not only at reinforcing the view that physiotherapy is useful as supportive therapy in PD but also at investigating the extent to which AT protocols can provide further benefit.

S  The variability of programs applied in studies make difficult comparison of results

Guidelines on PD

Guidelines on PD

Suggestions for future researches

GRADE-based recommendations

Keus et al. European Physiotherapy Guideline for Parkinson’s disease. 2016

(Cognitive movement strategies)