Webinar Series - LSVT Global · 2019-08-23 · • vertical loss (downward first) S = Speech &...

LSVT Global® Public Webinar Series

Title: Application of LSVT BIG to Advanced and Atypical Parkinson's Disease

Presenters: Laura Gusé, BSPT, MPT

Heather Cianci, PT, MS, GCS

Date Presented: August 21, 2019

Copyright:

The content of this presentation is the property of LSVT Global and is for information purposes only. This content should not be reproduced without the permission of LSVT Global.

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mailto:[email protected]

8/21/2019

Copyright LSVT Global, Inc. 2019 1

Atypical and Advanced Parkinsonian Disorders: An Overview and Discussion

of Application to LSVT BIG®

This work was supported, in part, by the: National Institutes of Health - R01 DC01150, R21DC006078, R21 NS043711, Michael J. Fox Foundation, Parkinson Alliance and Davis

Phinney Foundation

Laura Gusé, BSPT, MPTChief Clinical Officer of LSVT BIG

LSVT Training and Certification Faculty

Heather Cianci, PT, MS, GCSLSVT BIG Training and Certification Faculty

Innovation in Science. Integrity in Practice.

Instructor Biographies

Laura Gusé, BSPT, MPT

Ms. Gusé received her Master’s Degree in Physical Therapy from the University of North Dakota in 1997. She has worked extensively in the area of neurodegenerative disorders since then, both in outpatient and inpatient settings. She has specialized in treatment of Parkinson disease and Multiple Sclerosis and was certified in LSVT BIG® in 2009. She has been an LSVT BIG faculty member since 2011, having taught over 75 courses in six countries over the last eight years in addition to online courses. Since 2014, she has served as the Chief Clinical Officer of LSVT BIG. In that role Ms. Guse’ oversees the training, curriculum and product development related to LSVT BIG, and has helped to create many of the current LSVT BIG treatment tools, webinars, and courses.

Heather Cianci, PT, MS, GCS

Ms. Cianci is the founding therapist of the Dan Aaron Parkinson's Rehab Center at Pennsylvania Hospital in Philadelphia, PA. She received her bachelor's in PT from the University of Scranton in Scranton, PA and her master's in gerontology from Saint Joseph's University in Philadelphia. Heather received her GCS in 1999. She was certified in LSVT BIG in 2007 and is the Co-coordinator and PT Faculty for the Parkinson Foundation’s (PF) Allied Team Training for PD. She has authored book chapters on rehabilitative strategies for PD, and Frontotemporal Degeneration and is the author of an educational manual on fitness for the PF. Heather has lectured for various state Physical Therapy Associations, the PF, national continuing education companies, and Philadelphia-area conferences and support groups about PD. Her research includes movement strategies for bed mobility, falls, freezing of gait, and functional movement disorders.

Disclosures

• All of the LSVT BIG faculty have both financial and non-financial relationships with LSVT Global.

• Non-financial relationships include a preference for the LSVT BIG as a treatment technique.

• Financial Relationships include: Ms. Gusè is an employee of LSVT Global, and both Ms. Gusè and Ms. Cianci receive consulting fees and travel reimbursement from LSVT Global, Inc.

Information to Self-Report Activity for PT and OT

Professionals

• This LSVT Global webinar is NOT state registered for CEUs, but it may be used for self-reported CEU credit as non-registered CEUs.

• If you are a PT or OT professional and would like to self-report your activity, e-mail [email protected] to requesta certificate after completion of the webinar which will include your name, date and duration of the webinar.

• Attendance for the full hour is required to earn a certificate.

• Licensing requirements for CEUs differ by state. Check with your state licensing board to determine if your state accepts non state registered CEU activities.

Plan for Webinar1. Logistics (questions, handouts)

2. Discuss application of LSVT BIG toindividuals with atypical and advanced PD

3. Survey will automatically launch at theconclusion of the webinar (less than 5minutes to complete)

Objectives

Upon completion of this webinar, participants will be able to:• Define advanced Parkinson disease

(PD) and typical features that characterize advanced PD

• Describe several atypical parkinsonian disorders

• Discuss the application of LSVT BIG and how the LSVT BIG protocol can be customized to meet the needs of individuals with advanced or atypical PD

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Clinical Diagnosis of Idiopathic PD

Early Motor symptoms (2/3)

(bradykinesia, tremor, rigidity)

Insidious onset – nonspecific non-motor and motor early symptoms

Asymmetrical distribution (unilateral initially progressing to bilateral symptoms later on)

Positive Response to DA replacement

Differential DX Jankovic 2003; Pal et al., 2002

Advanced PDWhat is considered

“Advanced”?

Early Moderate Advanced

Rating Parkinson Disease Severity

Modified Hoehn and Yahr Scale

STAGE 0 = No signs of disease.STAGE 1 = Unilateral disease.STAGE 1.5 = Unilateral plus axial involvement.STAGE 2 = Bilateral disease, without impairment of balance.STAGE 2.5 = Mild bilateral disease, with recovery on pull test.STAGE 3 = Mild to moderate bilateral disease; some postural

instability; physically independent.STAGE 4 = Severe disability; still able to walk or

stand unassisted. STAGE 5 = Wheelchair bound or bedridden unless aided.

Goetz CG, Poewe W, Rascol O, et al. Movement Disorder Society Task Force report on the Hoehn and Yahr staging scale: status and recommendations. Mov Disord. 2004;19(9):1020-28.

Additional Features

Onset of motor complications, despite aggressive pharmacological and behavioral managements.

Motor Complications• Wearing Off; On-Off Fluctuations• Dyskinesias• Less responsive to drugs

Giugni & Okun, 2014; Varanese et al, 2010

MOTORCharacteristics of Advanced PD

• Increased severity of bradykinesia,hypokinesia, & rigidity, freezing

• Difficulty walking; use wheelchair more often or bedridden

• Not able to live alone, help needed with everything

• Increased falls• Greater need for assistive devices• Worsening of posture


NON-MOTORCharacteristics of Advanced PD

• Dementia and increased neuropsychological changes (slow processing, attention, etc.)

• Psychosis and hallucinations• Depression, Anxiety, and Apathy• Sleep Disorders• Autonomic Dysfunction• Pain


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These motor and non-motor complications, may dramatically

impair quality of life.Potential Secondary Impairments

Cardiovascular Deconditioning

Loss of muscular strength/weakness

Fixed postural deformities

Pain

Loss of normal range of motion

Impaired balance

Aspiration

What makes atypical Parkinsonismsdifferent from idiopathic PD?

Have one or more features similar to PD (rigidity, bradykinesia, tremor, postural instability)

Have added symptoms not seen in PD (“Parkinson’s Plus”)

Disease course and underlying pathology differs from PD

They do not respond well or in the same way to anti-Parkinson medications

Can be difficult to distinguish from PD initially

PSP – Progressive Supranuclear Palsy

MSA – Multiple System Atrophy

CBD – Corticobasal Degeneration

LBD – Lewy Body Dementia

FTD – Frontotemporal Degeneration

“Most Common” Atypical Parkinsonisms

What Causes Atypical Parkinsonism?

Alpha-synucleinopathies & Tauopathies

Alpha-synuclein is the primary structural component of Lewy bodies, as seen in:

-- PD-- MSA-- Lewy Body Dementia

Tau proteins help support and stabilize the “skeleton” of brain cells in the CNS• When there is a defect in the tau, they accumulate

abnormally and produce neurofibrillary tangles, as seen in:-- PSP -- Alzheimer’s-- CBD -- FTD

Incidence and

Prevalence

• Very rare but frequently misdiagnosed as PD

-Rates vary from 1-6 per 100,000 except for LBD at 400 per 100,000

• Life expectancy-Rates vary from 5 – 10 years

• Hospitalizations generally due to:

oUTIsoAspiration pneumoniaoFalls

Levin et al, 2016

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Progressive Supranuclear Palsy (PSP)

Remember “FIGS” to help with

differentiating PSP from PD

F = Frequent, sudden falls early in disease course

• generally posteriorly

I = Ineffective Medication• anti-PD medications are not particularly helpful

G = Gaze Palsy• vertical loss (downward first)

S = Speech & Swallow Changes

Other PSP Symptoms

• Emotional and personality changes-frontal lobe dysfunction

• Apathy• “Rocket sign” – patient quickly moves

from sitting to standing without thinking and falls backwards into the chair

• Bradyphrenia – slowness of thought • Eye disturbances:

• double vision • blepharospasms – forceful, involuntary

eyelid closing • reduced blinking • difficulty maintaining eye contact • “square wave jerks” rapid, involuntary,

lateral eye movements that interfere with precisely aiming the eyes at a target

Multiple System Atrophy (MSA)

1. MSA-P (parkinsonian): Striatonigral degeneration implies parkinsonism with some degree of cerebellar dysfunction.Slow, stiff movements

2. MSA-A (autonomic): Shy-Drager syndrome reflects a predominance of autonomic failure.Orthostatic hypotension, constipation, urinary incontinence

3. MSA-C (cerebellar): Olivopontocerebellar atrophy indicates primarily cerebellar defects with minor degrees of parkinsonism.Ataxia, balance, coordination, gait, and speech

Also common is frontal-executive dysfunction. Memory and visual spatial functions can also be impaired.

Corticobasal Degeneration (CBD)

Remember “CIAO” to help with differentiating CBD from PD

C = Cognitive changes• mild early on and can progress to dementia

I = Ineffective Medication• anti-PD medications are not particularly helpful

A = Asymmetrical Presentation & Apraxia (inability to perform coordinated movements or use familiar objects)

• alien-limb phenomenon

O = Odd movements or feelings• slowness, stiffness, shakiness, clumsiness

Lewy Body Dementia

Progressive cognitive decline within 12 months of onset of parkinsonism

Two of the core features

• Fluctuating cognition• Visual hallucinations• Parkinsonism

• One core and one suggestive feature

Often with rapid progression of posture changes – generally trunk flexion and/or lateral flexion

McKeith, et al. Third report of DLB consortium. Neurology 2005; 65:1863

Frontotemporal Degeneration

• “The hallmark of FTD is a gradual, progressive decline in behavior and/or language (with memory usually relatively preserved).

• “As the disease progresses, it becomes increasingly difficult for people to plan or organize activities, behave appropriately in social or work settings, interact with others, and care for oneself, resulting in increasing dependency on caregivers.”

• Generally occurs in people in their 50s & 60s

http://www.theaftd.org/understandingftd/ftd-overview

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General Points to Remember

• The atypical Parkinsonisms are not managed well with medication or surgical treatment like in PD

• Symptoms and presentations can vary greatly

• Compensatory strategies may need to be implemented earlier (vs. restorative treatment methods used in idiopathic PD)

Rehab focus in both Advanced PD (H&Y 4 to 5) and Atypical PD

• Maintain or improve physical capacity:Vocal loudness Bigness of movementsVoice quality Quality/Control of movementPitch range PostureSpeech intelligibility BalanceRange or motion Strength

• Maintain vital functions: swallowing and moving safely

• Functional communication and movement to improve and maintain function, enhance safety and reduce caregiver burden

• Use of external cueing or augmentation (care team)

Multi-disciplinary team is key!

Medical Team

• Neurologist• Neurosurgeon• General practice

physician• Nurses• CNP/PA in Neurology• Physiatrist• Pharmacist

Allied Team

• Speech therapists• Physical therapists• Occupational

therapists• Clinical

neuropsychologist• Social workers• Nutritionist

Behavioral intervention is the most EFFECTIVE therapy for improving communication and function!

LSVT BIG Adaptations and Considerations

Delivery• Certified LSVT BIG

Physical/Occupational Therapist• 1:1 intervention

Time of Practice• 4 consecutive days per week for

4 weeks• 16 sessions in one month• 60 minute sessions• Daily carryover assignments (30

days/entire month)• Daily homework (30 days/entire

month)

LSVT BIG Treatment SessionMaximal Daily Exercises

1.Floor to Ceiling – 8 reps2.Side to Side – 8 each side3.Forward step – 8 each side4.Sideways step – 8 each side5.Backward step – 8 each side6.Forward Rock and Reach – 10 each side (working up to 20) 7.Sideways Rock and Reach – 10 each side (working up to 20)

Functional Component Tasks

5 EVERYDAY TASKS– 5 reps each For example:

-Sit-to-Stand-Pulling keys out of pocket-Using cell phone

Hierarchy Exercises

Patient identified tasks: Getting out of bed, Playing golf, Getting in and out of a carBuild complexity across 4 weeks of treatment towards long-term goal

Walking BIG

Distance/time may vary

Core exercises‐“Building Blocks”

Practice using larger amplitude in functional

tasks which are important to

you!

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How do the LSVT BIGDaily Exercises help you?

• Starting and stopping movement when you want.

• Direction changes ‐ turns• Endurance or Stamina• Balance • Strength• Range of Motion• Posture• Safety with movement

Video – Example of Standard Exercise

Can these exercises be adapted?

YES!!

Video – Example of Adaptation

Video – Example of Adaptation

What are some other common adaptations used in LSVT BIG?

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Physical Challenges

Balance- Use physical support in standing as needed or perform exercises in sitting or supine when needed

Endurance- reduce repetitions and scale intensity as needed

Use Assistive or adaptive devices as needed (walking devices, raised toilets, higher chairs, etc.)

Take care to limit exacerbating orthostatic hypotension

Early caregiver training when physical assistance is needed or WILL be needed. Learn proactively!

Cognitive and Non-Motor Challenges

Early caregiver training when carryover of function to home and homework is challenging.

Intensity of dosage is key in producing meaningful and more lasting changes. May even need more than 16 sessions.

Simple and redundant cueing along with modeling facilitates motor learning and retention. “BIG” can be

learned by almost anyone!

Goal of LSVT BIG with Advanced or Atypical PD: It’s all about FUNCTION!

• Reduces caregiver burden• Improves safety and

independence• Improved quality of life and

self efficacy

Cued BIG Functional Movement

• Keep it BIG every day!• May need to customize for

practical implementation• Team support is needed• Use the Homework Helper

DVD!

Daily Exercises Vital

Functional Task Specific Training in LSVT BIG-More than just exercise!

• Translation of larger, better quality movements trained in functional tasks which are relevant to the individual.

• May need family input to choose the tasks that are mostmeaningful to the patient

Examples… Personalized,PurposefulPractice

Walking or Wheelchair Mobility Training

• Environment and distance tailored to each person’s abilities and goals

• Therapist may train in home or replicate the individual’s own walking scenarios, e.g., walking in small home

• Strategies to help freezing of gait included• Use assistive device as needed (walker,

cane, wheelchair, etc.)• May need more frequent cues to “Think BIG”

and “Keep it BIG” from caregivers

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LSVT BIG Homework!

Daily Carryover Assignments

- Practice using bigger, better movements around othersoutside of therapy in a variety of“real world” situations.

Exercise practice at home

- With coach/caregiver asneeded

- With LSVT BIG HomeworkHelper videos

- 1-2 times per day

Lifelong Support After LSVTDaily exercise practice life‐long

• With coach/caregiver• LSVT Homework Helper Videos‐

Purchase DVD or Download

Group Exercise Options!• LOUD for LIFE® and BIG for LIFE®

Regular LSVT “Tune‐ups” every 3‐12 months

Other enjoyable fitness for PD

There is HOPE!

• Don’t discount therapy just because the disease is advanced or it is an atypical PD

• People with advanced PD and atypical PD can have amazing outcomes!

• FUNCTIONAL communication and movement of any kind can dramatically improve quality of life (even if supplementation is required)

“Here are some activities that I had avoided but which are now part of my routine again: getting up from a low couch, getting into and out of my car (which is low to the ground), putting bills into my wallet, retrieving my cell phone

from a pants pocket and putting it back, properly donning a sports

jacket, buttoning a shirt.All in four weeks!”

- Ralph F.

Summary

LSVT BIG is applicable to all stages of PD and can be customized to each patient’s needs and treatment settings

LSVT BIG can increase independence, speed, quality and/or safety with communication, mobility and ADLs

Restore Function! Improve Function! Maintain Function!

Atypical and Advanced PD carry unique challenges requiring creative solutions and increased caregiver involvement

How to Ask Questions

1. Type in the question box on your control panel

2. Raise your hand! (click on the hand icon in your control panel)

Your name will be called outYour mic will be unmuted, then you can ask your question out loud.

3. Email [email protected] if you think of questions later!

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Where are Other Places One Can Learn More About PD?

• Parkinson’s Foundation:• www.parkinson.org

• American Parkinson’s Disease Foundation• https://www.apdaparkinson.org

• Michael J. Fox Foundation• https://www.michaeljfox.org/

• Davis Phinney Foundation• https://www.davisphinneyfoundation.org/

• World Parkinson Coalition• http://www.worldpdcoalition.org/

Related Organizations• Cure PSP www.psp.org• MSA Coallition www.multiplesystemsatrophy.org• The Association for Frontotemporal Degeneration

www.theaftd.org• The Lewy Body Dementia Association

www.lbda.org• The Alzheimer’s Association www.alz.org

How Do I Locate LSVT Certified Clinicians?

1. www.lsvtglobal.com2. Click on3. Search Options

• LSVT BIG (Physical Therapy & Occupational Therapy)4. Enter your location5. Click on “I agree to the terms and conditions”

Then-Ask your doctor for a referral to one of these clinicians!

FIND LSVT CLINICIANS

Opportunities to learn more about LSVT BIG

and LSVT LOUD

• Monthly Webinars on Hot Topics!

• On Demand Webinar Library

• Patients & Family Section

• Featured Blog Articles, Testimonials, and Videos

• Live Seminars

• LSVT Global Facebook Page

• Ask our experts!

FIND IT ALL AT

www.lsvtglobal.com

[email protected] or [email protected]

Next webinar information:

Application of LSVT LOUD to Advanced and Atypical PD

Date: Wednesday, September 25, 2019 Time: 2:00 PM - 3:00 PM Eastern Daylight Time (EDT) (EDT is UTC - 4 hours)

PLEASE COMPLETE THE SURVEY!

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Webinar Series - LSVT Global · 2019-08-23 · • vertical loss (downward first) S = Speech &...

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