PWR! EXERCISE FOR BRAIN CHANGE FOR PEOPLE WITH PARKINSON S DISEASE

Transcription

1 PWR! EXERCISE FOR BRAIN CHANGE FOR PEOPLE WITH PARKINSON S DISEASE Terry Tatarian, PT Samantha Klepper, PT, DPT Elizabeth Dolan, PT, DPT Integris Health Jim Thorpe Rehabilitation

2 PWR = Parkinson Wellness Recovery Founded in 2010 by Becky Farley, PhD, MS, PT, who has dedicated her PT career to working with people with Parkinson s Disease (PD) Initially developed the LSVT BIG exercise program Later developed PWR! program using the Exercise for Brain Change model

3 We believe that people with Parkinson s disease can get better and stay better with exercise. -Becky Farley, CEO and Founder of PWR!

4 Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it. -Plato

5 Integris PWR! Video tflowmodule/generic_page,20053 Show the PWR! video to patients, families, and physicians to help spread the word about our PWR! progam! Great job, Liz!

6 Parkinson s Disease: Definition Primarily a motor system disorder Loss of dopamine-producing brain cells in the substantia nigra (SN) Dopamine is the chemical that relays information from the SN to other parts of the brain to control movements of the human body Dopamine is necessary for coordinated movements PD is a severe loss of dopamine-producing cells (60-80%) (NIH, 2012; NPR, 2012)

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8 Parkinson s Disease: Diagnosis Clinical diagnosis Officially diagnosed when other diagnoses are ruled out, by signs and symptoms, and if dopamine replacement drugs are effective MRI, CT, PET to rule out other disorders Most common misdiagnosis is Essential Tremor (NIH, 2012; NPR, 2012)

9 Parkinson s Disease: Prevalence > 1 million people in US living with PD; 50,000-60,000 new diagnoses each year 4-6 million worldwide 14 th leading cause of death in US Mean age of diagnosis = 62 years old (NPR, 2012)

10 Parkinson s Disease: Symptoms Primary Shaking, resting tremor, slowness of movement (bradykinesia), stiffness or rigidity in trunk and extremities, decreased balance, postural instability Secondary Small handwriting (micrographia), reduced arm swing, foot drag, freezing, loss of facial expression (hypomimia), low voice volume (hypophonia), decreased reflexes (NPR, 2012)

11 Typical Impairments Difficulty walking Decreased balance Loss of flexibility Postural deviations Loss of fine motor abilities Decreased coordination (NPR, 2012)

12 Non-Motor Symptoms Associated with Parkinson s Disease Loss of olfaction Sleep difficulties Cognitive impairments Constipation Bladder dysfunction Sweating Sexual dysfunction Fatigue Pain (limb) Tingling Lightheadedness Anxiety Depression

13 Medical Management of Parkinson s Disease Non-motor symptoms are highly treatable with medication. Most common medicine to treat PD is Carbidopa/Levodopa. The typical dosage is 25/100mg immediate release. This pill is usually yellow in color regardless of manufacturer.

14 Medical Management continued If patients begin losing effectiveness of medications, Deep Brain Stimulators (DBS) may be an option. Signs of losing effectiveness of meds may include: more hours with sx, delayed relief of sx, wearing off between dosages/need to take more frequently, and drug induced side effects. DBS has shown to provide 5 additional hours of good movement, improve quality of life, make routine activities easier, and reduce medication use.

15 Key Principles of PWR! Exercise as neuroprotection Inactivity as prodegenerative Exercise and neurorestoration Forced use, task-specific, and intensive exercise approaches. (Hirsch and Farley, 2009)

16 Intensive Amplitude-Specific Training normal amplitude use may enhance activation of damaged pathways and slow or halt their degradation amplitudespecific approach is similar to forced use paradigms in the treatment of strokerelated hemiparesis (Farley, et al, 2008)

17 PT Evaluation Comprehensive Inquire how impairments personally affect Ask about neurologist and medications; Proper dosage? Regular visits? Observe gait, posture, functional transitions? Low amplitude movements? Measure flexibility, ROM, strength, gait, balance by using standardized outcome measures

18 Suggested Outcome Measures Tinetti Gait and Balance Timed Up and Go Hamstring Flexibility Sit and Reach ROM MMT Single Leg Balance Functional Reach Four Square Step Berg Balance

19 Plan of Care Comprehensive to address many impairments! Exercises/activities should include cardiovascular, strength, flexibility, balance, gait training, postural correction, coordination, multi-tasking, fine motor/gross motor movements, all BIG movements with purpose and intent; incorporate PWR Moves with any exercise. Think high intense, amplitude-specific movements!

20 Billing & Reimbursement Common Charges: Gait training, Therapeutic Exercise, Therapeutic Activity, Neuro Re-education Remember to combine SLP and PT dollar amounts! Speak Out! Program is 4x week x 4 weeks =$1136 Add KX modifier when over $1900 G-codes: Sections: Mobility & Moving Around and Changing & Maintaining Body Position (APTA, 2013)

21 PWR Moves Hands Reach Up Rock Twist Step Walk

22 Flexibility Emphasize whole body Yoga Dynamic stretches Static stretches Hamstrings, hip adductors and flexors, trunk extensors, shoulder adductors Perform daily!

23 Twist, Reach, & Rock Twisting, reaching, and rocking improves trunk mobility and flexibility while decreasing rigidity Incorporate as much as possible with other exercises Perform in sitting and standing Can reach for objects or just perform movements Examples: corner twist, cone reach, hula hoop, kayak (use a cane, dowel rod, therapy bar)

24 Functional Transitions Supine > Sit Sit > Stand Rolling left/right Supine/prone on floor > quadruped > kneeling > standing Perform several repetitions of each with big, powerful movements!

25 Postural Correction Supine thoracic stretch on rolled towel or foam roller Corner/doorway stretch Cervical/scapula retraction Use mirror for visual feedback; back against wall for tactile feedback Shoulders back, head up!

26 Balance Exercises Single leg Unstable surfaces (foam) Eyes closed Challenge balance while multi-tasking, i.e. ball toss, math problems, speaking loud, in conjunction with strength exercises Products: Airex pad/beam, BOSU ball, Sportcat, dynadisk, magnets, metronome

27 Gait Training/Stepping: PWR Walk Cueing to improve hip flexion/ankle dorsiflexion, while maintaining posture and balance Stepping: multidirectional steps, treadmill use for incline and speed, sidestepping on treadmill, cones/hurdles, on/off soft surfaces, up/down steps, by verbal commands or by mirroring your steps Pick your feet up! Touch your heels first!

28 Agility Activities Bungee resistance walk/jogging Ladder drill Hurdles/cones Tai-Chi Dancing Ball dribble/bounce while walking Towel/scarf toss

29 Fine Motor Activities Hand flicks Scarf/towel toss and grasp Purdue pegboard Velcro board Rubber bands Digiflex Grasping/manipulating small objects Writing Piano Games (dominos, monopoly, cards)

30 What s in the Future for Patients with Parkinson s Disease? Sx are highly variable. Best way to combat a movement disorder is to MOVE! Similarly, moving aids with fighting depression, fatigue, and sleep disorders. Proper fitness, sleep, and nutrition along with following your physician s recommendations on medications works to delay debilitating complications.

31 Key Points Individualize treatment plan Make plan comprehensive Challenge patient Involve family and encourage support groups, such as the Parkinson Foundation Encourage life long participation BIG and PWR-ful!!!!!

32 PWR Up!

33 References/Resources American Physical Therapy Association. Farley, B., Fox, C., Ramig, L., and McFarland, D. (2008). Intensive amplitude-specific therapeutic approaches for Parkinson s Disease: Toward a neuroplasticity-principled rehabilitation model. Topics in Geriatric Rehabilitation, 24(2), Hirsch, M. and Farley, B. (2009). Exercise and neuroplasticity in persons living with Parkinson s Disease. European Journal of Physical and Rehabilitation Medicine, 45(2), National Institute of Health (NIH). National Parkinson Foundation. Oklahoma Parkinson Foundation. Parkinson Wellness Recovery.