USE OF EXERCISE IN PARKINSON’S PATIENTS TO PREVENT FALLS By Cali Trepp Case Exemplar Significance of Quality Issue Perspectives Organizational Plan A Parkinson's patient with impaired balance attempts to get out of his chair and falls. Financial: “Patient falls are a leading cause of injuries in hospitals, considered to be among the most expensive, and continue to be a patient safety concern ( Evans, Hodgkinson, Lambert, & Wood, 2001.)” Psychological: Exercise is patients with Parkinson’s Disease significantly improved depressive disorder status. Depressive disorder delays the recovery of physical function and makes it more difficult to perform ADL’s (Lee, Lee, & Song, 2015). Specific exercise programs may reduce fear of falling in patients with Parkinson’s Disease (Cakit ,Saracoglu, Genc, Erdem, & Inan, 2007). Implement organizational scoring system to evaluate mobility, balance, and fall risk specific for patients with Parkinson’s disease (NICHE). Score patients during any visit to hospital or clinic. This allows health care providers to track changes in specified areas and to evaluate effectiveness of interventions. Teaching Parkinson’s patients on the benefits of weekly exercise and use goal setting to determine an exercise program appropriate for the individual. Provide discharge instructions on benefits of exercise in patients with Parkinson’s disease. Also provide instructions for at home exercises in case barriers do not allow individual to work outside of home. Make referrals for Parkinson’s patients to rehab clinics, specialized exercise facilities, etc. Utilize follow-up calls to evaluate effectiveness of exercise interventions applies. Literature Review The Effects of Speed-Dependent Treadmill Training and Rhythmic Auditory-Cued Overground Walking on Gait Function and Fall risk in Individuals with Idiopathic Parkinson's Disease This study examined and compared the immediate and retention effects of speed-dependent treadmill training and rhythmic auditory-cued (RAC) overground walking on gait function and fall risk in individuals with Parkinson's disease. Effect of Physical Exercise—Movement Strategies Programme on Mobility, Falls, and Quality of Life in Parkinson’s Disease This study suggests that combined exercise therapy and movement strategy weekly training helped improve gait freezing, balance, mobility, and fall risks, as reflected by the improved Tinetti and NFOG-Q scores, and the reduced number of falls. Fall Risk Factors in the Hospital Setting: A Systematic Review This systematic review attributes falls with increased health care costs and reviews fall risk factors. Gait and Step Training to Reduce Falls in Parkinson’s Disease This journal assesses the benefit of gait and strep perturbation training in individuals with PD. Parkinson’s disease is an idiopathic neurodegenerative disorder resulting in motor, postural, and gait impairments. Impairments in these areas contribute to an increase fall risk and limitations in mobility (Bloem, Grimbergen, Cramer, Willemsen, & Zwinderman, 2001). “Morris et al. (2001) estimated that 50 to 70 pecent of individuals with PD fall within a one-year period.” More than 45% of falls occur during functional mobility tasks and ambulation (Ashburn, Stack, Ballinger, Fazakarley, & Fitton, 2008). SMART Criteria By March 1, 2016, there will be an implementation of a exercise promotion program for Parkinson’s patients to reduce falls. All staff will be deemed competent by August 1, 2016 following new educational seminars. References Evidence-based Practice (EBP) Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. “This study’s results provide evidence that a 30-minute training session three times per week for six weeks was of sufficient intensity to produce meaningful changes and retention in walking function. Given these training parameters, the clinician should be able to effectively implement these gait interventions in individuals with PD in daily practice. Due to the inherent variability of clinical symptoms in individuals with PD it is necessary to individualize training parameters and progression of each training session (Harro et al., 2014).” Safety Definition: Minimize risk of harm to patients and providers through both system effectiveness and individual performance. “A 6-week, externally-cued, locomotor training …, produced significant improvements in walking speed, endurance, and dynamic balance during walking…. These changes are clinically relevant as they may translate to enhanced gait capacity, reduced fall risk, and improved safety for community mobility in persons with PD (Harro et al., 2014).” Ashburn, A., Stack, E., Ballinger, C., Fazakarley, L., & Fitton, C. (2008). The circumstances of falls among people with Parkinson’s disease and the use of falls diaries to facilitate reporting. Disability and Rehabilitation, 30(16), 1205-1212. doi:10.1080/09638280701828930 Bloem, B. R., Grimbergen, Y. A., Cramer, M., Willemsen, M., & Zwinderman, A. H. (2001). Prospective assessment of falls in Parkinson’s disease. Journal of Neurology, 248(11), 950-958. Cakit, D., Saracoglu, M., Genc, H., Erdem, R., & Inan, L. (2007). The effects of incremental speed-dependent treadmill training on postural instability and fear of falling in Parkinson's disease. Clinical Rehabilitation, 8, 698-705. Ehab, G., Barsnley, S., & Chellappa, R. (2012). Effect of physical exercise-movement strategies programme on mobility, falls, and quality of life in Parkinson's disease. International Journal of Therapy & Rehabilitation, 19(2), 88-96. Evans, D., Hodgkinson, B., Lambert, L., & Wood, J. (2001). Falls risk factors in the hospital setting: A systematic review. Internation Journal of Nursing Practice, 7(1), 38-45. http://dx.doi.org/10.1046/j.1440-172x.2001.00269 Harro, C. C., Shoemaker, M. J., Gamble, A. C., Harring, K. B., Karl, K. L., McDonald, J. D., . . . VanHaistma, R. J. (2014). The effects of speed-dependent treadmill training and rhythmic auditory-cued overground walking on gait function and fall risk in individuals with idiopathic Parkinson's disease: A randomized controlled trial. NeuroRehabilitation, 34(3), 557-572. http://dx.doi.org/10.3233/NRE-141051 Lee, N.-Y., Lee, D.-K., & Song, H.-S. (2015). Effect of virtual reality dance exercise on the balance, activities of daily living, and depressive disorder status of Parkinson’s disease patients. Journal of Physical Therapy Science, 27(1), 145-147. http://dx.doi.org/10.1589/jpts.27.145 Morris, M. E., Huxham, F., McGinley, J., Dodd, K., & Iansek, R. (2001). The biomechanics and motor control of gait in Parkinson disease. Clinical Biomechanics (Bristol, Avon), 16(6), 459-470. Protas, E., Mitchell, K., Williams, A., Qureshy, H., Caroline, K., & Lai, E. (2005). Gait and step training to reduce falls in Parkinson's disease. NeuroRehabilitation, 20(3), 183-190. QSEN Competencies Nursing Implications Practice: Patient’s with Parkinson’s disease should exercise weekly to increase balance, improve gait freezing, and to decrease fall risk. Health care providers should individualize this regimen for each patient. Education: Although there is research to support the use of exercise, there is no current guideline recommending the practice in Parkinson’s patients. Education will be required for health care providors to teach patients about recommendations and develop individualized patient goals. Research: A broader sample with wider range of disease severity would help to identify which individuals would be most responsive to training. Examine the effect of the each training protocol on non-motor symptoms associated with PD. Examine the effects of different types of exercise on fall risk. SWOT Analysis Strengths: Increase balance and mobility Decrease fall risk Decrease fear of falling Increase task performance Increased self efficacy Weaknesses: Time consuming Energy consuming Transportation Cost Patients willingness Opportunities: Home Therapy Track Progress Decrease health care costs Improve patient outcomes Education of staff Follow-up phone calls Threats: Funding Time consuming Staff compliance