Current Concepts in Physical Therapy for People with Parkinson’s Disease Tim Pazier, MPT Franciscan Health System PWR! certified clinician LSVT BIG certified clinician

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

Overview The effect of Parkinson’s disease (PD) on movement The role of physical therapy in PD Exercise principles to improve function Framework for exercise and PD

The effect of PD on movement Progressive neurodegenerative disease Motor deficits: ◦ slowness of movement (bradykinesia) ◦ decreased amplitude (hypokinesia) ◦ rigidity, tremor ◦ decreased balance/postural reactions ◦ freezing ◦ postural changes

The effect of PD on movement Non-motor deficits that impact movement: ◦ altered sensory perception/activation ◦ difficulty changing strategies ◦ difficulty dividing attention ◦ poor self-monitoring ◦ reduced vitality ◦ depression, anxiety elevated

PD and Physical Therapy Historically: Physical Therapy prescribed once person is falling By then, > 70% loss of dopamine cells Ideally, we want people in therapy at the first signs of the disease

Physical Therapy (PT) Role of the physical therapist: ◦ prescribes therapy based on movement analysis and patient goals ◦ assesses equipment needs ◦ advise home modifications as needed ◦ help teach caregivers/family ways to assist the person with PD (cueing as needed)

Goals of PT Slow sensorimotor deterioration Prevent falls Establish home exercise program that challenges the person with PD Follow up every 3-6 months

The science behind exercise Neuroplasticity – changes in brain connections that restores or compensates for lost function. Neuroprotection – changes in brain connections that spares, rejuvenates, or slows their degeneration.

Science, exercise, and PD - in the lab Exercise may slow, halt, or reverse the progression of PD in animal studies: ◦ protection of viable dopamine neurons (neuroprotection) ◦ restoring compromised neural pathways (neuroplasticity) ◦ increasing reliance on undamaged systems (neuroplasticity)

Science, exercise, and PD - in the lab Findings in the lab can be applied in the clinic Changes in brain function can be seen indirectly: ◦ Improved balance ◦ Increased speed and amplitude of movement ◦ Decreased freezing

Principles of recovery and improved function Use it or lose it! ◦ inactivity contributes to PD Use it AND improve it! ◦ extended training can strengthen neural connections Continuous exercise matters ◦ gains will be lost if exercise stopped

Principles of recovery and improved function Timing matters ◦ starting earlier better ◦ gains can be made even in advanced PD Importance of salience ◦ exercise needs to be relevant to the person Push the effort! ◦ activity beyond self-selected effort

Principles of recovery and improved function Repetition key for learning ◦ lots of practice needed Specificity matters ◦ therapy should focus on what is difficult Empower ◦ people with PD CAN get better

Exercise and Physical Therapy No one exercise program found to be the best approach However, HOW you exercise is the key… Parkinson’s Wellness Recovery (PWR!) (see )

Parkinson’s Wellness Recovery (PWR!) NOT a specific exercise regimen, BUT a framework for treatment Utilizes the latest research Can be incorporated into any exercise regimen

PWR! Framework for PD Prepare! Activate! Reflect! Motivate!

Prepare! Remove fear of movement Simplify movements Focus attention Movements modeled to enhance awareness Cardio training to “prime the pump” Alignment important

Activate! Push effort BEYOND self-selected Whole body movements via PWR! MOVES - building blocks for function May need cues for completing movement Add complexity (dual task), duration (sustain holds), intensity (effort to 8/10 on a 0-10 scale)

Reflect! Increase awareness of movements Help identify normal performance Reduce reliance of vision Goal is to internalize and self-cue movements: “step BIG” “reach BIG” “turn BIG”

Motivate! People with PD need external motivation ◦ Dopamine helps drive motivation Must be salient to the person “I want to work on moving better so I can play tennis again” “I want to walk with my wife/husband” Goal is to empower!

Types of exercises/treatment approaches for PD Treadmill Tai chi Boxing Tango Tandem cycling (forced spinning) Nordic walking Sensorimotor agility program Auditory cueing - metronome LSVT LOUD/BIG

LSVT = Lee Silverman Voice Treatment LOUD/BIG focuses on: ◦ high effort ◦ single attentional focus (AMPLITUDE) ◦ overlearned movements ◦ LOTS of repetition ◦ sensory awareness retraining

LSVT LOUD/BIG Outcomes: ◦ LOUD participants able to sustain loudness 2 yrs after training ◦ BIG participants exhibit faster gait and bigger strides, improved reaching, improved trunk rotation

PWR! MOVES concepts that can be incorporated into any exercise program

PWR! Hands

PWR! Reach

PWR! Reach

PWR! Reach

PWR! Rock

PWR! Rock

PWR! Twist

PWR! Step

PWR! Turn

PWR! Voice Can be added to any PWR! Moves Voice adds attentional and physical effort Promotes greater activation (as seen in LSVT LOUD/BIG hybrid) Focus on breath with movement important

PWR! progression PWR! Moves are the building blocks for function Functional activities (examples): - getting in/out of bed - sitting   standing - walking Progress to sports, hobbies, recreation

PWR! video

What we want… HIGH effort Awareness of movement Work towards whole body movements Translate movements into functional activities Self cueing/monitoring Support of caregivers/family to reinforce NO days off, no excuses!!!

People with PD CAN get better and STAY better longer with exercise!!!