1. T HINK BIG! E XERCISES FOR I NDIVIDUALS WITH P ARKINSON ’ S D ISEASE Betty MacNeill, PT, DPT January 2013 SED Meeting

2. P RESENTATION O BJECTIVES Identify the symptoms of Parkinson’s disease (PD) that benefit from exercise interventions Identify both traditional and non- traditional therapeutic models for managing the symptoms of PD Define and discuss the basic philosophy associated with the LSVT-BIG intervention model Identify and discuss the 4 fundamental treatment concepts of the LSVT-BIG model Describe the basic exercise protocols associated with LSVT-BIG and provide a rationale for each Develop confidence in applying some LSVT- BIG techniques and principles with selected patient populations

3. P ATHOPHYSIOLOGY /E TIOLOGY Pathophys: Loss of dopanergic cells in the substantia nigra leads to a deficiency in dopamine for use by the communication pathways in the basal ganglia, which are critical to producing normal movement and postural control, and neural circuits to the frontal lobe, which are critical for mental processing, motor planning, and personality.

4. PARKINSON’S DISEASE Classical Clinical Features = TRAP Tremor, resting R igidity, cogwheel A kinesia, bradykinesia P ostural Instability

5. C OMPREHENSIVE L IST OF SYMPTOMS IS MUCH MORE HELPFUL FOR UNDERSTANDING THE FULL SPECTRUM OF THE CHALLENGES FACED BY INDIVIDUALS WITH IPD See handout for further explanations Motor symptoms (in addition to the 4 Cardinal Signs of PD): Micrographia, Speech difficulties, Lessened facial expression & smiling, Swallowing difficulties, Decreased blinking and the appearance of staring, Low back pain or ache accompanied by poor posture, Cramps or a burning sensation in thighs or legs, Lack of arm swing on the affected side, Episodes of feeling "stuck in place" when initiating a step (so called "freezing"), Slight foot drag on one or both sides Non-motor symptoms: Loss of smell, Feelings of hot or cold, excessive sweating, oily skin, increased dandruff, Sleep Disturbances, Depression and/or anxiety, Decreased “executive function”, Dementia, characterized particularly by decreased memory for recent events

6. S TAGES OF D ISEASE P ROGRESSION Modified Hoehn and Yahr Staging 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 = Moderate to severe bilateral disease; frequent loss of balance; 50% physically dependent Stage 5 = Non-ambulatory; 80-100% dependent for ADL’s

7. Who should exercise? How much exercise? Which symptoms and/or movement challenges are affected by exercise (if any)? Exercise Considerations

8. P HYSICAL T HERAPY M ANAGEMENT – E XERCISE C ONSIDERATIONS General guidelines do not differ much from those applied to other patient diagnoses. Make decisions for treatment interventions based on: Impairments, functional limitations, and disabilities Also consider for patients with IPD: Timing of optimal effect of medications On/Off phenomena (Clinical fluctuation) Unique characteristics of postural and gait disturbances Effects of aging Concurrent pathologies

9. P HYSICAL T HERAPY M ANAGEMENT – S UMMARY OF H ANDOUT RE : E XERCISE M ODELS Many different and effective models are available for helping patients with PD exercise For best results, the patient must exert an “effort” and be motivated to perform multiple repetitions on a daily basis Marketing “Exercise as Medicine” is a good way to encourage patient involvement and explain the neuroprotective qualities of adequate exercise Emphasis for tonight, however, is on the LSVT- BIG Model for Intervention

10. LSVT – BIG ONE A PPROACH TO EXERCISE FOR INDIVIDUALS WITH PD

11. W HAT IS “ LSVT * – BIG ”? Definition: Intensive amplitude-based exercise program for limb motor system Background: Founded upon the principles of LSVT* - LOUD, which is an intensive amplitude-based exercise program for speech motor system Main premise: With exaggerated exercise movements, the patient will learn to use their bigger movements automatically in everyday life Better posture Better flexibility Better movements Better balance *LSVT = Lee Silverman Voice Therapy (www.LSVTglobal.com)www.LSVTglobal.com

12. LSVT-BIG F UNDAMENTAL TREATMENT CONCEPTS 1. Emphasis on AMPLITUDE is first 2. SENSORY Calibration is second aspect 3. The exercise program must be INTENSIVE a. High physical and mental effort b. Dosage/repetition/difficulty 4. Quantification/Empowerment is necessary for follow through

13. LSVT-BIG F UNDAMENTAL TREATMENT CONCEPTS AMPLITUDE Defined as the largest range of motion that can be performed with the highest effort with the most maximally efficient biomechanics every trial / every day Patients must be approached with high expectations on a regular basis. Requires vigilance from clinician and patient

14. LSVT-BIG F UNDAMENTAL TREATMENT CONCEPTS SENSORY CALIBRATION OR RETRAINING Defined as the process of teaching the patient to self-monitor and to accept that what feels “too big” is really WNL Important for therapists to give feedback about normalcy Calibration is at the heart of the matter:  Retrain faulty sensory perceptions  Establish new associations between effort and normal movement  Create new motor memories (BIGGER plans)

15. LSVT-BIG F UNDAMENTAL TREATMENT CONCEPTS INTENSIVE EFFORT Full exercise program has a standardized protocol Prescribed dosage and method of delivery include: a. Frequency: 16 1-hr individual sessions; 4x/week b. Duration: 4 weeks c. Strength: High effort Practice and repetition are essential ingredients to provide the neural protection and up-training benefits

16. LSVT-BIG F UNDAMENTAL TREATMENT CONCEPTS QUANTIFICATION / EMPOWERMENT Key is to motivate patient with feedback, because the expectation is that individuals with PD can get better!!!! REQUIREMENTS: 1) Push the patient to generate high effort 2) Reinforce! Motivate! 3) Empower with potential 4) Document outcomes

17. LSVT-BIG O VERVIEW OF D AILY EXERCISE SESSION FEEDBACK G UIDELINES FOR THERAPISTS DRIVE BIG EFFORT: Best model for teaching – “Do what I do” (minimizes cognitive load) SHAPE: Optimize alignment first through tactile, visual, auditory, and proprioceptive cues STABILIZE WITH FEEDBACK: Reinforce, practice and motivate the individual’s own actions. Patients with PD need more reinforcement/motivation than others CALIBRATE: Retrain sensory perceptions – effort must feel BIG in order to look NORMAL

18. LSVT-BIG O VERVIEW OF D AILY EXERCISE SESSION SHOULD BE 50-60 MINUTES PER DAY I. MAXIMAL DAILY EXERCISES 1. Multidirectional Sustained Movements (2) 2. Multidirectional Repetitive Movements (5) 3. Functional Movements (1-5 depending on patient) II. HIERARCHY TASKS (Includes ADL’s) III. CARRYOVER ASSIGNMENTS

19. LSVT-BIG O VERVIEW OF D AILY EXERCISE SESSION DEMONSTRATION / PRACTICE ACTIVITIES I. MAXIMAL DAILY EXERCISES 1. Multidirectional Sustained Movements (2) Purpose of Exercises: Sustained muscle activation and active stretching. A. Floor to ceiling stretch in sitting B. Side to Side stretch in sitting  NOTE: 10-20 secs. would be the average sustained time. A “hand flick” can be added when the patient is able to sustain the position achieved.

20. E XAMPLES OF “M ULTIDIRECTIONAL S USTAINED M OVEMENTS ” WITH AN E XERCISE GROUP End position for the “floor to ceiling” stretch in sitting “Side-to-side” stretch with modification of hand placements

21. LSVT-BIG O VERVIEW OF D AILY EXERCISE SESSION DEMONSTRATION / PRACTICE ACTIVITIES I. MAXIMAL DAILY EXERCISES 2. Multidirectional Repetitive Movements (5) Purpose of these exercises: Differentiating starting and stopping Changing directions Sequential endurance Balance Strengthening

22. LSVT-BIG O VERVIEW OF D AILY EXERCISE SESSION DEMONSTRATION / PRACTICE ACTIVITIES I. MAXIMAL DAILY EXERCISES 2. Multidirectional Repetitive Movements (5) A. Step and Reach (3) 1) Forwards 2) Sidewards 3) Backwards B. Rock and Reach (2) 4) Forward / Backward 5) Side to side

23. E XAMPLES OF “M ULTIDIRECTIONAL R EPETITIVE M OVEMENTS ” WITH E XERCISE GROUP Forward Step and Reach Sidewards Step & Reach

24. LSVT-BIG O VERVIEW OF D AILY EXERCISE SESSION ADDITIONAL DAILY ACTIVITIES II. HIERARCHY TASKS (Includes ADL’s) Purpose of exercises/tasks: Overlearn familiar commonly-used and salient everyday movements Reminder for BIG movements at home Encourages compliance and carryover Requires task analysis for maximal benefit

25.  Rolling  Sit to Stand  Walk & Turn  Everyone needs these, but there is some flexibility associated with personal choice Other Examples: Floor to Stand Getting out of bed Sit & reach Stand & reach Walk & reach Stand & turn LSVT-BIG O VERVIEW OF D AILY EXERCISE SESSION ADDITIONAL DAILY ACTIVITIES H IERARCHY TASKS :

26. LSVT-BIG O VERVIEW OF D AILY EXERCISE SESSION ADDITIONAL DAILY ACTIVITIES III. CARRYOVER ASSIGNMENTS What are they? Assignments the PT man- dates to implement “bigness” into real life. They must fit into the patient’s daily living activities for that day, so they change on a regular basis. Examples:

27. B OTTOM L INE Think and Act BIG Because if you don’t use it, then you’ll lose it!