Current Concepts in Physical Current Concepts in Physical Therapy for People with Therapy for People with

Parkinson’s DiseaseParkinson’s Disease

Tim Pazier, MPTFranciscan Health System

PWR! certified clinicianLSVT BIG certified clinician

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

it”it”

PlatoPlato

Overview Overview The effect of Parkinson’s disease

(PD) on movementThe role of physical therapy in PDExercise principles to improve

functionFramework for exercise and PD

The effect of PD on The effect of PD on movementmovementProgressive neurodegenerative

diseaseMotor deficits:

◦ slowness of movement (bradykinesia)◦ decreased amplitude (hypokinesia)◦ rigidity, tremor◦ decreased balance/postural reactions◦ freezing◦ postural changes

The effect of PD on The effect of PD on movementmovementNon-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 TherapyPD and Physical TherapyHistorically: Physical Therapy

prescribed once person is fallingBy then, > 70% loss of dopamine

cellsIdeally, we want people in

therapy at the first signs of the disease

Physical Therapy (PT)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 PTGoals of PTSlow sensorimotor deteriorationPrevent fallsEstablish home exercise program

that challenges the person with PD

Follow up every 3-6 months

The science behind exerciseThe science behind exerciseNeuroplasticity – 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 - Science, exercise, and PD - in the labin the labExercise 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 - Science, exercise, and PD - in the labin the labFindings in the lab can be applied

in the clinicChanges in brain function can be

seen indirectly:◦Improved balance◦Increased speed and amplitude of

movement◦Decreased freezing

Principles of recovery and Principles of recovery and improved functionimproved functionUse it or lose it!

◦inactivity contributes to PDUse it AND improve it!

◦extended training can strengthen neural connections

Continuous exercise matters◦gains will be lost if exercise stopped

Principles of recovery and Principles of recovery and improved functionimproved functionTiming 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 Principles of recovery and improved functionimproved functionRepetition key for learning

◦lots of practice neededSpecificity matters

◦therapy should focus on what is difficult

Empower◦people with PD CAN get better

Exercise and Physical Exercise and Physical TherapyTherapyNo one exercise program found

to be the best approachHowever, HOW you exercise is

the key…

Parkinson’s Wellness Recovery (PWR!)

(see www.nfnw.org )

Parkinson’s Wellness Parkinson’s Wellness Recovery (PWR!)Recovery (PWR!)NOT a specific exercise regimen,

BUT a framework for treatmentUtilizes the latest researchCan be incorporated into any

exercise regimen

PWR! Framework for PDPWR! Framework for PD

Prepare!Activate!Reflect!

Motivate!

Prepare!Prepare!Remove fear of movementSimplify movementsFocus attentionMovements modeled to enhance

awarenessCardio training to “prime the

pump”Alignment important

Activate!Activate!Push effort BEYOND self-selectedWhole 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!Reflect!Increase awareness of

movementsHelp identify normal performanceReduce reliance of visionGoal is to internalize and self-cue

movements: “step BIG”“reach BIG”“turn BIG”

Motivate!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 Types of exercises/treatment approaches for PDapproaches for PDTreadmillTai chiBoxingTangoTandem cycling (forced spinning)Nordic walkingSensorimotor agility programAuditory cueing - metronomeLSVT LOUD/BIG

LSVT LOUD/BIGLSVT LOUD/BIGLSVT = Lee Silverman Voice

TreatmentLOUD/BIG focuses on:

◦high effort◦single attentional focus (AMPLITUDE)◦overlearned movements◦LOTS of repetition◦sensory awareness retraining

LSVT LOUD/BIGLSVT LOUD/BIGOutcomes:

◦LOUD participants able to sustain loudness 2 yrs after training

◦BIG participants exhibit faster gait and bigger strides, improved reaching, improved trunk rotation

PWR! MOVESPWR! MOVESconcepts that can be concepts that can be incorporated into any incorporated into any

exercise programexercise program

PWR! Hands

PWR! Reach

PWR!Reach

PWR!Reach

PWR!Rock

PWR! Rock

PWR!Twist

PWR! Step

PWR!Turn

PWR! VoicePWR! VoiceCan be added to any PWR! MovesVoice adds attentional and

physical effortPromotes greater activation (as

seen in LSVT LOUD/BIG hybrid)Focus on breath with movement

important

PWR! progressionPWR! progressionPWR! Moves are the building

blocks for function Functional activities (examples):

- getting in/out of bed- sitting standing- walking

Progress to sports, hobbies, recreation

PWR! videoPWR! video

What we want…What we want…HIGH effortAwareness of movementWork towards whole body

movementsTranslate movements into functional

activitiesSelf cueing/monitoringSupport of caregivers/family to

reinforceNO days off, no excuses!!!

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

exercise!!!exercise!!!