new integrating lifestyle medicine into neurologic rehabilitation...

Integrating Lifestyle Medicine into Neurologic RehabilitationPromote optimal health Whole person wellness Prevention of dis-ease and dis-ability

Montana Physical Therapy Summit 2019 MAPTA Fall Conference September 28th - 29th, 2019 Rita Pascoe, DPT, NCS

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Objectives

! Describe and defend the physical therapists role in implementing lifestyle medicine into clinical practice

! Describe how changes in lifestyle and health behavior may positively effect brain and nervous system health

! Develop specific tools and strategies to integrate lifestyle medicine and motivational principles into neurologic rehabilitation

! Be able to implement motivational interviewing and health promotion practices into neurologic patient care

! Understand resources for referral for patients needing specific, ongoing, or other skilled needs outside of the physical therapy scope of practice

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Reflection

What does Lifestyle Medicine mean to you? Do you implement Lifestyle Medicine or Health Promotion in your practice? Why is it important?

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Lifestyle Medicine

Definitions:

“Lifestyle medicine is the evidence-based therapeutic approach to prevent, treat and reverse lifestyle-related chronic diseases.” - American College of Preventative Medicine

“Lifestyle medicine is the evidence-based practice of helping individuals and families adopt and sustain healthy behaviors that affect health and quality of life. Examples of target patient behaviors include, but are not limited to, eliminating tobacco use, improving diet, increasing physical activity, and moderating alcohol consumption.” - American College of Lifestyle medicine

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Health Promotion and Wellness

Core Definitions (APTA Policy BOD Y03-06-16-39): ! Health: A state of being associated with freedom from disease,

injury, and illness that also includes a positive component (wellness) that is associated with quality of life and positive well-being

! Health Promotion: Any effort taken to allow an individual, group or community to achieve awareness of – and empowerment to pursue – prevention and wellness

! Wellness: A state of being that incorporates all facets and dimensions of human existence, including physical health, emotional health, spirituality, and social connectivity

! Prevention: (Institute for Work and Health) ! Primary: Prevent a disease or injury from occurring ! Secondary: Reduce the impact of disease/injury through screening and

early intervention to prevent long-term problems ! Tertiary: Soften the impact of ongoing illness and injury to improve

function and quality of life as much as possible

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Health Promotion and Wellness

Health Priorities for Populations and Individuals (APTA HOD P06-15-20-11)

• Physical therapists provide education, behavioral strategies, patient advocacy, referral opportunities and identification of supportive resources after screening for:

• - Stress Management - Smoking cessation • - Sleep health - Nutrition optimization • - Weight management - Alcohol moderation • - Violence-free living - Adherence to health care

recommendations

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In my practice, Lifestyle Medicine and Health Promotion looks like: - Foundational approach to patient care - Strategy and perspective when interacting with patients, starting with the initial evaluation and extending through every interaction - Pairing of traditional rehabilitation with additional focus on health and wellness, in all aspects of the patients life - Empowering patients for long term behavior change - Tapping into intrinsic motivation and personal goals - Promoting a more lasting effect on function and quality of life

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Why Is it Important?

! 6 in 10 adults in the US have at least one chronic disease (related to lifestyle modifiable risk factors)

! Lifestyle or chronic diseases (non-communicable diseases) are the major cause of morbidity and mortality. They are strongly associated with risk factors or behaviors, such as physical inactivity, unhealthy diet, and tobacco use, and are thus largely preventable.

! Leading cause of death and disability in the US: ! Heart Disease - Lung Disease ! Stroke - Alzheimer’s Disease ! Cancer - Diabetes

! Key Lifestyle Risks for Chronic Disease: ! Tobacco and Alcohol Use ! Poor Nutrition ! Lack of Physical Activity

CDC: National Center for Chronic Disease Prevention and Health Promotion, August 2019. Bezner, PTJ, 2015

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Relevance to the Neurorehab

! Shorter rehab stays and decreased reimbursement increase the risk of post-rehabilitation health decline, and compromising the health of individuals with neurologic disability

! Individuals with a disability are less likely to engage in recommended amounts of physical activity

! Mobility and other functional limitations can challenge the ability to live a healthy lifestyle

! Significant barriers exist that limit exercise and physical activity in the adult neurologic population

! Co-morbid conditions and lifestyle related behaviors can exacerbate neurologic symptoms

Quinn L, JNPT, 2017. Morris D, MedBridge Course 2018. Rimmer, JNPT, 2013.

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Barriers to implementation

! Time ! Lack of interest or awareness (patient, public, and other health

care providers) ! Lack of education or knowledge ! Lack of reimbursement ! Lack of resources ! Limited counseling skills ! Lack of self-efficacy ! Decreased focus on prevention by physical therapists ! Perception that the physical therapy work environment is not

suitable for health promotion

! Bezner, PTJ, 2015

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Reflection

! What do we know about our patients priorities and goals? ! How ready are they to make the necessary lifestyle changes? ! What motivates our patients? ! What are the barriers to finding out these answers?

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Physical Therapy for Sustained Behavior Change (PT4SBC)

! Definition: Physical Therapy for sustainable behavior change aims to optimize movement to improve the human experience by merging the guiding style of motivational interviewing with attitudinal foundations of mindfulness, principles of motor learning, and whole health/well-being.

ANPT Synapse Center, Appendix B ! Consider the similarities of neuroplasticity and motor learning,

along with behavior change and motivational interviewing: ! motivation, self-confidence, repetition, salience/meaningful tasks,

timing and type of feedback, and error tolerance

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The Most Important Components? And the Hardest?

! Behavior Change ! Motivational Interviewing ! Motivational Principles in Rehabilitation

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Behavior Change

Theories

! Transtheoretical Model ! Health Belief Model ! Social Cognitive Theory ! Self Determination Theory ! Resilience Model

Common Themes

! Self-efficacy ! Autonomy ! Motivation ! Readiness

ANPT Synapse Center, 2019 Bezner, PTJ, 2015

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Transtheoretical Model

! Time-based continuum of behavior change ! Decisional balance, processes of change, self-efficacy ! https://pcna.net/wp-content/uploads/

2018/12/16_models_of_behavior.pdf ANPT Synapse Center, 2019

Preventative Cardiovascular Nurses Association, accessed July 2019

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Transtheoretical Model

Interventional Strategies ! Consider stages of change, attitudes toward exercise, and

priorities ! Patient-led goal setting ! Facilitate patient change – empower self-efficacy, self-

management, and resilience ! 5 A’s and 5 R’s – see smoking cessation

Morris D, MedBridge, 2018. Billinger, S, et al. ANPT Synapse Center, 2019.

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Transtheoretical Model17

Health Belief Model

! Health behavior change dependent upon the belief that: ! There is a risk for a negative health condition ! There is a positive expectation of avoiding the negative

health condition by taking action ! That you can successfully complete the recommended action

to be taken ! Perceived benefits >>> perceived barriers to change

ANPT Synapse Center, 2019

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Social Cognitive Theory

! Inter-personal theory; personal beliefs/factors interacting with environmental factors to influence behavior

! Personal Factors: self-efficacy and outcome expectations ! Environmental Factors: Physical environment, social

context (observed behaviors, opinions of others)


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Strategies for Behavior Change

Commonalities: ! Engagement ! Open Inquiry ! Active Listening, reflective listening ! Shared decision making ! Goal setting ! Action Planning ! Accountability ANPT Synapse Center, 2019

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Behavior Change in Neurorehab

! Barriers to Health Behavior Change: ! Cognitive and communication deficits ! Psychosocial and environmental barriers ANPT Synapse Center, 2019

! “Findings showed that barriers to physical activity participation arise from personal factors that, coupled with lack of motivational support from the environment, challenge perceptions of safety and confidence to exercise.”

Mulligan, et al. Adapt Phys Activ Q. 2012.

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Motivational Interviewing (MI)

! Motivational Interviewing: collaborative conversation style for strengthening a person’s own motivation and commitment to change

! The addition of motivational interviewing to usual care may lead to modest improvements in physical activity for people with chronic health conditions. O’Halloran, et al, 2014.

! See it in action on YouTube: The Effective Physician Motivational Interviewing https://www.youtube.com/watch?v=URiKA7CKtfc&t=329s

ANPT Synapse Center, Appendix A, 2019.

Collins Medbridge online course, 2019.

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Motivational Interviewing (MI)

! Guiding Style of conversation ! Collaboration: cooperation between patient and clinician ! Acceptance: Non-judgement, not trying to sway the patient ! Evocation: Evoke from patient’s that which they already have ! Compassion: Listen with empathy

Collins T. Medbridge online course, 2019. ANPT Synapse Center, Appendix A, 2019.

Pignataro, 2018

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MI in Neurorehab

! Builds Therapeutic Alliance ! Empowers participation ! Acceptance of deficits ! Build self-efficacy, self-awareness and sense of control

! 3 Core Characteristics in PT practice ! Clear focus on changing behavior ! Use of reflective listening to understand patients perspective

about changing their behavior ! Emphasis on evoking the patient’s motivation for change


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Adapting MI to Cognitive and Behavioral ImpairmentsMI Standard Principle

Cognitive and Behavioral Challenge

MI Modification

Assumes Intact Cognition

Impaired attention or concentration, disorientation

Repetition, simple verbal and visual materials

Uses open-ended questioning

Aphasia, impaired attention and processing

Clear and concise questions, provide sufficient time, provide acceptable choices

Uses Reflective Listening

Impaired Processing

Simple reflections, sufficient time

Adapted from: Martino et al, Modification of motivational interviewing, Subst Abuse Treat, 2002. ANPT Synapse Center, 2019.

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Adapting MI to Cognitive and Behavioral Impairments

Mild Impairment Moderate Impairment

Severe Impairment

Support/manage autonomy of client choices: - Clients

preference for autonomy

- Engage in shared decision making

Uphold autonomy for decisions not impacting safety: - Provide 3 good

choices - Even “trivial”

involvement in decision making

Delegate decision making: - Advise directly

on most appropriate choice of action

- Use family/caregiver to determine choice

Adapted from: The Freedom of Choice Framework, Bhatt et al. Aging & Mental Health, 2018. ANPT Synapse Center, 2019.

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Assessment and Outcome Measures

! Readiness to change ruler, self-efficacy ruler, self efficacy scale

! Patient-specific Functional Scale, Goal Attainment Scale ! Goal setting work sheets, action planning guides ! Diagnosis Specific Tools: (Participation, QOL)

! Academy of Neurologic Physical Therapy -> Practice Resources -> ANPT Outcome Measure Recommendations

! https://www.sralab.org/rehabilitation-measures Shirley Ryan Ability Lab Rehabilitation Measures Database

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Reflection

! How have you been able to promote patient motivation, autonomy, and self-efficacy in your clinical setting?

! How can we promote these characteristics during our traditional rehabilitation sessions?

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Motivational Principles

! Intrinsic Motivation Factors ! Autonomy: Feeling in control of our own actions and lives ! Competency: Perceiving self as capable and competent ! Social Relatedness: Need to feel included, accepted and

connected with others ! Self-Efficacy: beliefs about own capabilities to produce

desired effects

Lewthwaite, Rebecca. Neuroconsortium, 2015

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Building Autonomy

! Studies done by Chiviacowsky, et al: exercise groups that could choose when they would use a tool or strategy during a task would perform better at that task

! Controlling language, “you must, you should” can increase a cortisol response (stress response) and inhibit learning

! Offering choices, even simple choices, “which task do you want to do first, what color of ball do you want to use?”, helps increase autonomy

! Feeling connected, valued, and relaxed creates a dopamine release, which helps with learning

! Always give “good choices”, and denote you value their opinion Lewthwaite, Rebecca. Neuroconsortium, 2015

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Building Competency

! Dobkin et al: Group that had feedback and encouragement during their walking task did better than control group

! Feedback types: Positive, normative ! Give positive expectations, “lift” negative expectations,

give perception of success and progress, connect efforts to desired outcomes/goals

! “If you do X, Y, and Z, you will improve” ! “Active people like you, with your experience, usually do

really well this this task/exercise” Lewthwaite, Rebecca. Neuroconsortium, 2015

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Building Relatedness

! Peer support ! Community based support groups

! Eagle Mount, Senior Center, Cancer Support Community, Stroke/PD/MS support groups, online support networks

! Build comradery in clinic between like patients ! Take an interest in patients personal life, and understand

what is meaningful to them


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Building Self-efficacy

! Sources of self efficacy: ! Personal performance/accomplishments ! Vicarious experiences ! Verbal persuasion ! Physiological/mental state

! Signs of low self-efficacy: ! “I can’t do that” or other direct expressions ! Hesitancy to begin an activity, cautious movements

! “How confident are you that you can …..” ! Low self-efficacy is from 0/10 up to 6/10


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Building Self-efficacy

! With activities that are successful, ask “how can we make that even more challenging?”

! With activities that aren’t successful, “ok, now we know where to start!”

! Create challenging tasks and conditions, but not 100% successful (75-80% success rate is good)

! Accomplishments should be attributable to patient, make progress measureable and interpretable by patient

! Celebrate! Point out specific, even small, achievements of importance, and how that may impact their goals

! Research has supported self-efficacy as a primary correlate of physical activity in PD and MS

Ellis, JNPT, 2013; Lewthwaite, neuroconsortium, 2015

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REVIEW

Health Priorities for Populations and Individuals (APTA HOD P06-15-20-11)

• Physical therapists provide education, behavioral strategies, patient advocacy, referral opportunities and identification of supportive resources after screening for:

• - Stress Management - Smoking cessation • - Sleep health - Nutrition optimization • - Weight management - Alcohol moderation • - Violence-free living - Adherence to health care

recommendations

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Nutrition: Scope of Practice

! APTA policy – within scope of PT practice ! Montana PT Practice Act – no language limiting us from providing nutrition

services, HOWEVER ! Montana Code Annotated 2017: TITLE 37. PROFESSIONS AND OCCUPATIONS CHAPTER 25. NUTRITIONISTS Part 3. Licensing Scope Of Dietetic-Nutrition Practice 37-25-301. Scope of dietetic-nutrition practice. Only a nutritionist can provide the following services: (1) assessing the nutrition needs of individuals and groups and determining resources and constraints in the practice setting; (2) establishing priorities and objectives that meet nutritive needs and are consistent with available resources and constraints; (3) providing nutrition counseling for any individual; (4) developing, implementing, and managing nutrition care systems; and (5) evaluating, adjusting, and maintaining appropriate standards of quality in food and nutrition services.

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Nutrition

! Anticipate nutritional issues in our patients ! Disease specific, demographic, BMI

! Screen: mini-nutritional assessment ! Determine readiness for dietary behavior change ! Provide general information (nutrition education only) ! Recognize need for referral to a registered dietician

Morris, D et al, 2009

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Nutrition

! Dietary Guidelines for Americans (disease prevention): U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. https://health.gov/dietaryguidelines/2015/guidelines/

! Choose My Plate

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Nutrition: Stroke

! Malnutrition can be common, associated with worse

outcomes ! Dysphagia has been shown to be associated with

malnutrition and dehydration ! Decreased mobility, arm/facial weakness, depression and

impaired cognition can all impact nutrition ! Nutrition plays a role in all the known metabolic risk

factors that can potentially contribute to a second stroke ! American Heart Association/American Stroke Association ! https://www.stroke.org/en/healthy-living/healthy-eating

Marcel Arnold, et al. PLoS One. 2016; ANPT synapse center, 2019

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Nutrition: Multiple Sclerosis

! Diet can increase the inflammatory process (high in SFA’s or TFA’s)

! Increase risk of developing MS with diet low in PUFA’s ! Low fat diet may reduce rate of relapse and fatigue ! High levels of vitamin D slow progression, optimal dose? ! Supplementation with B12? ! Several diets proposed (Wahls Protocol), no good

evidence

Bagur MJ, et al. Adv Nutr. 2017

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Nutrition: Multiple Sclerosis Naturopathic Perspective

! Recommend nutrient dense and anti-inflammatory foods ! Mediterranean Diet most practical ! Gut/Brain link, “leaky gut” or IBS symptoms may be

related ! Specific foods and supplements recommended, email

[email protected] and ask for handouts from presentation, from the National MS Society

Leary-Chang, ND and Vespignani, ND. August 2019.

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Nutrition: Parkinson’s Disease

! National Parkinson’s Foundation ! https://www.parkinson.org/blog/tips/nutrition

! Motor and non-motor symptoms in PD can affect nutrition ! Protein and Levadopa interaction (take meds 30-60

minutes prior to eating, or wait 2 hours after eating to take meds)

! Foods can be neuroprotective or neurodegenerative

Ruscigno M, 2016

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Nutrition: Spinal Cord Injury

! Shopping and meal prep difficulties – problem solve with OT ! Increased risk of medical complications (DM, obesity, CV

disease, osteoporosis, skin health) ! BMI cannot be used to accurately assess healthy weight ! Specific protein recommendations for wound healing and acute

injury (1.2 – 2.0 grams protein / kg of body weight) ! HDLs tend to be lower due to decreased activity. C-reactive

protein increases with stress/injury, and correlated with increased risk of heart disease

! Bone health: decrease caffeine, smoking. Increase Ca, Vit D, and weight bearing

! Neurogenic bowel/bladder: Increase fiber and fluid. Cranberry juice for UTI prevention?

Barton, Kim. NW SCI. April 12, 2011.

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Nutrition and Brain Health

! Naturopathic perspective: Mito Food Plan, Institute for Functional Medicine. Supportive for neurodegenerative disease

! MIND diet: Mediterranean-DASH Intervention for Neurodegenerative Delay

! Supplements – refer to Pharm D, RD, MD, ND ! http://ods.od.nih.gov/ - NIH office of dietary supplements

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Sleep Health

! Sleep is critical for immune function, tissue healing, pain modulation, cardiovascular health, cognitive function including depression/anxiety, and learning and memory.

! Poor sleep quality may also contribute to the development of neurologic conditions: ! May play an important role in the accumulation of Beta-amyloid and

to the development of Alzheimer's disease ! REM disorders have been associated with the development of

Parkinson's disease and other neurodegenerative disorders ! Sleep is frequently altered in individuals with neurologic conditions

such as stroke, Parkinson's disease, Alzheimer's disease, multiple sclerosis, and spinal cord injury. Can impact their ability to learn and potentially influence recovery.

Siengsukon CF, PTJ, 2017

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Sleep Health

! “To integrate sleep health in prevention, health promotion, and wellness interventions, therapists should”: ! Assess overall sleep health and screen for risk of sleep

disorders – ask general sleep questions ! Refer for additional assessment as needed ! Provide sleep hygiene education ! Provide an appropriate exercise and physical activity

program ! Consider positioning to promote sleep quality ! Address bed mobility issues Siengsukon CF, PTJ, 2017

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Sleep Health

! Sleep Hygiene Education: ! Go to sleep and wake up at the same time each day ! Use the bed for only sleep and sex ! Develop a relaxing bedtime routine ! Adopt an appropriate exercise program ! Avoid caffeine 4 hours before bedtime ! Avoid alcohol and smoking 3-4 hours before bedtime ! Avoid OTC sleeping pills ! Avoid day time napping, or keep to 30 minutes ! Make sleeping environment comfortable and relaxing ! Avoid large meals or spicy foods 2-3 hours before bed

Siengsukon CF, PTJ, 2017

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Sleep Health

! RCT in 2016 found that people with multiple sclerosis who engaged in a moderate-intensity aerobic exercise program, and a low-intensity walking and stretching program, had improved sleep quality. (Siengsukon CF, et al)

! Consider type and amount of clothing and sheets/blankets, as well as adapted devices, to help with bed mobility and position changes at night

! Consider type and placement of lighting for safety ! Help problem solve pain management, positioning,

spasticity management at night

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Stress Management

! Negative stress (distress), or chronic stress, is stress that has a negative impact on health and wellness

! Positive stress (eustress) is stress that is typically motivating, short-term, and within our coping abilities

! Stress management refers to the techniques aimed at addressing distress

! Signs of distress include: increased fatigue, tension, irritability, elevated BP/HR

! Chronic stress contributes to chronic health conditions and can exacerbate neurologic symptoms

Bezner, 2015; ANPT, 2019

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Stress Management

! Screening for stress, anxiety and depression ! Self reported questionnaires (PHQ-9) – may be limited with cognitive

or communication difficulty ! Instruct in relaxation techniques (diaphragm or 4-7-8 breathing,

progressive muscle relaxation, visualization, meditation, autogenic training, biofeedback, massage)

! Physical activity prescription to manage stress, consider t’ai chi and yoga

! Time management techniques ! Recognize need to refer to another provider

! Red flags: suicidal ideation, excessive crying, hopelessness


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Stress Management

! Stress can contribute to the development and progression of neurodegenerative diseases

! Prevalence of depression in SCI, TBI, PD, MS is much higher than that of the average healthy adult population

! Involve family, friends, peers, support groups ! There’s an app for that - headspace, calm, etc


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Smoking Cessation

Employ 5 A’s and 5 R’s ! Ready to change, use 5 A’s: Ask, advise, assess, assist, arrange ! Not yet ready to change, Use 5 R’s: Relevance, Risks, Rewards,

Roadblocks, Repetition

Montana DPHHS ! Montana Quit Line: https://dphhs.mt.gov/publichealth/mtupp/

quitline.aspx ! https://montana.quitlogix.org/en-US/Just-Looking/Health-

Professional CDC o https://www.cdc.gov/tobacco/data_statistics/fact_sheets/

health_effects/effects_cig_smoking/index.htm

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Physical Activity and Exercise

“If exercise could be packaged into a pill it would be the single most widely prescribed and beneficial medicine in the nation.” - Robert Butler, founding director of the National Institutes on Aging

“In adults with neurologic conditions, exercise and physical activity have been shown to have the potential both to decrease risk of disease onset, and to improve motor and cognitive function and quality of life.” - Quinn, JNPT, 2017

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Physical Activity:

! “movements of the body that use energy, and can encompass a range of everyday activities including walking, gardening, and climbing stairs, but also includes specific forms of sport or exercise, such as playing soccer, running on a treadmill, or doing Pilates or yoga.”

Exercise:

! “exercise interventions are programs with a defined prescription of mode, intensity, frequency, and duration.”

! FITT Principle – frequency, intensity, time, and type

! Aerobic exercise has to potential to help drive neuroplasticity changes

! Positive outcomes on motor symptoms, behavior, and quality of life, and cognitive function for individuals with HD, MCI, AD, PD, MS and dementia

Quinn et al, JNPT, 2017

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Screening and Testing: ! Physical Activity:

! Physical Activity Vital Sign – from exerciseismedicine.org ! Physical Activity Scale for the Elderly (PASE) ! Fitbit, wearable step counters/activity trackers

! Exercise: ! ACSM’s medical screening and risk stratification, may be warranted for

moderate to high intensity exercise ! Submaximal exercise testing:

! Designing your own sub max test, calculating THR and MHR ! 6 min walk test.

! Recent study in chronic stroke: Woodward, PTJ, 2019

! Recumbent Stepper ! Billinger et al, Med Sci Spor Exer, 2012, and PTJ 2008. https://www.youtube.com/watch?v=wZe9TJQVc1Q

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Screening and Testing: ! Lifestyle Medicine Biomedical Vital Signs:

! Body Mass Index: Body Weight (kg) / Height (m2) ! Blood Pressure, Heart Rate

! Contradictions to starting exercise or stopping exercise ! Rate of Perceived Exertion ! Lipid Panel, Blood Glucose/A1c

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Physical Activity and Exercise Prescription: ! Special Considerations in neurorehabilitation – mobility

limitations, disease specific issues ! APTA Physical Fitness for Special Populations Pocket

Guide http://www.apta.org/PFSP/

! CDC Physical Activity Guidelines: https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf

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Common Barriers: ! Access ! Time ! Mobility Impairments ! Cognitive/communication ! Co-morbidities ! Knowledgeable Trainers ! Personal/Social

Newitt et al. Disabil Rehabil, 2016 Quinn et al, JNPT, 2017

Strategies for Implementation: ! Personalized programs

! Disease pathophysiology ! Disease staging ! Personal Preference

! Integrate behavior change and motivational interviewing

! Finding the benefits ! Action plans for specific

barriers

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Models of Carefor Health and Wellness

! Lifespan management of neurodegenerative diseases: ! assessment upon diagnosis to establish baseline status and

identify key impairments and activity limitations. ! ongoing consultation with follow-up visits scheduled

regularly, to facilitate exercise adherence, identify changes in functional abilities, and collaborate on setting new goals as needed.

! advisory and coaching role over the course of the disease, incorporating behavioral interventions to facilitate exercise adherence and uptake.

Quinn, JNPT, 2017

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Models of Carefor Health and Wellness

New exercise program: ! PT required for exercise prescription. 1-4 visits every 2-4 weeks.

Long term follow ups at 6-12 months for exercise progression, or sooner if change in condition.

Skilled Maintenance Care: ! PT required to maintain or progress function and exercise. Set up

HEP, gym, caregiver programs. PT every 1-3 months, recheck key outcome measures, exercise progression/modification, functional training.

! http://www.apta.org/Payment/Medicare/CoverageIssues/SkilledMaintenance/

Long-term Delivery Model (Dental Model) ! PT required every 6-12 months (new episode of care each time) to

assess functional status and change in needs ! http://www.apta.org/AnnualCheckup/Form/

ANPT, 2019; Ellis, Terry podcast.

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Putting it all together

Case Example 1: ! 30 year old female newly diagnosed with MS. Mother

recently passed away from complications due to MS. Single mother. Previously active/regular exercise. ! MI used to assess overall health/wellness goals ! Stress Management, depression, pain management ! Nutrition

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Case Example 2: ! 18 year old male with AIS B tetraplegia x 2 years. Chronic leg

wound, underweight. Not engaging in regular physical activity or exercise. ! MI used to understand what is meaningful to him, assessing barriers

to change and barriers to implementing health care recs ! Skilled referral needs – nutrition ! Physical activity, standing frame use ! Collaboration with other healthcare professionals

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Case Example 3: ! 70 year old male with CVA and history of peripheral neuropathy.

Spouse reports depression, isolation and sedentary activity. History of falls. ! MI used to determine readiness to change, patient

preferences and overcoming barriers ! Behavior change for AD use, activity and safety recs ! Engagement in physical activity/exercise

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Case Example 4: ! 75 year old female with PD; co-morbidities include OA, HTN,

peripheral neuropathy. Reports falls, anxiety and low self-efficacy regarding her condition. ! MI used for assessing self-efficacy, perceptions, goals, motivation ! Building self-efficacy in clinic sessions, use of affirmations ! Skills for anxiety management, sleep promotion ! Involvement of peer support

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Questions/Comments/Discussion

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References

! Peer-reviewed Journal Articles: ! Rimmer J, Henley K. Building the Crossroad Between Inpatient/Outpatient Rehabilitation and Lifelong

Community-Based Fitness for People With Neurologic Disability. JNPT, v37, June 2013. ! Bezner, JR. Promoting Health and Wellness: Implications for Physical Therapist Practice. PTJ, v95 n10,

October 2015. ! Quinn L, Morgan D. From Disease to Health: Physical Therapy Health Promotion Practices for Secondary

Prevention in Adult and Pediatric Neurologic Populations. JNPT, v41, July 2017. ! Mulligan, Hale, Whitehead, Baxter. Barriers to physical activity for people with long-term neurological

conditions: a review study. Adapt Phys Activ Q. 2012 Jul;29(3):243-65. ! O’Halloran, et al. 2014. Motivational Interviewing to Increase Physical Activity in People with Chronic

Health Conditions: A Systematic Review and Meta-Analysis. Clinical Rehabilitation 28 (12): 1159–71. doi:10.1177/0269215514536210.

! Ellis T, Motl R. Physical Activity Behavior Change in Persons With Neurologic Disorders: Overview and Examples From Parkinson Disease and Multiple Sclerosis. JNPT, v37, June 2013.

! Chiviacowsky S et al. Altering mindset can enhance motor learning in older adults. Psychology and Aging, 2001.

! Dobkin B et al. International randomized clinical trial, stroke inpatient rehabilitation with reinforcement of walking speed (SIRROWS), improves outcomes. Neurorehabilitation and neural repair. 2010.

! Morris, David, et al. Strategies for optimizing nutrition and weight reduction in physical therapy practice: The evidence. Physiotherapy Theory and Practice, 25(5–6):408–423, 2009

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References:

! Peer-Reviewed Journal Articles: ! Marcel Arnold, et al. Dysphagia in Acute Stroke: Incidence, Burden and Impact on Clinical

Outcome. PLoS One. 2016; 11(2): e0148424. Published online 2016 Feb 10. doi: 10.1371/journal.pone.0148424

! Bagur, MJ, et al. Influence of Diet in Multiple Sclerosis: A Systematic Review. Adv Nutr. 2017 May 15;8(3):463-472.

! Siengsukon CF, Al-dughmi M, Stevens S. Sleep health promotion: Practical information for physical therapists. Phys Ther. 2017;97(8):826-836.S

! Siengsukon C, et al. Randomized controlled trial of exercise interventions to improve sleep quality and daytime sleepiness in individuals with multiple sclerosis: a pilot study. MS Journal. 2016; 2:1-9.

! Woodward J, et al. Cardiopulmonary Responses During Clinical and Laboratory Gait Assessments in People With Chronic Stroke. PTJ, v99 i1, January 2019.

! Billinger et al, Modified total-body recumbent stepper exercise test for assessing peak oxygen consumption in people with chronic stroke. PTJ, 88 (10), October 2008.

! Billinger et al. Recumbent Stepper Submaximal Exercise Test to Predict Peak Oxygen Uptake. Medicine and Science in Sport and Exercise. August 2012.

! Newitt, Rosemarie, Barnett, Fiona, and Crowe, Melissa (2016) Understanding factors that influence participation in physical activity among people with a neuromusculoskeletal condition: a review of qualitative studies. Disability and Rehabilitation, 38 (1). pp. 1-10.

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References:

! Online Learning, Expert Opinion, Podcasts, etc: ! Billinger S, Bradford E, Gansen J, Fritz S, Hutchnson, K, Miczak K, Rafferty M, Resnick A: Health

Promotion and Wellness Strategies Applied to Neurorehabilitation. ANPT Synapse Center and Handout with Resources. Last updated January, 2019.

! Morris, D. Prevention, Wellness and Health Promotion: Neurologic Physical Therapy. MedBridge Online Course, October 2018.

! Collings, Tracey. Patient-Centered Care; Motivational Interviewing and Health Coaching. Medbridge Online Course, August, 2019.

! Pignataro, Rose. Transformative Dialogues: The use of motivational interviewing in physical therapy. #PTTransforms blog, July 2018.

! Neuroconsortium: Neurologic Physical Therapy Professional Education Consortium, distance learning through Casa Colina Centers for Rehabilitation, Rancho Los Amigos National Rehabilitation Center and the USC Division of Biokinesiology and Physical Therapy. June – December 2015.

! Michelle Leary-Chang, ND and Marco Vespignani, ND. Lifestyle, nutrition and supplement recommendations for optimal MS management. University of Washington, Webinar, August 2019.

! Ruscigno, Matt. Nutrition’s Impact on Parkinson’s Disease. www.todaysdietician.com, May 2016. ! Northwest Regional SCI System: Everyday nutrition for individuals with SCI. Vickeri Barton, RD,

CD and Susie Kim OTR/L. Harborview Medical Center, Seattle, WA. April 12, 2011. ! Ellis, Terry. APTA neurology section, degenerative disease SIG, podcast Deep Dive

Neurodegenerative Disease, August 2019 ! Billinger, S. APTA neurology section, stroke SIG, podcast physical activity and exercise in stroke,

September 2019.

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