1 clinical practice guidelines for physical therapy …clinical practice guidelines for physical...

CLINICAL PRACTICE GUIDELINES FOR PHYSICAL THERAPY IN PATIENTS WITH

PARKINSON'S DISEASE

Charbel MACARIPh i l Th i t AUBMCPhysical Therapist, AUBMCMaster in Neurological Rehabilitation

OUTLINE OUTLINE

Definition, Epidemiology and Pathogenesis SSymptomsStages of the DiseasePrognosisPhysical Therapy Diagnosis

Clinical practice guidelines Objectives E id f l i d d tiEvidence for conclusions and recommendationsPhysical therapy assessmentOutcome measure

Goals of treatment Goals of treatment Physical therapy treatment

Treatment strategies Guidelines in physical therapy treatment Guidelines in physical therapy treatment

DEFINITION, EPIDEMIOLOGY AND PATHOGENESIS

DefinitionParkinson's disease (PD) is a degenerative disorder ofthe central nervous system that often impairs thesufferer's motor skills speech and other functionssufferer's motor skills, speech, and other functions

EpidemiologyEpidemiologyIncidence of 4.5 to 20.5 per 100,000Prevalence of 31 to 347 per 100,000e a e ce o 3 to 3 pe 00,000Estimated one in three adults older than 85 years willhave PD

DEFINITION, EPIDEMIOLOGY AND PATHOGENESIS

PathogenesisDecrease in the dopamine (DA) stores of the substantianigra of the basal gangliaConsequent depigmentation of this structure gPresence of Lewy bodies The loss of DA from the substantia nigra (SN) leads toalterations in both the direct and indirect pathways of thep ybasal ganglia, resulting in a decrease in excitatory thalamicinput to the cortex and perhaps a decrease in inhibitorysurround that leads to the symptoms of Parkinson’s disease

Etiology Remains unknownMultifactorial (toxic exposure genetics and aging)Multifactorial (toxic exposure, genetics, and aging)

SYMPTOMS SYMPTOMS

Bradykinesia and AkinesiayRigidityTremorPostural InstabilityGait problemsGait problemsPerception, Attention, and Cognitive DeficitsOther Symptoms (Sleep disturbancesOther Symptoms (Sleep disturbances,constipation, sexual dysfunction, orthostatichypotension)

STAGES OF THE DISEASESTAGES OF THE DISEASE

MODIFIED HOEHN AND YAHR STAGING

Stage 0 No signs of disease

Stage 1 Symptoms are very mild and appear only on one side of the body (e.g. tremor, posture, locomotion, andfacial expression)

Stage 1 5 Symptoms appear only on one side of the body but with axial involvementStage 1.5 Symptoms appear only on one side of the body but with axial involvement

Stage 2 Symptoms appear on both sides without impairment of balance

Stage 2.5 Symptoms appear on both sides and still mild, with recovery on pull test

Stage 3 Symptoms are mild to moderate, some postural instability occurs, but patients are physically independent

Stage 4 Symptoms are severe, the patient is severely debilitated and needs some assistance, but can still walk or stand unassisted

Stage 5 Symptoms are very severe, the patient is typically wheelchair-bound or confined to a bed, unless aided

PROGNOSIS PROGNOSIS

Tremor-dominated Develop more slowlyCognitive impairments less frequent

Akinetic-rigidRapid courseRigidity and hypokinesiaBalance and gait problemsBalance and gait problems

CLINICAL PRACTICE GUIDELINES CLINICAL PRACTICE GUIDELINES

Royal Dutch Society for Physical TherapyThe guidelines have been developed inaccordance with the ‘method to develop andimplement guidelines’implement guidelinesThe scientific evidence has been summarized in aconclusion, including the extent of the evidence, gIf no scientific evidence was available,recommendations were been formulated on thebasis of consensus within the guidelinebasis of consensus within the guidelinedevelopment groupDiagnostic and therapeutic processesDiagnostic and therapeutic processes

CLINICAL PRACTICE GUIDELINES CLINICAL PRACTICE GUIDELINES

ObjectivesObjectivesDescribe ‘optimal’ physical therapeutic care forpatients with PD with respect to effectiveness,patients with PD with respect to effectiveness,efficiency and tailored care, based on currentscientific professional, and social viewsLead to a complete (or desired) level of activitiesand participationPrevent chronic complaints and recurrences

EVIDENCE FOR THE CONCLUSIONS AND RECOMMENDATIONS

The guidelines are based on the conclusionsThe guidelines are based on the conclusionsfound in randomized clinical trials (RCT’s),systematic reviews, and meta-analysessystematic reviews, and meta analysesFor the interpretation of results found in theliterature differences in the study designs wereliterature, differences in the study designs weretaken into account

LEVEL OF EVIDENCELEVEL OF EVIDENCE

A 1 Meta-analyses (systematic reviews), which include at least some randomized clinical trials atquality level A2 that show consistent results across studies

R d i d li i l i l f d h d l i l li ( d i d d bl bli d ll dA 2 Randomized clinical trials of good methodological quality (randomized double-blind controlledstudies) with sufficient power and consistency

B Randomized clinical trials of moderate methodological quality or with insufficient power, or otherd i d h i l d d i h i l i inon-randomized, cohort or patient-control group study designs that involve inter-group comparisons

C Patient series

i iD Expert opinion

GRADING OF THE RECOMMENDATIONS ACCORDING TO THE LEVEL OF EVIDENCE

Level of scientific evidence of the intervention Description of conclusion or recommendation in the guidelines

1. Supported by one systematic review at qualitylevel A1 or at least two independent trials at quality

‘It has been demonstrated that …’level A1 or at least two independent trials at qualitylevel A2

2. Supported by at least two independent trials at ‘It is plausible that …’quality level B

3. Supported by one trial at quality level A2 or B, orresearch at quality level C

‘There are indications that …’research at quality level C

4. Based on the expert opinion (e.g. of workinggroup members)

‘The working group takes the view that …’

PHYSICAL THERAPY DIAGNOSISPHYSICAL THERAPY DIAGNOSIS

PHYSICAL THERAPY DIAGNOSISWHO INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH

ImpairmentsActivity limitations Participation problems

PHYSICAL THERAPY DIAGNOSISPHYSICAL THERAPY DIAGNOSIS

Functions Activities Participation

Impairments Limitations in Participation problems

Musculoskeletal, Cardio-vascular and Respiratory S

Mobility such as transfers and changing body

i i ( i i i

Interpersonal interactions and relationships

System

Pain

position, (maintaining body position), reaching and grasping and gait

Education, work and employment

Sensory functions

Mental functions

Other activities, such as household activities

Self-care and domestic life

Community, social and civic life

Digestive tract

Uro-genital functions

civic life

Sleeping functions

PHYSICAL THERAPY ASSESSMENTPHYSICAL THERAPY ASSESSMENT

On or Off period

TransfersBody postureBody postureReaching and graspingBalance GaitInactivity Falling Mental impairments

OUTCOME MEASUREOUTCOME MEASURE

OUTCOME MEASUREOUTCOME MEASURE

Unified Parkinson’s Disease Rating ScaleQuestionnaire Patient Specific ComplaintsQuestionnaire History of FallingFreezing of Gait questionnaireRetropulsion testTi d U d G F i l R h TTimed Up and Go test or Functional Reach TestSix-minute walk testTen meter walk testTen-meter walk testBerg balance test

PARTICIPATION PROBLEMSPARTICIPATION PROBLEMS

Social relationsSocial relationsWorkH bbHobbySports

PHYSICAL THERAPY TREATMENTPHYSICAL THERAPY TREATMENT

PHYSICAL THERAPY GOALSPHYSICAL THERAPY GOALS

Early phase Early phase Mid phaseL t hLate phase

PHYSICAL THERAPY GOALSPHYSICAL THERAPY GOALS

Early phase (Hoehn and Yahr 1 to 2.5)y p ( )Prevention of inactivityPrevention of fear to move or to fallPreserving or improving physical capacity (aerobic capacity, muscle strength, and joint mobility)

Physical therapyInformation and adviceInformation and adviceExercise therapy (possibly in a group)BalanceBalance

PHYSICAL THERAPY GOALSPHYSICAL THERAPY GOALS

Mid phase (Hoehn and Yahr 2 to 4)As in early phase, and also

Maintain or improve activities, especiallyTransfersBody postureReaching/graspingBalanceGait

Physical therapy Cognitive movement strategies and cueing strategiesBalance Gait trainingGait training

PHYSICAL THERAPY GOALSPHYSICAL THERAPY GOALS

Late phase (Hoehn and Yahr 5)Late phase (Hoehn and Yahr 5)As in mid phase and also

Maintain vital functionMaintain vital functionPrevention of pressure soresP ti f t tPrevention of contractures

PHYSICAL THERAPY TREATMENTPHYSICAL THERAPY TREATMENT

Time of treatmentTime of treatmentContra-indicationsD l t kDual tasksTreatment Strategies

Cognitive movement strategiesCueing strategies

Clinical guidelines

PHYSICAL THERAPY TREATMENTPHYSICAL THERAPY TREATMENT

Time of treatmentOn- and Off periodsCognitive moving strategies and cueing strategies

Contra-indicationsMental impairments, such as impairments in cognitionMental impairments, such as impairments in cognition(e.g. poor memory, dementia and severehallucinations), personality and attention are relativecontra-indications for the treatment of health problemsprelated to PDHydrotherapy in freezing

PHYSICAL THERAPY TREATMENTPHYSICAL THERAPY TREATMENT

Dual tasksPerforming two or more tasks at the same time(dual tasking or multitasking)Patients with PD find it difficult to pay full attentionto all tasksN ti ff t it d b l l d tNegative effect on gait and balance can lead tounsafe situations, in daily life as well as during thetreatmenttreatmentAvoiding performance of dual tasks, increases thesafety of patients with PD and decreases falls

PHYSICAL THERAPY TREATMENTPHYSICAL THERAPY TREATMENT

Treatment StrategiesgCognitive movement strategiesComplex (automatic) activities are transformed to anumber of separate elements which are executed innumber of separate elements which are executed ina defined sequence, and which consist of relativelysimple movement elementsComplex movements are organized in such a wayComplex movements are organized in such a waythat the activity is performed consciouslyMovement or (part of the) activity will be practiced

d h d i h i dand rehearsed in the mindPerformance has to be consciously controlled andcan be guided by using cues for initiationg y g

COGNITIVE MOVEMENT STRATEGIESCOGNITIVE MOVEMENT STRATEGIES

Standing Up from Chair

COGNITIVE MOVEMENT STRATEGIESCOGNITIVE MOVEMENT STRATEGIES

Moving Chair Backward

COGNITIVE MOVEMENT STRATEGIESCOGNITIVE MOVEMENT STRATEGIES

Moving Chair Forward

COGNITIVE MOVEMENT STRATEGIESCOGNITIVE MOVEMENT STRATEGIES

Lying to Standing

PHYSICAL THERAPY TREATMENTPHYSICAL THERAPY TREATMENT

Treatment StrategiesCueing strategiesPerformance of automatic and repetitive movements is disturbedas a result of fundamental problems of internal controlS ll d d l l hi d dSo-called cues are used to complete or replace this reduced oreven absent internal controlCues are stimuli from the environment or stimuli generated by thepatient which increase attention and facilitate (automatic)patient, which increase attention and facilitate (automatic)movementsIt is suggested that cues allow a movement to be directlycontrolled by the cortex, with little or no involvement of basalygangliaNot all patients benefit from using cues

PHYSICAL THERAPY TREATMENTPHYSICAL THERAPY TREATMENT

Cues can be generated internally (stretch,Cues can be generated internally (stretch,wave)Stimuli outside the body can be divided intoStimuli outside the body can be divided into

Moving stimuli (light of a laser pen, a moving foot, afalling bunch of keys)falling bunch of keys)Non-moving stimuli (sound of a metronome, stripeson the floor and the grip of a walking-stick)on the floor, and the grip of a walking stick)

PHYSICAL THERAPY TREATMENTPHYSICAL THERAPY TREATMENT

Rhythmical recurring cues are given as aRhythmical recurring cues are given as acontinuous rhythmical stimulus, which canserve as a control mechanism for walkingserve as a control mechanism for walkingOne-off cues are used:

keep balance for example when performingkeep balance, for example when performingtransfersInitiating ADLInitiating ADLGetting started again after a period of freezing

CUEING STRATEGIESCUEING STRATEGIES

Rhythmic recurring cuesAuditory • The patient moves on music of a walkman

• The patient moves on rhythmical ticking of a metronome• The patient or someone else sings or counts

Visual • The patient follows another person• The patient walks over stripes on the floor or over stripes he projects to himself with a laser pen• The patient walks with an inverted walking-stick and has to step over the grip

Tactile • The patient taps his hip or leg

O ffOne-off cuesAuditory • Initiation of movement, for example, stepping out at the third count

Visual • Initiation of movement, for example, by stepping over some else’s foot, an object on the flooror an inverted walking-stickor an inverted walking-stick

• Maintenance of posture, for example, by using a mirror or by focusing on an object (clock,painting) in the environment

Cognitive • Initiation of movement (and continuation of walking), for example, by focusing on the spot thewants to go to and not on the doorway he has to go throughwants to go to, and not on the doorway he has to go through

PHYSICAL THERAPY TREATMENTPHYSICAL THERAPY TREATMENT

Cueing strategies (to initiate and continue theCueing strategies (to initiate and continue theactivity) and cognitive movement strategies,and also avoidance of dual tasking areand also avoidance of dual tasking areimportant in improving the ability to reach,grasp and move objectsgrasp and move objects

MULTIDISCIPLINARY TEAMMULTIDISCIPLINARY TEAM

Occupational TherapistOccupational TherapistExercise of reaching, grasping, and moving objectsIdentify alter any dangers and give possibleIdentify, alter any dangers and give possibleadaptations in the home environment

Speech TherapistSpeech TherapistDietician

CLINICAL GUIDELINES IN PDCLINICAL GUIDELINES IN PD

FREQUENCY AND DURATION OF TREATMENTFREQUENCY AND DURATION OF TREATMENT

Level of Evidence (3)Level of Evidence (3)There are indications that a period of at leastfour weeks is needed to decrease limitations infour weeks is needed to decrease limitations infunctional activitiesTo improve physical capacity, exercising for atTo improve physical capacity, exercising for atleast eight weeks is necessary, in which period alow frequency of treatment (e.g. once a week toadjust the exercise program) is sufficient

Kamsma et al 2002Kamsma et al. 2002

IMPROVEMENT OF PERFORMANCE OF TRANSFERS

Level of Evidence (2)Level of Evidence (2)Application of cognitive movement strategiesimproves the performance of transfersimproves the performance of transfersThere are indications that the use of cues incombination with the application of cognitivecombination with the application of cognitivemovement strategies improves the performanceof transfers in patients with PD

Morris et al 2000Morris et al. 2000

NORMALIZING BODY POSTURENORMALIZING BODY POSTURE

Level of Evidence (3)Level of Evidence (3)There are indications that in patients with PD,exercise programs to improve coordination ofexercise programs to improve coordination ofmuscle activity make the performance of activitieseasierChange in posture towards flexion can often becorrected by applying feedback (mirror) or verbalfeedback (also from the caregiver)

Schenkman et al 1998Schenkman et al. 1998

STIMULATE REACHING AND GRASPINGSTIMULATE REACHING AND GRASPING

Level of Evidence (3)Level of Evidence (3)Reaching, grasping and moving objects is improvedby applying cueing strategies, cognitive movementby applying cueing strategies, cognitive movementstrategies and avoiding dual tasking

Morris et al 2000Morris et al. 2000

STIMULATE BALANCESTIMULATE BALANCE

Level of Evidence (1)Level of Evidence (1)Exercise program consisting of exercising balanceand training strength is effective in stimulating theand training strength is effective in stimulating thebalance in patients with PDExercise program focused on walking, mobility ofp g g, ythe joints and muscle strength, decrease thenumber of falls

Hirsch et al 2000Hirsch et al. 2000

IMPROVEMENT OF GAITIMPROVEMENT OF GAIT

Level of Evidence (2, 3)Level of Evidence (2, 3)Applying visual and auditory cuesApplication of cues in combination with theApplication of cues in combination with theapplication of cognitive movement strategiesimproves gait initiation and stride lengthp g gArm swing, wide base, heel contact Training of muscle strength Training of muscle strength Training of trunk mobility

Lewis et al 2000Lewis et al. 2000

IMPROVEMENT OF GAITIMPROVEMENT OF GAIT

Treadmill, Level of Evidence 2Treadmill, Level of Evidence 2Gait exercises on a treadmill increase comfortable walking speed and stride lengthwalking speed and stride length

de Goede et al 2004de Goede et al. 2004

PREVENTION OF INACTIVITY AND MAINTENANCE OR IMPROVEMENT OF MAINTENANCE OR IMPROVEMENT OF PHYSICAL CAPACITY

Level of Evidence (2, 3)( , )Exercise program focused on the improvement of jointmobility combined with activity related (e.g. gait or balance)

i i ADL f ti iexercises improves ADL functioningProgram focused on the improvement of muscle strengthincreases muscle strengthincreases muscle strengthExercise program focused on the improvement of aerobiccapacity improves motor skills

Bridgewater et al 1997Comella et al. 1994Bridgewater et al. 1997Reuter et al. 1999

FALL PREVENTIONFALL PREVENTION

Level of Evidence (4)Balance trainingRefer patients with PD to a course for falls prevention inthe early stage of the disease which aim at improvingthe early stage of the disease, which aim at improvingstrength, balance (preserving the body posture) andcoordinationFalls training (training of falling or techniques of falling)Falls training (training of falling or techniques of falling)is an effective means to reduce the fear of fall or thefalls riskTeaching patients ith PD ho to stand p from aTeaching patients with PD how to stand up from asitting position on the floor, the fear to fall decreases inthese patients

Willemsen et al 2000Willemsen et al. 2000Gray et al. 2000

AIDS AIDS

Level of Evidence (1,3)( , )Use of a walking frame has to be advised against incase of freezingIn an elderly high-risk population living in institutionalcare, hip protectors prevent hip fractures due to falls,when the hip protectors are worn at the right momentp p g

• Footwear The physical therapist takes responsibility (if necessary

h i h h i l h i ) f htogether with the occupational therapist) for theapplication of, and the training in the use of thedifferent (walking) aids

Parker et al 2002g

Parker et al. 2002Cubo et al. 2003

CONCLUSION CONCLUSION

Implementation of the clinical guidelines in ourImplementation of the clinical guidelines in ourdaily practice (physical therapy department)Adequate use of the guidelines with the patientAdequate use of the guidelines with the patientReporting between physical therapists and

th h lth f i lother health care professionalsStaying up to date with new guidelines and withnew scientific studies

THANK YOUTHANK YOUFOR YOUR PRESENCE