parkinson wellness recovery (pwr!) guidelines to treating...
TRANSCRIPT
Parkinson Wellness Recovery (PWR!)
Guidelines
to Treating People
with Parkinson’s Disease
September 14, 2017
Shana Gatschet, OTR/L, CAPS
Michelle Drinnen, OTR/L
PWR! What is it?
Parkinson Wellness Recovery
www.pwr4life.org
PWR Professionals (FB)
Parkinson Wellness Recovery
●Nonprofit organization founded in 2010 by Dr.
Becky Farley PhD, MS, PT
●Implements cutting edge research on exercise
and brain change to real world healthcare
paradigms
●Dr. Farley is also the developer of evidenced
based therapy approach of LSVT BIG
PWR!
● Dr. Farley’s PWR! Center is a “Community NeuroFitness
Center of Excellence” in Tucson, AZ
● Promotes “Exercises as Medicine”
● Her PWR! Gym is offered to people with PD to have
access for life to increase longevity and quality of life in
hopes that end stage PD is eradicated
● Framework is founded on clinical research in motor
control, motor learning, exercise and physiology.
What is Parkinson’s Disease?
● Neurodegenerative, chronic and progressive movement brain disorder that
progresses slowly in most people
● It involves the malfunction or death of neurons that produce dopamine.
Dopamine is a chemical concentrated in the substantia nigra that controls
movement to be smooth and coordinated
● When diagonosed, ~ 60-80%of the dopamine-producing cells are damaged or
die, PD symptoms appear
● At diagnosis, many are already less active than healthy peers. Poor body
awareness effects one’s “perception” of true movement quality. Yet, only 12-
15% are typically referred to a fitness program or therapy.
● 6-7 million people worldwide are diagnosed; 2% of the population
6 Primary Features of PD
*Resting Tremors
*Rigidity
*Bradykinesia
*Loss of Postural Reflexes
*Flexed Posture
*Freezing
● Definite DX: of at least 2 of these
with one as tremor or bradykinesia
● Probable: Tremor or Bradykinesia
present
● Possible: at least 2 of the last four
are present
PD Symptoms
Early Motor Symptoms: decreased arm swing when walking, masked face,
stooped posture, micrographia, hypophonia, slow shuffling gait, clumsy hands,
falls when fatigued or in a hurry/stressed/distracted
Primary Motor Symptoms upon diagnoses:
Rigidity, Bradykinesia, Incoordination
Non-Motor Symptoms:
Emotional: depression, anxiety, apathy
Cognitive: attention, executive function
Autonomic: sleep, constipation, pain
Stages of PD
Stage 0 No signs of disease
Stage 1 Unilateral disease
Stage 1.5 Unilateral plexus axial involvement
Stage 2 Bilateral disease, without impairment of balance
Stage 2.5 Mild bilateral disease, recovery on Pull Test
Stage 3 Mild to Moderate bilateral disease: some postural instability, independent living capacity
Stage 4 Severe disability, able to ambulate and stand unassisted
Stage 5 Wheelchair bound or bedridden unless assisted
Causes?
● Head injury/Brain swelling
● Free radicals
● High iron and manganese (welding)
● TIAs, Brain Tumors or Lesions near Brainstem
● Medications
● Street drugs
● Viral infection
● Carbon monoxide
Research
● Research advances and clinical science research suggest
certain types of exercise may promote brain change
(neuroplasticity) in persons with PD
● This data challenges the assumption that PD as a
neurodegenerative disease has no potential for brain
change or repair (neuroplasticity)
● Yet many physicians are unaware of the scientific
literature and animal science underlying exercise-induced
brain repair or reorganization (neuroplasticity)
Neuroplasticity
● When it comes to “Brain Change” or neuroplasticity, it’s
more than just “what you do...it’s HOW you do it!”
● Exercise for Brain Change helps optimize and repair brain
health to address the cognitive, physical and emotional
symptoms of PD that interferes with everyday activities.
Why is exercise so important?
● PD is the ONLY chronic neurodegenerative disease for
which these are highly effective symptomatic therapies
● 3 options that reduce motor symptoms and/or disability in
PD
○ Medications (that target dopamine)
○ Neurosurgery (DBS)
Exercise
Research shows Brain Change
Data from animal models:
● NeuroProtection (Brain Health) Capable of protecting vulnerable DA
neurons from toxic events or rescuing those that are not compromised.
● NeuroRestoration (Brain Repair) Adaption of compromised signaling
pathways within the damage of the basal ganglia circuits
● Compensation (Brain Adaptation) Produce compensatory strategies
occurring outside the CNS (ANS, metabolism, peripheral musculature) or
other areas outside the damaged basal ganglia pathways
Differences between PWR! and LSVT ® BIGPWR!
● Amplitude training-PD specific functional
framework for comprehensive research based
programming
● 4 Functional movements-building blocks of
function (UP/ROCK.TWIST/STEP)
● 5 positions-prone/supine/all4’s/sit/stand
● May be implemented across all levels of severity
● Not standard protocol
● Patient centered protocol, frequency/duration is
determined by therapist to produce optimal long
term outcomes
● Offered by therapists or fitness professionals, ratio
1:1 or groups
● Framework is adaptable, can be integrated with
other neuroplasticity-principled approaches or
techniques
● A framework that is continually updated as new
research or approaches emerge
LSVT ® BIG
● Amplitude training is a single approach
● 7 Movement exercises-Driven by LOUD
protocol
● 2 positions- Sitting and Standing
● Protocol is not adaptable
● It is a standard Protocol
● Protocol requires frequency of 4xweek/4
weeks as minimal duration
● Only available 1:1 by certified OT & PT
● A protocol that is prescribed that may NOT
-PD Neuroplasticity-
Principles framework to optimize
learning and function
● PREPARE
● ACTVATE
● REFLECT
● MOTIVATE
PREPARE- (verbal, mental, physical)
Functional readiness: remove inhibitors of fear, stress and pain
ROM with target range
Sensory stimulation/Kinesthetic Awareness
Vestibular readiness- weight shift, rock, pivot, rotation
Movements- demonstrate and breakdown task, mental imagery/estimate steps,
Trial by each person first, deliberate performance, demand readiness prior to
movement/PWR! UP.
Quality of alignment
ACTIVATE-(drive system for maximal motor output and muscle activation)
● Perform PWR! Moves- high effort for maximal activation (push beyond end
point/range)
● Increase ROM, speed, resistance, reps, time, frequency/duration of high
intervals vs sustained efforts
● Give example of FUNCTION
● Continuously monitor perceived efforts (+8/10)
● Remember: motor output is inhibited if fear, stress or pain is present
● Add external cues: visual (color dots) auditory (metronomes, music, clapping)
somatosensory (tactile, vibration, wt bearing, rhythmic movement)
REFLECT- (focus intention internally to sustain attention; recognize efforts
to move bigger/faster)
Hold them accountable to correct movements
Remain positive
Constant pushing for maximal effort
Ask, “how did that make you fee?”, Reflect with other to improve self monitoring
Help them identify what is normal again
Remind/Reinforce EFFORT
Send home assignments, write down one daily reflection
Expect generalization of normal activities
MOTIVATION - (exercise=increased dopamine;
increased dopamine=internal motivator for brain behaviors)
● Depression and apathy are part of PD
● Need to be pushed to participate and engage
● Share success among peers
● Remind/promote exercise with function to translate to meaningful activities
● Continuously educate importance of exercise and effort (reduce falls, better
quality of life to be more active with family/friends, decrease freezing, slow
down progress of PD/PD fight
PWR! MOVES
PWR! Hands
PWR! UP
PWR! REACH
PWR! ROCK
PWR! TWIST
PWR! STEP
PWR! WALK
PWR! TURN
PWR! VOICE
PWR! MOVES
PWR! HANDS
*Deliberate extension/abduction of fingers/hands and wrists
*Addresses flexed posturing of hands, micrographia and temporary relief of tremor
*Activity to reduce resting tremor: BIG pronated hands with shoulders in IR,
tapping on LE-looks normal in social setting
*Sensory input to train ability to focus and divide attention quickly
PWR! MOVES
PWR! UP
● Used with any movements that require lifting body against gravity
● Counteract stooped posture
● Actively stretches trunk flexors
● Reinforces good alignment and posture
● Strengthens extensor antigravity muscles
● Change in head position and visual field stimulates the sensory system for
dynamic stepping/righting responses
PWR! MOVES
PWR! REACH
*Add to all PWR! MOVES to retain normal coordination patterns between trunk
and arms
*Addresses efficient movements & postural responses
*Challenges balance by moving COG outside BOS
*Increases overall attention to activation
*Requires task switching, increases effort, improves alignment
*Weight bearing position mobilizes shoulders, activates postural muscles,
strengthen UEs
*Crosses midline
PWR! MOVES
PWR! ROCK
● Fundamental movements for whole body actions with functional mobility
(walking, turning, stopping forward projection, supine to sit)
● Impaired ability to “ROCK” or weight shift in lateral or backwards direction is
MAJOR contributor to freezing, shuffled gait and falls
● Rhythmic rocking: may reduce rigidity, trigger stepping, righting response.
Promotes wider BOS during ambulation/turning, strengthens abductors,
moves COG outside BOS
PWR! MOVES
PWR! TWIST
*Emphasises counter rotation between shoulder and hips
* Reduces rigidity to decrease risk of muscular skeletal deformity and back pain
* Retains the axial rotation required for dynamic balance
PWR! MOVES
PWR! STEP
● Large scale repetitive stepping in a variety of directions
● Improves strength
● Improves ability to weight shift for turns
● Increases ground clearance
● Moves COG or BOS
● Increases speed and size of steps to respond to balance
PWR! MOVES
PWR! WALK
● Retains perception of effort and amplitude (step size) for normal movement
● Aerobic endurance
● First get quality: PWR! UP with long, wide steps
● Progression:
○ Add arms with elbows bent, then extended
○ Flick fingers with each reach
○ Punch across chest
PWR! MOVES
PWR! TURNS
● Reduce/prevent falls and strengthens muscles important for balance
● Emphasize large BOS
● Whole body rocking
● Exaggerated weight shifting to prepare to turn
● Activities: pivot turns, 45 degree turns, penguin turn, clock turn
PWR! MOVES
PWR! VOICE
*Adds attentional and physical effort, promotes greater activation, challenges
physical coordination as a dual task
* Target LOUDER but do not strain
* Holds “Ahhhs” with sustained postures
* Deliberate articulation
* Emphasize gestures
PWR! ROUTINES
* SITTING
* STANDING
* WALKING
* FLOOR
* FLOW
PWR! ROUTINES
SITTINGPWR! UP
PWR! TWIST
PWR! ROCK/REACH SIDE
PWR! REACH DOWN/UP
PWR! REACH/TWIST
PWR! REACH/TWIST/COMBO
PWR! REACH FORWARD AND BACK
PWR! UP SIT TO STAND
PWR! BREATHE
PWR! ROUTINES
STANDING
PWR! UP
PWR! ROCK & REACH SIDE TO SIDE
PWR! REACH AND TWIST
PWR! REACH AND TWIST COMBO
PWR! REACH & TWIST ACROSS & BACK
PWR! STEP THROUGH
PWR! BREATHE
PWR! ROUTINES
PWR! WALK
PWR! UP
FORWARD
BACKWARD
SIDEWAYS
HIGH KNEES
TURNS
STOPS & STARTS
REVERSALS
PWR! ROUTINES
FLOORPWR! UP-PRONE
PWR! REACH & TWIST-PRONE
PWR! UP- SUPINE
PWR! REACH-BOTH ARMS
PWR! REACH ALTERNATING ARMS
PWR! SNOW ANGEL
PWR! UPPER BODY REACH & TWIST
PWR! STEP UP COMBO
PWR! LOWER BODY TWIST
PWR! SCOOT
PWR! ROLL
PWR! BREATHE
PWR! ROUTINES
FLOW
PWR! PRONE
CHILD’S POSE
PWR! STRETCH
PWR! UP HANDS & KNEES
PWR! REACH ARMS AND LEGS
PWR! REACH AND TWIST ARM
PWR! REACH AND TWIST LEGS
PWR! STEP HANDS & KNEES
PWR! UP TALL KNEELING
PWR! DOWN
PWR! STEP ½ KNEE
HALF KNEE REACH AND TWIST
PWR! BREATHE
Anti-Freezing Tips
● Staggered wide stance, never with toes lined up.
● “Jump start” the first step (march in place, rock, count, sing, etc.)
● PWR! Up (especially in problem areas or areas that cause anxiety)
● Visual cues (tape on floor, sticky notes on walls)
● Treadmill training/pole walking with metronome
● Walk in sync with beat of music in cluttered/problem areas
○ Add motor/cognitive tasks, perform with high vigor/attention, PWR! Up - Plan - GO
● Mental imagery, verbalize intention, “see” the success
● Complex PWR! Moves, Tai chi, etc
● Agility drills; build into complex environments
● Boxing, juggling, rebounder, Bal-a-Vis-X
● Multi-directional stepping to a complex sequence
● Train the brain to talk alternative routes
PWR! MOVES and ROUTINES
~Videos~
Let’s move...
Let’s collaborate with our TEAM
OT - PT - ST
Discuss treatment plans
Areas of strength/weakness and precautions
Exercise to Optimize Brain Repair, Adaptation
and Behavioral RecoveryTiming Matters
-Start today. No excuses.
Continued Exercise Matters
-A substantial break in motor activity can be degenerative.
-See OT/PT/ST for reassessment every 3-6 mo.
-Commit
-Increase daily activities
Intensity Matter
-Work harder, Bigger, Faster, Longer
Complexity Matters
-Change the exercise environment:
Physical area: Small spaces, crowded area, uneven surface
Add secondary motor components - carry items, visual
distractions
Add cognitive tasks - speak to others, recite numbers by 2’s…
Saliency Matters
-Keep attentional focus high to keep motivation high (group exercise,
goals, positive reinforcement, add leisure activities)
-Track progress
Specificity Matters
-Work on symptom based plan of care
-Retrain body awareness (yoga, tai chi, pilates)
-Train for strength, balance, agility/coordination
-Incorporate external cues - lines, targets, metronome, music, BIG
steps, breathing, counting
Affirmations
Belief --- Action --- Results --- Belief --- Action --- Results
PWR! Information
Certifications
PWR! Therapist (OT/PT)
3-6 mo. Assessments
1:1 intensive Rehab
PWR! Instructor (personal trainer, fitness instructor)
Optimal PD specific fitness classes
Educational empowerment and resource referral
*Find a PWR! Professional* Listing on www.pwr4life.org
PWR! Information
PWR! Moves
Videos on website and YouTube
PWR! Retreat pwr4life.org
● 7 day/6 night PD specific exercise retreat in annually in May in Arizona
● Activities, exercise, seminars for those with PD and their care partners
● Q&A with physicians and researchers
References
Coles, M., Muhammed All Parkinson’s Center. Living with Chronic Disease. PWR!
Retreat 2013, Scottsdale AZ
Farley, B. Exercise to Slow/Halt/Reverse Parkinson’s Disease?
Hirsch, M.A., Farley, B.G. (2009) Exercise and Neuroplasticity in Person’s Living
with Parkinson’s Disease. European Journal of Physical Rehabilitation Medicine
45:215-29
Slide and handout copy approval by Dr. Becky Farley. 4.24.17