L31: Physiotherapy Management of Parkinson's Disease Flashcards
What are 8 purposes of physiotherapy in PD?
- Delay and minimise the effects of PD
- Improve or maintain flexibility and muscle strength
- Improve or maintain balance
- Improve or maintain respiratory function and cardiovascular fitness
- Maximise residual movement ability and function
- Train movement strategies
- Educate clients and carers on the disease, your approach & their role
- Maximise QoL
What are the 3 stages of PD?
- Early stage
- Mid stage
- End stage
What is the main approach for stage of PD?
Program must be tailored to changing needs
What are 3 management approaches in the early stage of PD?
- Checking for other issues
- Preserve or improve physical capacity: Aerobic capacity, strength, joint mobility exercises
- Prevent inactivity
What are 3 management approaches in the mid stage of PD?
- Referral
- Strategies to improve function, particularly gait, balance and upper limb tasks
- Maintain physical capacity, including posture
What are 2 management approaches in the end stage of PD?
- RACF
- Preserve vital function and prevent complications (e.g. respiratory)
What are 7 evidences for physiotherapy in PD?
- Improvement in gait, balance, reducing freezing of gait, improving function/PD symptoms
- Conventional physiotherapy, exercise (level 1)
- Dance
- Treadmill
- Tai Chi
- External cues/strategies (level 1)
- Balance training (level 1)
- Dual task training (level 2)
- Breakdown sequences (level 2)
- Progressive resistance training (level 2)
What are 7 strategies for movement dysfunctions (training strategy different for each impairment) for PD?
- Hypokinesia: Strategy training
- Akinesia: Strategy training
- Dystonia: Prolonged stretch, botox + exercise
- Tremor: Mainly drugs treatment, physio for stabilisation
- Rigidity: Rotational exercise
- Postural instability: Balance retraining
- Dyskinesia: Mainly drugs treatment
What is the strategy for hypokinesia for PD?
Hypokinesia: Strategy training
What is the strategy for akinesia for PD?
Akinesia: Strategy training
What is the strategy for dystonia for PD?
Dystonia: Prolonged stretch, botox + exercise
What is the strategy for tremor for PD?
Tremor: Mainly drugs treatment, physio for stabilisation
What is the strategy for rigidity for PD?
Rigidity: Rotational exercise
What is the strategy for postural instability for PD?
Postural instability: Balance retraining
What is the strategy for dyskinesia for PD?
Dyskinesia: Mainly drugs treatment
What are the 4 strategies for motor performance for PD?
- Reduction of rigidity, increase ROM, flexibility
- Improve balance, posture
- Increase strength, endurance
- Environmental modification
What should you use to improve motor performance for PD?
Use cues to improve motor performance
PD has trouble with _____ generated, _____, _____ movements
internally; automatic; sequential
What are 5 cognitive cues for motor performance for PD?
Use cognitive cues to consciously control movement that is usually automatic
- Start with external + internal cues
- Then remove external cues
- Over time, the internal cues will become more automatic (using basal ganglia), thus less effective
- Modify cues to become novel again (using cortex)
- Over time may be less able to use internal cues
What are 3 things that the choice of cue depends on for motor performance for PD?
- Deficit
- Stage of disease
- Often combine different cues
What are 3 external cues for PD?
- Visual
- Auditory
- Proprioception
What are 4 features of visual external cues for motor performance in PD?
- Taped lines on floor (50-70 cm apart) and step over the lines - to normalise step length (hypokinesia)
- Mark foot placement for turning in a confined space - to improve step length and freezing
- Single strips where freezing occurs - to prevent/overcome freezing
- Cue cards: Simple step by step instructions in large print - to break down movements
What are 3 features of auditory external cues for motor performance in PD?
- Verbal cues: Say “big steps” to improve step length •
- Exercise to music - to improve rhythm of movement
- Metronome to improve gait initiation, cadence & speed
What are 2 features of proprioception external cues for motor performance in PD?
To help initiating movement
- Rhythmical sensory cues: Rocking side to side to initiate walking or rolling
- Taking a step back before starting to walk
What are 3 internal cues for PD?
- Focus attention
- Prepare in advance
- Single task
What are 5 features of focus attention internal cues for motor performance in PD?
- Train to think consciously about each step of the movement
- Can be sufficient to initiate and sustain movement
- Cognitive cues to emphasise a component of movement (e.g. think “big steps”) • Practice: Repetition enhances movement execution
- • Ensure skills are generalised to all environments
What are 3 features of prepare in advance internal cues for motor performance in PD?
- Visualise the movement (e.g. appropriate step length)
- Use written instructions on cards
- Mentally rehearse each step of a movement
What are 2 features of single task internal cues for motor performance in PD?
- Can dual task during gait with cues in early PD
- Avoid dual task in later PD because too dangerous
What are 2 characteristics of end-stage PD with cognitive impairments?
- Cognitive strategies become less effective
- May benefit more from
- External cues
- Environment restructuring ○ Demonstration
What are 7 management of rigidity for PD?
- Slow, rhythmic rotational movements of trunk and limbs
- Usually rigid in the morning
- Combined with relaxed deep breathing
- May incorporate Yoga or Feldenkrais
- Muscle stretching: Shoulder abd + ER + thoracic E + hip E
- Postural awareness using visual feedback
- Lying supine or prone 30 minutes/day
- Prone is better for early PD
- Supine is better for later PD
- Evidence: 10 week spinal flexibility program improved axial mobility and functional performance
What are 7 managements for balance training for PD?
Facilitation of balance reactions
- Both internally and externally-generated
- Aiming to increase speed of reactions
- Balance reactions can first be practised cognitively > progress to automatic reactions
- Train in various positions
- Find the most appropriate balance strategy for the patient
- Compensatory stepping: ↑ step length, ↓ initiation time
- Evidence: Balance training under altered visual and somatosensory conditions 3x/week improved balance on SOT
What are 7 managements for increasing active movements for PD?
- Large amplitude movements
- Start with bilateral symmetrical patterns > progress to reciprocal movements
- Emphasise exercises to achieve mobility throughout the spine
- Rhythm and music can facilitate movement
What are 3 managements for treadmill training for PD?
- Treadmill is better for early-mid PD
- May help with walking training
- Varying evidence
- No difference between treadmill and overground
- Training treadmill better
- Positive findings
What is a management for strength training for PD?
Progressive resisted exercises for trunk, UL & LL
What are 3 managements for tai chi training for PD?
- Controlled movement of COM over BOS, attention, awareness of movement
- 6 months + longer term follow up
- Tai chi reduces falling in PD
What are 2 managements for upper limb training for PD?
- Cues to increase size of movement, speed
- Handwriting training: Write between 2 lines to guide for writing size
What are 4 managements for virtual reality games training for PD?
- Multidirectional COM movements
- Alternating steps
- Stationary control of COM
- Cognitive demand: Attention, real-time, use visual feedback, planning, dual task
What are 7 managements for partnered dancing training for PD?
- Both partnered and non-partnered dancing improved performance on the BBS and quiet stance measures, but there was no difference between the two dancing programs
- Dancing (tango) found a significant improvement in miniBESTest results when tested 3, 6 and 12 months
- Auditory cues: Music
- Visual cues: Partner demo, mirrors
- Stability: Holding partner
- Dancing involves big steps, turning, crowds
- Social benefits
What are 4 managements for cardiovascular fitness training for PD?
- May alleviate depression, fatigue, loss of self-esteem and insomnia
- Mild to moderate PD can maintain exercise capacity with regular aerobic exercise
- Structured aerobics classes are beneficial
- Any aerobic exercise that encourages whole body movement
What are 2 managements for falls for PD?
- Ask about falls, falls circumstances
- Modify activities/factors associated with falls
What are 7 managements for environmental restructuring for PD?
- Educate client and carer
- Movement strategies identified for the home can be incorporated into treatment
- Reduce clutter, rehang doors, rearrange furniture
- Reduce need for turns
- Tape in difficult areas
- Lighting
- Cue cards
What are 6 cognitive strategies for PD?
Use cognitive strategies especially for late PD
- Avoid simultaneous tasks
- Write instructions down
- Speak slowly
- Allow for bradyphrenia (slowness of thought)
- Use cues
- Mental rehearsal
What are 2 types of walking aids in the prescription of equipment of equipment?
- Walking aids with a laser line - help freezers to walk over the line
- Does not work if the line just stays on
What are 3 types of equipment for bed mobility in the prescription of equipment of equipment?
- Bed poles
- Bed cradles
- Satin sheets
What are 3 new technologies for PD?
-
Non-invasive brain stimulation (rTMS, tDCS) to facilitate plasticity or extracellular dopamine levels
- Unclear parameters & usage
- Some evidence for positive effects, some evidence for no effects
-
Accelerometry on wrist to monitor symptoms, upload data to clouds, then clinician can use the data for assessment and management
- Measure, detect gait, movements
- Exergaming (e.g. kinect)
What are 8 models of service delivery for PD?
- Physiotherapy is one component of MDT
- Combination of 1:1 therapy, group therapy and independent practice
- Review clients regularly
- Provide top-up programs as required
- Home programs to improve functions
- Lee Silverman Voice Treatment Big (LSVT BIG): Intensive exercise of high-amplitude movements to overcome bradykinesia and hypokinesia in PD.
- PD Warrior: No evidence but good
- Expensive for physio and patient
- Boxing classes: Trunk rotation, unilateral movements, stepping
What is the main treatment approach to PD?
Drug is the main treatment approach to PD.
- Drug therapy is more difficult to manage late PD
What is the on-off effect in the Pharmacological Management of PD?
Effect of on/off medication on movements
- Do assessment during on period and off period for comparison
- Know what medication they are on, what effects, when they have it
What are 8 side effects of PD drugs?
- Dyskinesia: Involuntary movements which occur when dopamine level is highest
- Nausea
- Constipation
- Postural hypotension
- Depression
- Confusion and hallucinations
- Compulsive behaviours
- Hypersexuality
What are 7 characteristics of Deep Brain Stimulation (DBS)?
- Electrodes implanted in STN or GPi
- Thalamus for essential tremor
- Pedunculopontine nucleus (PPN)
- High frequency impulses that block electrical signals from target regions
- Potential to affect many pathways
- Use DBS when drugs are no longer controls symptoms, or if severe side effects of drugs
- DBS is good for tremor-dominant PD, less good for PIGD
- Used in combination with dopamine replacement therapy
- Reduced dosage
- Improvement in side effects
- Improved gait and posture
- Speech unchanged
