Lecture 8: Parkinsons intervention Flashcards
side effects dbs
HA’s super intense
* makes sense, they drilled into your brain
Therapy for parkinsons is based on the stage of the disease your in
Stages
* Early - working to alleviate symptoms/get them better
* Middle
* Late
Restorative-Improving impairments, activity limitations, and participation restrictions
Preventative-Minimizing potential complications and indirect impairments
Compensatory-Modifying task, activity, or environment to improve function
often dont get refferals to pt at this stage - unless coming from parkinsons clinic
aerobic ex good for slowing progression of pd
* so thats part of why its important to see them early
middle stages pd
can still do things, its just slower
* very important to do aerobic to slow progression
* stopping moving is about the worst thing you can do
* these pts wont want to leave the house as much due to symptoms - dont want them to stay home
late stages
more compensatory shit
* think assistie devices etc…
* teaching how to do skin checks
figure out what dilinates pd pts from others
* cognition
* slow movement
* tremors etc…
no evidence that theres a gold standard tx for pd
* some pts will do well w/ big and loud while others wont
People w/ PD have motor learning difficulties - will learn slower, take many more repeittions
* motor learning deficits
* slower learning rates
* reduced efficiency
* increased context specificity training - could work on sit to stand in a chair but they wont be able to tranfer it to other chairs
* complex movement sequences and movements depdent on internally generated cues more difficult than external cues - can improve performnce but works best in early stages
* early and middle stages- can improve performance through practice and additional sensory information
* amount of persistence of learning variable
* learning lower than healthy age matched people
* advanced stages and pronounced cognitive deficits training will likely be less successful
what type of practice is better for people w/ pd, blocked or random?
blocked - this is doing the same task over and over
* however, for most normal people random is better
works best if you use small words and there is less time in between
repeatedly practicing a single skill or task before moving on to another, focusing on repetition and building mastery of that specific skill
blocked practice
motor learning w/ pd
* large # of repetitions to develop procedural skills
* focus full attention on desired movement
* Environment modified to reduce clutter and competing attentional demands that may trigger freezing episodes
* Task modified to minimize competing cognitive demands (they have trouble w/ dual tasking)
* long and complex movement sequences avoided or broken down into component parts - while whole works best you can’t do the whole if you cant do the part
* blocked pratice order reducing effects of contextual interference
* structured instructional sets improve movement speed and consistency
* advanved disease and cognitive deficits-repetitive drill like practice used together with increased focus on caregiver training to ensure safety
external cues w/ pd
* facilitate movement utilizing premotor cortex-active in generation of movement in response to visual or auditory stimuli
* bypass supplementsry motor are BG - so basically bypassing where the problem is and relying on other areas
* external cues heighten pt attention through common mode of action to bypass diminished internal cueing of the BG
* focusshifted to less automatic movement using alternative, more conscious motor control pathways
that external cue might be putting something infront of them to reach for to faciliatte that wt shift
or lines of the floor to help w/ gait
* putting them far apart trying to increase stride length
external cues:
* effective in triggering sequential movements and improving movement characteristics-mild to mod
visual cues
* stationary floor markings-perpendicular to gait path about one step length apart
* dynamic transportable cues (laser light) mounted on assitive device or clothing
freezing episodes reducd
improved stride length and velocity
rhythmic auditory stimulation-metronome
* improve gait speed, cadence, and stride length
* beat is typically set 25% faster than preferred pace - to get them to walk faster
auditory cues such as “big step” improve gait: 1,2,3 stand, ready set go, big first step
can be self directed auditory cue
cues should be consistent, not rushed and have rhythmical quality
auditory cues greater influence on temporal components of movement (gait cadence, stride synchronization) than spayisl components
multisensory cueing effective
good strategy w/ lines is making them further apart - kind of like an opposite festinating giat
they’re better in closed environment but live in an open one
not effective for all pts
works best early/middle
if they progress really quickly its not going to work well
* think starting w/ gait/postural instability
once they have dementa, then external cues dont really work unless they’re lready really well trained w/ it.
EX training w/ pd
* amplitude-based behavioral intervention
* “training big”
* concept = repetitive high amplitude movements yield greater improvements in motor performance as possibly have neuroprotective effect
* patient guided by physical therapist to ex at high intensity (8/10 borgs rpe scale) for 1 hour 4 times a week for 4 weeks w/ large amplitude, multiple repeittions, and whole body movements that increase in complexity.
big movements should be done multiple times a day for a long time
relaxation ex
* gentle rocking to produce generalized relaxation of excessive m tension owing to rigidity - sometimes tell them to tighten first then relax
* rocking chair temporarily relax pt and enhance sit to stand transfers
* slow, rhythmic, rotational movements of extremities and trunk can precede interventions such as rom and stretching, and functional training - this is you helping them move through the motion - helps relax that rigidity
* rhythmic initiation specifically designed to help overcome the ffects of rigidity w/ pd - you start by taking them through the, motion then they start to take over that goes up to resisted movement
breathing - can do d2 patterns to promote respiration
* phenominia can be a problem
pt w/ parkinsons only gets so much e = use it efficently - probs mostly due to rigidity - fighting thier own muscles
flexibility ex w/ pd
* combination od static (PROM), and dynamic (AROM), and facilitated PNF EX
* flexibility ex minimum 2 to 3 days/week ideally 5 to 7 days/wk
* minimum of 4 reps per stretch for 15-60 sec
* stretching common areas of limitation
* stretching can be combined w/ joint mobilizationa to reduce tightness of joint capsule or ligaments around joint
* accessory movement to improve rom and decreased pain
* stretching more effective if warmed with active ex or external heating modality
* HEP-pt and cargiver
can use heat
* stretch after heat is used
think also doing trunk rotational ex not just extremities
try and add stretches into irl activitied to make them more functional
dont want to do a program thats too hard because they might get frusterated
* lots of americans dont do ex programs because they start too hard
hold relax/contract relax
benefits from additionsl attention and cueing strategies during active strteching ex
* they dont know where their body is
* just like they dont realize they’re whispering
dont do ballistics because of increased risk injury
more at risk for osteoporosis - wolfs law
stretching may cause increased pain for these pts
20 - 30 mins
want the stretches to be comfrotably uncomfrtable
* should be able to tolerate
* if body is tighening against the stretch they are no longer strdtching
* needs to be relaxed
resistance training w/ pd - lots of really goog evidence, especially postural muscles - think strengthening spinal extensors becuase it takes them out of that kyphotic posture. really training every extensor is a good idea because they’re in that hunched forward pos. note they dont have great force production. try to deviate between fast and slow movements to grade control (their brain struggles w/ this). note strengthening doesnt necisarily transition to balance - need to work on balance as wll
- specific areas if weakness targeted-antigravity extensor muscles
- muscles assocated w/ poor posture and functional deficits
- postural instability, falls, and fall injury due to weakness
- Frality and injuries: cooperative studies of intervention techniques trials benefiy of ex
- strength training: improve muscle force, bradykinesia, and qol
- greater improvments in balance and strength: combined program of balance training and high intensiy resistance training for knee extensors and flexors and ankle pfs as compared to balance training alone
she be doing function in least restrictive pattern (think if they can do sit to stand w/o hands dont use hands) and least restrictive assistive device
note w/ their bed mobility they’re going to really struggle w/ rotation due to the rigidity
* they’re going to use straight plane movmeemnts over rot - work on rot
work on different surfaces - think mat vs soft bed
bridging useful for end stages because it gives them a lot more abilities w/ hygene - helps care givers a lot
sit to stand
* poor timing in controlling COM forward velocity, which tends to be lower
* * insufficient upward momentum (LE extension torques)
* * level of agonist-antagonist coactivation and rigidity
* inital rocking
* cueing stratgies (counting, placing one hand between the pts shoulder blades) to assist forward lean
* inflated disc/cushion forward weight shift and seat off
* improved le muscle strength
* raise seat to lower
* avoid blocking flexion/weight shift forward they have less power, let them rocking forward and dont block them - be on the side for this so they can rock forward
backward stepping uses a plaetheria of mucles that are weak
* helps w/ upright posture because its hard to do it w/ kyphosis
any pt thats a fall risk should be training this
hard if trunk rot is lost early
work on balance in many surfaces
lots of training methods
* not much detail here
data is undtermined
locomotor training
* primary gait impairments - body is not telling them to take the right size steps
* slowed speed
* decreased stride length
* lack of heel-toe sequence w/ forward progression
* chacterized by a shuffling (festinating) gait pattern
* diminished contralateral trunk movement and arm swing
* overall flexion while walking
problem w/ treasmil is if they’re holding on it doesnt encourage trunk rotation
* arm swing comes from trunk rotation - so if they have decreased trunk rot they’ll have decreased arm swing - not vice versa
can do pole walking instead of using assitive devices
* upright reciprocal pattern
* can pace themselves w/ music
*
may teach them to drag foot over obstcle to tell their brain that they’ve cleard it
* make sure foot is all the way on stair and feel it b4 taking that step
when you use a brace, you’re not using the muscles under that brace
when you use a spinal orthosis they arent using those m to hold themsleves up. at some point this will be needed
* however probs dont use this early stgE
* USED WHEN COMPESENTORY SHIT IS NEEDED
weak m = trouble breathing
swallowing impacted = aspiration phenominia
aerobic ex = neuroprotective
should be 60-80% max hr
* however, their hr might skyrocket - might get there walking
slows rate of progression parkinsons if doing high intensity
can be anything
aquatic therapy good because dont have to worry about falling
firmer mattress = easier to get up
