Neuromuscular 2 Unit 3 Parkinsons Flashcards
When treating PD patients, what would happen if the patient has depression, anxiety, apathy and/or cognition issues? What can we (the PTs) do?
They will be low energy, they may have impaired learning and low compliance
- We may need to have simple commands and give them reminders
When treating PD patients, what would happen if the patient has postural hypotension (drop of 20 SBP or 10 DBP and 10% increase in HR) and/or have bladder urgency/infrequency? What can we (the PTs) do?
They may have dizziness, falls with blackouts, and/or injury
- They may need compression stockings, salt on food, hydration, pause with STS
- They may need pelvic floor exercises, MD referral
When treating PD patients, what would happen if they have sleep disturbances or psychosis? What can we (the PTs) do?
- They may have fatigue
- May require referral for sleep study, medication adjustment for psychosis
PD across the continuum of care
What is considered the Early/Mild stages of the Hoehn and Yahr Scale?
Stage 1 - 2
What is considered the Moderate/Middle stages of the Hoehn and Yahr Scale?
Stage 3 - 4
What is considered the Severe/Late of the Hoehn and Yahr Scale?
Stage 5
With the Hoehn and Yahr Classification of Disability, what is Stage 1?
Minimal disability, unilateral symptoms
With the Hoehn and Yahr Classification of Disability, what is Stage 2?
Bilateral, or midline involvement (no balance impairment)
With the Hoehn and Yahr Classification of Disability, what is Stage 3?
Postural instability present but can still live independently
With the Hoehn and Yahr Classification of Disability, what is Stage 4?
All symptoms present, standing/walking only possible with assistance
With the Hoehn and Yahr Classification of Disability, what is Stage 5?
Wheelchair or bed bound
What is the Treatment focus with the Early/Mild stages (H&Y 1-2)?
Restoration
- The interventions should be focused on strength, execution, task-specific training, preventing inactivity, improving flexibility and preventing possible deformities by working on postural endurance and postural training
- Additionally you want to address any asymmetries in gait, such as arm swing, and also address any impairments that you know at this time
- Fall prevention and disease progression education is ideally started at this stage
What is the Treatment focus with the Moderate/Middle stages (H&Y 3-4)?
Compensation, while also training restoration
- This is the stage where sensory cueing becomes very important and the importance of assistive devices may be warranted
- There is typically more difficulty with dual tasking
- Creating a fall log might also be benefical at this stage to give you an idea of how falls are affecting their ADLs and how you can help to prevent them
What is the Treatment focus with the Severe/Late stages (H&Y 5)?
Compensation
- We will be providing a lot of caregiver education for transfer safety and skin integrity awareness
- It can take a long time to reach this stage, however its important to prevent things such as contractures, pressure sores, and pneumonia (unfortunately, people with PD die with aspiration pneumonia)
- Emphasis on providing family education especially with transfer training can help improve patient care at home
- This may also be an appropriate time to educate the family and the patient about the possibility of moving to a skilled nursing facility
What should be the intensity for Aerobic exercise? What are the Benefits of Aerobic Training for PD patients?
PTs should implement moderate - to high intensity aerobic exercise
There are improvements in:
- Oxygen consuption
- Motor and nonmotor impairments
- Functional activities (ex., gait, balance, ADLs)
- QOL
No one form of aerobic exercise is superior to another, however the emphasis should be placed in intensity
What is important to consider when prescribing Aerobic Training for PD patients?
- Gradual progression is recommended to avoid MSK injury
- Mode should be determined based on safe participation
With Aerobic Training, what is the goal of intensity (based on the ACSM guidelines)? What is typically encouraged for PD patients to complete in terms of time and intensity?
How can this be beneficial?
Goal of at least 150 min/week at moderate intensity (30min 5x/week)
- It typically encouraged for PD patients to engage in at least 20 min of High-intensity exercise
- It can help with:
- Deconditioning, its also been shown to decrease or slow the disease process and help stimulate neuroplastic changes (this will increase nutrition and growth factors to stimulate neuroplasticity and help preserve the dopamine-producing neurons
What are some examples of Aerobic Training a PD patient can do?
Bike (cycling)
- Consider 3-wheels for stability
- “Forced” Tandem biking/cycling has shown to be beneficial. If the patient can recruit a family member or friend, it would be more enjoyable but it would also increase their intensity by way of “forced” use.
–89-90RPMs, with a trainer
Walking
- This can be done on ground or by using a treadmill. With a treadmill, the patient can choose to do it with or without bodyweight support, they can do it flat, at an incline, and they can also choose to use UE support (or do it without support)
Swimming
With Cardiovascular Training, what is recommended?
Increased Intensity = Increased Neuroplsticity
Recommended: (Make sure to know this!!!!)
- 30 min / 5x per week (Mod intensity)
- 20 min / 5x per week (high intensity)
- 50 min / 5x per week (low intensity)
With PD patients, what are some parameters for Resistance Training?
- Programs should be progressive
-
Resistance training with instability (RTI) > than resistance training alone to improve strength/power
–Complete resistance training on balance pad, dyna disc, balance disc, BOSU and SB - Resistance training can be implemented alone or as part of a multimodal intervention
–Power yoga, low intensity exercise, turning-based training, conventional PT
With Balance and Fall Interventions, when are Fall outcomes most reduced? And when are they less effective?
- Fall outcomes most reduced in patients with Mild PD; and Less effective in patients with Severe PD
Dopamine replacement medication does not improve reactive responses
Wiith falls, what are some contributors to falls for PD patients?
- Sensory, reactive, proactive issues
- Static/dynamic balance, mobility, turning, STS
- Orthrostatic Hypotension (may be medication)
- Urinary incontinence
- Home environment
Balance Interventions
When training for reactive balance, what are some exercises that can be done?
- Lateral and Anterior/Posterior perturbation training
- Rebounder
- Abrupt stops and starts
- Ball catch
Balance Interventions
When training for Anticipatroy balance (self initiated movements), what are some exercises that can be done?
- Consider Wii balance board
- Gait with head turns
- Reach for objects on the floor
- Weight shifting
Balance Interventions
With balance interventions with PD patients, what are exercises that can help the patient with Adapting between the sensory systems?
- Sunglasses
- Light off
- EC
- Foam
- Rocker boards
- Mats on the floor
- Gait over varied terrain
- Training narrowing BOS
Balance Interventions
With balance interventions with PD patients, what are exercises that can help the patient with Compensatory Balance Strategies??
Multidirectional stepping
Balance Interventions
With balance interventions, when should dual tasking be used?
Dual Tasking is important to train early in the disease
- However, should be taken out as the disease progresses
What are the Characteristics of Stooped Posture?
Most common
- Flexion of neck and trunk
- Shoulders rounded with IR
- Flexion of hips and knees
What are the Characteristics of Camptocormia Posture?
- Extreme involuntary forward flexion of thoracolumbar spine in standing and walking
- Subsides in recumbent positions
What are the Characteristics of Pisa Syndrome Posture?
- Increased lateral flexion
- Subsides with passive correction in recumbent positions
What are the characteristics of a Shuffling Gait Pattern?
- Shortened step length, decreased foot clearance and flexed knees and hips
- Rigid trunk and decreased/asymmetrical arm swing
- Bradykinesia, worses with dual tasking
Gait Characteristics
What is Festination Anteropulsion? What Triggers this?
- The COM gets too far ANTERIOR, “run away train” (leads to falls)
- TRIGGERS: Wheeled walkers without hand breaks, forcing through a freeze, being pulled on during a freeze
Gait Characteristics
What is Festination Retropulsion? What Triggers this?
- The COM get too far POSTERIOR, under scaled balance reaction, small steps to recover (leads to falls)
- TRIGGERS: Backing up, Reaching overhead, opening door, carrying items too close to body
What Triggers Freezing of Gait (Akinesia)?
Triggers: Tight/narrow spaces (doorways, elevators), cluttered areas, crowds, anxiety/stress/rushing, turning/pivoting, changes in floor pattern
With PD patients, should PTs implement External Cueing?
Yes, PTs should implement external cueing to reduce motor disease severity and freezing of gait, and improve gait outcomes
- Cueing including visual, auditory (rhythmic auditory stimuli), or somatosensory cueing superior in comparision to no cueing
- No one mode of cueing is superior to another
What are the Benefits of External Cueing?
Improvements in:
- Motor disease severity
- Spatiotemporal parameters of gait (gait speed, stride length, cadence)
- Functional gait outcomes (mobility, turning and distance walked)
- Freezing of gait
What type of External Cueing is used most commonly for gait training? What can this cue be beneficial for?
Visual Cueing is the most common
- Improve Stride Length
–150% longer than current
–Target = 40% of patient height (24-28in)
- Improves turning
- Improves initiation of Gait
What is Auditory Cueing? How can it help patients with PD?
Rhythmic cueing with use of metronome, music, clapping or snapping
- This can be used as a mode to improve speed of gait or cadence, as well as speed of any movement or intervention
–With Stepping, it can help 25% faster than baseline
–100-125 bpm can be used for higher functioning patients
Rhythmic cueing can be used with interventions, such as PNF patterns to improve axial rotation, resistance training or boxing
With Freezing of Gait, What are the 4 S’s?
If you find that your patient is stuck in a freezing episode,
- You first teach them to STOP. Its important to not try to force or push your patient out of their freezing. this will only result in frustration.
- Once they stop, remind them to relax and correct their posture by STANDING TALL to get their COM over their BOS
- Next, they will SWAY laterally from side to side
- Once they have initiated movement from side to side a few times, they can STEP LONG/BIG and begin to initiate their gait again
If a caregiver is with the patient when they are having an episode, they can also aid the patient by placing their foot perpendicular to the patients and giving them a visual cue of something to step over, so that they can help to break the freezing episode
With Festination of Gait, what are the 3 S’s?
Similar to Freezing of Gait, except there is only:
- Stop, Stand Tall, and Step Long/Big
- As soon as they recognize their steps quickening, they need to STOP so that they can reset their COM over their BOS. Some patient do not recognize when they do this, its important to educate them about the signs so they can train themselves to stop as soon as they can.
When can Extrenal Cueing not be effective?
With Advanced disease, Severe reductions in step length, Dementia
This may or may not have short-term carryover when cueing is removed
What are the benefits of Task-Specific Training with PD patinets?
Improvements in:
- task that was specifically trained
- UE strength, dexterity, sensation, and goal attainment
- Mental imagery
- Turning and functional mobility
- Bladder function
Task-specific mental imagery paired with actvively performing the task resulted in improvements in the target outcomes
With Task-Specific Training, what stage of PD is Sit to Stand/Stand to Sit beneficial? What will PTs typically notice during this stage?
During H&Y Stage 2 progressing to Stage 3
- Their problems with postural instability will start to progress, this will be evident in their execution of a sit to stand
- We will notice the patient will start to fall back into their chair as a result of poor dynamic postural control
- Also bradykinesia will slow their movements which will not allow them to translate their weight far enough anteriorly at a quick enough pace to be able to stand up
What can us, PT do to help PD patient manage their Tremors and Dexterity?
- We should discuss about their mental health, such as stress and anxiety, because this can increase the severity of their tremor
- Educate them that activities such as yoga or meditation may promote relaxation to reduce their tremor
- If they are reporting difficulty eating or dressing themselves, we can recommend weighted utensils or bigger buttons to make the task easier
- Also to make ADLs easier, we must educate them on different options and which members of the health care team can assist them treating their tremors; such as OT for additional adaptive aids and/or get help with their handwriting. Or back to their physician to dicuss medical options
What are Community-Based Exercises defined as?
- Programs in which groups of inidviduals exercise together
- Programs in which individuals follow a predetermined exercise program in the community setting either at home or in a community facility
- Not necessary to be lead by a PT
What are the benefits of Community-based Exercises?
Improvements in:
- Motor and nonmotor Sx
- Functional outcomes (gait, balance, mobility, ADLs, walking capacity and velocity, walking measures, turning and falls/fears of falling)
- QOL
What is LSVT BIG? What are its 4 principles?
A training program specific for PD patients
-
1. Amplitude
-Max effort (8/10 on modified Borg scale)
-Speed increases with large movements
-“THINK BIG” -
2. Sensory Re-calibration
-What feels like normal movement to patient is actually hypokinetic - 3. Mode
- Intensive standardized exercise program
- Intensive and High Effort
- 16 one hour sessions, 4x/week, 4 weeks
- 4. Empowerment: “You dont look like you have PD”
This is organized into 16 treatment sessiosn with 4, 60 min training sessions per week
With LSVT Methods, In Week 1, How long is the Max Daily
Exercises, FunctionalComponent Tasks and how long is the Big Walking, Hierarchy Tasks?
Max Daily Exercises, FunctionalComponent Tasks:
- 45 min
Big Walking, Hierarchy Tasks
- 15 min
With LSVT Methods, In Week 2, How long is the Max Daily
Exercises, FunctionalComponent Tasks and how long is the Big Walking, Hierarchy Tasks?
Max Daily Exercises, FunctionalComponent Tasks:
- 40 min
Big Walking, Hierarchy Tasks
- 20 min
With LSVT Methods, In Week 3, How long is the Max Daily
Exercises, FunctionalComponent Tasks and how long is the Big Walking, Hierarchy Tasks?
Max Daily Exercises, FunctionalComponent Tasks:
- 35 min
Big Walking, Hierarchy Tasks
- 25 min
With LSVT Methods, In Week 4, How long is the Max Daily
Exercises, FunctionalComponent Tasks and how long is the Big Walking, Hierarchy Tasks?
Max Daily Exercises, FunctionalComponent Tasks:
- 30 min
Big Walking, Hierarchy Tasks
- 30 min
What are the Therapist Condiserations when teaching LSVT to patients?
- MODEL: Do what I do
- SHAPE: Optimize alignment first
- DRIVE BIG EFFORT: Increase motor output
- STABILIZE: Repetitions, reinforce, motivate
- CALIBRATE: Teach self monitoring
What is PWR!?
“Parkinson Wellness Recovery”
This Program has 4 Basic Power moves that can be practiced in multiple positions and progress to make them more physically and cognitively challenging, can be done individually or in group setting
What are the benefits of Behavioral Changes Approaches in PT?
Improvements in:
- Improved participation: Disease related QOL and physical activity
- Improved activities: walking capacity
- Improved body structure and function: motor disease severity, bladder function
(Behavioral-change strategies sucha a goal-setting, coaching and/or problem solving)
(This can be in the form of mobile health technology)
What are the Benefits of Integrated care for PD patients?
Improvements in:
- Reduction in motor disease severity
- Nonmotor Sx
- Functional outcomes
- QOL
- Health care utilization (levodopa quivalent daily dose)
What are common elements of success with treating PD patients?
- High repetition, High intensity
- Dynamic (movment of COM)
- Patient enjoyment
-Group vs individual - H&Y Stage 1-3 most responsive
-Later stages consider weighted FWW with brakes, UStep, Nordic walking poles to remain active
