Parkinson's Disease Evidence Based Interventions Part II Flashcards
Skilled exercise that entails perceptual and a higher level cognitive processing may specifically target
- Prefrontal and associated cortical circuits important for executive function
What global factors may be activated due to exercise
- Reduced oxidative stress
- Reduced neuro-inflammation
- Increased expression of neurotrophic factors
PTs should implement moderate to high intensity aerobic exercise in Parkinson’s patients to improve
- Oxygen consumption (VO2)
- Reduce motor disease severity
- Improve functional outcomes
What is the cycle to stopping falls in PD
- Early & periodic PT evaluation
- Balance training 3x/wk for 6 mo: individualized, can combine with other interventions, use caution in later stages of disease
- Community based exercise program
- Assess and treat fear of falling: Falls efficacy scale & behavior change strategies
To improve overall blood flow and connectivity in the cerebellum do aerobic exercise but if trying to improve cognitive function use skilled exercise (True/False)
- True
Considerations when choosing interventions
-Falls are a potential risk with balance exercises but did not increase number of adverse events
- Type of exercise & level of supervision should be chosen based on individual’s safety profile
- Resistance training should be performed “ON” medication
What is integrated care
- Medical providers who work together to understand you & your care partner’s needs
- Can reduce the severity of the motor symptoms of PD & improve your QOL
- Work with different clinicians based on needs
- May encounter these providers in multiple settings
What does mobility require
- Dynamic neural control to quickly & effectively adapt locomotion, balance, & postural transitions to changing environmental & task conditions
What is sensorimotor agility
- Coordination of complex sequences of movement
- Ongoing evaluation of environmental cues
- Ability to quickly switch motor programs when environmental conditions change
- Ability to maintain safe mobility during multiple motor & cognitive tasks
How is the basal ganglia critical for sensorimotor agility
- Automaticity
- Self initiated gait/postural transitions
- Quickly change motor programs
- Sequencing actions
- Using proprioceptive info for kinesthesia/multi segmental coordination
- Task switching
- Suppression of irrelevant info before executing an action
Describe the relationship between neuroplasticity and task specificity
- Task specific exercises targeted at a single, specific balance or gait impairment in pts with PD have been shown to be effective
Electryographic activity in bradykinetic muscles often is fractionated into multiple bursts & is not well scaled for changes in movement distance or velocity (True/False)
- True
Compensation strategies for gait impairments related to PD
- External cues
- Internal cues
- Changing balance requirements
- Altering the mental state
- Motor imagery or action observation
- New walking pattern
- Alternatives to normal walking: bicycling, ice skating, crawling, etc.
Define freezing of gait (FoG)
- A brief, episodic absence or marked reduction of forward progression of the feet despite the intention to walk
- One of the most common reasons for falls and dependency
Freezing during gait occurs more often when a person is
- Negotiating a crowded environment
- Negotiating a narrow doorway
- Making a turn
- Attention is diverted by a secondary task
- Stepping over obstacles
- Change in surface
What current therapies for PD are inadequate for treating FoG
- Deep brain stimulation (DBS)
- Levodopa
What are the 5S to help a PD patient get unstuck during FoG
- STOP
- Stand tall
- Shake it off
- Shift your weight
- Step or Shoot Up
What features does a U-Step walker for PD patients have
- Reversed braking system
- Rolling resistance control
- Spring loaded front wheel
- Laser & sound cueing module
- Easily transported
- Comfortable padded seat
Mechanisms of cueing for FoG from habitual to goal directed motor control
- Executive role: facilitate response generation & prioritize focus of attention
- Stabilizing role: prevent deterioration of the gait pattern
- Preparatory role: re-integrate coupling postural control with stepping
Success of executive function in mobility requires
- Ability to divide attention
- Ability to effectively focus attention on particular stimuli while ignoring others
- May have to inhibit a response such as obeying the walk signal if if other important info is present like an oncoming car
Define divided attention
- The ability to complete 2 different attention demanding tasks at the same time
Individuals with FoG may prioritize __________ task over mobility task during dual task analysis
- Cognitive
Define attention switching
- Refers to alternation of the focus of attention between 2 different tasks or sources of information
Mobility in complex environments requires constantly switching attention including
- Posture
- Locomotion
- Surrounding sensory input
Define sustained attention
- Ability to maintain attention to a task over prolonged periods
- Cognitive/environmental distractions may contribute to FoG & may increase risk for falls
Define selective attention
- The ability to intentionally focus attention on one source of information while excluding irrelevant information
- Flanker test
Executive dysfunction is most often associated with FoG including
- Response inhibition
- Switching attention
- Performance on the Stroop task (names of colors are a different color than what it says) has been related to FoG
What cognitive domains are most affected in people with PD who freeze
- Inhibition: executive control & selective
- Shifting: switching & divided
Example of task prioritization during agility training
- The patient completes a secondary cognitive task during agility training and is instructed to switch prioritization between the mobility/stepping component (left) and the cognitive component (right)
Example of visual-auditory cue conflict during boxing
- Simultaneously, the instructor visually cues for a left punch and verbally cues for a right punch. For this trial, the patient is instructed to respond to the visual cue only and ignore the auditory cue.
Agility exercises should be performed in what kinds of environments
- Environments in which freezing typically occurs
To facilitate use of proprioceptive information and reduce overreliance on vision, an agility program should progress balancing and walking tasks by
- Wearing dark sunglasses to reduce visual contrast sensitivity
- Use of “no body” glasses to obscure the bottom half of the visual field so the body cannot be seen
- Exercises can be performed on a variety of surfaces to require adaptation to altered somatosensory information from the surface
It is even more difficult for a person with PD than age-matched elderly people to perform multiple tasks, possibly because the basal ganglia are responsible for
- Allowing automatic control of balance & gait & for switching attention between tasks
You can increase the challenge of an exercise using the principles for exercise progression which includes
- Reducing the base of support (BOS)
- Increasing surface compliance to reduce surface somatosensory info for postural orientation
- Increasing speed or resistance with weights
- Adding secondary cognitive tasks to automate posture & gait
- Limiting visual input of the body with “no body” glasses or of the environment with dark sunglasses to increase use of kinesthetic info
- Increasing the length of remembered sequences & improving the form of each subcomponent of the movements (Tai Chi, Pre-pilates)
Key points of strategy training
- Compensatory strategies to bypass the defective basal ganglia
- Learning strategies to improve performance through practice
Key points of management of secondary sequelae of disease
- Affects on musculoskeletal and cardiorespiratory systems that occur as a result of deconditioning, reduced physical activity, advanced age, and comorbid conditions
Key points of exercise and fall prevention
- Promotion of physical activities that assist the person in making lifelong changes in exercise and physical activity habits as well as preventing falls
Strategy training techniques include
- Visual cues/targets for stepping
- Rhythmic cues for cadence
- Visualizing walking with long steps
- Mentally rehearsing the desired movement pattern before the action is performed
- Part practice
- Avoiding dual task performance
- Verbally reciting phrases such as “thinking big” or “long steps”
- Mental singing for rhythmic cues
For newly diagnosed individuals and those with mild to moderate disease, it is recommended that therapists provide
- High intensity
- Variable
- Distributed practice
- Regular booster sessions over longer term
For people who are more severely affected or those with cognitive impairment, very advanced age, or comorbidities that compromise skill acquisition, ___________ strategies are recommended
- Compensatory
What are the secondary sequels of disease
- Loss of ROM: may contribute to loss of postural control, gait, & decline in overall function
- Loss of LE strength: contributes to problems with balance, falls, & functional decline win older people
What does Levodopa, antiparkiinsonian medications, & dopamine replacement NOT improve
- Levodopa: axial rigidity
- Antiparkinsonian medications: Bradykinetic postural responses
- Dopamine replacement: inflexible program selection
Perceived barriers to engaging in exercise in people who have PD, are ambulatory, and dwell in the community include:
- Low outcome expectation from exercise
- Lack of time to exercise
- Fear of falling
- These barriers are potentially modifiable
Advocate that vigorous exercise begin immediately on diagnosis, if possible, and continue throughout the course of the disease for as long as the individual is able to exercise (True/False)
- True
Dual-task gait assessment using targeted cognitive tasks should include assessment of
- Cognitive flexibility
- Task prioritization (trade-off effects)
- Factors known to modulate susceptibility to dual-task interference (age, gender, processing speed, stress, and cognitive reserve)
Task difficulty is determined by the combination of
- Task novelty
- Task complexity
Define dual tasking
- The simultaneous performance of two attention-demanding tasks with different goals, whereby one task can be denoted as the primary and the other as the secondary task
Factors that affect dual task performance are
- The environment in which the task takes place
- The nature of the secondary task
- The age and disease-specific factors of each individual
Gait has been found to deteriorate during dual task (DT) performance in PD, resulting in
- Decrease of gait velocity
- Cadence and step length
- Increase in gait variability
- Increase in double support time
- Falling and FOG are more commonly provoked in DT conditions
Executive function refers to a set of abilities which flexibly guide behavior towards goals and includes
- Switching between cognitive sets or tasks
- Appropriately inhibiting & generating responses
- Updating working memory contents
Outcome measure for dual task training
- Duality Trial
Define consecutive and integrated task training
- Consecutive: training 2 tasks separately
- Integrated: practicing 2 tasks simultaneously
Who benefits from dual task training
- People with a lower DT gait velocity at baseline and better cognitive function were more likely to experience a greater benefit.
- Individuals with PD seem to benefit from consecutive dual-task training regardless of disease severity, their cognitive capacity and UPDRS-III scores
Describe the HiBalance Program
- Targets 4 main subtypes of balance control: stability limits, anticipatory postural adjustments, sensory integration, & motor agility
- Incorporates principles of motor learning & gradual integration of dual task exercises involving cognitive or motor tasks
PRET-PD Trial- EMG Outcomes
- Pts with mild-to-moderate Parkinson’s disease partially restores the triphasic electromyographic pattern and improves movement velocity
- This finding is similar to the effect of medication and deep brain stimulation
- The improvement in the triphasic electromyographic pattern and muscle strength is significantly associated with improvement in peak velocity
- Findings indicate that resistance exercise can drive neurophysiological changes
Bradykinesia is a cardinal feature of PD that is accompanied by impaired muscle activation patterns including
- Reduction in the magnitude and duration of the first agonist burst
- Increase in the number of agonist bursts during the acceleration phase of the movement
- Reduction of the magnitude of the antagonist burst
Describe forced exercise
- A mode of aerobic exercise in which the exercise rate is mechanically augmented to assist the participant in achieving & maintaining an exercise rate that is greater than their preferred voluntary rate of exercise
- Mechanically augmented cycling
- Bodyweight supported treadmill training
Proposed mechanisms for effects of forced exercises
- Faster pedaling rates increase afferent input from muscle spindles & GTO’ which triggers increased release of neurotrophic factors & NTs
- Activation of proprioceptors may improve sensorimotor integration leading to improved kinesthesia & decreased bradykinesia
- Improvements in motor Sx with forced exercise are not seen with voluntary exercise at a self selected pace even though HR, power, & MET’s are higher
What are the benefits of forced exercise
- Global improvement in motor function for pts with PD
- Supports angiogenesis and synaptogenesis, increases defense from oxidative stress, and improves mitochondrial performance
- Increased cortical and subcortical activation (thalamocortical pathways)
- Increases neurotrophic proteins
- Enhanced UE function with LE intervention supports theory of improved neural drive with forced exercise
- Evidence for improved cognition, learning, & memory
What is rhythmic auditory stimulation (RAS)
- Directly stimulates the neural circuitry that controls movement to activate our mechanism of action
- Entrainment: a neurologic process in which the auditory & motor systems of the brain are coupled due to an external rhythmic cue
- Entrainment over time can both enhance neuroplasticity & cause neuroplastic changes that produce improved motor outcomes
