Parkinsons - 2a PT management Flashcards
the majority of standardized tests recommended by the PD EDGE are in what domain
activity
which standardized tests recommended by the PD EDGE are in the participation domain (2)
PDQ-8 or 39
Parkinsons’ Fatigue Scale
- also activity measure
which standardized tests recommended by the PD EDGE are in the impairment domain (2)
MoCA
MDS-UPDRS
- also activity measure
what is the PD EDGE
group APTA formed to eval best standardized tests and measures for parkinsons’
what test is the gold standard for evaluating parkinsons
UPDRS
- unified parkinson’s disease rating scale
what does the UPDRS measure and what are its 6 sections
measures dz severity, progression, and effect of meds
6 sections of BSF & activity:
1. cognition
2. ADLs
3. motor exam
4. complications of therapy (SE of meds)
5. modified Hoehn and Yahr Scale
6. schwab and england ADL scale
what makes the UPDRS so comprehensive
sections and 5 and 6 are stand alone tools incorporated into test
what is the MDS-UPDRS and what are its 4 sections
movement disorders society UPDRS
- revised, condensed version of UPDRS
- non-motor aspects of experiences of daily living (nM-EDL)
- motor aspects of experiences of daily living (M-EDL)
- motor exam
- motor complications
what is the gold standard test specific to disease severity
hoehn & yahr scale
what are the 6 hoehn and yahr stages
0: no visible sx
1. PD sx unilateral
2: PD sx (B), no difficulty amb
3: PD sx (B), min difficulty amb
4: PD sx (B), mod diff amb
5: PD sx (B), unable to walk
what is a pull test
give someone forceful posterior perturbation & measure amt of steps to recover
(+) = >2 steps
(-) = recovers, only 1-2 steps
what is a concern w pts w a 3.0 on the modified Hoehn and Yahr scale
high risk for falls
- may need adaptive equipment
what is the modified hoehn and yahr scale
1.0: unilateral only
1.5: unilateral & axial
2.0: bilateral, balance is good
2.5: mild bilateral, (-) pull test
3.0: mild to mod bilateral, some postural instability, (I)
4.0: severe disability, able to walk/stand w ADs
5.0: wc bound or bedridden unless aided
what are 3 standardized tests to assess bradykinesia
10m walk test
9-hole peg test
5 xSTS test
what does the 10m walk test look at, what does it look like in parkinsons and what is the prompt you give pts w/o PD
looking at gait speed
walks at slower velocity
walk at preferred speed vs fastest
what is a predictor of falls in the 5xSTS test
16sec score predictor of falls in PD population
what standardized test is used to measure rigidity and how is this measured
UPDRS item 22
0 - absent
1 - slight
2 - mild to mod
3 - marked, full ROM easily
4 - severe, ROM difficult
what standardized test is used to measure resting tremor and how is this measured
UPDRS item 20
0 - absent
1 - slight/infrequent
2 - mild in amp, or mod but intermittently present
3 - mod amp and present most of time
4 - marked in amp, interferes w feeding/ADLs
what standardized test is used to measure dyskinesia and how is this measured
section IV of UPDRS
0 - non-existent
1 - mild
2 - present at rest, doesn’t interfere w activity
3 - mod, causes interference w activity
4 - severe
what is the most common reason we get a referral for someone w PD and what do we want to do ab this
falls
advocate for early referrals to dec risk of falls and progression of dz
at what point does postural instability usually present
middle stages of health condition
what type of balance test will be most challenging for people w PD and why
external perturbations
- d/t slow motor response
what are 5 standardized tests used to measure postural instability and what aspects do they each assess
- mini BESTest
- looks at subsystems of balance, very comprehensive - 5x STS
- internal perturbations - Pull Test
- external perturbations - FGA
- stability w amb
- focus on improving gait and balance - ABC Scale
- self report of confidence
- help pinpoint activities they feel most unstable to incorporate
what ABC Scale score is predictive of falls and what is the MDC in PD
69
MDC = 13
what are 3 ambulation standardized tests used and what do they each specifically assess
10m walk test
- gait speed, fall risk
6MWT - amb endurance
FGA
what is FGA score is a predictor of fall risk in PD? and what score is the MDC for PD?
</=18
MDC = 4
what are 6 additional domains to assess w standardized tests and what domain is a specifically emerging area for us
cog (OT, SLP)
sleep ***
depression (psych)
akinesia
fatigue
fear of falling
what is a standardized test for cog
MoCA
what is a standardized test for sleep
parkinson’s disease sleep scale (PDSS)
what are 2 standardized tests for depression
geriatric depression scale
beck depression inventory
what is a standardized test for akinesia
freezing of gait questionnaire
what is a standardized test for fatigue
parkinson’s fatigue scale
what is a standardized test for fear of falling
ABC scale
what is a standardized test to assess participation level
PDQ39
what is the PDQ39 and its 8 subscales
disease specific measure of quality of life
self-report questionnaire
8 subscales:
- mobility
- ADLs
- emotional well-being
- stigma
- social support
- cog
- communication
- bodily discomfort
how can stigma impact someone w PD’s participation level
stigma ab a sx (ex: drooling) can be embarrassing and lead to pt self-limiting activities
what are 10 BSF impairments to look at/for in clinical exam
strength
ROM
sensation
ms tone
tremor
dyskinesia
vestib function
pain
respiratory function
cardiac function
why is it important to assess if there is a strength impairment
won’t see impaired isolated ACOM or abnormal synergies bc corticospinal tracts are intact
what ROM impairments do you commonly see in PD
joint play
ms length
trunk rotation
what does impaired ROM often result from and lead to in PD
from rigidity
lead to developing flex posture w forward head, kyphotic posture, sedentary and sitting a lot
-> won’t see typical rotation and wt shift at trunk
at what point in the dz process do you see impaired sensation and why
common to be impaired later in dz process
- not primary impairment
- not direct result of PD
- often older adults from typical aging changes in sensation and neuropathy
what are 3 common sensation impairments
proprioception
light touch
kinesthesia
why can you see impaired vestibular function, how does it present, and how is this integrated into our PT interventions
w trunk rigidity, lack of mvmt overall, dec rotation of head and trunk -> lead to slower firing of CNVIII vestibular firing d/t lack of activation and moving of head that would trigger signals of vestibulocochlear nerve
see hypofunction where minimal mvmts of head will result in exaggerated responses
- important to encourage more head motion and turns
what are 2 common reasons for a pain impairment
dec ms length
rigidity
what are 2 ways that respiratory function is impaired and why
trunk rigidity and poor posture
-> dec chest expansion & vital capacity
what are 2 common cardiac function impairments and why? why are these especially relevant to PT interventions?
orthostasis
hemodynamic response
bc of deconditioning often
want to optimize CV health as much as possible bc common source of mortality in PD
what are 3 areas to assess in the activity level of the clinical exam
- balance, trunk control, endurance
- functional mobility
- rolling, scooting, sup to sit, STS, bed to chair, amb, dual task, stairs - ADLs
what is a mainstay of PT treatment for PD and why
external cueing (ie auditory, visual cues)
- can be very effective in initiation and keeping mvmts fluid
what was the traditional treatment paradigm for PT and how has this shifted today
compensate for paucity of mvmt by teaching behavioral and cog strategies to bypass BG circuits
shifted to encourage exercise in managing PD
when is environmental modifications introduced in PD
pushed off for awhile
why is exercise so heavily supported in managing parkinsons now
inc dopamine and other neurotrophins (BDNF) which support functioning of BG circuits and mvmts
what is the contemporary framework for PT in PD
start PT EARLY in dz process
- PT referral at time of dx
focus on primary impairments, and prevent secondary impairments
- “dental model”
what type of exercise does evidence support in PD
regular aerobic strongly supported
evidence for resistive strength training, stretching, and balance exercises also
what is the most common trigger for referral to PT
a fall
why might a group exercise class be a good option in PD
less isolating
dec stigma if PD exercise group
what are 9 PT interventions that there is strong evidence for
aerobic exercise
resistance training
balance training
external cueing
community based exercise
gait training
task specific training
behavior change approach
integrated care
recommendation for aerobic exercise and 3 reasons why
mod to high intensity
inc VO2
dec motor dz severity
improve functional outcomes
4 benefits to implementing resistance training
dec motor dz severity
improve strength & power
improve non-motor sx
improve function and QOL
5 benefits to implementing balance training
improve postural control
improve balance/gait
improve mobility
improve balance confidence
improve QOL
what PT intervention is there low quality of evidence for its implementation
flexibility exercises
3 benefits to implementing external cueing
dec motor dz severity
dec freezing of gait
improve gait outcomes
3 benefits to implementing community based exercise
dec motor dz severity
improve non-motor sx
improve function & QOL
5 benefits to implementing gait training
dec motor dz severity
improve stride length
improve gait speed
improve mobility
improve balance
benefit to implementing task specific training
improve task specific impairment levels and functional outcomes
benefit to implementing a behavior change approach
improve physical activity and QOL
benefit to implementing an integrated care approach
dec motor dz severity and improve QOL
what intervention was there moderate quality of evidence for and what was the recommendation
telerehabilitation
to improve balance
what was the statistically significant outcome of the SPARX Trial
significant difference b/w high intensity exercises (80%MHR) and controls
- only applicable to early stages
parameters for aerobic exercise in PD
3-5x/wk
duration: inc 20min -> 60min
(progress duration/freq before intensity)
mod intensity: 13 on RPE scale
- 60-80% MHR
mode: walking, cycling
- early stages overground
*during “on” cycle w meds
parameters for resistive exercise in PD
2-3x/wk w min of 1 rest day between training sessions
- can be same day as aerobic exercise training
1 to 3sets of 8-12reps
- rest each ms group 2-4min between sets
resistance of 40-80% of 1RM
modes: machines, free wts, elastic bands
what are 6 current trends in neurorehab
tai chi
kayak
boxing
agility course
pilates
boot camp
what does tai chi help to improve in PD (2)
anticipatory postural control
-> improves balance
improve bradykinesia thru emphasis on timing & fluidity and continuing mvmt pattern once initiated
what does kayaking help to improve in PD (3)
promote axial rotation
improve rigidity
address brady & hypokinesia
- inc speed and encourage faster/larger amp mvmts
what does boxing help to improve in PD (4)
internal/external perturbations
-> improve balance
improve akinesia of gait
axial rotation
counters brady and hypokinesia in UE
what does an agility course help with in PD (3)
direction changes, turns
improve sequential coordination
dec akinesia or freezing
what does pilates help with in PD (2)
strengthening
spinal ext and rotation
what does a boot camp for PD entail (4)
10min of each activity
- progress w dual/cog
- progress w wt/resistance
- progress by inc speed/amp
how to manage tremors: PT, equipment, meds
use mvmt to diminish tremor
- gesture, pass object from hand to hand
travel mugs w lids
half fill to avoid spills
adaptive spoons, pens
meds: MAOIs, DBS, ablation
what are PT interventions for rigidity and flexibility
focus on trunk and spine ms
PNF B UE D2 w DBE
hook lying LTR, counter rot
frequent position changes
rocking chair (parasym)
yoga & tai chi
kayaking
boxing
daily stretching
- low evidence but include
how do you structure PT management for bradykinesia and what is a primary example of an intervention
goal directed
high amp mvmts
multiple reps
LSVT-BIG
- 1hr 4x/wk for 4wks
what PD population does LSVT-BIG have the best outcomes
earlier stages of PD
what are 3 characteristics in PD does LSVT-BIG help improve
improve gait velocity
improve stride length
improve reaching velocity
what are 3 major factors associated w recurrent falls in PD
progressing PD
postural instability
cog impairment
what are characteristics that distinguish fallers from non-fallers
hx of falls
presence of FOG
preferred gait speed <1.1m/s
PT interventions to improve balance (strengthening, ROM, anticipatory/reactive, sensory input, gait) led to what significant outcomes
37% decline in fall rates in active phase
significant dec in fear of falling and improved balance (mini BESTest)
what evidence is available on Tai Chi and Qigong
low level evidence studies, don’t have a large scale RCT
definitely worth doing for anecdotal evidence if someone is interested
what are PT interventions for postural instability (7)
internal perturbations (proactive or anticipatory)
- wt shifts
- alt stances
- reaching
- axial rotation + reaching
- throwing/boxing
external perturbations (reactive)
- SR, RS to upper and lower trunk
- nudges
- catching balls
alter tasks, positions, environment
falls diary
environment changes
ADs
tai chi
what are 3 interventions to help w someone who has difficulty w direction changes
TUG
obstacle course
figure 8 pattern
what are 5 compensations in later stages of PD if the pt has difficulty w direction changes
avoid sharp turns
turn in large arc
attention/cog strategies
clock turn strategy
concentrate on high stepping
what are PT interventions and cueing to work on a STS (5)
part -> whole task training
mental rehearsal
proprioceptive cues
auditory cues
environmental modifications
what are PT interventions and strategies for improving rolling and bed mobility in PD (4)
part task, log-roll
wake up 30min early
- take meds
- HEP for AROM/stretching
mental rehearsal, imagery
environmental modifications
- bed rail, silk sheets or pjs
what are strategies for negotiating doorways (2)
vertical strip of colored tape thru doorway
visual spotting of object past the doorway
what are 2 types of cues and 4 examples of each to manage hypokinesia in gait
visual cues
- laser line walkers/canes
- theraband on walkder
- tape lines on floor
- pennies
behavioral cues
- postural alignment
- inc UE swing
- trunk rotation
- cadence
what are 3 PT interventions for akinesia or FOG and why does each work
rhythmic auditory stim (RAS)
- music, metronome, counting
cycling program
- external pacing cue of pedals
BWSTT, treadmill training
- inc gait speed
what are 5 benefits to group classes for someone w PD
educational component
social interaction/support
address impairment & activity
add music, make it fun
improved adherence rates
