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THINK BIG!EXERCISES FOR
INDIVIDUALS WITH PARKINSON’S
DISEASEBetty MacNeill, PT, DPT
January 2013 SED Meeting
PRESENTATIO
N
OBJECTIVES
Identify the symptoms of Parkinson’s disease (PD) that benefit from exercise interventions
Identify both traditional and non-traditional therapeutic models for managing the symptoms of PD
Define and discuss the basic philosophy associated with the LSVT-BIG intervention model
Identify and discuss the 4 fundamental treatment concepts of the LSVT-BIG model
Describe the basic exercise protocols associated with LSVT-BIG and provide a rationale for each
Develop confidence in applying some LSVT-BIG techniques and principles with selected patient populations
PATHOPHYSIOLOGY/ETIOLOGY
Pathophys: Loss of dopanergic cells in the substantia nigra leads to a deficiency in dopamine for use by the communication pathways in the
basal ganglia, which are critical to producing normal movement and postural control, and
neural circuits to the frontal lobe, which are critical for mental processing, motor planning, and personality.
PARKINSON’S DISEASEClassical Clinical Features =
TRAP•Tremor, resting•Rigidity, cogwheel•Akinesia, bradykinesia•Postural Instability
COMPREHENSIVE LIST OF SYMPTOMS IS MUCH MORE HELPFUL FOR
UNDERSTANDING THE FULL SPECTRUM OF THE CHALLENGES FACED BY
INDIVIDUALS WITH IPD See handout for further explanations Motor symptoms (in addition to the 4 Cardinal Signs of PD):
Micrographia, Speech difficulties, Lessened facial expression & smiling, Swallowing difficulties, Decreased blinking and the appearance of staring, Low back pain or ache accompanied by poor posture, Cramps or a burning sensation in thighs or legs, Lack of arm swing on the affected side, Episodes of feeling "stuck in place" when initiating a step (so called "freezing"), Slight foot drag on one or both sides
Non-motor symptoms: Loss of smell, Feelings of hot or cold, excessive sweating, oily skin,
increased dandruff, Sleep Disturbances, Depression and/or anxiety, Decreased “executive function”, Dementia, characterized particularly by decreased memory for recent events
STAGES OF DISEASE PROGRESSION Modified Hoehn and Yahr Staging
Stage 0 = No signs of diseaseStage 1 = Unilateral diseaseStage 1.5 = Unilateral plus axial involvementStage 2 = Bilateral disease without
impairment of balanceStage 2.5 = Mild bilateral disease with
recovery on “pull test”Stage 3 = Mild to moderate bilateral disease;
some postural instability; physically independent
Stage 4 = Moderate to severe bilateral disease; frequent loss of balance; 50% physically dependent
Stage 5 = Non-ambulatory; 80-100% dependent for ADL’s
Who should exercise? How much exercise? Which symptoms and/or movement
challenges are affected by exercise (if any)?
Exercise Considerations
PHYSICAL THERAPY MANAGEMENT – EXERCISE CONSIDERATIONS
General guidelines do not differ much from those applied to other patient diagnoses. Make decisions for treatment interventions based on: Impairments, functional limitations, and disabilities
Also consider for patients with IPD: Timing of optimal effect of medications On/Off phenomena (Clinical fluctuation) Unique characteristics of postural and gait
disturbances Effects of aging Concurrent pathologies
PHYSICAL THERAPY MANAGEMENT – SUMMARY OF HANDOUT RE: EXERCISE MODELS
Many different and effective models are available for helping patients with PD exercise
For best results, the patient must exert an “effort” and be motivated to perform multiple repetitions on a daily basis
Marketing “Exercise as Medicine” is a good way to encourage patient involvement and explain the neuroprotective qualities of adequate exercise
Emphasis for tonight, however, is on the LSVT-BIG Model for Intervention
WHAT IS “LSVT* – BIG”? Definition: Intensive amplitude-based exercise
program for limb motor system Background: Founded upon the principles of LSVT* -
LOUD , which is an intensive amplitude-based exercise program for speech motor system
Main premise: With exaggerated exercise movements, the patient will learn to use their bigger movements automatically in everyday life Better posture Better flexibility Better movements Better balance
*LSVT = Lee Silverman Voice Therapy (www.LSVTglobal.com)
LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS
1. Emphasis on AMPLITUDE is first2. SENSORY Calibration is second aspect3. The exercise program must be INTENSIVE
a. High physical and mental effortb. Dosage/repetition/difficulty
4. Quantification/Empowerment is necessary for follow through
LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTSAMPLITUDE
Defined as the largest range of motion that can be performed with the highest effort with the most
maximally efficient biomechanics every trial / every day
Patients must be approached with high expectations on a regular basis.
Requires vigilance from clinician and patient
LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS
SENSORY CALIBRATION OR RETRAINING
Defined as the process of teaching the patient to self-monitor and to accept that what feels “too big” is really WNL
Important for therapists to give feedback about normalcy
Calibration is at the heart of the matter: Retrain faulty sensory perceptions Establish new associations between effort
and normal movement Create new motor memories (BIGGER plans)
LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS
INTENSIVE EFFORT
Full exercise program has a standardized protocol Prescribed dosage and method of delivery include:
a. Frequency: 16 1-hr individual sessions; 4x/week
b. Duration: 4 weeksc. Strength: High effort
Practice and repetition are essential ingredients to provide the neural protection and up-training benefits
LSVT-BIG FUNDAMENTAL TREATMENT CONCEPTS
QUANTIFICATION/EMPOWERMENT
Key is to motivate patient with feedback, because the expectation is that individuals with PD can get better!!!!
REQUIREMENTS: 1) Push the patient to generate high effort2) Reinforce! Motivate!3) Empower with potential4) Document outcomes
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSIONFEEDBACK GUIDELINES FOR THERAPISTS
DRIVE BIG EFFORT: Best model for teaching – “Do what I do” (minimizes cognitive load)
SHAPE: Optimize alignment first through tactile, visual, auditory, and proprioceptive cues
STABILIZE WITH FEEDBACK: Reinforce, practice and motivate the individual’s own actions. Patients with PD need more reinforcement/motivation than others
CALIBRATE: Retrain sensory perceptions – effort must feel BIG in order to look NORMAL
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION
SHOULD BE 50-60 MINUTES PER DAY
I. MAXIMAL DAILY EXERCISES1. Multidirectional Sustained Movements (2)2. Multidirectional Repetitive Movements (5)3. Functional Movements (1-5 depending on
patient)
II. HIERARCHY TASKS (Includes ADL’s)
III. CARRYOVER ASSIGNMENTS
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSIONDEMONSTRATION/PRACTICE ACTIVITIES
I. MAXIMAL DAILY EXERCISES 1. Multidirectional Sustained Movements (2)
Purpose of Exercises: Sustained muscle activation and active stretching.
A. Floor to ceiling stretch in sitting
B. Side to Side stretch in sitting
NOTE: 10-20 secs. would be the average sustained time. A “hand flick” can be added when the patient is able to sustain the position achieved.
EXAMPLES OF “MULTIDIRECTIONAL SUSTAINED MOVEMENTS” WITH AN EXERCISE GROUP
End position for the“floor to ceiling” stretch in sitting
“Side-to-side” stretch with modification
of hand placements
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSIONDEMONSTRATION/PRACTICE ACTIVITIES
I. MAXIMAL DAILY EXERCISES2. Multidirectional Repetitive Movements (5)
Purpose of these exercises: Differentiating starting and stoppingChanging directionsSequential enduranceBalanceStrengthening
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSIONDEMONSTRATION/PRACTICE ACTIVITIES
I. MAXIMAL DAILY EXERCISES2. Multidirectional Repetitive Movements
(5) A. Step and Reach (3)
1) Forwards2) Sidewards3) Backwards
B. Rock and Reach (2)4) Forward / Backward5) Side to side
EXAMPLES OF “MULTIDIRECTIONAL REPETITIVE MOVEMENTS” WITH EXERCISE
GROUP
Forward Stepand Reach
Sidewards Step & Reach
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION
ADDITIONAL DAILY ACTIVITIES
II. HIERARCHY TASKS (Includes ADL’s)Purpose of exercises/tasks:
Overlearn familiar commonly-used and salient everyday movementsReminder for BIG movements at homeEncourages compliance and carryoverRequires task analysis for maximal benefit
Rolling Sit to Stand Walk & Turn
Everyone needs these, but there is some flexibility associated with personal choice
Other Examples:
Floor to StandGetting out of bedSit & reachStand & reach Walk & reachStand & turn
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSIONADDITIONAL DAILY ACTIVITIESHIERARCHY TASKS:
LSVT-BIG OVERVIEW OF DAILY EXERCISE SESSION
ADDITIONAL DAILY ACTIVITIES
III. CARRYOVER ASSIGNMENTSWhat are they? Assignments the PT
man-dates to implement “bigness” into real life. They must fit into the patient’s daily living activities for that day, so they change on a regular basis.
Examples:
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