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HELP PD is a unique exercise protocol designed to delay mobility losses in Parkinson ’s disease. Developed at OHSU’s Neurological Sciences Institute by Dr. Fay Horak and her team of researchers, including lead trainer, Sue Scott, MS. HELP PD uses 6 specific physical activities (parts of Tai chi, Kayaking, Pilates, Lunges and obstacle courses) to target 5 key mobility constraints of PD: rigidity, freezing, bradykinesis, poor coordination and sensory integration. This program was presented for the International Council for Active Aging, ICAA, in December 2009
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HELP PD - Pd specific agility training compressed pictures
- 1. Research: A unique way to share your story Renewable Fitness & ABLE Bodies
- 2. Tough Love vs Spanking Renewable Fitness & ABLE Bodies
- 3. Parkinson’s-Specific Agility Training Sue Scott, MS Renewable Fitness
- 5. Select, initiate & maintain movement
- 8. Multi-taskingRenewable Fitness & ABLE Bodies
- 10. Laurie A King, PT, PhD
- 11. Researchers
- 13. Three PD-focused PhD
- 16. Medications don’t help reduce fallsRenewable Fitness & ABLE Bodies Falls are Leading Cause of Death
- 19. Flexibility
- 20. Social Ties
- 22. Compensation
- 23. Neuroprotection3 Renewable Fitness & ABLE Bodies
- 27. Back pain, stiffness
- 30. “Useful tricks”
- 31. External cues
- 34. Break down task into parts
- 35. Mental rehearsal
- 36. Think BIG
- 37. Use alternative parts of the brainRenewable Fitness & ABLE Bodies
- 41. Increase brain plasticity Start exercise early in PD to PROTECT & PRESERVE neurons and function Renewable Fitness & ABLE Bodies
- 44. Balance & Agility training vs: Strengthor Aerobic
- 45. Larger improvements in motor function
- 46. More new synapses Renewable Fitness & ABLE Bodies
- 47. Task Specific AgilityTraining for Rats Sensori-motor Tasks Largely controlled by basal ganglia Renewable Fitness & ABLE Bodies
- 49. Walking speed
- 50. Stride Length
- 51. Improved
- 52. Flexibility
- 53. Strength & Mobility
- 55. Quality of life
- 56. Reduced
- 57. Medications
- 58. FallsRenewable Fitness & ABLE Bodies
- 59. What type of exercise is best for PD? Lance Armstrong (Endurance)? Muhammad Ali (Agility, quickness/power)? Arnold Schwarzenegger (Strength)? Guru? (Tai Chi, Yoga, Pilates) Renewable Fitness & ABLE Bodies
- 60. EXERCISE IS MEDICINE Active Ingredient: Mode Strength: Intensity How often: Frequency How long: Duration Renewable Fitness & ABLE Bodies
- 61. Exercise can target . . . Mobility Constraints of PD Physical Activities/Challenges Improve specific problems with mobility Renewable Fitness & ABLE Bodies
- 63. Brady- & hypo-kinesia- Slow, small movements
- 64. Freezing -Initiating movement
- 65. Coordination - Turning, rolling, quick switching
- 66. Sensory Integration - Coordinate sensory input
- 67. Executive function – Tasks & attentionRenewable Fitness & ABLE Bodies
- 68. RIGIDITY Characteristics – increased muscle tone, stiffness High tonic background activity (flexors) Co contraction (axial muscles) Results/Symptoms Joint pain, stiffness Flexed Posture Lack of trunk rotation Vertebral flexibility, ROM Difficulty turning while walking, rolling over in bed Enbloc movement Renewable Fitness & ABLE Bodies
- 69. Strategies to HELP Rigidity Large, flowing moves Spinal suppleness Lengthen flexors Strengthen extensors Somatic self-awareness Practice difficult transitions Tai chi Pilates/yoga Think BIG Reciprocal, Whole-Body Movement Lunges Renewable Fitness & ABLE Bodies
- 70. BRADYKINESIA Slow, small, weak movements/responses Inefficient muscle recruitment patterns Reduced postural stability Gait Weak push-off Delayed, reduced lift-height of swing limb Small stride length, slowed turning Multi-joint reaching, absent arm swings Not improved by medications Renewable Fitness & ABLE Bodies
- 72. Self initiated & paced
- 73. Get their imaginations to help
- 74. Go BIG, rehearse
- 75. Require postural control & adjustments
- 76. Voluntary, reactive, anticipatory, quick
- 77. Practice large protective steps
- 78. Lunges, boxingRenewable Fitness & ABLE Bodies
- 81. Crowded rooms, doorwaysRenewable Fitness & ABLE Bodies
- 83. Obstacle Courses
- 84. Quick turns, negotiating narrow or tight spaces – corners or near walls
- 85. Ducking , stepping over obstacles
- 86. Picking up objects while walking
- 87. Quick changes in directions and foot placementWith permission: ABLE Bodies Balance Training, 2008; Human Kinetics
- 88. SEQUENTIAL COORDINATION Characteristics Selection & sequencing Inflexible program selection Difficulties/symptoms Complex motor actions Postural transitions New and challenging environments Not improved by dopamine replacement
- 90. Whole Body Multi-segmental
- 91. Quick selectionRenewable Fitness & ABLE Bodies HELP for Sequential Coordination
- 93. Associated w/Bradykinesia –o/estimation of motion
- 94. Poor use of proprioception
- 95. Decreased perception of movement
- 96. Overdependence on visionRenewable Fitness & ABLE Bodies
- 97. Strategies for Better SI Reduce visual input Wear dark sun glasses No-body glasses Dim room, slightly Use variety of surfaces Reduce external feedback & cues With permission: ABLE Bodies Balance Training, 2008; Human Kinetics With permission: ABLE Bodies Balance Training, 2008; Human Kinetics
- 98. External Cues Use initially, then limit As disease progresses, use again Renewable Fitness & ABLE Bodies
- 99. COGNITIVE CONSTRAINTS Characteristics & Symptoms Multi-tasking difficult High stress Increased fall risk Renewable Fitness & ABLE Bodies
- 100. PD Affects Automaticity of Balance Control Doing Math Increases Falls During Balance Disturbances 40 No math Math 30 % of Trials with Falls 20 No Falls 10 0 CONTROLS PARKS ON PARKS OFF Used with permission; Presented at the Movement Disorders Conference in Paris June 7-11, 2009: We-215. Effect of cognitive dual-task on balance in Parkinson’s disease, R.M. Allen, P. Carlson-Kuhta, J.V. Jacobs, J.G. Nutt, F.B. Horak.
- 101. Cognitive Strategy:Dual Tasks Addition of a second task Dual tasks improve Attention skills Automatic Balance With permission: ABLE Bodies Balance Training, 2008; Human Kinetics Renewable Fitness & ABLE Bodies
- 102. Order of Difficulty Verbal Tasks Engage in conversation Easy recitation Motor Tasks Balance something on a tray Toss/catch a ball Pick up object from the floor in passing Cognitive Tasks Word Winks/Tongue Twisters Math Alphabetize words, order numbers Renewable Fitness & ABLE Bodies
- 104. Basal ganglia Neural plasticity protection Renewable Fitness & ABLE Bodies
- 105. Renewable Fitness & ABLE Bodies
- 106. Renewable Fitness & ABLE Bodies Assembly Required
- 107. HELP PD Rx for Agility Tai Chi Kayaking Boxing Lunges Obstacle Courses Pilates & misc. Renewable Fitness & ABLE Bodies
- 108. Research Big, flowing, sequential Coordinated, multi-segmental (upper/lower) Weight shifts in multiple directions Sensory integration Mindful of movement, breath, body Upright posture Renewable Fitness & ABLE Bodies TAI CHI Prayer Wheel Cat Walking Cloud Hands Repulsing the Monkey
- 109. KAYAKING BIG, flowing, reciprocal, multi-segmental, whole body Axial mobility, rigidity Pictures with permission: ABLE Bodies Balance Training, 2008; Human Kinetics
- 111. Quick task changes
- 112. Plan ahead, manage obstacles, decisions
- 113. Multiple directions, environments
- 114. Practice difficult situationsRenewable Fitness & ABLE Bodies
- 115. BOXING Jab, Cross Hook Ducking Footwork Kicks Shouting! Float like a butterfly . . . Sting like a bee! Quick, light, powerful, flexible, sequential, BIG, endurance, backward walking, mental agility, Renewable Fitness & ABLE Bodies
- 116. Lunges BIG, flowing, multi- directional Reciprocal arms, legs Vary direction, size, speed, environment, Trunk rotation In-Place Walking Corrective With permission: ABLE Bodies Balance Training, 2008; Human Kinetics With permission: ABLE Bodies Balance Training, 2008; Human Kinetics Renewable Fitness & ABLE Bodies
- 117. BIG Lunges Multiple directionsCoordinate legs/arms
- 118. Arm SwingsReciprocal limb motion around spine Pictures with permission: ABLE Bodies Balance Training; 2008; Human Kinetics
- 119. Pilates, misc. Develop: Extensor Strength Spinal Suppleness Somatic awareness, breathing, relaxation Transitional skills (ADLs) From: Low Back Disorders; Stuart McGill; Human Kinetics, 2007
- 120. Extensor (Axial)Strength & Length Bridges Bird Dog Heel Slides Paddle arms Pilates Plus; Alan Herdman From: Low Back Disorders; Stuart McGill; Human Kinetics, 2007 ABLE Bodies Balance Training
- 121. Spinal Suppleness Knee rolling & Cossack arms Telescoping Arms Cat & Camel & Shell pose Thread the Needle Undulate, Undulate! Renewable Fitness & ABLE Bodies
- 122. Practice difficult ADLs Chair Stands Half kneeling to stand Get up from floor Rolling on floor
- 124. Increase complexityRenewable Fitness & ABLE Bodies The BIG Six
- 125. Attention Training My pizza is cold 4 31 19 7 T__ L__ S__ B__ __ F__V __G __R Renewable Fitness . . .imagine the possibilities
- 126. Word Winks:Mental Agility T T T T Think Renewable Fitness . . .imagine the possibilities
- 127. Word Winks fry fry Renewable Fitness . . .imagine the possibilities
- 128. Tongue Twisters What noise annoys an oyster most? Noisy noise annoys an oyster most (Google has bazillions of ideas) Require concentration Help diminishing verbal skills - BIG enunciations, loud voice Renewable Fitness . . .imagine the possibilities
- 129. Other ways to assembleHELP PD strategies Renewable Fitness & ABLE Bodies
- 130. Strength Training Focus on Extensors Stretch Flexors Upper/Lower body Think BIG Functional Renewable Fitness . . .imagine the possibilities
- 131. Endurance Training Safely make it more PD-Specific? Involve more balance Elliptical, treadmill vs: recumbent bike Changes in direction, environment, surface, tasks Go BIG! – try trekking poles Mix it up, variety Renewable Fitness . . .imagine the possibilities
- 132. Community Programs Pilates Tai Chi Yoga Aerobics Dance Martial Arts Others (Zumba Gold is Big, quick, imaginative & fun) Renewable Fitness . . .imagine the possibilities
- 133. As PD Progresses . . .make changes All stages: Flexibility, postural alignment, BIG movements, deep breathing, kinesthesia, mind body connections Early: Sports—physical & mental agility, stamina, strength (neuroprotective) Later: Walking, transitions, useful tricks, external cues, fall prevention Renewable Fitness & ABLE Bodies
- 135. Musculoskeletal Injuries: Rigidity, difficulty initiating movementRenewable Fitness & ABLE Bodies
- 136. BIG, Flexible, Reciprocal, Sequential Self initiated, Self paced Upright & Supple Posture Mind-Body Connections Sensory Integration Arm and leg coordination Quickness Endurance Renewable Fitness & ABLE Bodies Strategies for basal ganglia and neuroplasticity
- 139. Neuro-plasticity
- 140. Increase number of synapses
- 141. Cell proliferation?Prevent falls Reduce cardiovascular events Improve, motor function Maintain quality of life, social ties, independence, connections to community, Renewable Fitness & ABLE Bodies . . . Imagine the Possibilities
- 142. What’s the Best Exercise? The one they’ll do! Renewable Fitness & ABLE Bodies
- 143. Sue Scott email RenewableFitness@comcast.net Ph: 503-720-9161 Physical Therapy April 2009; v89:4 Active Aging Today January 2010 I think my work here is done Thank You!
- 144. Parkinson's Disease Upright posture requires good kinesthesia Stooped posture reduces stability Upright Control Strengthen Extensors Lengthen Flexors Hip Extensors (back/hip) Hip Flexor (Abs) Knee Extensor (Quad) Knee Flexor (Hamstring) Ankle Flexor (Tib) Ankle Extensors (Calf)
- 145. Strength & Endurance w/ Dual Task Renewable Fitness & ABLE Bodies
- 146. Exercise preserves neural function Neuroprotective . . . Can exercise slow progression? More Function/ Neurons Improved function! NoExercise Less Years after Diagnosis Renewable Fitness & ABLE Bodies
- 147. Spinal Rotation Gentle, lithe rotation along long axisof spine Renewable Fitness & ABLE Bodies
- 149. Reduces depression and apathy
- 152. How intense and often?
- 153. How long does it last when you stop?
- 154. Does it reduce the rate of decline?
- 155. Who would benefit the most? Both young and older benefit Start: The earlier the better Renewable Fitness & ABLE Bodies
- 156. Renewable Fitness & ABLE Bodies
Notas do Editor
- In today’s workshop we’ll discuss multi-tasking and attention training. Part of attention training, trains individuals to be able to effectively switch between two tasks. Here’s a story about a mom, who like most moms, excels in multitasking. She is trying to raise kids without spanking. Her tactic, you’ll notice requires her to switch attention between the road and her child. Let’s see how she does it.Tough Love vs. Spanking - Good Argument Most of the American populace thinks it improper to spank children, so I have tried other methods to control my kids when they have one of 'those moments.' One that I found effective is for me to just take the child for a car ride and talk. Some say it's the vibration from the car, others say it's the time away from any distractions such as TV, Video Games, Computer, IPod, etc. Either way, my kids usually calm down and stop misbehaving after our car ride together. Eye to eye contact helps a lot too. I've included a photo below of one of my sessions with my son, in case you would like to use the technique. Sincerely,Your Friend
- PD is a degenerative disorder of the CN that often impairs the sufferer’s motor, speech and other functionsSecond most common neurodegenerative disease after Alzheimer'sNormally develops after age of 50 – only 15% of cases under 40Progression may take 20 years, but is not predictableMost causes are idiopathictoxicity, head traumaSometimes accompanied by dementia, Lewy bodies, Prevalence1 million US, 4-6 million world wide; 120-180 of 100,000 Amish even higher at 970/100,000 World’s highest – Nebraska 407Parsi community in Mumbai 328 –Aspand seeds MAO inhibitors -long term use -opposite effect United state 13-20/100,000 .5-1% in 65-69; 1 in 20 people over 80Occupation Welders Physicians, dentists, lawyers, scientists, teachers computer programmers – younger ages of onsetNotable sufferers:Michael J Fox, Vincent PriceMuhammad AliEugene O'Neill, Salvador DaliPope John Paul II, Billy GramJanet Reno, YasirArifatPierre Trudeau –Canadian Prime MinisterAdolf Hitler
- Collection of cell bodies (gray matter) base of brainStructures includeThalamas, Putamen,globuspalidus, Caudate nucleus substantianigra,AmygdalaAs these cell bodies began to function less effectively, atrophy and die these Continuous feedback loop -between basal ganglia and motor cortexcontribute to balance and gait by contributing to Automaticity of balance and postural transitions, Selecting and quicklychanging motor programs when environmental conditions change, sequencing complex actions, multi-segmental coordination self-initiated and pacing of gait and other transitionsSensory Integration –ongoing evaluation of environmental cues, contexts & proprioceptive information for kinesthesia Multi-tasking – Directing attention between tasksability to maintain safe mobility during multiple motor and cognitive task
- The expertise that contributed to the program includes internationally recognized neurologist specializing in movement disorders for more 35 years and 5 physical therapists experienced in treating people with PD, including 3 with PD-focusedPhDsSix certified athletic trainers who regularly work with people with PD also were helpful in designing the program.
- Sue Scott, BS MSIn 2003 developed AB. The mission of AB Techniques to help individuals live more active lives connected to the values and communities. make this information available to otherSignificant improve balance, strength, flexibility and everyday activity.
- Falls are leading cause of death among individuals PDPostural instability is caused by impaired central cortical drivePeople with PD have difficulties w/ reactive & voluntary movement selecting, initiating , executing failure of postural reflexes Rigidity, stiffness & joint pain Impaired kinesthesia Sensory integration poor cognitive function orthostatic hypotension Individuals with PD fall 5x age match; 38% fall 18% fractureMany modes of exercise, including strength, aerobic and agility training, all are shown to help people avoid falls Medications don’t help with many of the inevitable,anticipated problems that lead to fallsSome aspects of PD are made it worse: (kinesia – poor use of proprioception and decreased perception of movement) BP med make us dizzy, tired, spacydyskinesia experienced by some on PD meds is sometimes worse Why do we fall? It’s commonly reasons like freezing. .Thenthey lose their balance. Exercise reduces falls and fractures. Finding the most effective kinds of exercise is an attractive option. if exercise is a promising rehabilitative therapy . . . What’s the best exercise?
- Immobility that follows sedentary life impairs heart, muscles, social relations, independence leads to increased falls, fractures and decreased balance confidence and disabilityRegular exercise, especially exercise that we enjoy . . . . is easier to stick with AND . . .ImprovesCV System & EnduranceStrength & Balance Flexibility AttitudeSocial Ties
- Understanding the gears/mechanisms/catalist that drive these change is part of what moves research forward.There appear to be 3 main onePreventionCompensationNeuro-protection
- Like an apple a day keeps the doctor away . . . exercise is preventative medicine. . . exercise can help prevent/ameliorate some inevitable problems of PD, includingFalls, cardiovascular events, mobility disability, Back pain, stiffness,fatigue, apathy, inactivity, depression Exercise is just plain good for us all, PD aside.
- Compensation – physically, mentally, through education and understanding and working with others we get wiser, smarterabout handling PdImproved Motor function . . . Activities that practice difficult motor patterns, improveendurance, flexibility,strength, balance and balance confidence also results insequential coordination - upper/lower body– arm swingsautomatic balance control, sensory integrationWe compensate better because we are more able, capable Useful tricks learned from experience, from PT and trainers, PD patients learn useful tricks – External cues: - help w us anticipate, prepare for movementVisual targets - using lines, marks on floor or in environment, Rose –vertical lines help us stay upright Mirrors Sound, vibration - Rhythm music – anticipate movementsomatic cues - light touch Cognitive strategiesBreak down tasks into partsJohn ARGUE recent workshops stress this technique.He has a term for phenomenon that PD patients display with multitasking. Cascading eventsImprove parts having trouble with – Task Specific training – supported by literatureLeaning left to turn rightMental rehearsalsThink BIG based on research by Becky FarleyUsing other parts of the brain when basal ganglia begin to degenerate is a whole other compensatory process.Dorsolateral Prefrontal Cortex Instead of Supplementary Motor Cortex Neuro-plasticity – the brain changes it’s behavior, function as it adapts to the loss of bg.
- New findings suggest that an intense exercise can drive neuro plasticity and neural protection in ways that are protective against neural degeneration. Changes in how the brain function, how the brain behaves - neuroplasticityTheory and now research shows Chronic exercise [in animals and humans] may reverse motor deficits by changing brain function. Neuro-protection– improved efficiency of function slows neural degenerationincrease brain transmitters – dopamine synthesis and releaseReduction in cell death – Protection of dopaminergic cell bodies and terminalsImprove cell functionIncrease/facilitate/drives/develops brain plasticity – make new synaptic connectionsStarting early appears imperative
- Neural protection in animal studiesAbove & beyond the expected improvements in CV statusincrease in dopamine synthesis and releaseBetter motor function increased running speed & distance was a result of decreased cell death, preservation of cell bodies & terminals Conversely non-use of a limb, in casted rats resulted in increased motor deficits and losses of dopaminergic terminalsAgility- trained rats showed greater improvements in motor deficits Attributed to significantly greater number of new synaptic connections … neuroplasticityAnd in other studies Neurogenesis, cell proliferation, was demonstrated (8)
- Task-specific training drives neuroplasticity and greater improvements in motor skillsAGILITY TRAIING StudiesAgility training for PD rats is Task specific agility training (acrobatic, environmental enrichment type, high-beam balance courses that require changes in techniques - set switching, reprogramming of tasks) . . . Tasks that are largely sensori motor and controlled by basal ganglia
- In Human studies with both stroke and PD patients , show training, especially those aimed at singular impairments has been rehabilitative, including these debilitating mobility constraints of PD: Specifically: Improves some important kinematics of gaitWalking speed, step length, amplitude of movement, slow stepping,ImprovedFunctionDaily livingFlexibilityAxial mobility & supplenessStrengthIn part, via muscle activation patternsMobilityPostural transitions, compensatory steppingQuality of life ReducedFalls Medications Reduced medications- Levodopa efficacyFunctional abilitiesreduced decline in executive and visuospatial abilities,
- We go to the PD research: Most all of these can show improved quality of life; well tolerated reduces stressaerobic improves - cv function and protects neurons improves Levodopa efficacy, participants feeling less stressed, less fatigued and refreshed. strength training – function and balanceAgility training seems a good fit because mobility challenges facilitate basal ganglia preservation and neural plasticityThe very somatic training of the gurus in alternative exercises guru - Tai chi reduces falls improves balance; Pilates is length with strength, Yoga, tai chi, Pilates can improve strength, flexibility, self and kinesthetic awareness
- What is the Best exercise – Robert N Butler Dr., Pulitzer Prize winner, gerontologist, psychiatrist, head of the International Longevity Center (ILC) at the Mount Sinai Medical Center and medical editor-in-chief of "Geriatrics", a journal for primary care physicians, from 1986 to 2000.Ex is Rx medicine – exercise could be packaged into a pill.Its potential is maximized by our ability to use and apply it. What Active ingredient (mode) of a certain Dose (strength or intensity) frequency and duration (how often how long to take). Tenets of Ex Sc say the mode should be specific – similar to desired outcome, In terms an exercise prescription for PD I think we have a pretty good feel for mode and intensity. Mode–what specific kinds will work like Active ingredient to facilitate the changes we want. Neuro protection & plasticity, specific kinds of reduction in motor deficits to improve motor function – specifically to changemotor behavior mode of exercise – aerobic. – combinations of aerobic and agility -Perhaps better if therapist/trainer incorporate balance training, set switching, dual taskIntensity – provide challenge, overload AND be engaging? prescribed: duration, frequency
- What Fay began to ask:What then are specific targets exercise prescriptions should/can address for PD?In framing her answer, The long-term prognosis with PD is patients will begin to experience severe, progressive and debilitating sensori motor problems – mobility problems – they’ll losing the skills to get around safely – Her targets, her guidelines for selecting modes of exercises and other activities became the constraints of mobility that so badly hinder those with PDtraining may be the best match for ex activity to desired outcomeThe most effective exercise is designed to specifically target specific needs
- Most Common Anticipated & Debilitating Constraints of PD to mobilityRigidity High axial tone co contraction of agonists/antagonist flexed alignment of trunk Reduced trunk rotation reduced joint range of motion Brady KinesiaSlow, small movements Narrow base of support Lack of arm wingsFreezing: Poor anticipatory postural adjustments Abnormal mapping of body and movement Abnormal visual-spatial maps Divided attention affects mobilitySequential Coordination . . . inflexible program selection difficulty changing strategies quickly Poor rolling, turning, sit to stand, getting on off floorSensory integration . . . inaccurate without vision imbalance on unstable surfaces Poor alignment with environmentExecutive function quick switching, multitasking, attention deficits
- RIGIDITY: described as Joint Stiffness & increased muscle toneCharacteristicsHigh tonic background activity (v-dependent resistance to stretch), especially in flexorsresistance to passive movement 3-5x in agonist and antagonists muscle groupsCo contraction during movement and automatic postural responses (axial muscles)Antagonistic muscle activation is larger and occurs earlier, resulting in co activation of muscle group Lack of flexibilty and ROM in axial muscleResultsStiffness & Joint pain, – joint pain frequent initial manifestationFlexed PostureLack of trunk rotation Difficulty turning, rolling over in bed, turn while walkingEnbloc - Vertebral flexibility ROM – pelvis/shoulder girdleCervicalFemur/pelvisTo help - do things to increase mobility in spine
- BIG to increase amplitude of movementReciprocal movements reduce/limit co contraction/activationKayaking motions to increase rotation of shoulder/girdle over pelvis and pelvis/femur lunge walking – large flowing upright with arm swingsTai chiLithe, gentle, sequential, flowing, segmental flexibility,somatic self-awareness of alignment and posture to fight flexed posturefocus on breath body &movementPilates/yogaGentle lengthening flexors, strengthening extensorsaxial rotations, undulationsLarge, flowing movements Spinal mobility - suppleness, rom, better alignmentSelf-awareness for upright postural align during transitionsPractice difficult transitions – that have become difficult because of rigiditySelf awareness of upright postural alignment during transitionsPractice for difficult postural transition on and off floor, turning Spinal mobility suppleness in the spineLengthen flexorStrengthen extensor
- Bradykinesia –degeneration(loss or atrophy of nerve cells) in multiple areas of the brain, including the cerebral cortex and basal gangliaResults in difficulties planning, selecting, initiating and executing voluntary movement and reactive too. aSense of over-estimation of body motion result inSlow, small, weak movements and responsesReduced voluntary, anticipatory and reactive limits of stability (especially in backward direction)Inefficient muscle recruitment patternsElectromyograpic activity in bradykinetic muscles often is fractionated into multiple bursts and is not well scaled for changes in movement, distance or velocity. Caused by impaired central cortical drive Gait Delayed time to lift swing limb in gaitWeak push-off Reduced leg liftSmall stride length Lack of arm swing Slowed Turning, multi-joint reaching, single-joint movementNot improved by medications
- Because Bradykinesia is caused by impaired central neural drive dysfunction . . . cognitive or central strategies are effectivePut their minds to it in central whole body waysFacilitate/require/cajole self pacing self initiation Go BIG – Becky Farley – use their imaginationsSelf initiation, pacing as well as Amplitude & speed initiate selfpacing of arms/legs Train usingActivities that require quick postural adjustments anticipatory & reactive adjustments - like lunges and in boxingIs also helpful to Practice large protective steps, while tilting past their limits of stability. . . .Promote weight-shift control and postural adjustments during anticipatory, reactive & voluntary movement
- Movement hesitationDelay or complete inability to initiate a stepMajor contributor to fallsNot well understood – executive disorders – central neuralCharacterized by difficultiesShifts of attentionPreplanning movement strategiesQuickly selecting a correct central motor programPoorly understood
- Train in environments where freezing occurs –Doorways, obstacle courses with clutter and distractionLunge walking a reciprocal pattern through a doorway, from darkened hallway, floor surface changes
- Basal ganglia play an important role in INFLEXIBLE PROGRAM SELECTION task switching motor program selection and suppression of irrelevant information before executing an action. Delay between anticipatory adjustments and voluntary movementInflexible program selection and poor sequential coordination result in difficulties with:Coordination between body parts New and challenging environmentsPostural transitions turning, standing, rolling overSequencing complex motor actionsDopamine replacement does not improve inflexible program selection.
- Help for SI and Inflexible program selectionTai chi helps patients learn increasingly complex sequences of whole-body movement and to focus on smooth timing and synchronization multi-segmental movements. Lunges provide practice changing motor strategies during stopping, starting and changing direction, changing stepping limb and changing the size and placement of steps. Sequencingboxing actions into a remembered sequence practices quick selection and sequencing of complex motor programs - work on delay between anticipatory postural adjustments and voluntary movement
- In large part problems with SI in PD stem from impairment/dysfunction of the bg. basal ganglia are critical for high-level integration of somatosensory and visual information necessary to form an internal representation of the body and its relationship environment. Abnormal kinesthesia and use of proprioception. I.e.: examples of poor kinesthesia: PD patients showed impaired perception of arm position and movement and decreased response to vibration. Horak et al and Wright et al showed an impaired ability to detect rotation of a surface or the passive rotation of their torso AND that this poor kinesthesia was worsened by Levodopa medication. They have poor use of proprioceptive information and decreased perception of movement are associated with over-estimation of body motion (bradykinesia) and over-dependence on vision. Putamen ,globuspalidus Caudate nucleus Thalamas, substantianigra,Amygdala
- sensory cues, visual and somatic, and external feedback regarding quality and size of movement from the therapist should be used initially, but then progressively decreased as patients develop a more accurate internal sense of body position
- External cues are powerful and effectiveDevelop ability to self initiate, self paceAgility dots, tape or other marks on floor or walls MusicMirrorsLightsWulf’s book includes having subjects imagine their effect on the environment and imagining themselves doing Whole-skills action. Her research starts with the elite athlete concept of being in the zone and uses research to look at how we teach beginning skills to beginners. Quick read, great ideas, good research. You’ll come away with new ideas that will wow both you and your PD clients. John Argue’s new work – asks them to imagine their paths, before walking them
- The basal ganglia are responsible for automatic control of balance and gait and for switching attention between tasks. Adding a cognitive task, such as talking on a cell phone to a dynamic balance task, such as walking, is considered a fall risk predictor for elderly people. Similar multi-tasking is even more difficult and a greater fall risk for people with PD. One study of postural sway during quiet stance in individuals with PD and a history of falls, found that postural sway increased most whenever a cognitive task was added. The ability to carry out a secondary cognitive or motor task while walking or balancing is a critical element of mobility for people with PD. Executive function
- Dual task – the addition of a second taskwhile maintaining postural stabilityDual Tasks improve Attention skills automatic balance Walk and recite a rhyme Walk and juggle a ballWalk and talk/text on cell phone?Do Math?Being able to do two things at once is a vital mobility skill
- Verbal TasksCarry on conversationAnswer questionsEasy recitation – something they know wellMotor TasksToss/catch a ballBalance somethingPick up object from the floor in passingCognitive TasksWord WinksTongue TwistersAlphabetize words order numbersfunctional
- SummarizeConstraints – caused by impaired function of BG a Characteristics & Symptoms consequencesthose constraints have on mobility disabilityStrategies –Neuroprotective strategies – to help preserve function of bg and modify constraintsYou likely noticed a lot of Commonality among and between the constraints and the strategies to address them. We did too. Some strategies addressed more than one constraint making them more productiveA major commonality in constraints and strategies is role BG plays So we felt that our exercise solution should also in a major way address the role of the BG.Let’s take a look at that. . .
- Strategies – attributes: like BIG flowing, flexible, require planning, dual tasksTo address our constraintsBased on: Role of basal ganglia in motor deficitsPrinciples of neural plasticity and protectionConstraints of PDCombination of Mobility-specific tasksSingularly proven techniquesSystematic sensori motor challenges
- Physical activities drive the program. Selected are activities that are large, reciprocal, flowing. That involve whole-body CoMs in multiple directionsBut that are task/goal specific require planning, change and sensory integrationThat interact with cortical function are centrally driven . . . ie: self initiated, self-paced: In these ways drive neuroprotection and neuroplasticity.. The
- What’s a reasonable way to put all these elements together?
- These then are the exercise modes we selected because we felt they could best address constraints on mobility for individuals with PD. Tai ChiKayakingBoxing (Tennis)Lunges (fencing)Obstacle CoursesPilates, et alLooked at others Tennis, fencing,Our Pilates, etc section is a bit of a catch all with miscellaneous stuff Rx Intensity (strength or dose) : Challenging but safe details in perspective in Physical Therapy, April 2009Rx Frequency & duration: We’re testing this program using 60-75 min 3x each week approximately 10 minutes on each of the 6 activities
- Tai Chi chosen because Research – strong regarding balanceMovements are big, flowing Sequential, coordinated - upper and lower body coordinationWeight transfers in multiple directionsFreezing especially can be helped with tai chi because of its emphasis on completing weight shiftsPD patients have display small or incomplete weight shifts. This contributes to freezingmindfulness, helps with focus, awareness, sensory integration: awareness, breathing tied to movementDr. StrawberryGatts was instrumental in helping us with a selction of tai chi moves in multiple directions
- Complex big flowing movements whole body, multi-segmental, Aim is for axial mobility Shoulder Girdle o/pelvisPelvis o/femurReciprocalReciprocal movements help reduce co contraction, co activaton and rigidityRequires pacing and orderingUpright posture, supple spine shoulder girdle/pelvis & pelvis/femurSequential Add challenges for SI or dual tasksSeated, seated on disc, swivel chair, standing, moving, Can be combined with lunges
- Quick, fast, flexible motions Quick weight changes Multiple directions, changing environments Practice difficult situationsPlan ahead, manage obstacles, make decisionsChanges in speed, direction, size of stepsForward movementsHigh knees w/ upright posture–trunk rotation, try SkippingTire course – quick feetSideways movesLateral shuffleGrapevineLayer into these skillsFigure 8 pathways through cluttered, but safe, terrainPivot turns Into and out of corners, near wallsDuck under, step over obstacles
- Quickness powerLight, flexible movements in all directionsReactiveanticipatoryBackwards walking, Mental agility and planningTeach skills and patterns using basic movesJab, Cross, Hook, Ducking, KicksMove around the bag backwardsStay centered in their stanceTrunk rotation, arm and shoulder extensionShouting boom! Boom! Kick, cross! BIG
- Added to KayakingChanges in environment are tough for PD patientsCorners, doorways, darkened areas
- Coordination of arms and legsLunges w/reciprocal limb motion around spine
- Develop:Extensor Strength Spinal Suppleness &ROM, trunk rotationSomatic awareness, breathing, relaxationTransitional skills (ADLs)
- Spinal strength & length. all phases – high knees, tai chi, lunges boxing, kayaking Pilates includes exercises to strengthen back extensors & stretch spinal flexors Suppleness – help them achieve and maintain vertebral alignmentReciprocal movement <co contraction
- Spinal ROM cervical, cat and camel thread the needleHalf kneeling to standGet to floorRoll over - telescoping Cossack armGet up from floorHalf kneeling to standChair StandsBridging
- Available through speech therapy at OHSUSustainedAlternatingSelectivedividied
- What noise annoys an oyster most? Noisy noise annoys an oyster mostGoogleA tree-toad loved a she-toadWho lived up in a tree.He was a two-toed tree-toad,But a three-toed toad was she.The two-toed tree-toad tried to winThe three-toed she-toad's heart,For the two-toed tree-toad loved the groundThat the three-toed tree-toad trod.But the two-toed tree-toad tried in vain;He couldn't please her whim.From her tree-toad bower,With her three-toed power,The she-toad vetoed him
- You’ve likely already have heard many ideas
- Commonalities among strategies were also those that addressed the role of bg – Also common among strategies were techniques to facilitate Neural plasticity – ie learning, challengesAddresses role of basal ganglia- self initiated, self paced, setchanges, motor program, attention switching Addresses role of basal ganglia and principles for neuroplasticity -BIG, Flexible, Flowing whole-body, multiple directions self initiated/paced, set & program ∆s – agility, learning new tasksMind-Body Connections - Kinesthetic & sensory . Full breaths tied to movement. Dual Tasks. Useful tricks.Upright Posture Erect postureSpinal suppleness - axial rotation. Length, strength & suppleness. Arm and leg coordination -Reciprocal limb movements; trekking, lunges, walking, arm swingsQuick - Agility training, variety of tasksEndurance - Continuous, aerobic
- So in that context, they should enjoy exercise and physical activities as long, as much, as possible. Best way to stay active . . . Is to stay active But within that context, challenge them to add on what you learn here todayResearch with PD patients shows that mortality increases and longevity decreases for PD patients placed in w/ nursing home situations vs community dwelling
- Strength & EnduranceDual task: reading advertising saving gas lowering green house effects
- While its not been empirically proven, yet, Dr Horak and others believe that is the theory certainly is plausible and seems intuitive . this slidefrom Dr Horak’s lab. It suggests the kind of difference exercise may have on the progression PD and the inevitable problems associated with it.Preserves neural functionThe second one is free for you to use without reference.
- Knees roll to sideThread the needleCossack arms
- Prevents anticipated problems Prevents falls, improves balance and strength Keeps heart and lungs healthy Maintains posture and flexibility (back pain) Improves mobility and function Reduces depression and apathyMay slow disease progression . . . ?
- Inner sense of Awareness of where your body is and how it moves