Download PWR Up! Exercise for Brain Change for People with

PWR!
EXERCISE FOR BRAIN CHANGE FOR
PEOPLE WITH PARKINSON’S DISEASE
Terry Tatarian, PT
Samantha Klepper, PT, DPT
Elizabeth Dolan, PT, DPT
Integris Health
Jim Thorpe Rehabilitation
PWR = Parkinson Wellness Recovery
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Founded in 2010 by Becky Farley, PhD, MS, PT, who
has dedicated her PT career to working with people
with Parkinson’s Disease (PD)
Initially developed the “LSVT BIG” exercise
program
Later developed PWR! program using the “Exercise
for Brain Change” model
“We believe that people with
Parkinson’s disease can
get better and stay better with
exercise.”
-Becky Farley, CEO and Founder of PWR!
“Lack of activity destroys the
good condition of every human
being, while movement and
methodical physical exercise save
it and preserve it.”
-Plato
Integris PWR! Video
http://integrisrehabilitation.com/#/injt/tex
tFlowModule/generic_page,20053
Show the PWR! video to patients, families, and physicians
to help spread the word about our PWR! progam!
Great job, Liz!
Parkinson’s Disease: Definition
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Primarily a motor system disorder
Loss of dopamine-producing brain cells in the
substantia nigra (SN)
Dopamine is the chemical that relays information
from the SN to other parts of the brain to control
movements of the human body
Dopamine is necessary for coordinated movements
PD is a severe loss of dopamine-producing cells
(60-80%)
(NIH, 2012; NPR, 2012)
http://health-careforall.com/wp-content/uploads/2011/07/Parkinsons-disease.jpg
http://diseasespictures.com/wp-content/uploads/2012/11/Parkinsons-Disease-5.jpg
Parkinson’s Disease: Diagnosis
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Clinical diagnosis
Officially diagnosed when other diagnoses are
ruled out, by signs and symptoms, and if dopamine
replacement drugs are effective
MRI, CT, PET to rule out other disorders
Most common misdiagnosis is Essential Tremor
(NIH, 2012; NPR, 2012)
Parkinson’s Disease: Prevalence
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> 1 million people in US living with PD; 50,00060,000 new diagnoses each year
4-6 million worldwide
14th leading cause of death in US
Mean age of diagnosis = 62 years old
(NPR, 2012)
Parkinson’s Disease: Symptoms
Primary
Shaking, resting tremor, slowness of movement
(bradykinesia), stiffness or rigidity in trunk and
extremities, decreased balance, postural instability
Secondary
Small handwriting (micrographia), reduced arm swing,
foot drag, freezing, loss of facial expression
(hypomimia), low voice volume (hypophonia),
decreased reflexes
(NPR, 2012)
Typical Impairments
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Difficulty walking
Decreased balance
Loss of flexibility
Postural deviations
Loss of fine motor abilities
Decreased coordination
(NPR, 2012)
Non-Motor Symptoms Associated with
Parkinson’s Disease
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Loss of olfaction
Sleep difficulties
Cognitive impairments
Constipation
Bladder dysfunction
Sweating
Sexual dysfunction
Fatigue
Pain (limb)
Tingling
Lightheadedness
Anxiety
Depression
Medical Management of Parkinson’s
Disease
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Non-motor symptoms are highly treatable with
medication.
Most common medicine to treat PD is
Carbidopa/Levodopa.
The typical dosage is 25/100mg immediate
release.
This pill is usually yellow in color regardless of
manufacturer.
Medical Management continued
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If patients begin losing effectiveness of medications,
Deep Brain Stimulators (DBS) may be an option.
Signs of losing effectiveness of meds may include:
more hours with sx, delayed relief of sx, wearing
off between dosages/need to take more
frequently, and drug induced side effects.
DBS has shown to provide 5 additional hours of
good movement, improve quality of life, make
routine activities easier, and reduce medication use.
Key Principles of PWR!
Exercise as neuroprotection
 Inactivity as prodegenerative
 Exercise and neurorestoration
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“Forced use, task-specific, and intensive
exercise approaches.”
(Hirsch and Farley, 2009)
Intensive Amplitude-Specific Training
“normal amplitude use may enhance
activation of damaged pathways and slow
or halt their degradation…amplitudespecific approach is similar to ‘forced use’
paradigms in the treatment of strokerelated hemiparesis”
(Farley, et al, 2008)
PT Evaluation
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Comprehensive
Inquire how impairments personally affect
Ask about neurologist and medications; Proper
dosage? Regular visits?
Observe gait, posture, functional transitions? Low
amplitude movements?
Measure flexibility, ROM, strength, gait, balance by
using standardized outcome measures
Suggested Outcome Measures
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Tinetti Gait and
Balance
Timed Up and Go
90°-90° Hamstring
Flexibility
Sit and Reach
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ROM
MMT
Single Leg Balance
Functional Reach
Four Square Step
Berg Balance
Plan of Care
Comprehensive to address many impairments!
Exercises/activities should include cardiovascular,
strength, flexibility, balance, gait training, postural
correction, coordination, multi-tasking, fine
motor/gross motor movements, all BIG movements with
purpose and intent; incorporate PWR Moves with any
exercise.
Think “high intense, amplitude-specific” movements!
Billing & Reimbursement
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Common Charges:
 Gait
training, Therapeutic Exercise, Therapeutic Activity,
Neuro Re-education
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Remember to combine SLP and PT dollar amounts!
 Speak
Out! Program is 4x week x 4 weeks =$1136
 Add KX modifier when over $1900
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G-codes:
 Sections:
“Mobility & Moving Around” and “Changing &
Maintaining Body Position”
(APTA, 2013)
PWR Moves
Hands Reach
Rock
Twist
Walk
Up
Step
Flexibility
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Emphasize whole body
Yoga
Dynamic stretches
Static stretches
Hamstrings, hip adductors and flexors, trunk
extensors, shoulder adductors
Perform daily!
Twist, Reach, & Rock
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Twisting, reaching, and rocking improves trunk
mobility and flexibility while decreasing rigidity
Incorporate as much as possible with other exercises
Perform in sitting and standing
Can reach for objects or just perform movements
Examples: corner twist, cone reach, hula hoop,
kayak (use a cane, dowel rod, therapy bar)
Functional Transitions
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Supine > Sit
Sit > Stand
Rolling left/right
Supine/prone on floor > quadruped > kneeling >
standing
Perform several repetitions of each with big, powerful
movements!
Postural Correction
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Supine thoracic stretch on rolled towel or foam
roller
Corner/doorway stretch
Cervical/scapula retraction
Use mirror for visual feedback; back against wall
for tactile feedback
“Shoulders back, head up!”
Balance Exercises
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Single leg
Unstable surfaces (foam)
Eyes closed
Challenge balance while multi-tasking, i.e. ball toss,
math problems, speaking loud, in conjunction with
strength exercises
Products: Airex pad/beam, BOSU ball, Sportcat,
dynadisk, magnets, metronome
Gait Training/Stepping: PWR Walk
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Cueing to improve hip flexion/ankle dorsiflexion,
while maintaining posture and balance
Stepping: multidirectional steps, treadmill use for
incline and speed, sidestepping on treadmill,
cones/hurdles, on/off soft surfaces, up/down steps,
by verbal commands or by mirroring your steps
“Pick your feet up! ”
“Touch your heels first!”
Agility Activities
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Bungee resistance walk/jogging
Ladder drill
Hurdles/cones
Tai-Chi
Dancing
Ball dribble/bounce while walking
Towel/scarf toss
Fine Motor Activities
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Hand flicks
Scarf/towel toss and grasp
Purdue pegboard
Velcro board
Rubber bands
Digiflex
Grasping/manipulating small objects
Writing
Piano
Games (dominos, monopoly, cards)
What’s in the Future for Patients with
Parkinson’s Disease?
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Sx are highly variable.
Best way to combat a movement disorder is to
MOVE!
Similarly, moving aids with fighting depression,
fatigue, and sleep disorders.
Proper fitness, sleep, and nutrition along with
following your physician’s recommendations on
medications works to delay debilitating
complications.
Key Points
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Individualize treatment plan
Make plan comprehensive
Challenge patient
Involve family and encourage support groups, such
as the Parkinson Foundation
Encourage life long participation
BIG and PWR-ful !!!!!
PWR Up!
References/Resources
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American Physical Therapy Association. www.apta.org
Farley, B., Fox, C., Ramig, L., and McFarland, D. (2008). Intensive
amplitude-specific therapeutic approaches for Parkinson’s Disease:
Toward a neuroplasticity-principled rehabilitation model. Topics in
Geriatric Rehabilitation, 24(2), 99-114.
Hirsch, M. and Farley, B. (2009). Exercise and neuroplasticity in
persons living with Parkinson’s Disease. European Journal of Physical
and Rehabilitation Medicine, 45(2), 215-229.
National Institute of Health (NIH).
www.nih.gov/disorders/parkinsonsdisease
National Parkinson Foundation. www.parkinson.org
Oklahoma Parkinson Foundation. www.parkinsonoklahoma.com
Parkinson Wellness Recovery. www.pwr4life.org