parkinson's pt management

RECENT ADVANCES IN THE MANAGEMENT OF PARKINSON’S DISEASE

Rajin TandanMPT- nEuro

104/11/2023

04/11/2023

2

Definition:

Parkinsons disease is a chronic, progressive disease of the nervous system characterised by cardinal features of rigidity, bradykinesia, tremor, and postural instability.

- Physical rehab 5th edition by susan B, o’sullivan.

04/11/2023

3

Etiology:

The term PD is used to refer to a group of disorders that produce the abnormalities of BASAL GANGLIA function.

Idiopathic parkinsonism most common form.

Secondary parkinsonism caused by virus, toxins, drugs, tumors.

- Physical rehab 5th edition by susan B, o’sullivan.

04/11/2023

Pathophysiology:

4

The basal ganglia (BG) are a collection of

interconnected gray matter nuclear masses deep within

the brain.

Caudate and lentiform nucleus (collectively termed the

striatum ) plus the Subthalamic nucleus and the

substantia nigra(pc).

Degeneration of dopaminergic neurons that produce

dopamine and cell bodies in SNpc.

04/11/20235

Loss of dopamine results in :

An overactive indirect pathway that is thought to underlie akinesia and rigidity.

An underactive direct pathway is thought to be responsible for bradykinesia.

04/11/2023

Signs and symptoms:

6

Rigidity – cogwheel, leadpipe Bradykinesia Tremor Postural instability (posture and balance) Motor planning- when, where, how Gait – festinating gait Speech, voice, swallowing disorders Autonomic nervous system Cardiopulmonary function

- Physical rehab 5th edition by susan B, o’sullivan.

04/11/20237

Recent advances

04/11/2023

Search criteria:

8

Journal of APTA Australian journal of physiotherapy Journal of Parkinsonism and related disorders Journal of movement disorders Journal of neuro rehabilitation and neural repair Journal of physical medicine and rehabilitation Journal of neurological sciences Journal of brain research

04/11/20239

Year: 2009-2013

Full text articles

Systematic reviews, RCTs and Experimental

comparative studies, pilot study.

Level of Evidence: Sacketts, NHMRC, Pedro.

04/11/2023

10

NHMRC 2009

04/11/2023

11

Sacckets:

1A = Systematic Review of Randomized Controlled Trials (RCTs)

1B = RCTs with Narrow Confidence Interval 1C = All or None Case Series 2A = Systematic Review Cohort Studies 2B = Cohort Study/Low Quality RCT 2C = Outcomes Research 3A = Systematic Review of Case-Controlled Studies 3B = Case-controlled Study 4 = Case Series, Poor Cohort Case Controlled 5 = Expert Opinion

04/11/2023

12

Interventions:

Neuroprosthesis Action observations Audio-Biofeedback training Irish set dancing Intensive Rehabilitation Treatment Augmented visual feedback Robot-assisted gait training Virtual games Physical Exercise

04/11/2023

13

Tremor

A neuroprosthesis for tremor management

through the control of muscle co-contraction

Authors: Juan Alvaro Gallego, et.al

Published year: 2013

Journal: Journal of NeuroEngineering and

Rehabilitation

04/11/2023

14

Objective: Pathological tremor is the most prevalent

movement disorder, which makes tremor a major

cause of loss of quality of life. Therefore, novel

forms for tremor management are required.

Research design: Pre-post experimental design.

04/11/2023

15

Method: A neuroprosthesis that regulated the level of

muscle co-contraction by injecting the current at a pair of antagonists through transcutaneous

neurostimulation was used.

6 patients suffering from parkinsonian or essential

tremor of different severity were taken, and the effect

of the neuroprosthesis during standard tasks was

evaluated.

04/11/2023

16

04/11/2023

17

Results: The neuroprosthesis attained significant

attenuation of tremor and reduced its amplitude.

04/11/2023

18

Conclusions: This study sets the basis for the

validation of the neuroprosthesis as an alternative,

non-invasive means for tremor management.

LOE: 3b (NHMRC)

04/11/2023

19

Bradykinesia:

Reduction of Bradykinesia of Finger Movements by a Single Session of Action

Observation in Parkinson disease

Authors: Marco Bove, et.al.

Year: 2013

Journal: Neurorehabilitation and Neural Repair

04/11/2023

20

Objective: To understand the effects of action observation on the spontaneous rate of finger movements in patients with

Parkinson disease.

Methods: 38 pts with PD and 14 healthy controls, were

randomly divided into 2 groups.

All participants performed a finger sequence at

their spontaneous pace at different intervals.

04/11/2023

21

04/11/2023

22

Results: Both VIDEO and ACOUSTIC training

increased the spontaneous rate in all participants.

Conclusions: The findings suggest that the

dopaminergic state contributes to the effects of action

observation, and the training may be a promising

approach in the rehabilitation of bradykinesia in PD.

LOE:1b (Sacckets)

04/11/2023

23

Posture and Balance:

Audio-Biofeedback training for posture and

balance in Patients with Parkinson’s disease

Authors: Anat Mirelman, et.al.

Journal: Journal of neuroengineering

and rehabilitation

Published year: 2011

04/11/2023

24

Objective: To test the feasibility and effects of

Audio-Biofeedback training modality

in patients with PD.

04/11/2023

25

Method: Seven patients with PD were included in a

study,that comprised of a six weeks intervention

program.

The training was individualized to each

patient’s needs and was delivered using an audio-

biofeedback (ABF) system with headphones.

04/11/2023

26

The device is worn on the patient’s lower back and is attached to headphones by which he hears the auditory feedback.

04/11/2023

27

Results: The ABF system was well accepted by all

participants, with high satisfaction with the

training. A significant improvement of balance,

was observed.

In addition, the training appeared to

have a positive influence on psychosocial aspects

of the disease and the level of depression.

04/11/2023

28

Conclusion: Audio-biofeedback training for

patients with PD is feasible and is associated with

improvements of balance and several psychosocial

aspects.

LOE: 4 ( Pedro)

04/11/2023

29

A comparison of Irish set dancing and exercises

for people with Parkinson’s disease: A phase II

feasibility study

Authors: Daniele Volpe, et.al.

Journal: BMC Geriatrics

Published year: 2013

04/11/2023

30

Objective: The objective of this study was to

evaluate the feasibility of Irish set dancing

compared with routine physiotherapy for people

with mild to moderately severe PD.

04/11/2023

31

Method: Twenty-four people with idiopathic PD

receive standard physiotherapy exercises or Irish set

dancing classes once per week plus a weekly home

program for 6 months (12 in each group).

Results: Both the Irish set dancing and physiotherapy

exercise program were shown to be feasible and safe.

Compliance and adherence to both the exercise and dance programs were very high.

04/11/2023

32

Conclusion: A larger multi-centre trial is now

warranted to establish whether Irish set dancing is more effective than routine physiotherapy for

enhancing mobility, balance and quality of life in

people living with idiopathic PD.

LOE: 2 ( Pedro)

04/11/2023

33

Short- and Long-Term Efficacy of Intensive Rehabilitation Treatment on Balance and Gait in

Parkinsonian Patients

Authos: Giuseppe Frazzitta, et.al.

Journal: Hindawi Publishing Corporation Parkinson’s

Disease

Year: 2013

04/11/2023

34

Objective: The aim of this study was to investigate

whether a 4-week inpatient multidisciplinary

intensive rehabilitation treatment (MIRT) is effective

in improving balance and gait and whether

improvements persist at a one-year follow up.

04/11/2023

35

Method: 20 PD inpatients, were taken for the

study. Patients were evaluated at admission, at

the end of the 4-week treatment, and at a 1-yr follow up.

04/11/2023

36

Outcomes:

UPDRS Berg Balance Scale six-minute walking test Timed Up and Go Test Comfortable-Fast gait speeds.

04/11/2023

37

Results: MIRT was effective in improving balance

and gait and that the improvement in gait

performances was partially maintained after 1 year

also.

LOE: 3a ( Pedro)

04/11/2023

38

The effects of augmented visual feedback during balance training in Parkinson’s

disease

Authors: Maarten RC van den Heuvel, et.al.

Published year: 2013

Journal: BMC Neurology

04/11/2023

39

Objective: To investigate whether a training program

capitalizing on virtual-reality-based visual feedback

is more effective than an equally-dosed conventional

training in improving standing balance performance

in patients with Parkinson’s disease

Study design: randomized clinical trial

04/11/2023

40

Methods: Patients with idiopathic Parkinson’s

disease,were participated in a five-week balance

training program

comprising ten treatment sessions of 60

minutes each.

Experimental group balance training using

augmented visual feedback

Control group balance training

04/11/2023

41

Training sessions consist of task-specific exercises

that are organized as a series of workstations.

Assessments were done before training, at six

weeks, and at twelve weeks follow-up.

04/11/2023

42

04/11/2023

43

Discussion: They hypothesize that balance training

based on visual feedback will show greater

improvements on standing balance performance

than conventional balance training.

LOE: 1b (Sacckets)

04/11/2023

44

Gait:

Robot-assisted gait training versus equal intensity treadmill training in patients with mild to moderate

Parkinson’s disease

Authors: Alessandro Picelli, et.al

Year: 2013

Journal: Parkinsonism and Related Disorders (Elsevier)

04/11/2023

45

Aim: The aim of this study was to compare the

effects of robotic gait training versus equal intensity

treadmill training and conventional physiotherapy on

walking ability in patients with mild to moderate

Parkinson’s disease.

04/11/2023

46

Methods: Sixty patients with mild to moderate

Parkinson’s disease were randomly assigned into

three groups.

All patients received twelve, 45-min treatment sessions, three days a week, for four consecutive

weeks.

04/11/2023

47

Robotic Gait Training group robot- assisted gait

training.

Treadmill Training group performed equal intensity treadmill

training without body-weight support.

Physical Therapy group conventional gait therapy according to

the PNF concept.

- Patients were evaluated before, after and 3 months post- treatment.

04/11/2023

48

Results: No statistically significant difference was

found on Robotic Gait Training group and the

Treadmill Training group after the treatment

evaluation.

04/11/2023

49

Conclusions: The study support the hypothesis

that robotic gait training is not superior to

equal intensity treadmill training for

improving walking ability in patients with

mild to moderate Parkinson’s disease.

LOE: 1b (Sacckets)

04/11/2023

50

Quality of life:

Virtual games and quality of life in Parkinson’s disease

Authors: Danilo Cruz

Year: 2013

Journal: Advances in Parkinson’s Disease

Research design: A randomised controlled trial

04/11/2023

51

Objective: To evaluate the efficacy of Nintendo

Wii training in quality of life in Parkinson’s dis-

ease patients when compared to traditional

physical therapy.

04/11/2023

52

Methods: Forty-four PD were taken. Both groups executed a

warm up session for 10 minutes.

PT group

followed a program that consisted of trunk and limb

mobilisation, balance, muscle strengthening, rhythmic

movement, postural alignment, double-task execution, bimanual

tasks, and gait training.

04/11/2023

53

Nintendo Wii group

executed a sequence of tasks according to a

previously established protocol, with similar

training exercises.

04/11/2023

54

Results: Subjects in the Nin- tendo Wii group showes greater

improvement. Also, significant differences were observed in

ADL, stigma, social support and communication when

comparing subjects before and after intervention in the

Nintendo Wii group.

Conclusions: Rehabilitation using Nintendo Wii may have

beneficial effects in quality of life of PD subjects, and

superior when compared to traditional PT.

LOE: 1b (Sacckets)

04/11/2023

55

Randomized Clinical Trial of 3 Types of Physical Exercise for Patients With Parkinson Disease

Author: Lisa M. Shulman

Year: 2013

Journal: JAMA Neurol.

Research design: Randomized Clinical Trial

04/11/2023

56

Objective: To compare the efficacy of treadmill

exercises and stretching and resistance exercises in

improving gait speed, strength, and fitness for

patients with Parkinson disease.

04/11/2023

57

Method: A total of 67 patients with PD who had

gait impairment were randomly assigned to 1 of 3

arms of the trial.

A higher-intensity treadmill exercise was

performed,

A lower-intensity treadmill exercise was

performed and

04/11/2023

58

Stretching and resistance exercises was performed.

These all exercises were performed 3 times a week for 3 months.

Outcome Measures :

> 6-minute walk

> peak oxygen consumption per unit time

> 1-repetition maximum strength.

04/11/2023

59

Results All 3 types of physical exercise improved

distance on the 6-minute walk.

04/11/2023

60

Conclusions:

The lower-intensity treadmill exercise resulted in the greatest improvement

in gait speed.

Both the higher- and lower-intensity treadmill exercises improved

cardiovascular fitness.

Stretching and resistance exercises improved muscle strength.

Hence, exercise can improve gait speed, muscle strength, and fitness for

patients with Parkinson disease.

  LOE: 1b (Sacckets)

04/11/2023

61

Falls:

Slow Down and Concentrate: Time for a Paradigm Shift in Fall Prevention among People

with Parkinson’s Disease?

Author: Emma L. Stack and Helen C. Roberts

Year: 2013

Journal: Hindawi Publishing Corporation

Parkinson’s Disease

04/11/2023

62

Aims. To survey falls beyond home, identifying

challenges amenable to behavior change.

Methods: They distributed 380 questionnaires to

PwP in Southern England, asking participants to

count and describe falls beyond home in

the previous 12 months.

04/11/2023

63

Results: Among 255 responses, 136 PwP reported

falling beyond home.They described 249 falls in detail,

commonly falling forward after tripping in streets.

Single fallers (one fall in 12 months) commonly

missed their footing, walking, or changing position and

recovered to standing alone or with unfamiliar help.

Repeat fallers (median falls, two) commonly felt

shaken or embarrassed and sought medical advice.

Very frequent fallers (falling at least monthly; median

falls beyond home, six) commonly fell backward, in

shops and after collapse but often recovered to

standing alone.

04/11/2023

64

Conclusion: Even independently active PwP who do not

fall at home may fall beyond home, often after tripping.

Falling beyond home may result in psychological and/or

physical trauma (embarrassment if observed by strangers

and/or injury if falling backwards onto a hard surface).

Hence prevention requires vigilance and preparedness:

slowing down and concentrating on a single task might

effectively prevent falling.

LOE: 2c (Sacckets)

04/11/2023

65

Summary:

Tremor:

Neuroprosthesis can be used as an valid,alternative, non-invasive means for tremor management.

Bradykinesia:

Dopaminergic state contributes to the effects

of action observation, and training by observing action may

be a promising approach

in the rehabilitation of

bradykinesia in PD.

04/11/2023

66

Posture and balance:

Audio-biofeedback

training for patients

with PD is feasible and

is associated with

improvements of

balance and several

psychosocial aspects.

Augmented visual feedback:

Balance training based on

visual feedback shows

greater improvements on

standing balance

performance than

conventional balance

training.

04/11/2023

67

Irish set dancing:

It showes superior

results to standard

physiotherapy in

relation to freezing of

gait, balance and motor

disability.

Intensive Rehabilitation Treatment:

MIRT was effective in

improving balance and

gait and that the

improvement in gait

performances was

partially maintained

also after 1 year.

04/11/2023

68

Gait:

Robotic gait training is

not superior to equal

intensity treadmill

training for improving

walking ability in patients with mild to

moderate Parkinson’s

disease.

04/11/2023

69

Physical exercise can

improve gait speed,

muscle strength, and

fitness for patients with

Parkinson disease.

Quality of life:

Rehabilitation using

Nintendo Wii may

have beneficial effects

in quality of life of PD

subjects, and superior

when compared to

traditional PT.

04/11/2023

70

Falls:

Slowing down and concentrating on a single

task might effectively prevent falling.

Using an appropriate walking aid outdoors

may afford extra postural stability and can

prevent falls.

04/11/2023

71

Thank you!!!