la malattia di parkinson: confronto tra modelli
TRANSCRIPT
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La Malattia di Parkinson: confronto tra
modelli riabilitativi in ambito sanitario ed
extrasanitario
18-19-20 Aprile 2016 Lido di VENEZIA Alberoni
Ospedale San Camillo
Marianna Capecci
Dip. Medicina Sperimentale e Clinica Clinica di Neuroriabilitazione
Ancona
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Definizione… operativa
Processo educativo, mirato a risolvere un problema che si focalizza sulle limitazioni nell’attività ed è mirato all’ottimizzazione della partecipazione sociale ed al benessere (well-being) del paziente e, di conseguenza, a ridurre lo stress in coloro che erogano l’assistenza (carer/family)
Wade, ‘05
• “La riabilitazione è l’archetipo dell’intervento complesso in medicina”
• È efficace nel ridurre morbilità e mortalità
• … ma, siamo incapaci di descrivere, nel dettaglio, quali approcci siano specificamente efficaci e su cosa.
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POSITION PAPER LA RIABILITAZIONE DELLE PERSONE IN CONDIZIONI DI CRONICITA’ E DISABILITA’ VERSIONE ESTESA SOCIETA’ ITALIANA DI MEDICINA FISICA E RIABILITATIVA (S.I.M.F.E.R.) Gruppo tecnico per l’elaborazione del documento: M. Massucci: Coordinatore
• La “CONDIZIONE DI CRONICITA’” è uno stato di alterazione della salute che si protrae nel tempo, usualmente oltre i 12 mesi, dovuta ad una o più situazioni morbose, che di norma comporta limitazioni del funzionamento (disabilità) e necessità di monitoraggio e/o di interventi sanitari prolungati, di tipo continuativo od intermittente.
• La/le situazioni morbose che conducono ad una condizione di cronicità possono agire in modo sinergico o indipendente nel tempo, essere reversibili o non reversibili, trasmissibili o non trasmissibili, a decorso ingravescente o stazionario o regressivo, e possono presentarsi in tutte le età.
• La PERSONA IN CONDIZIONE DI CRONICITA’/DISABILITA’” (CCD) è caratterizzata da una condizione di cronicità che determina persistenti limitazioni del funzionamento (disabilità).
• Tali limitazioni possono essere stabili, ingravescenti o ad andamento remittente, e necessitano di monitoraggio e/o di interventi riabilitativi protratti nel tempo o permanenti.
firmato Settembre – pubblicato Dicembre 2015
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COMPLESSITA’
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COMPLESSITA’
Nell’accezione più completa di complessità le componenti di tipo
- biologico,
- socioeconomico
- culturale,
- comportamentale ed
- ambientale,
diventano tutte determinanti di salute
Schaink AK et al. J Comorbildity 2012
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POSITION PAPER LA RIABILITAZIONE DELLE PERSONE IN CONDIZIONI DI CRONICITA’ E DISABILITA’ Position Paper SIMFER 2015
Da Department of Health. Improving Chronic Disease Management.
2004, modif. .
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The expanded chronic care model
Barr et al. Healthcare Quarterly, 7(1) November 2003: 73-82.doi:10.12927/hcq.2003.16763
The Ottawa Charter for Health Promotion refers to five action areas:
• develop personal skills
• re-orient health services
• build healthy public policy
• create supportive environments
• strengthen community action.
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1) SELF-MANAGEMENT SUPPORT, :ENGAGEMENT AND EMPOWERMENT OF CHRONICALLY DISABLED PEOPLE 2) DECISION SUPPORT, 3) DELIVERY SYSTEM DESIGN AND 4) INFORMATION SYSTEMS. These four circles now straddle the border between the health system and the larger community
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PUNTI CHIAVE
CRONICITA’
• PREVALENZA CRESCENTE
• Impatto ECONOMICO, SOCIO/SANITARIO PESONALE/umano
• --> Limitazioni del funzionamento (DISABILITA’)
• Bisogni assistenziali specifici: necessità di interventi riabilitativi, volti a favorire il recupero od il mantenimento dell’autonomia e del massimo livello di partecipazione sociale.
• La cronicità deve essere vista in termini di condizione di salute che si può presentare in tutte le età indipendentemente da singole condizioni morbose,
• Diverso approccio alle problematiche di salute:
– centrata sulla persona
– Secondo l’approccio biopsicosociale.
– integrazione dei saperi, delle competenze e delle professionalità,
– Sulla valutazione e misura dei bisogni, sulla progettazione individuale e sulla verifica
– di una visione sistemica ed inclusiva anche delle componenti non professionali,
– approccio attraverso reti integrate di servizi.
POSITION PAPER S.I.M.F.E.R. LA RIABILITAZIONE DELLE PERSONE IN CONDIZIONI DI CRONICITA’ E DISABILITA’ Gruppo tecnico per l’elaborazione del documento: M. Massucci: Coordinatore
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Prevalence of disability by cause Klijs B et al Plos One ‘11
( chronic non-specific lung disease)
(cardiovascular disease)
diabetes mellitus
ADULTS’ CHRONIC DISABILITIES
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MALATTIA DI PARKINSON
• Elevate Incidenza e prevalenza
• Patogenesi degenerativa
• Andamento lento
• Espressione Multisintom./dimensionale: sintomi – motori
– autonomici
– cognitivi
– Emotivo/comportamentale
• Terapia multidisciplinare: – farmacologica
– chirurgica
– riabilitativa
Archetipo della patologia cronica complessa associata a disabilita’
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Malattia di Parkinson: epidemiologia
• Prevalenza: – In Italia da 65 (Rosati ’80) a 257/100000 ab
(Morgante et al ’92)
• Incidenza: – Da 4.9 (Rosati ’80) a 23.8/100000ab/anno
(Rajput et al ’84)
– A Ferrara dal 1967 al 1987 incidenza stabile pari a 10/10000 ab/anno.!!
– Età media di insorgenza 62 anni (picco tra i70 e 79 anni)
• MP giovanile (esordio in età <40anni): tra 1%(Kurland ’58) 18.5% (Narabayashi ’87)- Schrag et al ’07: 3-5% nei paesi occidentali (10% in giappone)
• Variabilità nei dati!
• Differente struttura della popolazione • Criteri diagnostici • Criteri d’arruolamento
Tassi di prevalenza
età e sesso specifici
0
500
1000
1500
2000
2500
3000
3500
4000
20 30 40 50 60 70 80 90 100
età
ca
si/1
00
00
0 a
b
maschi
femmine
(Morgante et al ’92)
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Malattia di Parkinson: epidemiologia
• Proiezioni:
– crescita della prevalenza in Europa ed Asia !!! • Causa: aumento incidenza e sopravvivenza
(Dorsey et al ’07)
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Malattia di Parkinson: patofisiologia
• Malattia degenerativa del sistema nervoso centrale
• Degenerazione dei neuroni dopaminergici della pars compacta della substantia nigra
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Malattia di Parkinson e stadi di Braak
Neurophysiology - Cersosimo & Benarroch J Neuro Sci‘12
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PROTETTIVI
Fumo di sigaretta
caffè
Malattia di Parkinson: eziologia
DANNOSI
GENETICI FATTORI
AMBIANTALI
a-synuclein
parkin
DJ-1
PINK
1
LRRK2
Pesticidi
Manganese
MPTP idrocarburi
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Malattia di Parkinson: clinica - SINTOMI
SINTOMI ESORDIO SEDE/ note FREQUENZA
MO
TO
RI
TREMORE a riposo* PRECOCE ARTI, MENTO
ASIMMETRICO 70%
RIGIDITA’ * PRECOCE ARTI, ASIMMETRICO, 100%
BRADICINESIA * PRECOCE ARTI ASIMMETRICO,
ASSIALE PIU’ TARDIVAMENTE
100%
IPOFONIA MONOTONIA
DELLA VOCE PRECOCE - 98%
MICROGRAFIA PRECOCE - 90%
IPOMIMIA/AMIMIA PRECOCE - 100%
INSTABILITA’
POSTURALE * TARDIVO SINTOMO ASSIALE 100%
FESTINAZIONE DELLA
MARCIA TARDIVO
Generalm. L_DOPA
responsivo 30-40%
FREEZING DELLA MARCIA TARDIVO L-DOPA RESP.
L-DOPA RESIST. 46%
CADUTE TARDIVO
- una volta/anno
- settimanalmente Dovute o no a
freezing?
-70%
- 13%
* SINTOMI CARDINALI Jankovic ‘15
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Malattia di Parkinson: clinica - SINTOMI
SINTOMI ESORDIO SEDE/ note FREQUENZA
DIS
TU
RB
I A
UT
ON
OM
ICI
DISFAGIA TARDIVO liquidi inizialm.
DISF. URO/GENITALE TARDIVO Instabil. Detrusoriale
impotenza 55%**
IPOTENSIONE
ORTOSTATICA TARDIVO 15%
GASTRL./DISPEPSIA Qualsiasi stadio - 53%** STIPSI Qualsiasi stadio - 68%**
DROOLING TARDIVO CORRELATO ALLA
DISFAGIA 59% (27% severo)
IPERIDROSI Qualsiasi stadio 10%
DOLORE Precoce / tardivo (associato
agli OFF)
Articolare, addominale,
Poli distrettuale migrante, distonico
15%
Ipersonnia /sleep attacks Qualsiasi stadio 20-25% - 1/27%
DISTURBO DEL SONNO
REM
Qualsiasi stadio
anche preclinico 47%
IPOSMIA Qualsiasi stadio
anche preclinico 33%
FATICA Qualsiasi stadio 81%
**
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Malattia di Parkinson: clinica - SINTOMI
SINTOMI ESORDIO SEDE/ note FREQUENZA
DIS
TU
RB
I CO
GN
ITIV
O-
CO
MP
OR
TA
ME
NT
AL
I
APATIA Qualsiasi stadio si può associare a demenza 12-16%
DEPRESSIONE Qualsiasi stadio
anche preclinico
Overlaps di sintomicon MP
Presente in stadio 1 più che in
stadio IV
Predittivo di maggiore disabilità
(percepita?)
7-72%
ANSIA Qualsiasi stadio >40%
DISTURBI DISESECUTIVI Qualsiasi stadio DIP. Età e COMORBILITA’ 60-80%
DETER. COGNITIVO Tardivo Non all’esordio/infl. dall’età 10-40%
DISTURBI DEL
COMPORTAMENTO Tardivo
CORRELATA A
DOPAMINOAGONISTI
E DETERIORAMENTO COGNITIVO
17-80%
IN MEDIA 40%
SDR DISPERCETTIVA Tardivo CORRELATA A
DOPAMINOAGONISTI
E DETERIORAMENTO COGNITIVO 10-40%
SINTOMI ESORDIO SEDE/ note FREQUENZA
SIN
TO
MM
I
CO
RR
EL
AT
I A
LT
RA
TT
AM
EN
TO
A L
UN
GO
TE
RM
INE
CO
N
F.
DO
PA
MIN
ER
GI
CI
FLUTTUAZIONI
Tardivo
(5-12 ANNI)
n.a. 80%
DISCINEISE Tronco –arti 45%
DISTONIE OFF Arti – collo – tronco 25%
WEARING OFF n.a. 40%
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Malattia di Parkinson: stadiazione clinica sec. Hoehn & Yahr (‘67)
STADIO 0: NESSUN SEGNO DI MALATTIA
STADIO 1: COINVOLGIMENTO UNILATERALE
STADIO 1,5: COINVOLGIMENTO UNILATERALE E ASSIALE (RIGIDITA’ DEL COLLO)
STADIO 2: COINVOLGIMENTO BILATERALE SENZA ALTERAZIONE DELL’EQUILIBRIO
STADIO 2,5: COINVOLGIMENTO BILATERALE LIEVE CON INSTABILITA’ POSTURALE MA CAPACITA’ DI RIPRENDERE L’EQUILIBRIO QUANTO SPINTO
STADIO 3: COINVOLGIMENTO BILATERALE DA LIEVE A MODERATO ; INSTABILITA’POSTURALE (INCAPACE DI RIPRENDERE L’EQUILIBRIO SE SPINTO) ANCORA FISICAMENTE INDIPENDENTE
STADIO 4: DISABILITA’ GRAVE; IL PAZIENTE PUO’ ANCORA CAMMINARE O STARE IN PIEDI DA SOLO MA E’ GRAVEMENTE DISABILE
STADIO 5: IL PAZIENTE E’ ALLETTATO O IN SEDIA A ROTELLE SE NON AIUTATO
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DISABILITY IS EVER GROWING OVER TIME IN SPITE OF EFFECTIVE MOTOR SYMPTOM
CONTROL
(Schrag et al ’07)
years P
rogr
essi
on
rat
e
Motor symptoms
Disability
Limitations of Current Parkinson’s Disease Therapy Rascol et al , Ann Neurol 2003
EFFECTIVE MANAGEMENT OF
CLASSICAL MOTOR TROUBLES
REDUCED IMPACT ON SURVIVAL
THE ONSET OF REFRACTORY
MOTOR SYMPTOMS
AND NON MOTOR SYMPTOMS
SEVERELY AFFECTS
INDEPENDENCE AND
QUALITY OF LIFE
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Malattia di Parkinson: epidemiologia
• Sopravvivenza:
• Aspettativa di vita: – 38 (SD 5) aa per MP
con esordio tra i 25-39 aa (vn 49/SD5)
– 5(SD4) aa per MP con esordio >65 (n.v. 9 (5SD)
• Media dell’età attesa per il decesso
Ishihara et al ‘07
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Malattia di Parkinson: epidemiologia
• Mortalità – FATTORI PREDITTIVI
– ETA’ AVANZATA (relative rate (RR) 2.22; 95% (CI) 1.99–2.47, PER PTS 85+AA years),
– SESSO MASCHILE (RR 1.73; 95% CI1.60–1.87),
– GRAVE COMPROMISSIONE FUNZIONALE (RR 1.81; 95% CI 1.53–2.13)
– GRAVE COMPROMISSIONE COGNITIVA (RR 1.54; 95% CI 1.38–1.72)
– PROBLEMI DEL VISUS (RR 1.25; 95% CI 1.20–1.57),
– DECUBITI (RR 1.25; 95% 1.14–1.37),
– SCOMPENSO CARDIACO (RR 1.49;95% CI 1.35–1.65),
– DIABETE MELLITO (RR 1.22; 95% 1.11–1.35)
– POLMONITE (RR 1.39; 95% CI 1.09–1.77)
– LA SPECIFICA PRESENZA DI POLMONITE AB INGESTIS RAPPRESENTA IL FATTORE PROGNOSTICO INDIPENDENTE PIU’ FORTE rispetto alle altre comorbilità (RR 1.58; CI 0.97–2.56).
Fernandez et al 2002
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Malattia di Parkinson: TERAPIA
FARMACOLOGICA CHIRURGICA RIABILITATIVA
TEAM MULTIDISCIPLINARE
Summary of the recommendations of the EFNS/MDS-ES review on therapeutic management of Parkinson’s disease (Ferreira et al EJN ‘13)
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MdP: APPROCCIO SPECIFICO
Fase precoce Fase Intermedia Fase terminale
Hoehn & Yahr 1-2.5 Hoehn & Yahr 2.5-4 Hoehn & Yahr 5
Diagnosi
APPROCCIO RIABILITATIVO. Obiettivi: • Prevenire l’inattività • Promuovere la capacità fisica • Ridurre la paura di cadere (e le
cadute)
Interventi: • Promozione di uno stile di vita
attivo • Somministrazione di
informazioni per prevenire l’inattività ed aumentare le capacità fisiche
• Esercizi attivi (gruppo) per migliorare l’equilibrio, la potenza muscolare, la mobilità articolare e la capacità aerobica
• Coinvolgimento del partner o del carer
APPROCCIO RIABILITATIVO. Obiettivi: • Prevenire le cadute • Ridurre le limitazioni in:
Trasferimenti Postura Destrezza Equilibrio Cammino Disfagia
Interventi: Esercizi attivi, anche a domicilio, e attività funzionali mediante: • Strategie generiche • Strategie specifiche per la MP:
Strategie cognitive per il movimento
Strategie di Cueing esterno • Informazione per la riduzione dei
comportamenti e compiti multitasking
Terapia farmacologica. •Inibitori delle MAO-B •Inibitori delle COMT •Dopaminoagonisti •L-DOPA •Amantadina •Anticolinergici
Terapia farmacologica. •Inibitori delle MAO-B •Dopaminoagonisti •L-DOPA •Amantadina •Anticolinergici
Neurochirurgia funzionale •Pallidotomia •DBS: VIM,
•GPi •STN •PPN
•DUODOPA •Inf. Cont. APOMORFINA
APPROCCIO RIABILITATIVO. Obiettivi: • Mantenere le funzioni vitali • Prevenire le lesioni da
decubito • Prevenire contratture ed
anchilosi Interventi: • Adattamenti posturali a
letto o carrozzina • Mobilizzazione attiva
assistita • Informazioni aggiuntive
per la prevenzione di lesioni da decubito e contratture/anchilosi.
Mod da KEUS ‘07 e ’09 Position Paper Simfer 2015
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Cosa distingue significativamente il soggetto con PD in fase iniziale e il soggetto non PD ??
Studiati durante l’avvio (Rocchi ‘06) del cammino e il turninig (Carpinella et al ’06; Crenna et al ’07, Cole et al ‘10)
• Movement amplitude generation (Morris M et al ’94)
• APA (Rocchi ‘06, Burleigh et al., 1994; Elble et
al., 1994).
• Asimmetria, variabilità • Sdr Disesecutiva (Jankovic ‘16)
• Disturbi del sonno (Jankovic ‘16)
• Stipsi, (Jankovic ‘16)
• Ansia, depressione (Jankovic ’16)
• Effetto cueing (Lewis et al’07)
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GROUP N from
PD 699 ParkinsonNet trial
CONTROLS 1959 Longitudinal Aging Study Amsterdam (LASA)
Daily physical activity = LAPAQ
PD =t 111 min/day (interquartile range 58–206) on daily physical activity, Controls= 150 min for controls (interquartile range
89–232). On average 29% reduction in PD versus controls (95% CI, 10–44%; p\0.01
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While disease severity, gait, and disability in daily living predicted part of the inactivity, a portion of the variance remained unexplained, suggesting that additional determinants may also affect daily physical activities in PD. Because physical inactivity has many adverse consequences, work is needed to develop safe and enjoyable exercise programs for patients with PD.
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• The National Parkinson's Foundation (NPF) QII Registry data was used to analyze variables that correlate with levels of exercise in PD patients across disease severity
• Subjects were categorized into three groups:
– non-exercisers (0 min/week),
– low exercisers (1e150 min/week), and
– regular exercisers (>150 min/week).
4866 subjects were included in the baseline analysis and 2252 subjects who had second visits were included in the longitudinal data.
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Oguh et al Parkinsonism Rel Disord ‘14
VALUTAZIONE TRASVERSALE BASALE (N4866) Exercise “dose” matters as
demonstrated by the association of exercise frequency with less PD severity and better cognitive status”
subjects with a history of falls were less likely to engage in regular exercise. This might reflect the fact that an increased fear of falls leads to inactivity and hence less exercise
Correlazione dell’esercizio con:
- QoL
- Mobility
- TUG
- MCSI (Multidim. Cargiving Strain Index)
Predittività
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Oguh et al Parkinsonism Rel Disord ‘14
• VALUTAZIONE longitudinale (N2252)
• “Regular exercisers at baseline were associated with better QOL, mobility, and physical function less progression of disease, less caregiver burden and less cognitive decline one year later, after controlling for demographic and disease severity variables”
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It is not just any kind of EXPERIENCE
that facilitates neuroplasticity
The MEANINGFULNESS of the task
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L’ESERCIZIO: Termine generico con il quale si vuole indicare l’attività fisica pianificata, strutturata e ripetitiva, al fine di
coinvolgere ogni parte del corpo.
ESERCIZIO GOAL-BASED
Allenamento compito-specifico che possiede
parametri di:
• Intensità
• Ripetitività
• Specificità
• Difficoltà
• Complessità
ESERCIZIO AEROBICO
• Attività vigorosa e sostenuta che determina un innalzamento
• delle funzioni cardio-polmonari, con conseguente aumento del consumo di O2 e flusso sanguigno al cervello.
• Tipicamente, l’intensità dell’esercizio aerobico deve mantenersi tra il 60-85% della frequenza cardiaca massima.
Petzinger et al. Lancet Neurol 2013
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98% 81%
INTENSIVE TREADMILL TRAINING ELEVATES D2 RECEPTOR IN THE STRIATUM
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Goal-Based + Aerobic Exercise
Treadmill
Il Treadmill è solitamente utilizzato per migliorare le capacità del cammino.
Studi su treadmill hanno dimostrato che individui con Parkinson da lieve a moderato possono migliorare le performance del cammino, inclusa la velocità, la lunghezza del passo,
la cadenza, il ritmo del cammino e l’escursione articolare.
(Tomlison et al., 2014)
UPDRS (parte II, III , IV)
(Frazzitta ’12)
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Goal-Based /Aerobic Exercise
Petzinger ‘13
Exercise Outcome improved Ref
Danza
equilibrio, cammino e capacità di dual tasking.
Duncan e Earhardt (2012)
Amplitude training
velocità e ampiezza di movimento.
(Farley et al., 2005)
Tai Chi
lunghezza del passo, massima escursione articolare, cadute.
(Li et al., 2012)
Box
equilibrio e del cammino.
(Combs et al., 2010)
Strategie addizionali Giochi elettronici (WII), realtà virtuale, allenamento dual task,
?? equilibrio e capacità di dual tasking.
(de Bruin et al., 2010) (dos Santos Mendes et al., 2012)
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Types of interventions
Physiotherapy interventions aim to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person.
Physiotherapy encompasses a wide range of techniques, so we were inclusive in our definition of physiotherapy intervention (including those not directly delivered by a physiotherapist)
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Cochrane 2001 Cochrane 2014
Trials available for inclusion (N) 7 43
Participants randomised (N) 210 1673
Assessment period 2 weeks 24 months
Age (mean) 67 years
Male (%) 62
Hoehn & Yahr (mean) 2.4
Disease duration (mean) 7 years
The most frequently reported physiotherapy outcome measures were gait speed and timed up and go. The motor subscales of the UPDRS and PDQ-39 were the most commonly reported clinician-rated disability and patient-rated quality of life outcome measures respectively
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Approcci Riabilitativi Approcci classici
• Fisiochinesiterapia
streatching, l‘allenamento muscolare, la
rieducazione dei passaggi posturali, la
rieducazione dell‘instabilità posturale e del
cammino e l‘addestramento a strategie cognitive
• Terapia occupazionale
risolvere le difficoltà presenti nelle ADL
• Cues e stategie attenzionali
• Strategie attenzionali
incrementare l‘ampiezza del passo ed il loro
vantaggio rispetto alle cues è la maggiore
riproducibilità
• Il treadmill
Un ciclo di sedute di treadmill determina un
visibile miglioramento della performance motoria
nella MP rispetto al trattamento fisioterapico: si
può notare un aumento della lunghezza del passo,
aumento della velocità del cammino e riduzione
dei sintomi parkinsoniani
Approcci Riab. Alternativi
• Musicoterapia
• Danzaterapia
• Teatroterapia
• T’ai chi ch’üan
Tomlinson et al Cochrane 2013
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Misure di outcome
GAIT OUTCOMES such as:
a.TWO- OR SIX-MINUTE WALK TEST (M) (Kersten 2004);
b.WALKING SPEED:
i.10- or 20-metre walk test (s), (Kersten 2004),
ii.velocity (m/s) (Trew 2005);
iii. cadence (steps/min) (Trew 2005);
iv.stride length (m) (Whittle 1996);
v.step length (m) (Trew 2005);
c.FREEZING OF GAIT QUESTIONNAIRE, (Giladi 2000)
FUNCTIONAL MOBILITY AND BALANCE OUTCOMES
such as:
a.TIMED UP AND GO (S), (Podsiadlo 1991);
b.FUNCTIONAL REACH TEST (CM), (Duncan 1990);
c.BERG BALANCE SCALE,(Berg 1992; Qutubuddin
2005);
d.ACTIVITY SPECIFICBALANCECONFIDENCE (Powell 1995; Talley 2008).
CLINICIAN-RATED IMPAIRMENT AND DISABILITY : a.HOEHN AND YAHR, (Hoehn 1967);
b.UNIFIED PARKINSON’S DISEASE RATING SCALE (UPDRS), (Fahn 1987):
c. WEBSTER RATING SCALE (Webster 1968);
d.COLUMBIA UNIVERSITY RATING SCALE (Yahr 1969).
PATIENT-RATED QUALITY OF LIFE: a.PARKINSON’S DISEASE QUESTIONNAIRE-39 (PDQ-39), (Jenkinson 1997; Peto 1995);
b.PDQUALIF, (Welsh 2003);
c.PDQL, (Deboer 1996);
d.Short Form-36 (SF-36) or 12 (SF-12 (Ware 1992).
Tomlinson et al Cochrane 2013
Trials reported data on Falls (N)
5 (11%)
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Types of outcome measures
GAIT OUTCOMES such as:
a. TWO- OR SIX-MINUTE WALK TEST (M) (Kersten 2004);
b. WALKING SPEED:
i. 10- or 20-metre walk test (s), (Kersten 2004),
ii. velocity (m/s) (Trew 2005);
iii. cadence (steps/min) (Trew 2005);
iv. stride length (m) (Whittle 1996);
v. step length (m) (Trew 2005);
c. FREEZING OF GAIT QUESTIONNAIRE, (Giladi
2000)
Results WALKING SPEED • Physiotherapy and cardiovascular Exercise
with visual cues > conventional PKT (mean difference between arms 0.34 m/s)(Dias 2005);
• Treadmill with auditory and visual Cues > auditory and visual Cues (Frazzitta 2009; mean difference between arms0.1 m/s);
• Body weight supported treadmill training > Physical therapy ( Miyai 2002; mean difference between arms 0.16 m/s);
• Rhythmic auditory stimulation group > Standard Self paced training, no training (Thaut 1996; mean difference between arms 0.093 m/s);
• Downhill walking group > PKT(Yang 2010 ; mean difference between arms 0.15m/s))
RESULTS
Tomlinson et al Cochrane 2014
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gentilmente da Alice Nieuwboer
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CUEING: evidence based medicine
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FREEZING (FOG)
Tomlinson et al Cochrane 2013
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RESULTS
TYPES OF OUTCOME MEASURES
FUNCTIONAL MOBILITY AND
BALANCE OUTCOMES such as: a. TIMED UP AND GO (S), (Podsiadlo 1991);
b. FUNCTIONAL REACH TEST (CM), (Duncan 1990);
c. BERG BALANCE SCALE, (score ranges from 0 to 56;
with 0 to 20 = high fall risk; 21 to 40 = medium fall risk; and 41 to 56 = low fall risk (Berg 1992; Qutubuddin 2005);
d. ACTIVITY SPECIFICBALANCECONFIDENCE. a
16-itemself-report questionnaire that asks individuals to rate their confidence that they will maintain their balance in the course of daily activities. Each item is rated from 0% (no confidence) to 100% (complete confidence) (Powell
1995; Talley 2008).
Results
TUG
• LSVT BIG training > Nordic Walking, Home exercise (Ebersbach 2010; TUG)
• tango > waltz or foxtrot and Tai Chi (Hackney 2009; TUG)
Tomlinson et al Cochrane 2014
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BBS
TUG
STRIDE LENGHT
DANCE AND MUSIC IN PD REHABILITATION
GAIT VELOCITY
UPDRS III
PDQ-39
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NEUROCOGNITIVE CONTROL IN DANCE PERCEPTION AND PERFORMANCE
SOCIAL INTERACTIONS
MULTIPLE BODIES MOVING IN A
SPECIFIED RHYTHMICAL
MANNER WITH OR WITHOUT MUSIC
• limb coordination,
• flexibility,
• and strength
ESTHETIC ELEMENTS
TOPICS
1. MOTOR CONTROL, in terms of postural control, equilibrium maintenance, and stabilization;
2. TIMING AND ON-LINE SYNCHRONIZATION influenced by attention demands and motor experience;
3. the critical roles played by SEQUENCE LEARNING AND MEMORY;
4. strategic use of VISUAL AND MOTOR IMAGERY;
5. the insights into the NEURAL COUPLING BETWEEN ACTION AND PERCEPTION yielded through exploration of the brain architecture mediating dance OBSERVATION; and
6. a NEUROESTHETICS PERSPECTIVE that sheds new light on the way audiences perceive and evaluate dance expression.
Bläsing et al. Acta Psychologica 139 (2012) 300–308
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DOMAINS NEUROCHEMICAL SYSTEMS
Barone et al. THE PRIAMO STUDY. ‘09
reward, motivation
and pleasure DOPAMINE AND OPIOIDS
stress and arousal
CORTISOL, CORTICOTROPHIN-RELEASING HORMONE (CRH), ADRENO-CORTICOTROPIC HORMONE (ACTH);
Immunity
SEROTONIN AND PRO- OPIOMELANOCORTIN (POMC), ALPHA-MELANOCYTE STIMULATING HORMONE AND BETA-ENDORPHIN
social affiliation
OXYTOCIN
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ECONOMIA DEL CAMMINO
Tomlinson et al Cochrane 2013
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Qualità ed Economia del cammino
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L’intensità e la capacità residua influenzano l’effetto clinico
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UPDRS TOTALE
Tomlinson et al Cochrane 2013
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UPDRS ADL
Tomlinson et al Cochrane 2013
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UPDRS MOTORIA
Tomlinson et al Cochrane 2013
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Results
Types of outcome measures FALLS : a. NUMBER OF PATIENTS FALLING,
E.G. FALLS DIARy;
b. FALLS EFFICACY SCALE, (a total score of 70 or more indicating that a person has a fear of falling) (Tinetti 1990);
c. FALLS EFFICACY SCALE INTERNATIONAL, a 16-item questionnaire that includes the 10 original items of the standard Falls Efficacy Scale as well as six items regarding higher functioning and social activities. Each item is rated on a scale of 1 to 4, with 1 being ‘not concernedat all’ and 4 being ‘very concerned’ (maximum score out of 64) (Yardley 2005).
Results
N° and RATE of falls.
progressive strength training arm > movement strategy training arm (n = 10 versus n = 24; P = 0.006) (McGinley 2012)
mean latency to fall and the proportion of falls
• Combined balance and resistance training > Balance Training group (Hirsch 1996)
Tomlinson et al Cochrane 2014
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RELATIONSHIP BETWEEN COGNITIVE FUNCTIONS GAIT AND FALLS IN PD
Movement Disorders 2012
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MOTOR SYMPTOMS
• MOTOR symptoms
• Deficit in automatic sequenced motor tasks
• Bradikinesia
• Rigidity
• Tremor
• Postural alteration and instability
COGNITIVE DEFICITS
• Executive symptoms
• Poor self-awareness of limitations
• Deficits in motor programmig
• Planning
• Red. Adaptability:Respons inhibition and monitoring
• ATTENTION deficits
BEHAVIOURAL SYMPTOMS
• Apathy,
• mood depression (↓motivation)
• Fatigue
• Anxiety
• psychosis
DISABILITY
MORBIDITY
MORTALITY
GAIT AND BALANCE DISORDERS --- FALLS
CONCLUSION
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The rehabilitation efficiency in chronic care setting is challenging
DELIVERY OF EXERCISE AS PART OF A REHABILITATION PROGRAM REMAINS CHALLENGING IN TERMS OF
• social human and economic resources
• Executive symptoms
• Poor self-awareness of
limitations
• Deficits in motor programmig
• Planning
• Red. Adaptability:Respo
ns inhibition and monitoring
• ATTENTION deficits
• MOTOR symptoms
• Deficit in automatic sequenced motor tasks
• instability,
• freezing
• NON MOTOR symptoms
• Apathy, mood depression (↓motivation)
• Fatigue
• Orthostatic hypotension
ADHERENCE
ACCEPTABILITY
ACCESS COST
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What advanced technologies may provide to improve chronic disease care?
• Architectures may provide continuous
1. ecological MONITORING of symptoms
2. REHABILITATION TOOLS
• ad hoc delivery of cues (vibrotactile feedback-
metronome (Mazilu S et al. ‘12, Pepa et al ‘14))
• Home treadmill (Canning CG ET AL ‘12)
• Exergaming (Barry et al ’14)
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The architecture
Data acquisition
Sliding window
• Freeze index • Energy
Threshold
Cue
<
>
CLINICAL CENTER
personalized
2014 2014
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• 22 patients: 6 women e 16 men
• Methods: – Test 1 – Standard motor exercises (12 patients):
• TUG;
• TUG + dual task;
• Freezing path; – Test 2 – Free walk (10 patients);
• Evaluation of rest tremor influence (2 patients)
• DATA ANALYSIS: specificity, sensibility, efficacy (𝐸𝑓𝑓 =𝐹𝑂𝐺 𝑜𝑣𝑒𝑟𝑐𝑜𝑚𝑒𝑑
𝐹𝑂𝐺 𝑑𝑒𝑡𝑒𝑐𝑡𝑒𝑑
Frequency response of a subject with tremor
Frequency response of a subject with freezing
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System overview
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Features extraction
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Statistica comparison
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THE COMPUTER GAMES WORK BY
• combining real-time motion detection with engaging video games that can help motivate people to exercise.
• a low cost, home-based tool
EXERGAMING -
THERAPEUTIC TOOL
• Exercise:
• functional,
• purposeful and
• engaging
• in a quantifiable and reliable way
• Provide also virtualrealty
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Di Biagio Laura1, Ferretti Matteo2, Cingolani Daniele, Buzzatti Luca, Capecci Marianna and Ceravolo Maria Gabriella
Subjects; Seven PD patients with balance impairment (H&Y:3) received: - 2-week Nintendo-Wii Balance rehabilitation
followed by 2-week training on stabilometric platform (Group Wii-P) (4) or
- the same treatments in the opposite sequence (Group P-Wii). (3)
Each week consisted of 5 daily one-hour sessions.
Nintendo-Wii Balance: PENGUIN; BUBBLE; MARBLES
ASSESSMENT: 10mwt; tug; bbs. Assessment timing: at enrolment (T0), after the first 2-week treatment (T1), after the second 2-week treatment (T2), at one month (F1) and three months (F3) of first treatment end.
2014
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CONCLUSION - Exergaming • Feasibility:
– Yes.
– One of the potential benefits of exergaming interventions is that they can be administered in the home. Although not formally tested.
• Effectiveness: – little evidences on balance, disability and QoL
• Safety: – possibly – not formally tested or referred
Recommendations_ Games designed for PD should: i) target specific clinical features of PD; ii) be easier than commercial games; iii) avoid negative feedback; iv) include very clear instructions and goals; iv) introduce cognitively demanding aspects slowly and sparingly; and v) examine the use of new exergaming systems that do not require balance platforms or handheld controller.
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19
20
Conclusion. Patients with PD derived at least the same degree of cognitive benefit from non–cognition-specific training involving movement as from cognition-specific computerized training. For patients with PD, game consoles may be a less expensive and more entertaining alternative to computer programs specifically designed for cognitive training
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Mov Disord 2013
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Mov Disord 2013
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