Parkinson Wellness Recovery (PWR!)

Guidelines

to Treating People

with Parkinson’s Disease

September 14, 2017

Shana Gatschet, OTR/L, CAPS

Michelle Drinnen, OTR/L

PWR! What is it?

Parkinson Wellness Recovery

www.pwr4life.org

PWR Professionals (FB)

Parkinson Wellness Recovery

●Nonprofit organization founded in 2010 by Dr.

Becky Farley PhD, MS, PT

●Implements cutting edge research on exercise

and brain change to real world healthcare

paradigms

●Dr. Farley is also the developer of evidenced

based therapy approach of LSVT BIG

PWR!

● Dr. Farley’s PWR! Center is a “Community NeuroFitness

Center of Excellence” in Tucson, AZ

● Promotes “Exercises as Medicine”

● Her PWR! Gym is offered to people with PD to have

access for life to increase longevity and quality of life in

hopes that end stage PD is eradicated

● Framework is founded on clinical research in motor

control, motor learning, exercise and physiology.

What is Parkinson’s Disease?

● Neurodegenerative, chronic and progressive movement brain disorder that

progresses slowly in most people

● It involves the malfunction or death of neurons that produce dopamine.

Dopamine is a chemical concentrated in the substantia nigra that controls

movement to be smooth and coordinated

● When diagonosed, ~ 60-80%of the dopamine-producing cells are damaged or

die, PD symptoms appear

● At diagnosis, many are already less active than healthy peers. Poor body

awareness effects one’s “perception” of true movement quality. Yet, only 12-

15% are typically referred to a fitness program or therapy.

● 6-7 million people worldwide are diagnosed; 2% of the population

6 Primary Features of PD

*Resting Tremors

*Rigidity

*Bradykinesia

*Loss of Postural Reflexes

*Flexed Posture

*Freezing

● Definite DX: of at least 2 of these

with one as tremor or bradykinesia

● Probable: Tremor or Bradykinesia

present

● Possible: at least 2 of the last four

are present

PD Symptoms

Early Motor Symptoms: decreased arm swing when walking, masked face,

stooped posture, micrographia, hypophonia, slow shuffling gait, clumsy hands,

falls when fatigued or in a hurry/stressed/distracted

Primary Motor Symptoms upon diagnoses:

Rigidity, Bradykinesia, Incoordination

Non-Motor Symptoms:

Emotional: depression, anxiety, apathy

Cognitive: attention, executive function

Autonomic: sleep, constipation, pain

Stages of PD

Stage 0 No signs of disease

Stage 1 Unilateral disease

Stage 1.5 Unilateral plexus axial involvement

Stage 2 Bilateral disease, without impairment of balance

Stage 2.5 Mild bilateral disease, recovery on Pull Test

Stage 3 Mild to Moderate bilateral disease: some postural instability, independent living capacity

Stage 4 Severe disability, able to ambulate and stand unassisted

Stage 5 Wheelchair bound or bedridden unless assisted

Causes?

● Head injury/Brain swelling

● Free radicals

● High iron and manganese (welding)

● TIAs, Brain Tumors or Lesions near Brainstem

● Medications

● Street drugs

● Viral infection

● Carbon monoxide

Research

● Research advances and clinical science research suggest

certain types of exercise may promote brain change

(neuroplasticity) in persons with PD

● This data challenges the assumption that PD as a

neurodegenerative disease has no potential for brain

change or repair (neuroplasticity)

● Yet many physicians are unaware of the scientific

literature and animal science underlying exercise-induced

brain repair or reorganization (neuroplasticity)

Neuroplasticity

● When it comes to “Brain Change” or neuroplasticity, it’s

more than just “what you do...it’s HOW you do it!”

● Exercise for Brain Change helps optimize and repair brain

health to address the cognitive, physical and emotional

symptoms of PD that interferes with everyday activities.

Why is exercise so important?

● PD is the ONLY chronic neurodegenerative disease for

which these are highly effective symptomatic therapies

● 3 options that reduce motor symptoms and/or disability in

PD

○ Medications (that target dopamine)

○ Neurosurgery (DBS)

Exercise

Research shows Brain Change

Data from animal models:

● NeuroProtection (Brain Health) Capable of protecting vulnerable DA

neurons from toxic events or rescuing those that are not compromised.

● NeuroRestoration (Brain Repair) Adaption of compromised signaling

pathways within the damage of the basal ganglia circuits

● Compensation (Brain Adaptation) Produce compensatory strategies

occurring outside the CNS (ANS, metabolism, peripheral musculature) or

other areas outside the damaged basal ganglia pathways

Differences between PWR! and LSVT ® BIGPWR!

● Amplitude training-PD specific functional

framework for comprehensive research based

programming

● 4 Functional movements-building blocks of

function (UP/ROCK.TWIST/STEP)

● 5 positions-prone/supine/all4’s/sit/stand

● May be implemented across all levels of severity

● Not standard protocol

● Patient centered protocol, frequency/duration is

determined by therapist to produce optimal long

term outcomes

● Offered by therapists or fitness professionals, ratio

1:1 or groups

● Framework is adaptable, can be integrated with

other neuroplasticity-principled approaches or

techniques

● A framework that is continually updated as new

research or approaches emerge

LSVT ® BIG

● Amplitude training is a single approach

● 7 Movement exercises-Driven by LOUD

protocol

● 2 positions- Sitting and Standing

● Protocol is not adaptable

● It is a standard Protocol

● Protocol requires frequency of 4xweek/4

weeks as minimal duration

● Only available 1:1 by certified OT & PT

● A protocol that is prescribed that may NOT

-PD Neuroplasticity-

Principles framework to optimize

learning and function

● PREPARE

● ACTVATE

● REFLECT

● MOTIVATE

PREPARE- (verbal, mental, physical)

Functional readiness: remove inhibitors of fear, stress and pain

ROM with target range

Sensory stimulation/Kinesthetic Awareness

Vestibular readiness- weight shift, rock, pivot, rotation

Movements- demonstrate and breakdown task, mental imagery/estimate steps,

Trial by each person first, deliberate performance, demand readiness prior to

movement/PWR! UP.

Quality of alignment

ACTIVATE-(drive system for maximal motor output and muscle activation)

● Perform PWR! Moves- high effort for maximal activation (push beyond end

point/range)

● Increase ROM, speed, resistance, reps, time, frequency/duration of high

intervals vs sustained efforts

● Give example of FUNCTION

● Continuously monitor perceived efforts (+8/10)

● Remember: motor output is inhibited if fear, stress or pain is present

● Add external cues: visual (color dots) auditory (metronomes, music, clapping)

somatosensory (tactile, vibration, wt bearing, rhythmic movement)

REFLECT- (focus intention internally to sustain attention; recognize efforts

to move bigger/faster)

Hold them accountable to correct movements

Remain positive

Constant pushing for maximal effort

Ask, “how did that make you fee?”, Reflect with other to improve self monitoring

Help them identify what is normal again

Remind/Reinforce EFFORT

Send home assignments, write down one daily reflection

Expect generalization of normal activities

MOTIVATION - (exercise=increased dopamine;

increased dopamine=internal motivator for brain behaviors)

● Depression and apathy are part of PD

● Need to be pushed to participate and engage

● Share success among peers

● Remind/promote exercise with function to translate to meaningful activities

● Continuously educate importance of exercise and effort (reduce falls, better

quality of life to be more active with family/friends, decrease freezing, slow

down progress of PD/PD fight

PWR! MOVES

PWR! Hands

PWR! UP

PWR! REACH

PWR! ROCK

PWR! TWIST

PWR! STEP

PWR! WALK

PWR! TURN

PWR! VOICE

PWR! MOVES

PWR! HANDS

*Deliberate extension/abduction of fingers/hands and wrists

*Addresses flexed posturing of hands, micrographia and temporary relief of tremor

*Activity to reduce resting tremor: BIG pronated hands with shoulders in IR,

tapping on LE-looks normal in social setting

*Sensory input to train ability to focus and divide attention quickly

PWR! MOVES

PWR! UP

● Used with any movements that require lifting body against gravity

● Counteract stooped posture

● Actively stretches trunk flexors

● Reinforces good alignment and posture

● Strengthens extensor antigravity muscles

● Change in head position and visual field stimulates the sensory system for

dynamic stepping/righting responses

PWR! MOVES

PWR! REACH

*Add to all PWR! MOVES to retain normal coordination patterns between trunk

and arms

*Addresses efficient movements & postural responses

*Challenges balance by moving COG outside BOS

*Increases overall attention to activation

*Requires task switching, increases effort, improves alignment

*Weight bearing position mobilizes shoulders, activates postural muscles,

strengthen UEs

*Crosses midline

PWR! MOVES

PWR! ROCK

● Fundamental movements for whole body actions with functional mobility

(walking, turning, stopping forward projection, supine to sit)

● Impaired ability to “ROCK” or weight shift in lateral or backwards direction is

MAJOR contributor to freezing, shuffled gait and falls

● Rhythmic rocking: may reduce rigidity, trigger stepping, righting response.

Promotes wider BOS during ambulation/turning, strengthens abductors,

moves COG outside BOS

PWR! MOVES

PWR! TWIST

*Emphasises counter rotation between shoulder and hips

* Reduces rigidity to decrease risk of muscular skeletal deformity and back pain

* Retains the axial rotation required for dynamic balance

PWR! MOVES

PWR! STEP

● Large scale repetitive stepping in a variety of directions

● Improves strength

● Improves ability to weight shift for turns

● Increases ground clearance

● Moves COG or BOS

● Increases speed and size of steps to respond to balance

PWR! MOVES

PWR! WALK

● Retains perception of effort and amplitude (step size) for normal movement

● Aerobic endurance

● First get quality: PWR! UP with long, wide steps

● Progression:

○ Add arms with elbows bent, then extended

○ Flick fingers with each reach

○ Punch across chest

PWR! MOVES

PWR! TURNS

● Reduce/prevent falls and strengthens muscles important for balance

● Emphasize large BOS

● Whole body rocking

● Exaggerated weight shifting to prepare to turn

● Activities: pivot turns, 45 degree turns, penguin turn, clock turn

PWR! MOVES

PWR! VOICE

*Adds attentional and physical effort, promotes greater activation, challenges

physical coordination as a dual task

* Target LOUDER but do not strain

* Holds “Ahhhs” with sustained postures

* Deliberate articulation

* Emphasize gestures

PWR! ROUTINES

* SITTING

* STANDING

* WALKING

* FLOOR

* FLOW

PWR! ROUTINES

SITTINGPWR! UP

PWR! TWIST

PWR! ROCK/REACH SIDE

PWR! REACH DOWN/UP

PWR! REACH/TWIST

PWR! REACH/TWIST/COMBO

PWR! REACH FORWARD AND BACK

PWR! UP SIT TO STAND

PWR! BREATHE

PWR! ROUTINES

STANDING

PWR! UP

PWR! ROCK & REACH SIDE TO SIDE

PWR! REACH AND TWIST

PWR! REACH AND TWIST COMBO

PWR! REACH & TWIST ACROSS & BACK

PWR! STEP THROUGH

PWR! BREATHE

PWR! ROUTINES

PWR! WALK

PWR! UP

FORWARD

BACKWARD

SIDEWAYS

HIGH KNEES

TURNS

STOPS & STARTS

REVERSALS

PWR! ROUTINES

FLOORPWR! UP-PRONE

PWR! REACH & TWIST-PRONE

PWR! UP- SUPINE

PWR! REACH-BOTH ARMS

PWR! REACH ALTERNATING ARMS

PWR! SNOW ANGEL

PWR! UPPER BODY REACH & TWIST

PWR! STEP UP COMBO

PWR! LOWER BODY TWIST

PWR! SCOOT

PWR! ROLL

PWR! BREATHE

PWR! ROUTINES

FLOW

PWR! PRONE

CHILD’S POSE

PWR! STRETCH

PWR! UP HANDS & KNEES

PWR! REACH ARMS AND LEGS

PWR! REACH AND TWIST ARM

PWR! REACH AND TWIST LEGS

PWR! STEP HANDS & KNEES

PWR! UP TALL KNEELING

PWR! DOWN

PWR! STEP ½ KNEE

HALF KNEE REACH AND TWIST

PWR! BREATHE

Anti-Freezing Tips

● Staggered wide stance, never with toes lined up.

● “Jump start” the first step (march in place, rock, count, sing, etc.)

● PWR! Up (especially in problem areas or areas that cause anxiety)

● Visual cues (tape on floor, sticky notes on walls)

● Treadmill training/pole walking with metronome

● Walk in sync with beat of music in cluttered/problem areas

○ Add motor/cognitive tasks, perform with high vigor/attention, PWR! Up - Plan - GO

● Mental imagery, verbalize intention, “see” the success

● Complex PWR! Moves, Tai chi, etc

● Agility drills; build into complex environments

● Boxing, juggling, rebounder, Bal-a-Vis-X

● Multi-directional stepping to a complex sequence

● Train the brain to talk alternative routes

PWR! MOVES and ROUTINES

~Videos~

Let’s move...

Let’s collaborate with our TEAM

OT - PT - ST

Discuss treatment plans

Areas of strength/weakness and precautions

Exercise to Optimize Brain Repair, Adaptation

and Behavioral RecoveryTiming Matters

-Start today. No excuses.

Continued Exercise Matters

-A substantial break in motor activity can be degenerative.

-See OT/PT/ST for reassessment every 3-6 mo.

-Commit

-Increase daily activities

Intensity Matter

-Work harder, Bigger, Faster, Longer

Complexity Matters

-Change the exercise environment:

Physical area: Small spaces, crowded area, uneven surface

Add secondary motor components - carry items, visual

distractions

Add cognitive tasks - speak to others, recite numbers by 2’s…

Saliency Matters

-Keep attentional focus high to keep motivation high (group exercise,

goals, positive reinforcement, add leisure activities)

-Track progress

Specificity Matters

-Work on symptom based plan of care

-Retrain body awareness (yoga, tai chi, pilates)

-Train for strength, balance, agility/coordination

-Incorporate external cues - lines, targets, metronome, music, BIG

steps, breathing, counting

Affirmations

Belief --- Action --- Results --- Belief --- Action --- Results

PWR! Information

Certifications

PWR! Therapist (OT/PT)

3-6 mo. Assessments

1:1 intensive Rehab

PWR! Instructor (personal trainer, fitness instructor)

Optimal PD specific fitness classes

Educational empowerment and resource referral

*Find a PWR! Professional* Listing on www.pwr4life.org

PWR! Information

PWR! Moves

Videos on website and YouTube

PWR! Retreat pwr4life.org

● 7 day/6 night PD specific exercise retreat in annually in May in Arizona

● Activities, exercise, seminars for those with PD and their care partners

● Q&A with physicians and researchers

References

Coles, M., Muhammed All Parkinson’s Center. Living with Chronic Disease. PWR!

Retreat 2013, Scottsdale AZ

Farley, B. Exercise to Slow/Halt/Reverse Parkinson’s Disease?

Hirsch, M.A., Farley, B.G. (2009) Exercise and Neuroplasticity in Person’s Living

with Parkinson’s Disease. European Journal of Physical Rehabilitation Medicine

45:215-29

Slide and handout copy approval by Dr. Becky Farley. 4.24.17