Neuro exam 2 evidence
Strength training : evidence
2 year RCT progressive resistance exercise in PD Methods • progressive ex • non progressive resistance ex Findings • Non progressive group : worse over 2 yrs • Progressive group : improved, then maintained • Progressive > Non progressive : 7 point UPDRS diff (double MCID) Next steps : how to overcome PD pt's decrease force output? SPECIFIC TRAINING .... 1. Step 1 : overcome bradykinesia 2. Step 2 : torque based functional training (faster mvmt speed & greater torque) Meta analysis : resistance training effects on muscle force • Fig 4 : sig knee ext strength increase (effect size = .8) • Fig 8 : leg press (similar to knee ext strength) What happens in the PD brain with strengthening exercises? Methods • Resting state fMRI collected before & after single acute bout of exercise • Groups : 5 different resistance training groups • Group dosage : 3 sets of 8-12 reps B/w sets, 60 seconds of ™ or bike, HRR @ >60% x 35-45 min Findings : increase in substantia nigra activity → • increase dopamine availability in synapse → • increased force production (mitigates disease progression)
PD & walking : evidence
Ambulatory activity study : early PD stages already @ low active range Ppl w/ PD - changes in walking @ 1 yr • 12% reduction in total steps / day • 40% reduction in mod intensity minutes
Gait training : evidence strength & benefits
Benefits : Improves ... • step length • walking speed • walking capacity • functional mobility • balance reduces motor disease severity Caution / risks : • Routine safety procedures must be followed to prevent adverse effects • Potential pt discomfort w/ TM harness • Fatigue side effect • MS discomfort @ LE or back (avoided w/ activity modification) • Cost varies (potential robotic assisted gait training devices and/or specialized TM's)
Resistance training : evidence strength & benefits
Benefits : improve ... • strength & power • nonmotor symptoms (anxiety, cognition, depression) • activities • qol reduce ... • motor disease severity • fall rate Caution / risks : none???
Flexibility exercises : evidence strength & benefits
Benefits : axial ROM Caution / risks : none
Task specific training : evidence strength & benefits
Benefits : improvements ... • Specific task trained • UE strength, dexterity, sensation, and goal attainment • Mental imagery • Turning and functional mobility • Bladder function Caution / risks : • No increased risk • No increased cost • Some dropouts d/t lack of enjoyment w/ activity (pt preference should be considered)
Aerobic exercise (mod - high intensity) evidence strength & benefits
Benefits : improvements in ... O2 consumption motor and nonmotor impairments functional activities (eg, gait, balance, ADLs) QOL Caution / risks : Minor MS injuries (avoid by gradual progression of exercise duration & intensity) Choose safer aerobic exercise option
Balance training : evidence strength & benefits
Benefits : improvements in ... • outcomes : balance, mobility, gait, balance confidence • postural control impairments • QOL • nonmotor sx Caution / risks : • FALLS : small amt of adverse events • More costly d/t technology integration
Behavior change approach : evidence strength & benefits
Benefits : improves ... • BSF : motor disease severity & bladder fxn • Activity : walking capacity • Participation : disease-related qol & physical activity Caution / risks : • No sig risks or harms w/ behavior change • Additional PT training required for optimal delivery
Community based exercise : evidence strength & benefits
Benefits : improves ... • Motor sx (strength/power, posture, hand-upper extremity dexterity, hand-eye coordination) • Nonmotor sx (anxiety, depression, cognition and sleep) • functional outcomes (gait, balance, mobility, ADLs, walking capacity/velocity, turning) • falls/fear of falling • qol Caution / risks : NO sig difference b/w community based exercise & controls
External cueing : evidence strength & benefits
Benefits : improves ... • motor disease severity • spatiotemporal parameters of gait • functional gait outcomes • fog Caution / risks : • Routine safety procedures must be followed to prevent adverse effects • Potential high cost of technology for external cueing
Dual task training : evidence
Duality trial : does dual tasking improve gait velocity? Methods • 2 baseline assessments a few wks apart (determines whether dual tasking improves condition) • Groups : gait velocity & untrained auditory, gait velocity & untrained mobile phone task, gait velocity & trained backward digit span Findings • SLIGHT dual tasking improvement : pre v post implementation & retained @ 12 wks • PD pt's w/ FoG : did NOT retain gains @ 12 wks • Dual tasking does NOT increase fall risk Other evidence findings • Safe training method • Improves trained & untrained dual tasks • Potential improvements in both gait & cognition • Can be used to train automaticity • Some evidence of retention (less retention w/ freezers)
PT management of PD : CPG ... exercise recommendations & their ... a) Quality of evidence b) Strength of recommendation
High quality & strong rec ... • Aerobic ex • Resistance training • Balance training • Gait training • Task specific training • Community based exercise • Integrated care High quality & moderate rec ... • External cueing • Behavioral change approach Telerehab : moderate quality, weak rec Flexibility exercise : low quality, weak rec
Balance / neuromotor training : Peterson & Hoak (reactionary)
Joint strategy • NO definite transition b/w hip & ankle strategies • Very limited ankle strategies d/t co-contraction around joints Steps • Too slow d/t poor force production • Too small d/t hypokinesia Other • Excessive postural tone decreases available ROM • Postural perturbations = fall ... why? lack of postural synergy & co-contraction
Balance / neuromotor training : Mirelman
Method : • PD pt's • TT + VR vs TT only Findings : reduction in falls for ppl w/ PD • TT alone : reduced falls • TT + VR combo : greater reduction in falls (compared to TT alone)
5x STS : a) Purpose b) cutoff & MDC
Purpose : LE strength & fall risk Cutoff & MDC : Cutoff : > 16s = fall risk MDC : none
MDS - UPDRS : a) Purpose b) cutoff & MDC
Purpose : PD motor & nonmotor sx Cutoff & MDC : Cutoff : > 34/132 MDC : -
Minibest : a) Purpose b) cutoff & MDC
Purpose : balance assessment Cutoff & MDC : Cutoff : 17.5/28 MDC : 5.5
FGA : a) Purpose b) cutoff & MDC
Purpose : dynamic balance & motor performance while walking Cutoff & MDC : Cutoff : <18/30 MDC : 4 pts
10 mwt : a) Purpose b) cutoff & MDC
Purpose : gait speed Cutoff & MDC : Cutoff : no PD norms MDC : • CWS : .18 m/s • FWS : .25 m/s
ABC : a) Purpose b) cutoff & MDC
Purpose : patient's balance confidence Cutoff & MDC : Cutoff : <69% = fall risk MDC : 11-13%
PDQ-39 : a) Purpose b) cutoff & MDC
Purpose : quality of life in PD pt's Cutoff & MDC : different for each set
6mwt : a) Purpose b) cutoff & MDC
Purpose : walking distance Cutoff & MDC : Cutoff : no PD norms MDC : 82m
Balance / neuromotor training : cochrane review
Rate falls by exercise categories • Gait & balance ex (challenge anticipatory & reactive balance) • Resistance ex (turning on more force faster) • Tai chi (controlling COM within BOS) Rate of falls by amt of supervision : 100% supervision = larger effect size on balance ... why? • Enhances quality of balance • Safer environment : pt more willing to challenging themselves • Motivation / adherence : ensures pt will follow through Does exercise reduce # of fallers? • NO conversion of fallers to non fallers • Fallers likely remain fallers, PT reduces fall frequency Rate of falls by disease severity • Higher disease severity increases fall frequency : why? transition b/w sedentary time → upright time is too fast • Lower disease severity decreases fall frequency : why? earlier intervention improves outcomes # of fallers by disease severity
Aerobic exercise : evidence
Sparx II : difference b/w mod intensity ex vs high intensity ex? Methods : • Groups : usual care, mod intensity (4 days/wk @ 60-65% HRmax), high intensity (4days/wk @ 80-85% HRmax) • Outcome measure : UPDRS Findings • Usual care group declined over 3 mo • Mod intensity group declined by 2 points over 3 mo • High intensity group declined by ½ point over 3 mo Conclusion • Con: underpowered study ... CANNOT draw definitive conclusions • However high intensity ex potentially more beneficial than mod intensity ex Sparx III : study purpose & setup - SAME as sparx II + powered study Park in shape (cycling) : does the specific type of aerobic exercise influence outcomes? Methods • Groups : aerobic intervention (cycling) vs active control • Outcome measures : UPDRS III (motor score during "off state") Findings cycling group exceeds MCID, active control does NOT exceed MCID
Balance / neuromotor training : Park et al (anticipatory)
Stability margins Purpose : does PD "stooped position" cause postural imbalance? Methods • Sway tasks (reaching to control COM within BOS) • Groups : upright controls, stooped controls Findings : ppl w/ PD - smallest amt of sway / excursion (earlier instability d/t inability to control COM within BOS) CoP: narrow BOS in PD pt's ... • Pro : increases ability to step accurately if COM goes outside BOS • Con : decreases BOS & increases fall risk
PD & auditory cueing : evidence
• Auditory cueing : small - mod effect on BOTH gait velocity & stride length in PD pt's • Stronger relationship b/w step length & gait speed • Auditory cueing increases walking duration & speeds (> 100 steps / min) • Motor synchronization decreases attentional efforts • Clinical outcomes : significant findings in ... motor sx reduction, walking capacity & STS speed improvements, QOL improvements • Adherence & safety increases w/o adverse events