202360 EHR525 Week 12 Parkinson's Disease- Part B (DG) (1 Slide).pdf

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of th...

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice School of Allied Health, Exercise and Sports Sciences 1 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 1 EHR525 EXERCISE FOR NEUROLOGICAL & MENTAL HEALTH CONDITIONS Parkinson’s Disease- Part B Presenter: Daren Gray School of Allied Health, Exercise and Sports Sciences 2 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 2 What We Will Cover: ■ Diagnosis of Parkinson’s disease. ■ Treatment of Parkinson’s disease. ■ Exercise response in persons with Parkinson’s disease. ■ General recommendations and considerations for exercise testing and programming in Parkinson’s disease. School of Allied Health, Exercise and Sports Sciences 3 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 3 Diagnosis ■ No definitive test for PD. ■ Diagnosis is often based on medical history and the presence of signs and symptoms during physical examination. ■ Diagnosis by a process of elimination. ■ May take up to two (2) years for a formal PD diagnosis to be made. School of Allied Health, Exercise and Sports Sciences 4 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 4 Prognosis And Staging Of Parkinson’s Disease ■ PD affects all clients differently and progression varies greatly between individuals. ■ PS progresses at a very slow rate and life expectancy is not usually shortened. Note the staging scale School of Allied Health, Exercise and Sports Sciences 5 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 5 Unified Parkinson’s Disease Rating Scale (UPDRS) ■ Part I: Evaluation of mentation, behaviour, and mood. ■ Part II: Self-evaluation of the activities of daily life (ADLs) including speech, swallowing, handwriting, dressing, hygiene, falling, salivating, turning in bed, walking, and cutting food. ■ Part III: Clinician-scored monitored motor evaluation. ■ Part IV: Complications of therapy. School of Allied Health, Exercise and Sports Sciences 6 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 6 Unified Parkinson’s Disease Rating Scale (UPDRS) School of Allied Health, Exercise and Sports Sciences 7 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 7 Medications ■ Medication is the primary intervention for the treatment of symptoms related to PD (it does not influence progression). ■ Levodopa: Is synthesised into dopamine in the brain. □ Remains the mainstay of treatment for PD. □ Single most effective medication available to treat all cardinal symptoms. □ Always combined with carbidopa to prevent systemic adverse effects due to lower doses needed (Sinemet). □ About 40% of people treated with levodopa will develop motor fluctuations within six years of treatment (“On/off fluctuations”). School of Allied Health, Exercise and Sports Sciences 8 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 8 Medications ■ Dopamine agonists: Mimic the effects of dopamine without having to be synthesised. □ A front-line medication for symptom management. □ Can use used with levodopa in later stages of disease. ■ Anticholinergics: Block ACh synthesis counteracting the imbalance between Ach and dopamine. □ These drugs are most helpful to younger clients with PD whose chief complaint is a tremor. School of Allied Health, Exercise and Sports Sciences Note the two main classes of medications 9 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 9 Deep Brain Stimulation ■ Individuals with severe PD may undergo surgical treatment. ■ Deep brain stimulation (DBS) in PD involves electrical stimulation of the deep brain nuclei associated with the basal ganglia. ■ It is the surgical intervention of choice when motor complications are inadequately managed with the medications. ■ The stimulation is adjustable and reversible. ■ DBS is more effective than medical therapy in advanced PD in improving tremor, dyskinesia, motor function, and quality of life. School of Allied Health, Exercise and Sports Sciences 10 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 10 Benefits Of Exercise In Parkinson Disease ■ Regular exercise can decrease or delay secondary effects on musculoskeletal and cardiorespiratory systems that occur as a result of reduced physical activity. ■ Evidence demonstrates that exercise improves gait performance, quality of life, reduces disease severity, and improves aerobic capacity in individuals with PD. ■ Because PD is a chronic progressive disease, sustained exercise is necessary to maintain benefits. Note these general benefits of exercise ■ Exercise might also play a neuroprotective role in individuals with PD. School of Allied Health, Exercise and Sports Sciences 11 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 11 Pre-Screening And Assessment ■ Performed using ESSA Adult Pre-exercise Screening Tool. ■ Motor assessment to determine functional impairments: □ Postural assessment. □ Gait limitations. □ Bradykinesia, akinesia, gait freezing, tremor, rigidity, spasms. ■ Medication issues: □ Responsiveness to meds. □ “On/off” fluctuations. School of Allied Health, Exercise and Sports Sciences 12 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 12 Pre-Screening And Assessment ■ Falls history should also be recorded: □ Clients with PD with more than one (1) fall in the previous year are likely to fall again within the next 3 mths. ■ Don’t forget about non-motor symptoms: □ Cognition/dementia. □ Sleep. □ Depression. School of Allied Health, Exercise and Sports Sciences 13 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 13 Comorbidities With Parkinson's Disease ■ PD is associated with a number of comorbidies. ■ Incidence of comorbidities is often age-dependent. ■ Thorough pre-exercise screening of PD clients is essential. Jones et al. (2012). Parkinsonism Relat Disord, (18)10); 1073-1078. School of Allied Health, Exercise and Sports Sciences 14 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 14 Considerations with Exercise and PD ■ Safety first – choose and modify to limit risk with balance, falls and mobility issues. ■ Multimodal and Multidimensional exercises – Suggest Flexibility, CV, Strength, Balance and coordination. ■ Adaptation and Progression ■ Medical Clearance – note medications, comorbidities like Autonomic nervous system dysfunction can also occur in PD School of Allied Health, Exercise and Sports Sciences 15 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 15 Medication considerations with exercise and PD ■ Does Parkinson's disease (PD) medication affect the autonomic responses of individuals during acute exercise? ■ Fourteen people with PD and fifteen healthy individuals age-matched between 50 and 80 years performed a modified Bruce protocol. ■ Autonomic abnormalities during exercise in this population appear to be disease manifested and not impacted by medications used to treat PD DiFrancisco-Donoghue et al. (2009). Movement Disorders, 24(12); 1773-1778. School of Allied Health, Exercise and Sports Sciences 16 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 16 Effect of PD Medications On The Exercise Response ■ Carefully review PD medications for possible effects on exercise. ■ Levodopa/carbidopa may produce exercise bradycardia and transient peak dose tachycardia and dyskinesia. ■ Use caution when medications have recently changed because the response may be unpredictable. School of Allied Health, Exercise and Sports Sciences 17 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 17 Balance, Mobility And Gait Assessment ■ Balance and mobility evaluation should be used in making decisions regarding testing modes for test validity and safety. ■ Possible assessments (static/dynamic): □ □ □ □ □ □ □ □ □ □ Functional reach test. Tandem stance. Single limb stance. Pull tests. 360 turn. Timed Up and Go. Chair sit-to-stand. Tandem walk. Berg Balance Scale. 10-m walk test at a comfortable walking speed. School of Allied Health, Exercise and Sports Sciences 18 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 18 Cardiorespiratory Assessment ■ Test selection will be influenced by disease severity and balance/mobility: □ Treadmill testing. □ Cycle ergometry. □ 6-min walk test. ■ Follow ACSM absolute and relative contraindications to exercise testing. School of Allied Health, Exercise and Sports Sciences 19 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 19 Cardiorespiratory Assessment ■ Use of symptom-limited exercise testing is strongly recommended. □ Symptoms include fatigue, shortness of breath, abnormal BP responses, and deteriorations in general appearance. ■ Monitor physical exertion during testing by using RPE due to blunted cardiovascular response to exercise. ■ Individuals with PD may experience orthostatic hypotension because of the severity of PD and medications. □ Medications taken should be noted prior to performing the exercise test. School of Allied Health, Exercise and Sports Sciences 20 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 20 Muscle Strength Assessment ■ No preferred method for assessing muscle strength in PD. ■ Possible assessments: □ □ □ □ □ Manual muscle testing. Max reps performed with given load. Multiple RM load. Weight machines. Dynamometers. ■ Consider client safety when selecting test type. School of Allied Health, Exercise and Sports Sciences 21 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 21 Posture, Flexibility And Joint ROM Assessment ■ Postural changes are a hallmark characteristic of PD. ■ Postural changes can impact balance, mobility, falls, and exercise capacity. ■ Flexibility is reduced in PD due to postural changes and rigidity (upper body, trunk, shoulders etc). ■ Flexibility can be measured by using goniometry, the sit-and-reach test, and the back scratch test, etc. School of Allied Health, Exercise and Sports Sciences 22 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 22 Balance, Mobility, And Gait Training for PD ■ Balance, mobility, and gait training and mobility is crucial in PD. ■ Static, dynamic, and balance training during functional activities should be included. ■ Exercises may include a variety of challenging activities: □ □ □ □ □ Stepping in all directions, Step up and down. Reaching forward and sideways. Obstacles, turning around, Walking with suitable step length, standing up and sitting down). ■ Take steps to ensure the individual’s safety. School of Allied Health, Exercise and Sports Sciences 23 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 23 Cueing to support re-training PD learning. ■ Basal ganglia cannot provide correct cueing for motor sequencing. ■ External cueing may help to “bypass” basal ganglia circuitry. ■ Types of cues: □ Visual. □ Auditory. □ Somatosensory. School of Allied Health, Exercise and Sports Sciences 24 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 24 Recommendations For Cardiorespiratory Exercise Programming ■ Guidelines for healthy adults generally apply to PD with consideration of limitations imposed by the disease. ■ ■ ■ ■ Frequency: 3-5 days/week. Intensity: 40-80% MHR or RPE of 11-15. Time: ≤60 min of continuous or accumulated exercise. Type: Walking, cycling, or swimming dependent on the individual’s clinical presentation: ■ Stationary cycle, recumbent cycle, or arm ergometer are safer modes for individuals with more advanced PD. School of Allied Health, Exercise and Sports Sciences 25 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 25 Recommendations For Resistance Exercise Programming ■ Resistance training increases strength in individuals with PD similar to health individuals but the majority of interventions has been conservative. ■ Recommendations for resistance exercise in healthy older adults may be applied to individuals with PD. ■ ■ ■ ■ Frequency: 2-3 days/week. Intensity: 40-70% of 1-RM. Volume: Initially ≥1 set of 10-15 reps; then ≥1 set of 8-12 reps. Type: Emphasise extensor muscles of the trunk and hip to prevent faulty posture and all major muscles of lower extremities to maintain mobility. School of Allied Health, Exercise and Sports Sciences 26 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 26 Recommendations For Flexibility And Joint ROM Exercise Programming ■ Flexibility and ROM exercises are important for slowing postural changes and effects of reduced physical activity and rigidity. ■ Frequency: 1-7 days/week. ■ Intensity: Full extension, flexion, rotation, or stretch to the point of slight discomfort. ■ Time: Hold stretches for 10-30s. ■ Type: Slow static stretches for all major muscle groups should be performed with a focus on the upper extremities and trunk. □ Spinal mobility and axial rotation exercises are recommended for all stages. □ Neck flexibility exercises should be emphasised as neck rigidity is correlated with posture, gait, balance, and functional mobility. School of Allied Health, Exercise and Sports Sciences 27 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 27 Special Considerations For Exercise ■ Cognitive decline and dementia are common non-motor symptoms. □ Consider issues for exercise delivery and client communication. ■ Incorporate falls prevention and education into the exercise program. ■ Consider using dual tasking or multitasking activities for balance/gait. □ Attention may be limited in PD clients and decrease with progression □ Multitasking may better prepare an individual for balance perturbations. □ Incorporate dual tasking into balance training when they perform well in a single task. ■ Given consideration to the development and management of fatigue. ■ On/off fluctuations and timing of medications and exercise. School of Allied Health, Exercise and Sports Sciences 28 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 28 Summary ■ Diagnosis is generally based on medical history and the presence of signs and symptoms during examination. ■ Treatment PD involves symptom management via medications or surgery. ■ PD medications can have implications for exercise capacity and performance and it is important to be aware of their individual effects in each client. ■ Exercise responses can vary substantially between PD clients so close monitoring is important. ■ PD clients have an increased risk of falling and balance, mobility, and gait assessment should be performed in most clients. ■ General recommendations for programming in PD should include a comprehensive exercise regime that aims to improve or reduce the rate of functional decline with disease progression. School of Allied Health, Exercise and Sports Sciences 29 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 29 Other resources ■ Helpful clinical apps: https://apps.apple.com/au/app/walking-tall/id1450872540 https://apps.apple.com/au/app/beats-medical-parkinsons-app/id866567480 https://apps.apple.com/au/app/tremor-analysis/id1579194791 ■ https://www.parkinsons.org.au/ ■ https://www.healthdirect.gov.au/partners/parkinsons-australia ■ https://shakeitup.org.au/understanding-parkinsons/ ■ https://www.michaeljfox.org/ ■ Parkinsons Dance https://vimeo.com/122531753 School of Allied Health, Exercise and Sports Sciences 30 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 30