OK, so I'm going to talk about physical therapy in Parkinson's
disease.
Just a show of hands.
Who has participated in physical therapy at this crowd?
OK, good.
Wow.
Excellent.
So you'll be familiar with some things I review.
A little bit about me.
My name is Karen.
I got my doctorate in physical therapy back in 2006.
And part of my physical therapy doctoral program
was to specialize in a topic, and I
chose neurological disorders.
And I did a affiliation at the Adele Smithers Parkinson's
Treatment Center out on Old Westbury, Long Island.
So I exclusively treated Parkinson's patients
and did a lot of research in the field to obtain my doctorate.
And I've been treating patients ever since.
So this presentation will include an overview
of the effectiveness of exercise to treat
PD, a review of exercise regimens,
and then an overview of assistive devices
that you can use.
So is physical therapy effective to treat symptoms
of Parkinson's disease?
Yes.
Studies show that people that receive personalized PT
sessions as opposed to just doing home-based exercise
alone have better outcomes.
Studies show that people who receive
personalized one-on-one PT sessions
have better outcomes than group PT sessions.
And then there's large amounts of research showing
that several different types of exercise and wellness
will improve the symptoms of Parkinson's disease.
So the research is there.
Based on a review of 39 different trials,
physical therapy compared to no intervention at all improved
people's gait speed, endurance, freezing episodes,
functional mobility, balance, and functional disability.
So basically, everything.
Well, what type of exercise is the best?
That's what I get a lot of questions on.
And the fact is that there really is no golden standard.
There was a systematic review of 43 different trials
and they couldn't find what was better than the other.
More studies have to be done to accurately compare
the effectiveness of one form of exercise versus another
when working with patients who have Parkinson's disease.
So I tell my patients, pick an exercise
that has been proven to be effective,
and something that you enjoy doing.
Because motivation is key.
Continuity is key.
All of these studies that are out there, and there's
well over 100 of them, all of them
show very positive short-term outcomes, and not
so much long-term outcomes.
So for instance, if you're on a cycling program
and you stop for a few months, you
may lose the benefits that you gained right
after you finished cycling.
So what exercises will a physical therapist do with me?
These are four main categories that you can expect--
aerobic activity, strength training, gait training,
and balance training.
So I want to review aerobic activity.
When I treat my patients, I stress this more than anything.
Aerobic activity has been shown in multiple trials
to have an immediate positive effect on not only function,
but balance and gait.
So some aerobic activities that have been proven effective
include treadmill training, that's
full weight-bearing or partial weight-bearing, where you're
actually unloaded by kind of a harness device
on the treadmill.
Tai Chi, like Dr. Shtilbans was talking about,
has been proven for over a decade now to be effective.
Walking programs, dancing, which also has an added plus--
the rhythmic cuing has been seen to be beneficial as well.
And then my personal favorite, because it's
pretty low-risk for injury, is cycling.
Now the regimen that's been proven effective
is 45 minutes, three times a week, at 80 to 90
RPM, so revolutions per minute.
That's very intense cycling for anyone.
It's called forced exercise when you cycle or do
any aerobic activity that is outside of your comfort zone.
It's basically, this study took place, the cycling study,
and there were trainers and cycling instructors,
and they were, "Go.
You could do this.
Push harder.
Push harder."
That's forced exercise.
When you take someone and put them on a bike and say,
do the bike for 20 minutes.
Get your heart rate going.
That's not as effective as somebody
really forcing you to push to your max.
So if you're not going to join a group cycling class
or go to a physical therapist just
for the sheer fact of doing a cycling program,
there's a cycle you can buy at home.
It's pricey for sure.
But I wanted to throw it out there just
to let you know there is something out there.
It's called a Theracycle, and it's
a motorized bicycle that does assist
you to exercise at a faster pace than you can do on your own.
So it mimics forced exercise, which
has been shown to be very effective.
There's models for people that are wheelchair bound,
people that just can't get out of a chair
and transfer onto a bike.
There's models that include arm and trunk motion.
And you have ones that have adaptable seats and pedals.
So there's a bunch of different types.
A couple of my patients do have these at their homes,
and they do find it effective.
So next thing we're going to talk about
is strength training.
A review of trials looking at progressive resistance
exercise, which is what we would know as strength training,
did show that people with mild to moderate forms
of Parkinson's disease got stronger,
and they also had more walking endurance.
Unfortunately, it didn't seem to improve function.
So as far as being prescribed progressive resistance
exercise, which is typically what we think of weight
training, if you have mild to moderate form of Parkinson's
and your main goal is to improve your gait capacity,
that's what you should be doing.
Another form of strength training-- another program,
I should say-- that incorporates exercises that
will make you stronger is something called LSVT BIG.
Has anyone heard of that here?
You guys have.
OK, great.
So it's kind of a weird name for PT
because it's called Lee Silverman voice treatment.
And Lee Silverman just happened to be
the name of the first patient who
received voice therapy where the goal was to encourage thinking
big, thinking loud, exaggerating your typical motions
and typical speech patterns.
And Shara is going to talk more about this next.
So LSVT BIG is really an intensive one-on-one treatment.
It was created to help people with Parkinson's disease
address gait, balance, and difficulties with activities
of daily living.
The main point is to recalibrate how you're
perceiving your movements.
Because we all know that you feel
that you're doing something on a normal scale,
but it may appear to be smaller than the typical motion.
Your gait may be smaller strides,
but you feel like you're walking completely normal.
So this really works with the premise of thinking,
I need to do bigger motions.
I need to reach bigger.
I need to reach higher.
I put the website on the bottom just
so you guys could look it up if you're not familiar with it.
So it's a very intense regimen.
The studies that show this to be effective,
the people were doing these exercises for one hour,
four days in a row, four weeks in a row.
So you kind of got to separate a lot of time out of your day
to perform these.
On top of this, they were doing daily home exercises,
all with the premise of think big.
So these are just a few of the exercises.
A lot of them are done in chairs.
So safety is good, I think, with this.
I have done this exercise regimen
with quite a few of my patients.
So for instance, you start in a position,
you reach in a big way in a direction.
And then you end big with upright posture.
And you repeat that several times.
The next thing I want to talk about just
briefly is gait training.
Gait training can be done on the treadmill effectively.
So one of the studies that I thought was pretty interesting
was treadmill training, one hour, three days a week,
for anywhere between three to six months.
Things that helped these patients out-- auditory cues,
take longer strides, heel-to-toe, the addition
of music, rhythmic cuing.
And then also, just verbal encouragement
help these people to obtain safer gait in the long term?
Even up to six months after they stopped the gait training
program, people were still seeing
improvements in their gait.
Balance training.
And this is probably the number one thing
my patients worry about is preventing falls.
I want better balance.
I don't feel safe anymore.
So there was a fairly large study
of 70 people who had Parkinson's disease performing
four weeks of indoor balance training
and four weeks of outdoor balance training,
two hours per week, which is fairly attainable.
And they were compared to a control group where
it was just eight weeks of straight upper extremity
exercises.
And both groups were given a home exercise program
to do at home.
Now at the completion, and at a six-month follow up,
there were significant improvements in balance
and a reduction in injurious falls.
So falls that people said, yes, I hurt myself when I fall.
Not, no big deal.
I tripped and fell and I got right back up.
For the group that did the balance exercises,
so a very positive outcome.
Some of the exercises and training techniques
that they use in this study, and that you could actually
do in physical therapy with your PT,
are multisystem postural control strategies,
posture when you're sitting, posture when you're standing,
posture when you're going sit to stand,
stepping exercises, let's practice
walking over and around obstacles, basic strength
training, multitask training, floor transfers.
Let's get from the floor to a chair.
Walking with head turns, walking over various terrains.
And now let's just talk about fall prevention in general.
So through all my research over the past decade plus
there has never been a consensus saying,
exercise or any wellness activities really,
truly decrease your risk of falls.
Maybe it's a lighter fall.
But it's always a conflict.
One study will say, yeah, the falls were decreased.
The other study says, nope, it was the same as the placebo.
So there was limited evidence saying that you will
improve with exercise alone.
So I always encourage my patients
to live the safest lifestyle they can.
How do you prevent falls at home?
Assistive devices, like using a bench in the tub so
you don't have to step over the edge.
Using grab bars in the bathroom, so you
don't have to really put too much effort and body
rocking into getting off the toilet.
Safety with a wet floor in the shower.
Raised toilet seats, giving yourself a little extra boost
when you stand.
Using gate assistive devices, such as the rollater, which
you could also use as a chair if you become fatigued.
Eurostyle Lofstrand crutches, so you could still
have your normal gait pattern with a normal swing.
But you're using crutches for just more stability.
Or a typical rolling walker, which I feel like many people
don't get.
You get it in the hospital, and then you
use something a little bit less cumbersome
in the long run, typically.
You could also use canes.
So for people that have freezing episodes as one
of their major forms of disability,
you could use a laser cane.
The laser cane provides you a cue, a visual cue, to tell you,
I need to advance my step to this point.
And it's been proven to decrease the amount of freezing episodes
while walking.
Also if you're just looking for a basic cane,
this is my favorite, with the website, hurricane.com on it.
It's a tripod-based cane that accommodates
all types of terrain by allowing 10 to 15 degrees of motion
at the base of the cane.
It also folds up so you don't need to hold it all the time.
Comes with a wrist strap so you can not have it fall.
Because that's the worst.
You have a cane, you put it down, it falls.
And then people now with bad balance
are picking something up from the floor,
which you definitely don't want to do.
And it has the arthritic grip, which I like.
So what do you do now?
You have all this knowledge.
And what's the next step?
Well, you need to be medically cleared.
Because just because you do have Parkinson's disease
doesn't mean that you're able to exercise,
because you could have potential comorbidities.
So make sure you're medically cleared.
You want to obtain a prescription
for physical therapy.
And really all it needs to say on it
is the diagnosis, the amount of times
that you are recommended to go to physical therapy,
and the length of the prescription, which
is in the state of New York, up to 12 weeks
before you really need another script.
Find a physical therapist that has
experience working with patients with Parkinson's disease.
And if you don't have luck finding one,
at least bring them this PowerPoint
with all these references.
I referenced every name of the primary investigator
in all of the studies that I was referencing to you.
And they can also do a quick Google search.
And then arm yourself with knowledge.
If you feel that you're getting told
to do something that is harmful to you in any way, say,
this has been shown to not be effective.
Or this may be not the best use of our time together.
Make each PT session as productive as possible.
Keep on reading.
Stay motivated.
Because remember, you need to keep on exercising basically
forever, which is beneficial in so many other ways.
But stay motivated and get support if you need it.