Parkinson’s Disease Foundation

PD ExpertBriefing: Understanding the Progression of Parkinson’s

Led By: Ronald F. Pfeiffer, M.D.

To hear the session live on: Tuesday, June 26, 2012

at 1:00 PM EDT.

DIAL: 1 (888) 272-8710 and enter the passcode 6323567#.

To also view the session live on the computer by visiting:

http://www.pdf.org/parkinson_briefing_progression

If you have any questions, please email webcast@pdf.org

or call (212) 923-4700

Parkinson’s Disease Foundation

PD ExpertBriefing: Gait, Balance and Falls in Parkinson’s Disease

Led By: Terry Ellis, Ph.D., P.T., N.C.S.

To hear the session live on: Tuesday, January 15, 2013

at 1:00 PM ET.

DIAL: 1 (888) 272-8710 and enter the passcode 6323567#.

To also view the session live on the computer by visiting:

http://event.netbriefings.com/event/pdeb/Live/falls

If you have any questions, please contact

Valerie Holt at vholt@pdf.org or call (212) 923-4700

Introduction

Robin Anthony Elliott Executive Director

Parkinson’s Disease Foundation

PD ExpertBriefing: Gait, Balance and Falls in

Parkinson Disease

Terry Ellis, Ph.D., P.T., N.C.S. Director, Center for Neurorehabilitation Boston University College of Health and Rehabilitation Sciences: Sargent College

Goals for PD ExpertBriefing

•  Gain a better understanding of the nature of walking and balance problems experienced by people living with Parkinson's disease.

•  Learn about research that demonstrates the benefits of

rehabilitation and exercise to improve walking and balance in Parkinson’s disease.

•  Learn practical strategies to help improve walking and

reduce fall risk as it applies to you, or a loved one or a patient living with Parkinson's disease.

•  Slow walking •  Short, shuffling steps •  Foot drags or “catches” •  Arms swing less •  Stooped posture •  Difficulty initiating walking •  Difficulty turning

Problems with Walking in Parkinson’s Disease

•  Hypokinesia (small size of movements) •  Rigidity (stiffness) •  Freezing •  Weakness in the lower extremity muscles •  Reduced mobility of the joints in the lower

extremity and the spine

Why is Walking Problematic in Parkinson’s Disease?

Walking and Disability in Parkinson’s Disease:

Is There a Link?

Walking and Disability in PD

Difficulty with “ambulation”

is “Clinical Red Flag”

that marks emerging disability

Shulman L. Movement Disorders , 2010; 25 (1):S131-135

WALKING DISTANCE: 6 MINUTE WALK TEST

Patients Park-net trial

Controls Aging study

N 699 1959

Men 409 (58.5%) 921 (47.0%)

Age 68.6 (±7.7)

65.8 (±7.0)

Time since diagnosis

5.3 (±4.7)

Nimwegen MV. Physical Inactivity in Parkinson’s disease. J Neurol. 2011;258(12):2214-21

77 327 243 34 11% 47% 35% 5%

People with PD were about 1/3 less active (29%) compared to healthy elders.

Variable Baseline      

Mean  (SD)  [95%  confidence  interval]

One  year      

Mean  (SD)  [95%  confidence  interval]

Magnitude  of  Change    

(%  change  /  Effect  size#)

Age  (years)" 67.06  (8.75)  [64.01-­‐70.11]"  "  "

Years  with  PD" 4.44  (4.24)  [2.97-­‐5.91]"  "  "

Hoehn  and  Yahr  Stage  (median)" 2.0  (1-­‐3)" 2.0  (1.5-­‐3)"  "

LEDD  (mg)" 303.03  (294.38)  [197.77-­‐408.29]" 423.49  (359.66)  [296.13-­‐550.84]" 28  /  0.37"

         Steps*" 10,261.15  (4332)    [8625-­‐11,645]"

9159.44  (3534)    [7887-­‐10,325]"

-­‐12  /  0.28"

         Moderate  intensity  minutes*" 22.5  (24.2)    [13.7-­‐30.4]"

16.1  (18.7)      [9.2-­‐22.1]"

-­‐40  /  0.30"

MDS-­‐UPDRS  Motor  subsecYon" 28.18  (8.56)  [25.15-­‐31.22]" 28.52  (11.71)  [24.36-­‐32.67]" -­‐1  /  0.03"

MDS-­‐UPDRS  Item  3.10  (median)" 1  (0-­‐2)" 1  (0-­‐2)"  "

6  minute  walk  (meters)" 480.52  (135.61)  [432.43-­‐528.60]" 495.96  (154.60)  [440.23-­‐551.71]" 3  /  0.11"

Maximal  Gait  Speed  (meters/sec)" 1.77  (.50)  [1.56-­‐1.95]" 1.74  (.53)  [1.60-­‐1.96]" -­‐2  /  0.06"

Changes in Ambulatory Activity in People with PD Over One Year

Cavanaugh JT, Ellis T, Earhart GM et al. JNPT;2012:36:51

•  Slow progression of disability •  Optimize independence and participation in

home, work and leisure activities •  Improve walking

–  Speed – Distance –  Size of movements – Turning ability

Goals for People with Parkinson’s Disease

•  Practicing walking can improve walking •  Walking with a metronome or music can

help improve coordination, timing, speed and efficiency of walking

•  Using a pedometer can help with setting

goals and providing feedback about progress

Solutions

•  Auditory •  Visual •  Tactile •  Verbal •  Attention (thinking about the movement) •  Combination of Above

Solutions: Cueing

•  Replace the lost internal cueing mechanism with an external cueing mechanism

•  Acts as an internal “cue” or “trigger” to enable movement sequences to be carried out implicitly, automatically and without attention

How Does Cueing Work?

Reference Intensity Intervention________ •  Nieuwboer (2007) 3x / week Auditory, vibration or visual cue

E=153 30 mins at preferred frequency 3 weeks

PRACTICE TASKS »  starting and stopping walking

stepping sideways & backward walking – dual task

walking over uneven surfaces

Home Cueing Program

Results  •  +  step  length  •  +  velocity  •  decreased  freezing  •  no  carry  over  effects  at  6  wks  

•  Rhythmic Auditory Stimulus (RAS) – Metronome – Tone embedded into instrumental music

• 80 beats / min • 100 beats / min • 116 beats / min

– Music with a specific tempo

Delivery of Auditory Cues

   

Video Demonstrations      

NO CUES WITH CUES

People with PD can improve their walking

ability by using visual cues

               

 

A B C D E

EFFECTIVE CUES INEFFECTIVE CUES

1 foot

6 feet

Adapted from Martin, 1967 Orientation of Lines

     

Can People with Parkinson’s Improve Balance? … Lessen Risk of Falls?

Frequency of Falling

•  One third of healthy older adults over 65 experience a fall

•  Two thirds of people with PD living in the

community report falling in the past 12 months

Ashburn et al. Age Ageing (2001)

When, Where, How Do Falls Happen?

•  N = 124 (age = 72; disease duration = eight years) •  639 falls occurred •  80% occurred at home

–  Bedrooms –  Living areas –  Kitchens –  Gardens

•  45% of falls during walking •  32% during standing •  21% during transferring

Ashburn et al. Disabil Rehabil 2008;30(16)

Allen et al. Balance & Falls in PD: A Meta-analysis of the Effect of Exercise and Motor Training. Movement Disorders. 26(9):1605-1615.

Effects of Tai Chi on Falling in PD

•  195 persons with Parkinson’s disease •  Assigned to one of three groups:

–  Tai Chi – Resistance training –  stretching

•  Twice a week for 60 minutes over 24 weeks •  Incidence rate of falls was significantly lower in the Tai

Chi group compared to the stretching group •  No significant difference was found between the Tai

Chi and strengthening group

Fuzhong Li et al. N Engl J Med 2012;366:511-9

Effects of Balance and Strengthening on Falling

Goodwin VA et al. J Neurol Neurosurg Psychiatry 2011;82:1232-1238

•  N=130 •  Subjects: PD with

history of >2 falls in past year

•  RCT •  10 wk group Rx vs

usual care •  Strength and balance

training •  Led by PT •  Differences in fall rate

between groups not stat sig but clin relevant?

•  32% difference in fall rates between groups during Rx

•  26% difference 10-wks post Rx

Example Exercises

Recommendations

•  Be Active! •  Take action to reduce disability and optimize

independence and quality of life •  Treatment focusing on walking and balance can help

reduce disability •  Think prevention: Get treatment for walking and

balance even before you notice a problem •  Consult with a physical therapist who is knowledgeable

about Parkinson’s disease

•  Walk More: –  Use a pedometer –  Keep track of steps: write it down –  Set goals: # of steps per day –  Walk better: use a metronome or music to “entrain” to the beat

•  Improve Balance: –  Practice balance exercises (visit a physical therapist) –  Strengthening exercises (practice standing up from a chair)

•  Reduce Fall Risk: –  When standing still ... widen your base of support by standing with your feet

apart and not together –  Avoid multi-tasking … this will result in more attention directed at walking

and keeping your balance –  Reduce clutter in your house … crowded environments contribute to freezing –  Fall diary … write down the time of day, direction, activity, environment

where the fall occurred and look for patterns

Things You Can Do Today

Resources •  APDA Rehab Resource Center at Boston

University Exercise Helpline •  (888) 606-1688 or rehab@bu.edu

•  PDF General Helpline •  (800) 457-6676 or info@pdf.org

Questions About Exercise?

Resources from PDF Fact Sheets •  Falls Prevention •  Physical Therapy

and Parkinson’s

Parkinson’s Disease Resource List •  750 Resources

PD ExpertBriefings: •  Physical Therapy & Parkinson’s: What You Need to Know •  Also available as DVD

Professional Education: •  Online course.

PTs, rehab specialists can earn .8 CEUs.

Questions & Answers

Upcoming PD ExpertBriefings Under-recognized Non-Motor Symptoms of Parkinson's Disease Tuesday, March 12, 1:00 PM – 2:00 PM ET K. Ray Chaudhuri, D.Sc., M.D., Kings College London, London, UK Medical Therapies: What's in the Parkinson's Pipeline? Tuesday, April 16, 1:00 PM – 2:00 PM ET Kapil D. Sethi, M.D., F.R.C.P., Georgia Health Sciences System, Augusta, GA Improving Communication in Parkinson’s: One Voice, Many Listeners Tuesday, June 4, 1:00 PM – 2:00 PM ET Angela Roberts-South, M.A., C.C.C.-S.L.P., C.A.S.L.P.O .(Reg.), Ph.D. Candidate, Western University, Ontario, Canada

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