Vivas Benefit of aquatic exercise for Parkinson’s disease ... (2016) Benefit … · Benefit of...
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Benefit of aquatic exercise for Parkinson’s disease
Jamile Vivas Costa Psychosocial intervention and functional rehabilitation research group,
Department of Physiotherapy
FACULTY OF PHYSIOTHERAPY OF A CORUÑA
Content
S Overview of Parkinson’s disease
S Motor and Non-motor symptoms (ICF impairments)
S Evidence of Aquatic exercise and PD
S Guidelines recommendations
Parkinson's disease (PD)
S Parkinson’s disease is an idiopathic, slowly progressive degenerative CNS disorder
Pathophysiology PD
Clinical Features = TRAP
S Tremor at rest
S Rigidity
S Akinesia (or bradykinesia)
S Postural Instability
S Flexed posture and freezing
Jankovic, J Neurol Neurosurg Psychiatry 2008
Tremor
S RESTING TREMOR
S Unilateral
S Frequency 4 and 6 Hz,
S Prominent in the distal part of an extremity
“pill-rolling’’
Rigidity
S Rigidity is characterized by increased resistance, usually accompanied by the ‘‘cogwheel’’ phenomenon.
S It may occur proximally and distally
S Involves both flexor and extensor muscles
S Small muscles of face, tongue, larynx
Rohkamm, Color Atlas of Neurology © 2004 Thieme
Rigidity
Postural deformities
Bradykinesia
S Slowness of movement
S Slowness of initiation of voluntary movement with progressive reduction in speed and amplitude of repetitive actions
S Reaction time is also increased
MICROGRAPHIA
Postural Instability
S Normally it doesn't appear early in PD gait and balance disorders
S PIGD Type
S Anticipatory and compensatory righting reflexes are impaired
S Inability to make appropriate postural adjustments
Postural Instability
S Hesitation in starting to walk
S Steps are short, lacking heel strike and toe off
S COG falls anteriorly
S Festination
S Freezing briefly
S Turning in block
S Diminished or reduced arm swing and pelvic rotation.
Parkinson’s gait
Postural Instability
https://www.youtube.com/watch?v=ITv2SJjuAB8
ICF for Parkinson's disease
ICF for Parkinson's disease
Body functioning and structure
Impairments in Motor functions:
S Neuromusculoskeletal and movement-related functions
S Cardiovascular and respiration
S Digestive system
S Voice and Speech
S Postural deformities: Kyphosis and flexed hip and knees
ICF for Parkinson's disease
Body functioning and structure
Impairments in Non Motor functions
ü Autonomic dysfunction: orthostatic hypotension
ü Cognitive decline: dementia
ü Neurobehavioral disorders: depression, anxiety, psychosis
ü Sleep abnormalities: excessive sleepiness, sleep attacks
ü Sensory: olfactory dysfunction, pain, paraesthesia, akathisia
S Executive dysfunction: attention, set shifting and concentration such as planning, decision-making.
• Up to 70% of pwp experience non-motor symptoms and they may even be present in the early stage of the disease.
ICF for Parkinson's disease
Activities S Transfers
S Dexterity
S Self-care
S Communication
S Eating
S Gait
Participation S Domestic life
S Interpersonal relationships
S Major areas: work
S Community, social and civic life
Course of Parkinson's disease
S The natural progression of PD is variable (high and unpredictable)
S The number of impairments in functions, activity limitations and restrictions in participation will increase.
S Pwp are likely to become inactive.
S Increase their risk of co-morbidities.
S The loss in QOL increases with disease progression.
Parkinson's disease
No cure for PD TREATMENT OPTIONS
Pharmacological Therapy Surgical Rehabilitative care
Levodopa and other dopaminergic drugs
Deep brain stimulation (DBS)
Multidisciplinary approach
Parkinson's disease
Rehabilitative care
Neuropsychologist Speech Therapy Occupational Therapy Physiotherapy
The role of physiotherapy in objectively decreasing the severity of signs of the disease has not been fully addressed.
Effects of Aquatic exercise for PD 20
references found
3 RCT
Volpe et al 2016
Volpe et al 2015
Vivas et al 2011
9 pre-post
Pérez-de la Cruz et al 2016 Ayan & Cancela 2012a Ayan & Cancela 2012b Brugghemans 2011 Jacobs et al 2012 Pellechia et al 2004 Pospisil et al 2007 Queiróz et al 2007 Morini et al 2002
4 case studies
Coelho et al 2012 Hartley et al 2010 Lopez & Ferreira 2008
1 economic
Brefel et al 2002
3 reviews
Methajarunon et al (2016) SR Swarovsky et al (2015) SR Figueiredo (2008)
� To provide methodological information regarding progression within the program for a future larger trial.
� To assess and compare 2 different protocols of physiotherapy (land or water therapy) for people with Parkinson’s disease (PD)
Objectives
� Idiopatic Parkinson’s disease � 15 participants (8 ♂ y 4 ♀)
� 67.7 ± 5.5 years
Inclusion criteria Exclusion criteria- ≥ 24 no MMSE - Hoehn & Yahr II-III
- To follow a stable medication schedule
- Unable to walk independently - Surgical treatment for PD
Participants
Trial Flowchart
design
• Ferrol Parkinson’s Association - Spain • Performed in OFF-dose • Aquatic intervention - city spa. • Pool: 3.55m x 7.75m,1.30m deep; T 32ºC (89.6ºF).
First baseline assessment
(PRETest)
LAND-BASED PROGRAM
(Active control) 4w
WATER-BASED PROGRAM
(Experimental) 4w
Assessment
after intervention
(POSTtest)
Follow-up assessment
after 17 days
(POSTtest-2)
Study design
� Functional Reach Test (FRT)
� Berg Balance Scale (BBS)
� Timed Up and Go (TUG) � Gait: normal, preferred walking pattern.
Photocells and recorded by a video camera.
3m
� Unified Parkinson’s Disease Rating Scale (UPDRS)
Assessments
4 weeks, twice a week, nonconsecutive days
Experimental group - Water-based therapy Active control group – land-based therapy
1. Warm-up exercises 2. Trunk mobility exercises (Rotations from Halliwick concept) 3. Postural stability training 4. Task-oriented training
(n = 6) (n = 6)
Interventions
1. Warm-up exercises
Interventions
- Sagittal rotation (SR)
- Transversal rotation (RT)
2. Trunk mobility exercises
Interventions
- Balance control on standing - Balance control with 1 leg resting on a step
3. Postural stability training
Interventions
- Reaching forward, right and left directions - Sit to Stand training
4. Task oriented training
Interventions
Therapies significantly improved the functional reach in the same way. Only the group receiving AT improved the BBS and UPDRS
Results - Effect of the Therapies
Results - Effect of the Therapies
Considerations
S This pilot study shows the impact of an aquatic physiotherapy protocol on postural stability in PD
S Study Limitations: placebo group; duration of interventions; drug state of participants…
S Aquatic therapy in this protocol seems to be more effective than land-based protocol
S The preliminary positive results suggested that the intervention protocols seem suitable for PD
Study interventions and outcomes
Study interventions and outcomes
Evidence of Benefits of AT for PD
Conclusions
S Specific RCT using exclusively water-based therapy for people with PD are scarce
S Aquatic future CT should be aimed not only at reinforcing the view that physiotherapy is useful as supportive therapy in PD but also at investigating the extent to which AT protocols can provide further benefit.
S The variability of programs applied in studies make difficult comparison of results
Guidelines on PD
Guidelines on PD
Suggestions for future researches
GRADE-based recommendations
Keus et al. European Physiotherapy Guideline for Parkinson’s disease. 2016
(Cognitive movement strategies)