information - Association of Physiotherapists in Parkinson`s Disease

Transcription

11-7-2011
Welcome!
Organisers and Chairs
welcome & introduction
Dr. Samyra Keus & Dr Marten Munneke
Radboud University Nijmegen Medical Centre (RUNMC)
PhD Thesis 2010
Where you’re from?
North America?
What’s your job?
Patient Care ?
Europe?
Researcher?
Asia?
Africa?
South America?
South Pacific?
1
11-7-2011
What’s your PD experience?
Why are you here today?
To get the latest insights in Parkinson’s disease
To get the latest advances of physiotherapy in Parkinson’s
To get the latest advances of implementation of evidencebased physiotherapy in Parkinson’s disease
Beginner?
Skilled?
Block 1 – Parkinson’s disease
Block 2 – Interventions
11.30-12.50hr
09.50-11.00hr
Prof. Bastiaan Bloem
Parkinson’s disease and medical treatment
Prof. Meg Morris
Impairments, activity, participation and QOL
Prof. Margaret Mak
(Fear of) falls
Lunch - networking
Prof. Alice Nieuwboer
Festination and freezing
Dr. Erwin van Wegen
Understanding the mechanisms of cueing
Dr. Yvo Kamsma
Use of cognitive movement strategies
Prof. Lynn Rochester
Motor learning in PD
Block 3 – Interventions
13.50-14.50hr
Ann Ashburn
Use of falls diaries in clinical practice
Victoria Goodwin
Exercise to alleviate falling
Lee Dibble
High force resistance training
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11-7-2011
Block 4 – Future
15.20-17.00hr....17.30hr
Gert Kwakkel
Future perspectives of research
Maarten Nijkrake
ParkinsonNet
Mark Hirsch
Peer treatment
Samyra Keus
European guidelines
Marten Munneke
Panel discussion & take home messages
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13-7-2011
Mission impossible ...
Medical management of Parkinson’ss disease:
Parkinson
disease:
an update
Professor Bastiaan R. Bloem
Parkinson Center Nijmegen (ParC)
Radboud University Nijmegen Medical Center
Classical Parkinson’s disease
An expanding p
g
phenotype
A complex disease
NOT the cause of ALL symptoms!
Motor symptoms & signs
Additional symptoms & signs
Langston, Ann Neurol 2006;59:591‐596
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13-7-2011
Widespread lesions!
Important example
Falls are common in dementias
Parkinson’s disease is (also? mainly?) a neuropsychiatric disorder Results
Dual task problems (?)
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13-7-2011
Cueing and dual tasking in PD
Finding in freezers
Nanhoe‐Mahabier et al., submitted
Nanhoe‐Mahabier et al., submitted
Who is this?
The preclinical p
phase
What about this?
Neurology 2001,57:456-462
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13-7-2011
Parkinson SYNDROME
Diagnosing Parkinson’s disease
What is this?
And this?
This one is odd …
This is how it works
Parkinson’s disease
Symptoms that SHOULD be present
Symptoms that should NOT be present
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13-7-2011
An important distinction
Important role for allied health!
Atypical parkinsonism
Specific challenges
Allied health as a diagnostic tool
‘Bicycle sign’ for atypical parkinsonism
Main findings
Stopped cycling since diagnosis
P < 0.001
Aerts et al, submitted
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13-7-2011
Importance of compensation
(Deep) brain stimulation
Disease signs
Primary disease process
Compensatory strategies
Medical management
Allied health care
Freezing of gait
F
Freezing of gait
i
f it
Festination
Absent when being examined
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13-7-2011
The best test for freezing
Recommendations for clinical practice
Snijders et al., Parkinsonism Rel Disord, revision pending
Pathophysiology of freezing
Dopaminergic abnormalities
Dopa‐responsive freezing
Non‐
dopaminergic abnormalities
Dopa‐induced abnormalities
Courtesy of Alberto Albanese
Albanese et al., Neurology 2005;64:1958-1960
ON state freezing of gait
Espay et al., submitted
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13-7-2011
Two big dilemma’s
• When to start with treatment?
• Which drug to start with?
D
Drug treatment
t t
t
The source of the debate
Brand new guideline
Advantages NOW
Complications LATER
Beware of addiction!
Gambling
Drug addiction
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Fase 2
Modificatie van de ziekte
Verslechtering
Fase 1
Verbetering
Slowing disease progression?
Start
Effects for 1 mg per day
Effects for 2 mg per day
Deep brain surgery
Deterioration with time
2.5
3
Postural stability
2
Freezing of gait
2
1.5
1
1
0.5
0
0
Baseline
1 year
3 years
Postoperative
5 years
‐1
Baseline
1 year
3 years
5 years
Postoperative
Krack et al., N Eng J Med 2003;349:1925‐1934
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Delayed and selective deterioration
Stem cells
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Parkinson’s
disease
Page Title
/ heading goes
here
A slowly progressing neurological condition disease
Profile and progression of
impairments, activity limitations,
participation and quality of life in
•
•
•
•
•
•
Primarily affects the basal ganglia
1.5% older people - 6 million+ world wide
costs €5,000 to €10,000 per person per year
people with Parkinson’s and care-givers can experience substantial
home care costs and productivity losses
rate and level of disease are poorly understood
mapping disease progression – movement disorders – very important
Professor Meg Morris, PhD
Australia
Aim
of Physiotherapy
Page Title
/ heading
goes here
Parkinson’s
disease
Page Title
/ heading goes
here
“... To enable the person with PD to live well by
providing effective physiotherapy interventions
at optimal times to promote health and wellbeing and by educating the individual regarding
long-term self management strategies 1”
Impairments
Activity Limitations
Participation Restrictions
Quality of Life
1Morris, Marin
& Schenkman, Physical Therapy, 2010
Disease severity: modified
ICF
Page Title
/ heading
goesScale
here (1967)
Hoehn
& Yahr
Page Title / heading goes here
International Classification of Functioning, Disability and Health 1
Health
Parkinson’s
condition
(disease
Disease
or disorder)
H&YII
Hypokinesia
Body
function and
Tremor
structures
Postural instability
Rigidity
1WHO, 2001
Gait
Activities
Work
Participation
Transfers
Self-care activities
Education
Recreation
H&YI
Social support
Environmental
factors
Agefactors
Personal
Physical environment
Sex
Disease duration
Disease severity
H&YIV
H&YIII
H&YV
Sze-Ee Soh slide with permission
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PD/ heading
Medication
Status
Page Title
goes here
Impairments
Affects performance of well learned motor skills
Hypokinesia / bradykinesia
Freezing
Rigidity
Postural instability
Tremor (resting)
Dyskinesia
Dystonia
•
•
•
•
•
•
•
1.4
1.3
1.2
1.1
1
0.9
0.8
0.7
0.6
0.5
Cadence (steps/min)
Stride Length (m)
Hypokinesia: Stride Length Cadence Relationship
140
120
100
80
30
30
40
50
60
70
80
Three Dimensional Gait Analysis
40
90
50
60
70
80
90
Speed (m/min)
PD
Control
Morris et al. Brain 1994;117;1169-1181
Postural
Page Title
/ headingInstability
goes here &
Hypokinesia (off versus on)
Falls
Michael J Fox Trial Morris, Iansek et al.
FALLS
•
N=210
•
15 had incomplete calendars over 12 months
•
78 non-fallers in 12 months (40%)
•
117 fallers in 12 months (60%)
•
Total falls 1547 in 12 months
•
Maximum falls in an individual 277
•
Mode for falls in 12 months = 3
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Activity limitations
Freezing of gait
Do you walk normally?
Does gait affect ADL?
Freezing?
Feet Glued 52.2%
Freezing of Gait
How long?
Start hesitation 53%
Turning hesitation 52%
Affects performance of well learned motor skills]
•
•
•
•
•
•
•
Walking
Obstacle crossing
Turning
Sit to stand
Dressing
Handwriting
Driving ….
Quality
ofgoes
Lifehere
Page Title
/ heading
Participation Restrictions
Leisure, Work, Education, Societal roles...
Community ambulation Important
•
•
•
•
•
•
An individual’s perception of their position in life in
the context of the culture and value systems in
which they live and in relation to their goals,
standards, expectations and concerns1
22% fallers fell first in the community
74% fallers fell more than once
Community fallers fell less than non-community fallers
Falls in the community were more likely to result in an injury (56% compared
to 31%)
Community falls were more likely to need medical assistance (22%
compared to 6%)
Falls in the community are more often extrinsic / related to terrain than
intrinsic (such as freezing)
Lamont, Brauer, Morris et al (2010)
1World Health
QOL
dimensions
Page Title
/ heading
goes here
Organization, 2006
Research
Questions
Page Title
/ heading goes
here
1.
What are the factors that predict HRQOL in people with PD?
2.
How do people with PD rate their HRQOL?
3.
What are the main demographic factors, PD impairments and
activity limitations that contribute to HRQOL in PD?
Acknowledgement: Sze-ee Soh & Jennifer McGinley co-investigators
1Soh
et al, Physiotherapy 2011; S Soh with permission
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Study
1: Systematic
Page Title
/ heading
goes here
Electronic search
• Medline
• Web of Science
• CINAHL
• EMBASE
• PsychINFO
• Scopus
Review
Article
selection
Page Title
/ heading
goes here
Potentially relevant studies identified via
electronic search:
n = 1387
Key search terms
• Parkinson* disease
• Quality of life
• Health status
• Personal satisfaction
• Predict*
• Determinant*
• Prognos*
Duplicate studies identified:
n = 622
Studies excluded following
screening of titles and abstracts:
n = 680
Studies retrieved for more detailed
evaluation according to pre-specificied
inclusion/exclusion criteria:
n = 85
Quality
appraisal
Page Title
/ heading
goes here
Study design
Sample
characteristics
HRQOL
instrument
Factors
examined in
relation to
HRQOL
Limitations
✓
Stated (n = 26)
Limited (n = 3)
Study design
Described (n = 12)
Limited (n = 15)
Participants
Described (n = 24)
Limited (n = 5)
Non-responders
Described (n = 1)
Limited (n = 1)
Not described (n = 11)
Sampling method
Described (n = 10)
Limited (n = 15)
Sample size
Justified (n = 1)
Limited (n = 2)
Not justified (n = 26)
QOL definition
Defined (n = 5)
Limited (n = 9)
Not defined (n = 15)
Instrument
Justified (n = 7)
Limited (n = 17)
Clinimetrics
Adequate (n = 19)
Insufficient (n = 10)
Description
Described (n = 28)
Selection
Justified (n = 21)
Appropriate (n = 25)
Main predictors
Stated (n = 29)
Key findings
Stated (n = 29)
S Soh with permission
Results
Page Title
/ heading goes here
Research
objectives
Statistical
analysis
Results
Studies excluded following
detailed evaluation of full-text
report:
n = 74
Total studies included in systematic
review:
n = 29
Studies identified from targeted
hand-searching of reference lists:
n = 18
✓
Measures of HRQOL
• Health status – generic or disease-specific
• Most studies used one HRQOL instrument
N/A (n = 16)
✗
PDQ-39
✓
Limited (n = 3)
Unable to determine (n = 1)
Limited (n = 10)
SF-36
✓
✓
Described (n = 10)
S Soh with
permission
Non motor symptoms
Statistical
Analysis
Page Title
/ heading goes
here
30
• Most used multiple
regression models
• Stepwise regression
methods
Number of articles
25
Factors # that explained the variance in overall
HRQOL
Factors* examined in relation to HRQOL
20
15
Nonmotor
symptoms
10
Cognitive
impairment
Cognition 13, 14, 16, 19, 20, 22, 23, 26-28, 30, 31, 33
Memory 19
Executive function 19
Visuo-spatial skills 19
Confusion 33
Cognition
Neuro-behavioural
disorders
Depression 11, 13, 14, 16, 19, 20, 22-24, 26, 27, 29-31, 33, 36, 38-40
Anxiety 16, 19, 24, 29, 33, 38
Fatigue 13, 14, 25, 33, 38
UPDRS-I 16, 17, 27, 30
Psychosis 22, 23, 30
Hallucinations 33, 38
Apathy 38
Depression 11, 13, 14, 16, 19, 20, 22-24, 26, 27, 29-31, 33, 36, 38-40
Anxiety 19, 24, 29, 33, 38
Fatigue 13, 14, 25, 33
UPDRS-I 17, 30
Psychosis 30
Hallucinations 38
Sensory disorders
Pain and headache
Autonomic
disorders
Constipation 13, 33
Urinary incontinence 33
Autonomic symptoms 33
Sleep disturbances
Sleep problems
5
Confusion
20, 23, 26, 28
33
0
Pearson/Spearman
correlation coefficients
Linear regression models
Statistical methods
30
Number of articles
25
33
Pain and headache
33
20
15
Constipation 33
Urinary incontinence
33
10
13, 14, 22, 27, 31, 38
Sleep problems
13, 14, 27
5
0
Stepwise
linear regression
Hierarchical
regression
Standard
multiple regression
Statistical methods
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Predictors
Motor symptoms
Disease characteristics and demographic factors
HRQOL
HRQOL
Disease
characteristics
Demographic
variables
Age of onset 13, 22, 33, 35, 39, 40
Disease duration 12-14, 17-22, 27-31, 33, 35, 37, 39-41
Disease severity 11-15, 18-28, 30, 31, 33, 35, 36, 40, 41
Disease disability 13, 14, 16, 20, 24, 25, 27, 29-31, 33, 40
UPDRS-III 13, 14, 17, 19-21, 26, 27, 35, 41
Medication type 11, 40
Levodopa dosage 13, 18, 19, 26-28, 30, 31, 35, 37, 40
Duration of medication 17, 26
Falls 20, 28, 31, 33
Age 12, 14, 15, 17, 18, 20-24, 26-29, 37, 40
Sex 12, 14, 15, 18, 21-24, 26, 27, 29, 35, 40
Living status (including number of household members)
Relationship status 22-24
Employment 18, 22
Education 18, 21, 24, 29, 30
Income 22, 23, 41
Rural living 18
Financial problems 39
Co-morbidities 15, 19, 29
Ethnicity 21
Other 12, 21, 31, 41
Motor
symptoms
Functional ability
Difficulty dressing 33
Difficulty rising from chair 17, 33
UPDRS-II 14, 16, 17, 24, 27, 30, 40
Self-report functional status 12
Movement disorders
including
complications arising
from medication
therapy
Akinesia 20, 27
Bradykinesia 13, 16, 17, 19, 33, 37
Tremor 13, 16, 27, 33, 36-38
Rigidity 13, 16, 17, 19, 27, 33, 37
Non-tremor score 38
No of PD symptoms 36
Physical symptoms 16
PD type 27
Speech impairments 16, 17, 19
Facial expression 19
Clinical fluctuations 13, 22-24, 27, 30, 31, 33, 35
Dyskinesia 13, 22, 24, 27, 31, 33, 35
Dystonia 22, 23
End of dose deterioration 33
UPDRS-IV 16, 17, 24, 27, 35
12, 21, 28, 37, 39, 41
Disease duration
Disease severity 11-13, 15, 18, 20, 22, 23, 25, 26, 31, 36, 41
Disease disability 20, 24, 25, 27, 29, 30, 33, 40
UPDRS-III 13, 21, 26, 27, 35, 41
Medication type 11
Levodopa dosage 19, 26, 27, 35, 40
Duration of medication 17, 26
Falls 28, 33
18, 22, 23, 27
Age 22, 23, 26
Sex 12, 22, 40
Living status (household members)
Education 24, 30
Income 41
Rural living 18
Financial problems
Co-morbidities
22, 23
39
Postural instability and
gait disorders
19, 29
Other (survey language)
21
Discussion
Freezing 33
Postural instability 13, 16, 17, 20, 27, 33, 37
Gait impairment 13, 17, 20, 33, 36, 37
Axial impairments 19, 20
Difficulty turning 33
Festination 33
Propulsion and retropulsion 33
Lack of arm swing 33
Stooped posture 17, 33
Difficulty dressing 33
UPDRS-II 14, 24, 30, 40
Self-report functional status 12
Bradykinesia 19, 37
Tremor 36
Rigidity 13
Non-tremor score 38
No of PD symptoms 36
Physical symptoms 16
Clinical fluctuations 22, 24, 31, 33
Dyskinesia 24, 35
Dystonia 23
UPDRS-IV 16, 17, 24, 35
Postural instability 20, 37
Gait impairment 17, 33, 36, 37
Axial impairment 19
Difficulty turning 33
Individuals most likely to have poor HRQOL
• Depressed
• Advanced disease
• High levels of physical disability
No consistency in the way factors were
examined
Lack of clarity about concept of HRQOL
Study
2:goes
Epidemiological
study
Page Title
/ heading
here
Research question
• How does an Australian sample with PD rate their HRQOL?
• Does the HRQOL of an Australian sample with PD differ from people
living in other countries?
Design
Rationale
• Most HRQOL studies have used European, American and Asian
samples1
• Limited studies in Australia
• HRQOL specific to culture and value systems2
Sample
1 Schrag
2 Lau
Method
Page Title
/ heading goes here
et al, Mov Disord 2000; Croyle et al, Jour Clin Psych 2003; Tan et al, Parkinsonism Relat Disord 2004
and McKenna, Disabil Rehabil 2002
• Epidemiological: to describe and quantify
• Cross-sectional: one point in time
• 210 individuals with idiopathic PD
• Recruited as part of a randomised controlled trial 1
• Wide variety of sources and sites in metropolitan
Melbourne
• Neurologists, PD support groups, outpatient centres,
physiotherapists
1Watts et al,
BMC Geriar 2008
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PDQ-39
assesses
Page Title
/ heading
goes here
ED5D to assess QOL
QOL
PDQ-391
EQ-5D1
• Disease-specific
measure
• 8 dimensions
• Summary indices for
each dimension and
overall scale
• Higher scores = poorer
perceived HRQOL
• Generic health utility
measure
• 5 item descriptive
questionnaire
• Combined responses
converted into a
utility value (-1 to 1)
✓
✓
✓
✓
✓
1Peto
et al, Qual Life Res 1995
EQ5D VAS
1Williams,
Health Policy 1990
International
comparison
Page Title
/ heading goes
here
Best
Health
State
EQ-5D1
• VAS indicating
current health status
• Allows patients’
preference to be
compared directly
To identify studies in international samples
• Electronic search of the literature
• Medline, Cinahl, Web of Science, PsychINFO,
EMBASE, Scopus
• Tailored search strategy
• Parkinson* disease
• Quality of life, health status, life satisfaction
• PDQ-39
Worst
Health
State
1Williams,
Health Policy 1990
Statistical analyses
Results
Page Title
/ heading goes here
Dimensions of PDQ-39
Descriptive statistics
• Summary scores for PDQ-39 and EQ-5D
One-way repeated measures ANOVA
• Compare ratings for dimensions of PDQ-39
• Bonferroni adjustment for multiple comparisons
p<0.002
p<0.002
Meta-analysis
• Comparability of ratings between Australians and
international samples
• Heterogeneity: χ2 test and I2 test
• Random-effects model
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Study 2: Results
Study 2: Results
EQ-5D SI
• UK population weights
• Community-dwelling healthy Australians1
EQ-5D questionnaire
• 78.6% reported problems
100
Better
0,9
70
0,8
60
50
40
30
20
PD sample
Community-dwelling Australians
1
80
HRQOL (EQ-5D SI)
Proportion of participants
90
0,7
0,6
0,5
0,4
0,3
0,2
0,1
10
0
Worse
Mobility
Self-care
Usual activities
Pain
0
36-50
Anxiety
51-65
1Hawthorne
et al, Ann Med 2001
Results
Key Findings
International PD samples
Region
Country
• 27 samples from 28 studies
• 5 regions, 17 countries
North America
USA
South America
Ecuador
Brazil
Western Europe
Germany
Estonia
Norway
Finland
UK
France
Eastern Europe
Serbia
Poland
Slovak Republic
Asia-Pacific
Japan
Iran
Israel
China
Singapore
Age (years)
Disease duration
Disease severity
(modified HY scale)
UPDRS-II
Mean
Range
65.7
7.1
2.3
57-73
4-12
0-5
16.7
10-20
>66
Age group
Dimensions of EQ-5D
Dimensions of HRQOL most impaired
•
•
•
•
Physical function and mobility
Performing usual activities
Emotional problems
Pain
HRQOL of Australians with PD is poor
• Lower compared to unimpaired individuals
• Better relative to international samples
Metro
versus
rural
Page Title
/ heading
goes here
Method
study
Specific aims
Metropolitan sample
• Compare the HRQOL of people living in metropolitan
Melbourne with individuals from rural Victoria
• Examine the contribution of rural living towards
HRQOL in PD
• 210 individuals with idiopathic
PD from Study 2
Rural sample
• 24 individuals with idiopathic
PD
• Community-based
rehabilitation programs
• PD support groups
Hypothesis
• People with PD in rural Victoria will have poorer
HRQOL ratings1
• Rural life setting will be a significant predictor of
HRQOL1
1Klepac et
al, Eur J Neurol 2007
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Statistical analyses
Results
Rural Victoria and metropolitan Melbourne
Descriptive statistics
Characteristics
• Summary scores for PDQ-39, EQ-5D and AQoL
Rural sample
n
p-value
24
210
17 (71)
139 (66)
70.3 (7.3)
67.9 (9.6)
0.159
Disease duration [yrs], mean SD
8.7 (5.5)
6.7 (5.6)
0.047*
Disease severity, median (range)
3.0 (1.5-4)
2.0 (1-4)
0.174
21 (88)
179 (85)
1.000
Bivariate statistics
Male n(%)
• Demographic characteristics
• HRQOL ratings
Age [yrs], mean (SD)
Unemployed or retired n(%)
Standard multiple regression analysis
Metropolitan
sample
Living situation n(%)
• Contribution of rural living to variance in HRQOL
0.921
Alone
4 (17)
98 (18)
20 (83)
162 (77)
Supported residential services
0 (0)
9 (4)
Nursing home
0 (0)
1 (1)
With others
Matched pairs analysis
• Reduce variability due to age, sex and disease severity
0.819
Results
Results
Generic HRQOL (EQ-5D SI)
Disease-specific HRQOL (PDQ-39 SI)
Worse
Better
p=0.022
26.6
18.4
p=0.018
Worse
Better
Results
Study
4:Predictors
Page Title
/ heading
goes here
Specific motor symptoms
Contribution of rural living to HRQOL
Model 1
Rural living
Standardised
regression
coefficients
R2
0.178
0.03
(-1.49. -0.23)
0.007*
Multiple R = 0.18
R2 = 0.03
Adjusted R2 = 0.03
0.139
-0.049
-0.026
0.249
-0.015
-0.010
0.215
0.02
0.00
0.00
0.05
0.00
0.00
0.04
(-1.27, -0.08)
(-0.03, 0.01)
(-0.47, 0.31)
(0.03, 0.10)
(-0.53, 0.42)
(-0.60, 0.52)
(0.24, 1.04)
0.027*
0.482
0682
0.000*
0.819
0.882
0.002*
Multiple R = 0.41
R2 = 0.17
Adjusted R2 = 0.14
95% CI
Non-significant paths
p-value
Significant paths
R2: 44%
Adjusted R2: 42%
57
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Overall
conclusions
Page Title
/ heading
goes here
1.
•
What are the factors that predict HRQOL in PD?
Depression, disease severity and level of disability
2.
•
How does a sample of Australians with PD rate their HRQOL?
Australians with PD perceived their HRQOL to be poor
3.
How does the HRQOL of people with PD living in metropolitan
Melbourne compare with people in rural areas?
Individuals in rural areas had lower HRQOL
•
4.
•
What are the main demographic factors, PD impairments and activity
limitations that contribute to HRQOL in Australians with PD?
Self-care limitations, impairments in mental function and disease duration
Thank-you
& Acknowledgements
Page Title
/ heading goes
here
Sze-ee Soh
Jennifer McGinely
Mary Danoudis
Hylton Menz
Bob Iansek
Anna Murphy
Jenny Watts
Frances Huxham
Clarissa Martin
Joy Tan
Elizabeth Proud
Staff at the Melbourne School of Health Sciences
Participants from the MJFF trial and other trials
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11/07/2011
Margaret Mak PT, PhD
Department of Rehabilitation Sciences
The Hong Kong Polytechnic University, Hong Kong
Bloem et al. (2001), Charlett et al (1997)
Wood et al. (2002)
Physical
 35% - fracture
 Reduce function - gait,
balance, ADL, IADL
Psychological
 50% - fear of falling,
reduce confidence
 16-25% avoid
activities
 Increase postural sway (Adkin et al. 2003)
 Shorter one-leg-stance time (Jacobs et al. 2006)
 Poor postural response to pull/push (Jocabs and
Horak 2006, King and Horak 2008)
 Poor stability limits (Qutubuddin et al. 2007)
 Lower berg‟s balance score (Tanji et al. 2008)
 Prolonged timed-up-and-go time (Tanji et al. 2008)
Hely et al. (2004, 2008)
Bloem et al. (2001)
"How confident are you that you can . . .
 Assess fall efficacy related to falls i.e.
person‟s perceived confidence in
performing specific activities without
falling
 Fall efficacy scale
 Activity-specific balance confidence scale
Score: (1-10)
1. Take a bath or shower
2. Reach into cabinets or closets
3. Prepare meals not requiring carrying heavy or hot objects
4. Walk around the house
5. Get in and out of bed
6. Answer the door or telephone
7. Get in and out of a chair
8. Get dressed and undressed
9. Light housekeeping
10. Simple shopping
Total: (10-100)
Note: Higher score associated with lower falls self-efficacy.
"1" - extreme confidence "10" - no confidence at all
(Tinetti et al. 1990)
1
11/07/2011
0%
10
20
30
40
50
60
70
80
90
No confidence at all
100%
0%
Full confidence
10
20
No confidence at all
30
40
50
60
70
80
90
100%
Full confidence
How confident are you that you can maintain your balance
and remain steady when you....
1. walk around the house
How confident are you that you can maintain your balance
and remain steady when you....
1. walk around the house
2. walk up or down stairs
3. bend over and pick up a slipper from the front of a corset floor
4. reach for a small can off a shelf at eye level
5. stand on your tip toes and reach for something above your head
6. stand on a chair and reach for something
7. sweep the floor
8. walk outside the house to a car parked in the driveway
9. get into or out of a car
10. walk across a parking lot to the mall
11. walk up or down a ramp
12. walk in a crowded mall where people rapidly walk past you
13. are bumped into by people as you walk through the mall
14. step onto or off of an escalator while holding onto a railing
15. step onto or off an escalator while holding onto parcels such that you cannot hold onto
the railing
16. walk outside on icy sidewalks
(Powell and Myers 1995)
2. walk up or down stairs
3. bend over and pick up a slipper from the floor
4. reach for a small can off a shelf at eye level
5. stand on your tip toes and reach for something above your head
6. stand on a chair and reach for something
7. sweep the floor
8. walk outside the house to get to one form of transportation
9. get into or out of a transportation you mostly use
10. walk across a parking lot to the mall
11. walk up or down a ramp
12. walk in a crowded mall where people rapidly walk past you
13. are bumped into by people as you walk through the mall
14. step onto or off of an escalator while holding onto a railing
15. step onto or off an escalator while holding onto parcels such that you cannot hold onto
the railing
16. walk outside on wet and slippery ground
Mak et al. Arch Phys Med
Cantonese version of Activities-Specific Balance Confidence Scale (ABC
0%
10
20
30
40
50
60
70
80
90
Chinese)
100%
嘅
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
“
Rehabil 2007;88:496-503
”
嘅
嘅
嘅
嘅
 Self-perceived balance confidence level
 16 items - Indoor and more challenging
outdoor activities (Powell and Myers 1995)
 Full confidence (100) to No confidence
at all (0)
 Test-retest: r=0.92-0.99 (Powell and Myers 1995, Mak et al. 2007)
 Convergent validity: physical ability
(r=0.63), p < 0.001
嘅
ABC 活動平衡信心
**
120
*
?
**
?
100
score
80
60
40
20
0
** p<0.01
* p<0.05
對照組
Controls
N=80
( 沒跌倒記錄 ) 柏金遜症患者
( 有跌倒記錄 )
柏金遜症患者
PD non-fallers
PD fallers
N=70
N=59
2
11/07/2011
 Healthy subjects: 91 (Myer et al. 1998)
 PD: 59-72 (Adkin et al. 2003, Jacob et al. 2006, Mak and Pang 2009a)
 ABC score was associated with UPDRS
postural and gait score (r2=0.81, p<0.001), BBS
score (r2=0.64, p<0.001), and MiniBEST score
(r2=0.76, p<0.001) (Adkin et al. 2003, Leddy et al. 2011)
 To examine whether risk of falling is associated
with balance and mobility performance and
fear of falling in PD patients
 71 PD patients (33 were fallers)
 Potential risk factors into univariate regression
model
 Timed-up-and-go time*
 ABC score*
 One-leg stance time (p=0.059)
 ABC score is the best predictor of 6-minute
walk distance (r2=0.46, p<0.001) (Mak and Pang 2008)
(Mak and Pang 2009a)
UPDRS
- Unified Parkinson‟s disease rating scale
Predicting future falls in PD
Independent variables
Number (%)
of subjects
B
S.E.
Odds
ratio
95%
confidence
interval
p value
0.043
0.695
0.027
0.131
0.034
0.525
0.057
0.068
1.04
2.00
1.02
1.14
0.98, 1.11
0.72, 5.60
0.64, 1.03
0.05, 1.14
0.202
0.185
0.638
0.054
-0.025
0.648
0.022
0.129
0.042
0.593
0.063
0.081
0.97
1.91
1.02
1.14
0.90, 1.06
0.60, 6.12
0.90, 1.16
0.97, 1.33
0.552
0.275
0.727
0.110
0.01, 0.65
0.020*
Step 1
Age
Gender
Duration of PD
Depression
Step 2
Age
Gender
Duration of PD
Depression
ABC score >80
18 (25)
-2.771
1.192
0.06
ABC score =50-80
42 (59)
-2.324
1.317
0.10
0.01, 1.29
0.078
TUG time ≥16s
20 (28)
1.351
0.667
3.86
1.05, 14.27
0.043*
*p<0.05
PD
ABC
TUG
SE
Activities-specific balance confidence scale
Timed-up-and-go test
Standard error
(Mak and Pang 2009a)
(Mak and Pang 2009b)
92 patients
volunteered
Variable
20 patients were excluded
History of lower limb fracture (n=5)
Back or leg pain (n=10)
MMSE < 24 (n=2)
History of other neurologic diseases e.g stroke
(n=2), poliomyelitis (n=1)
72 patients included
Non-recurrent
fallers (n=55)
Recurrent
fallers (n=15)
p-values
0.485
Age (years)
Baseline measures:
• History of falls
• UPDRS
• TUG time
• ABC score
62.6 (7.8)
64.1 (6.9)
Female gender (n)
30
7
0.588
Positive fall history (n)
17
15
<0.001*
Geriatric Depression Scale score
5.4 (4.0)
6.1 (3.7)
0.577
Duration of PD (years)
7.2 (4.2)
9.4 (5.3)
0.091
Hoehn and Yahr stage
2.8 (0.5)
3.0 (0.3)
0.031*
UPDRS motor score
21.4 (8.9)
29.4 (9.1)
0.003*
TUG (s)
13.6 (3.1)
18.3 (8.8)
0.061
71.9 (14.9)
54.4 (15.9)
<0.001*
ABC score
2 patients lost to
follow up (died)
*P<0.05
70 patients
completed 12-month
follow-up
ABC Activities-specific balance confidence scale
TUG Timed-up-and-go
UPDRS Unified Parkinson‟s disease rating scale
Means (SD)
ABC
PD
TUG
UPDRS
unless otherwise indicated
Parkinson‟s disease
Timed-up-and-go
Unified Parkinson‟s disease rating scale
3
11/07/2011
Cut off point
Step
Variables entered
Wilk λ
Exact F
Statistics
df1
df2
P value
1
Fall history
0.676
32.57
1
68
<0.001**
2
UPDRS motor
score
0.570
25.23
2
67
<0.001**
3
ABC score
0.539
18.84
3
66
<0.001**
Sensitivity=93%, Specificity=86%
**P<0.01
ABC
UPDRS
Area under the curve (AUC) = 0.823
ABC = 69
Sensitivity = 93%
Specificity = 67%
UPDRS = 32
Unified Parkinson‟s disease rating scale
Area under the curve (AUC) = 0.736
Sensitivity = 47%
Specificity = 94%
(Mak and Pang 2009b)
Fall prediction
 ABC score < 69 (sensitivity=93%)
 UPDRS score < 32 (specificity=94%)
 Timed-up-and-go time >16s (OR=3.86)
 Abnormal posture, freezing of gait, poor
leaning balance, leg muscle weakness
(sensitivity=77%, specificity=82%) Latt et al.
(2009)
Address Fear of Falling in fall prevention program for PDs
Parkinson‟s disease
Muscle weakness
 UPDRS gait, UPDRS pull test and oneleg-stance time predicted ABC scores
(r2=0.51) (Jocabs et al. 2006)
 UPDRS - PIGD and Knee muscle
strength predicted ABC scores after
accounting for demographic and disease
severity (r2=0.49) (Mak et al. submitted)
balance and gait
deficits
Falls
PD symptoms
Self-restriction, functional decline, physical deconditioning
More fear of falling
Fracture
Institution
4
11/07/2011
 Exercise & walking training is better than
exercise (strength, balance) in enhancing
balance confidence (Brouwer et al. 2003, Hinman et al. 2002,
Liu et al. 2007, Robertson et al. 2001)
 Tai Chi (>56 sessions) is effective
(Sattin et al.
2005, Zhang et al. 2006)
 Exercises + Cognitive-behavioural
education (Identify fall risk factors, discuss
coping strategies to falls) could produce
gain in balance confidence (Tennstedt et al. 1998) &
reduced the fall risk by 31% at 14-month
follow-up (Clemson et al. 2004)
References
Treatment interventions
Muscle strength
balance and gait
 Lower extremity muscle strength
 Increase the stability limit
 Increase speed and amplitude of postural
response to perturbation
 Dynamic gait ability including freezing of
gait
 Cognitive-behavioural education
Movement speed and
amplitude






Functional mobility, physical abilities


FALLS

Adkin AL, Frank JS, Jog MS (2003) Fear of falling and postural control in Parkinson‟s disease.
Mov Disord18:496-502
Bloem BR, Grimbergen YAM, Cramer M, Willemsen M, Zwinderman AH (2001) Prospective
assessment of falls in Parkinson's disease. J Neurol 248:950-958
Bula CJ, Monod S, Hoskovec C, Rochat S (2010) Interventions aiming at balance confidence
improvement in older adults: an updated review. Gerontology DOI: 10.1159/000322241
Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K (2004) The effectiveness of
a community-based program for reducing the incidence of falls in the elderly: a randomized
trial. J Am Geriatr Soc 52:1487-1494
Jacobs JV, Horak FB, Tran VK, Nutt JG (2006) Multiple balance tests improve the assessment
of postural stability in subjects with Parkinson‟s disease. J Neurol Neurosurg Psychiatry
77:322-326
Latt MD, Lord SR, Morris JG, Fung VS (2009) Clinical and physiological assessments for
elucidating falls risk in Parkinson „s disease Mov Disord 24:1280-1289
Mak MK, Lau AL, Law FS, Cheung CC, Wong IS (2007) Validation of the Chinese translated
Activities-Specific Balance Confidence scale. Arch Phys Med Rehabil 88:496-503
Mak MKY, Pang MYC (2009a) Balance confidence and functional mobility are independently
associated with falls in people with Parkinson‟s disease. J Neurol 256:742-749
Mak MKY, Pang MYC (2009b) Fear of falling is independently associated with recurrent falls in
patients with Parkinson‟s disease: a 1-year prospective study. Journal of Neurology
2009;256:1689-1695.
Institution
Thank you
Acknowledgements:
Anna Lau, Cecilia Cheung, Raymond Chung, Man Cheung, X Shen, Yu
Liling, Irene Wong, YY Wong, Ted Wong
Funding: The Hong Kong Polytechnic University (PA4P, U303)
5
11/07/2011
Points to be addressed
Freezing and festination
Rehabilitation of freezing
and festination in PD
1. Imply severely disrupted motor control
2. Are related to imbalance and falling
3. Express wide BG dysfunction
24th of June 2011
Alice Nieuwboer
Dept Rehabilitation Sciences
4. Ameliorated with rehabilitation?
Common triggers
Turning making a wide arc (on)
Turning making a narrow arc (off)
1. Freezing and festination
are related?
Obstacle
Phenotypes of FOG
Group*turn
p<0.01
Festinating
No FOG
18%
23%
Trembling
Akinetic
Schaafsma et al, 2003
Willems et al 2006; Snijders et al 2008; Spildooren et al 2010
Motor behavior preceding FOG
Decline of motor control generic?
Freezing of gait
Comparing festination and pre-freezing strides (off)
1,20
P=0.0001
Stride amplitude (M)
Cadence step/min
300
1,00
Moore et al 2008, Delval et al 2010
 Step timing more variable
0,80
Pre
Hausdorff et al 2003; Plotnik et al 2008;
100
0,20
0,00
 Shorter stride amplitudes (off)
150
0,40
Freezing of finger
movements
 Bilateral step coordination disordered
200
0,60
 High frequency oscillations
P=0.0001
250
50
Normal
Fest
0
Freeze1
Freeze2 Freeze3
Normal Fest
Freeze1 Freeze2 Freeze3
Spatiotemporal dyscontrol common component
Nieuwboer et al, 2001; 2004; 2007; Snijders et al 2009; Chee et al 2009
Amplitude decline
Abnormal oscillations
Nieuwboer et al, 2009; Vercruysse et al 2011 submitted
1
11/07/2011
Freezing and Festination
Similar underlying repetitive motor control
disorder which is possibly generic and more
pronounced in freezers
Balance and falling?
Schaafsma et al, 2003
1. Related to balance / severity?
Nature balance deficit?
Total prevalence 52% in a selected cohort of N=210
Trembling of knees at step initiation
100
Repeated lateral weight shifting
90
80
(Anticipatory Postural Adjustments )
70
60
50
40
30
20
10
0
Jacobs et al 2009
NOFOG
FOG
76.2%
38.2%
79.2%
0-I
Lateral weight shifting disturbance
in response to cursor movement on
27.3%
II
III
IV
computer screen.
Unpublished data
Morris et al, 2011 in press Archives of Phys Med & Rehab
Freezing is a strong predictor of falls in PD
Kerr et al, 2010, Latt et al 2009
Balance and falling
Freezing and festination ~ weight shifting deficit
• Single leg stance instability
• Switching deficit between loading and unloading
Freezing and festination
express wide BG
dysfunction
2
11/07/2011
Cognitive (executive) dysfunction
24 Non-Freezers
27 Freezers
Mean
2.4
67.9
34.6
Descriptors
H&Y
Age
UPDRS III
Mean
2.3
66.3
31.9
SD
0.4
6.3
9.7
Gait and
Balance
BBS total
TUG
Fall history
26.5
2.4
11.2
1.9
2/22 (8.3%)
Distal
motor
UPDRS tremor 2.2
UPDRS REP
12.4
Distal freezing 0.5
Cognition
Scopa Total
MMSE
29.9
28.55
Freezing and DT walking
P value
SD
0.5
7.6
15.2
+DT FOG +9%
0.70
0.41
0.61
23.6
5.0
13.2
5.6
17/10 (62.9%)
0.05*
0.39
0.02*
2.3
4.6
0.8
2.3
13.9
2.0
2.8
11.5
1.9
0.99
0.32
<0.01*
3.7
1.3
25.7
27.4
6.2
2.2
0.02*
0.05*
+DT FOG +5%
+DT FOG +1%
+DT**
(Group*turn*DT p=0.08)
Impact of cognitive task on motor function >> in freezers
Naismith et al 200g, Amboni et al 2008, 2010
% errors
Cognitive task performance
10
9
8
7
6
5
4
3
2
1
0
Spildooren et al, 2010
Summary
 Both motor (habitual) and cognitive (goal-directed)
control is more affected in freezers
*
controls
nFR
FR
**
*
straight
 More vulnerable learners?
 Rehabilitation potential….
180°
360°
(group*turn p=0.04)
Impact of turning difficulty on cognitive function >> in freezers
Spildooren et al, 2010
Rehabilitation options
Freezing and Festination
Balance exercise?
Fall risk = α*FOG + ϐ*Knee strength + γ*Balance + σ
Problems
Training options
• Imbalance and falling
• Balance exercise
• Rhythmic weight shift strategies
• Repetitive movement
breakdown
• Cued or sensory augmented
training
• Executive dysfunction
•
Home+group exercise for 6 months (3*week)
Task integration or serial task
learning?
DeLatt et al, MDJ 2008; Allen N et al. MDJ 2010
3
11/07/2011
Weight-shifting strategies
Cueing and FOG
Imposing a normal spatiotemporal pattern alleviates FOG?
Spatiotemporal correction of (auditory) cueing << Freezers
Baseline is Best
Imposing an abnormal spatiotemporal pattern provokes FOG?
Visual cues
Auditory cues
Training in complex and 3D environments which require a
lot of switching between modes of control. Lots of ‘action
Increase of 40% cadence
leads to FOG
relevant information’…
Decrease of 50-25% step
length leads to FOG
Moreau et al, 2008; Chee et al 2009
Turning and FOG
Cued dual task turning
**
*
5
*
Fixed priority
No cues
Auditory
No cues
2
No cues
3
Auditory
4
No cues
Turn duration sec.
6
1
0
Freezers
N=60
N-freezers
group*time NS
N=65
37/94 FOG episodes
25/94 FOG episodes
Unilateral cueing reduces the number turns +FOG by 50%
Freezing in cued trials (19%) < no cues (69%)
Nieuwboer et al, 2009
Application of cueing matters
Spildooren et al, Poster et WCPT
On-line effects of cueing
1.With cueing groups were
comparable
2.Without cueing freezers
became much more variable
Spildooren et al, Poster et WCPT
Vercruysse et al, in revision for NNR
4
11/07/2011
Summary
Early stage motor control training to prevent
rhythm and amplitude breakdown
Key
Cues as training tool – with possible weaning
off to stimulate habitual control
Balance deficits and switching amenable to training?
Research is teamwork
Depts Rehabilitation & Movement Science
Joke Spildooren
Sarah Vercruysse
Elke Heremans
Stephan Swinnen
Nici Wenderoth
Jochen Vandenbossche
Eric Kerckhofs
Lynn Rochester
Wim Vandenberghe
Alice Nieuwboer
Faculty of Medicine Dept. Neuroscience
Funding bodies
Dual or serial tasking for freezers?
Bijzonder
OnderzoeksFonds
5
Cognitive movement strategies:
Cognitive movement
strategy training to improve
ADL in Parkinson’s disease
• Old concept, 80’s last century
• The use of cognitive (conscious)
movement control in PD
• Compensation for progressively
impaired automatic initiation and
execution of activities
Yvo Kamsma
1 July 2011
WCPT Parkinson
1
1 July 2011
WCPT Parkinson
2
Examples impaired mobility
Survey under PD patients
Major problems with gait and transfers
(mobility):
– Rising from a chair, sitting down,
getting in and out of a car
– Getting in/out of bed, turning in bed
– Walking under various conditions
=> Essential for physical independence
(Wimmers & Kamsma, 1998)
1 July 2011
WCPT Parkinson
3
1 July 2011
WCPT Parkinson
4
Turning in bed
Use of cognitive control
• Implies detailed insight into normal
performance of transfers and gait
• What are their features?
• How are they affected by PD?
• Do they allow cognitive control?
1 July 2011
WCPT Parkinson
•
•
•
•
5
Complex movement pattern, many elements
Pelvic rotation is crucial
Fast force generation, timing, dimensioning
Unfolds automatically, no clue how it’s done
1 July 2011
WCPT Parkinson
6
1
Reorganisation of the
activities
Complication
Gait and transfers contain features that are
particularly problematic for PD patients:
-
– Decouple different activities (e.g. risingwalking)
– Simplify the activities, break them down in
sequences of simple movement parts
– Create minimal dependency on speed and
force production
Complex patterns, many elements
Speed, timing
Adequate force production
⇒ Original execution is not fit for cognitive
control
⇒ Reorganisation of the activitity
1 July 2011
WCPT Parkinson
7
Reorganistion of rising
1 July 2011
WCPT Parkinson
8
Requirements for training
- Explanation of strategy principles
- Clear picture of the strategy:
- Demonstration by therapist
- Self instruction, verbalisation patient
- Practice
1 July 2011
WCPT Parkinson
9
Requirements for training
1 July 2011
– Bed related strategies
– Sitting and rising strategies
– Gait related strategies
Slowed information processing
Reduced (divided) attention capacity
Reduced flexibility (executive functions)
Dementia
WCPT Parkinson
10
• N=25 PD patients, H+Y 2-4
• Training programme:
Cognitive (frontal) dysfunctioning:
•
•
•
•
WCPT Parkinson
Early research (Kamsma et al., 1995)
Motor learning process:
- Cognitive phase, no automatization
-
1 July 2011
• Schedule:
11
1 July 2011
14 sessions
2x week - 1x 6mths
WCPT Parkinson
12
2
Results
Further evidence
• Evaluation by systematic video analysis
• 23 patients were well able to learn and reproduce the
strategies
• Experimental setting => home situation?
1 July 2011
WCPT Parkinson
13
• Positive results of other research:
– Nieuwboer et al. (2001): home physiotherapy
programme
– Morris et al. (2009): rehabilitation programme
• Mixed interventions: cueing and other strategies as
well
• Clinical effectiveness of cognitive strategies remained
unclear
1 July 2011
Recent research
•
•
WCPT Parkinson
14
Results
RCT, co-worker Baukje Dijkstra
3 (small) groups, H+Y 2-3:
1. Cognitive strategy training, N=12, trained PT’s,
at home,12 sessions, 1x week, 30 min
2. Usual care PT, N=12, 12 sessions, 1x week, 30 min.
3. Untreated controls, N=11
•
Evaluation:
–
–
–
Modified Parkinson Activity Scale (M-PAS),
Home situation
Recorded on video, blinded scoring 2 PT’s
1 July 2011
WCPT Parkinson
Before training
15
1 July 2011
Results (preliminary)
Measurement
Movement strategies
pre – post
p
pre – post
p
1.0 (-0.6 – 2.6)
0.186
0 (-1.1 – 1.1)
1
M-PAS gait
0.7 (-0.9 – 2.3)
0.343
0 (-1.2 – 1.2)
1
M-PAS bed mobility I
-0.6 (-1.7 – 0.5)
0.239
0.1 (-0.7 – 0.9)
0.818
M-PAS bed mobility II
0.1 (-1.6 – 1.8)
0.898
0.2 (-0.4 – 0.7)
0.529
M-PAS total
1.2 (-3.4 – 5.8)
0.566
0.3 (-2.1 – 2.6)
0.816
Values are mean differences (95% confidence interval) and p-values.
WCPT Parkinson
16
Reasons?
• Treatment frequency => higher?
• Experience PT => more patients?
• M-PAS: standard instructions
• Cognitive dysfunction (EF): coming
loose from routine behavior and apply
strategies when necessary => external
reminder?
Usual care physiotherapy
M-PAS chair transfer
1 July 2011
WCPT Parkinson
Results
Table 4: treatment effects
Groups
After training
17
1 July 2011
WCPT Parkinson
18
3
Conclusion
Thank you for your attention!
• No clear clinical evidence yet for
effectiveness
• Nevertheless patients and PT’s are
positive
• Recommendations:
– Address cognitive (EF) aspects
– Objective measurement of movement
behavior in the daily situation (ambulatory
monitoring)
1 July 2011
WCPT Parkinson
19
1 July 2011
WCPT Parkinson
20
4
What is cueing?
Paying attention to Attention
‘Applying external temporal (rhythmical) or spatial
stimuli associated with the initiation and ongoing
facilitation of motor activity (gait)’
Understanding the mechanisms of
external cueing in Parkinson’s
Disease
Contrary to:
Internal cueing (self-generated)
Erwin van Wegen
Rhythms, stripes, music, vibrations , …
Lim et al., 2005
Brief history of Cueing
•
1924 first description on cues (Von-Meyer Königsberg)
– Dancing on marching music, guided by a nurse, improved
gait and posture
•
1996 first RCT auditory cueing (Thaut et al.)
– Home based self-exercise
– RAS: rhythmically accentuated music
•
2007 The Rescue project (Nieuwboer et al.)
– first home-based cueing training program by physical therapist
– Largest RCT to date.
•
Many studies since…
•
Conclusions so far: Cueing works (what’s new?)
– Walking speed, stride length/cadence, balance, ADL,
– Transfer to QoL?,….
Motor problems in PD
How does it work??
?
 1. Problems with automatic maintenance
of movement amplitude during movement
sequences
 2. Problems with rhythm of sequential
movements/movement cycles
1
Mechanisms
Example 1
•
Parallel versus Transverse lines during walking on a treadmill: step
frequency
Parkinson: higher frequency, smaller steps
Transverse Lines: lower frequency, bigger steps
(Hanakawa ea 1999)
Mechanisms
•SPECT
1.
2.
3.
4.
5.
Motor problems in PD
R precuneus (bm 7)
L medial frontal Gyrus (bm 10)
L inferior parietal lobule (bm 39,40)
L insula
L cerebellar hemisphere
1.
2.
> act. in lateral
pre-motor areas
(spect)
3.
4.
5.
6.
 1. Problems with automatic maintenance
of movement amplitude during movement
sequences
L cerebellar hemisphere
L middle occipital gyrus (bm 19)
R inferior parietal lobule (bm 7)
L precuneus (bm 7)
R middle frontal gyrus (PMC, bm 6)
R anterior cingulate gyrus (bm 32)
L inferior parietal lobule (bm 40)
 2. Problems with rhythm of sequential
movements/movement cycles
Mechanisms
Example 2a (Samuel et al., 1997)
Example 2b
Looking at brain dynamics with
Magneto Encephalography (MEG)
rCBF unimanual finger sequences with a ‘pacing tone’ (PET)
Relative over-activity of lateral premotor /parietal areas
SMA
Control
Parietal
Pre Motor
Parkinson
Lat./Parietal/ Cx: Integration of sensory info (Binkofski et al., 1999).
2
Setup
Squeeze!e
Videoscreen w/ instructions
Source localization,
Frequency analysis
at significant sources (M1)
MEG dewar with 151 sensors
Left index finger: tactile stimulus
Right-hand: squeeze balloon, 80 bpm
Datacollection computer
Pressure
Switch
Movement paradigm
– Rhythmic cue (80 bpm)
– Squeezing a balloon with r. hand
Rhythmic:
Alpha power (7-11 Hz)
– Instruction
• ‘Squeeze on cue’
α: 7-11 Hz
Alpha power
Conclusion
• Increased alpha power activity reflects resting, nonfocused, relaxed state
• PD patients do not return to this state as quickly as
controls do, after cueing:
• Reflection of increased arousal/attention due to cueing?
No increase in alpha power after Rhythmic Cueing in PD
Context:
– More reliance on external cues
– Motor perseveration: ‘lingering’ in existing movement patterns
– Problems with set-shifting
3
Take home message
Mechanisms (simplified!)
• Indications for use of alternative braincircuits: ‘bypassing’ of
defective basale ganglia-SMA-motorcortex loops.
• Under influence of cues:
– brain activition patterns change
– Arousal/Attention increases
‘Medial system’
‘Lateral system’
• But:
– Still not shown DURING walking (how?)
– Longterm effects of cueing on brain dynamics are unknown
attention
for your ATTENTION
So, the truth is (still) out there..
[email protected]
Thanks to:
Prof. Dr. G. Kwakkel
Drs. C. de Goede
Mw. I. Burgers
Dr. I. Lim
Prof. Dr. E. Wolters
Prof. Dr. A. Nieuwboer
Dr. A. Willems
Drs. F Chavret
Dr. D. Jones
Dr. L. Rochester
Dr. K. Baker
Drs. V. Hetherington
Dr. A. Vardy
Dr. A. Daffertshofer
4
11/07/2011
Motor Learning in Parkinson’s
disease: limitations and potential
for rehabilitation
Lynn Rochester PhD
[email protected]
Clinical Ageing Research Unit
Aims
•
•
•
•
•
Definition
Neural substrates
Limitations
Evidence
Clinical Application
Motor learning – a definition
‘A set of processes associated with practice
or experience, leading to relatively
permanent changes in the capability for
movement’ (Schmidt 1999)
Stages of learning
Stage
Characteristics
Cognitive
Novel task
Receive instruction and feedback
Problem solve - what to do and how to do it
Error prone – variability of performance
Associative
Environmental cues associated to movements
Goal or skill attainment
↓error and ↑ consistency
Autonomous
(automatic)
↓ conscious control
↑ dual task (eg talking and driving)
Early
Late
Limitations in PD
Automaticity
in PD
(Wu et al., 2005)
• PD can achieve automaticity but comes at a cost
(Wu et al.,
2005)
• Motor sequence learning possible but attenuated
(Stephen
et al., 2011)
– Need more time
– Related to disease stage (UPDRSIII; H&Y; medication)
PD
• Dopaminergic medications impair early stage learning
(Kwak et al., 2010)
• Learning related activation declines at 2 years
(Carbon et
al., 2011)
Pre-training
PD > C
Lynn Rochester. Satellite Education
Session. WCPT, Amsterdam, 2011
1
11/07/2011
Other systems contribute
Should we train dual tasks?
Rodriguez-Oroz et al., 2009
•
•
Akinesia (bradykinesia,
hypokinesia), rigidity,
tremor
Executive and
attentional deficits
Multi-factorial
Multi-system –
cholinergic
dysfunction
Depression, anxiety,
apathy
Multi-task gait performance (Dual cog+motor)
Single session (20mins) dual task training (N=20 PD)
Dual task
step length
Change score m/s)
0,2
0,15
0,1
0,05
0
Training
Specificity
of training
Retention
•Multi-task training feasible – mild-moderate PD
•May have sustained effects
DUAL
↑Obstacle crossing
↑Cognitive function
2
11/07/2011
Features of cued motor learning
• Sensory information augments learning BUT limited
transfer of learning and generalisation to non-cued trials
(Verschueren et al., 1997)
• Sequence learning deficits may result from automatic
response activation during learning stage (Werheid et al.,
2003)
Training complex tasks
• Walking and talking
• Memorising and repeating
• Carrying and manipulating objects – eg walking
and selecting correct door key from pocket
• Incorporate concurrent tasks into complex tasks
– walking, turning, navigating
Cueing complex tasks
How can we evaluate motor
learning in the clinic?
H&Y 1
Complex exercise +
Cognitive cues &
dual-task exercise
H&Y 2
Introduce external
cues & faded
H&Y 3
practice
Consider
permanent cueing
devices
Automaticity - dual task
Retention – (separate from training effects)
Transfer – to other skills – eg gait, transfers
improve under different contexts
Potential for learning
3
11/07/2011
Automaticity
Primary
Secondary
Gait (10m)
TUG
Balance - standing
Cattle counter
Carry cup/tray with cup
Verbal fluency
Modified stroop
Digit subtraction (7’s,
3’s)
Days of week backwards
Remember shopping list
Practice points
Measure BOTH in isolation
and during dual task
• Include motor learning as part of therapy programme
• Select patients based on knowledge of potential
limitations
• Try different approaches to find the best one (exercise
and complex skill practice, cueing) according to disease
stage
• Faded practice (if relevant)
• Evaluate the effect of therapy (ART)
Acknowledgements
•
Ins titute for
A geing and
Health
UK NIHR Biomedical Research Centre for Ageing and
Age-Related Disease award to the Newcastle upon Tyne
Hospitals NHS Foundation Trust
Review: Nieuwboer et al., Parkinsonism & Related Disorders, 2008
4
The use of ‘fall diaries’ in practice
•
•
•
•
Background
Research study
Prospective / retrospective
Clinical implications
Ashburn A
Faculty of Health Sciences,
University of Southampton
Background
• Falls are common among people with PD
• Definition – ‘an event that results in a person
coming to rest unintentionally on the ground or
other lower level, but not as a result of a major
intrinsic event or overwhelming hazard’
• Previous work - We found people with PD
talked about location, fall-related activities,
landing, saving reactions and perceived cause
Stack et al Phys Res Inter 1999; 4:190-200
Aim of Study
To
• Explore circumstances surrounding falls
• Validate previous findings with a larger
sample
• Confirm the ability of people with PD to
complete fall diaries
Fall Diary
• Questions
–
–
–
–
–
–
–
(Stack et al Phys Res Inter 1999; 4:190-200)
Where were you when you fell ?
What were you trying to do ?
What do you think caused you to fall`?
How did you land ?
What injuries did you sustain ?
How did you get up again ?
What health care did you receive ?
• Interview or self-completion
Method
• Participants were recruited to an RCT to
test the effectiveness of exercises
• Inclusion criteria
– Confirmed diagnosis, independently mobile,
living at home, cognitively in tact, had fallen
more than once in the previous 12 months.
Ashburn A et al The Circumstances of Falls among People with PD
and the Use of Falls Diaries to Facilitate Reporting Disab & Rehab
2008;30(16) 1205-2012
1
Diary Procedures
Results
• Monthly Calendar (marked in days)
falls & near-falls for 6 months
-
• Telephone reminders
• Coded and counted frequencies of
responses
Fall-related Activities
Locations
• 511 (80%) in the
home
• 77 (12%) elsewhere 36 indoors / 41
outdoors
• 51 (8%) diaries
incomprehensible
The
Circumstances
of Falls among
People with PD
and the Use of
Falls Diaries to
Facilitate
Reporting
Ashburn A,
Stack E,
Ballinger C,
Fazakarley L,
Fitton C (2008)
1
2
3
4
5
6
7
8
9
Falls resulting
in Serious Injury
and/or Health
Service
Intervention
(n = 17)
Location, Activity and
Cause
Stumbled making
drink in kitchen
Lost balance
sitting on bed
Over-balanced opening
wardrobe in bedroom
Turned too quickly
unaided in hotel room
Twisted; lost balance
descending stairs, carrying
washing
Turned putting
food in fridge
Flying kite, wind
lifted me off feet
Tripped outside shop
walking to car
Lost balance taking a
few steps leaving Cafe
1 Caught trolley (which fell
0 over) getting out of bed
11 Slipped turning
off shower
1 Over-balanced
2 washing dishes
1 Turned too sharply dressing
3 in sitting room; overbalanced
1 Fell forward mopping
4 spillage in lounge
1 Froze on pavement
5 getting out of car
1 Turned quickly in shop;
6 caught display stand
• 142 participants (7 excluded – death or withdrawal
& 11 unintelligible) = 124
• Mean age - 72 years
• Mean time since diagnosis - 8 years
• Hoehn &Yahr (16 = II; 92 = III; 34 = IV)
• 639 falls [vast range]
• Ambulant – walking,
Living
Areas
19%
Kitchen
15%
Gardens
14%
Bedrooms
30%
Hall
7%
Getting Up and Intervention
Right side; fractured hip
Paramedics helped me up; hospital
and surgery (fracture)
Paramedics lifted me; admitted
(fracture)
Husband lifted me up; six hours in
hospital (fracture)
Wife and son helped up; X-ray,
surgery, night in clinic (fracture)
Husband called ambulance; ten
hours in hospital (fracture)
Partly in wardrobe; fractured
tibia
Right side, arm under body;
fractured hand, bruised back
On back; fractured ribs,
concussion
Very hard on back; fractured
ribs, bruises
On back; fractured ribs,
internal bruising
Face downwards, in sprawl;
fractured nose, damaged hand
On bottom; pain left leg and
buttock
On back; cut leg; bruised back
Grazing; bruising
On one knee; hurt hand
Left side; hurt left shoulder
Forward, hit head; cut
eyebrow, ear; dislocated tooth
Headlong; cut over eye;
closure of eye; bruising
Face first; cut face, nose bleed
Ambulant
45%
Bath
8%
Landing and Injury
Right side; fractured pelvis
turning, stepping up or down,
carrying something
With friends, called ambulance;
GP called two days later (fracture)
Helped up by son; X-ray (fracture)
Three ladies helped me up;
ambulance called; X-ray and
treatment (fracture)
Lifted by a gentleman; X-ray;
Ibuprofen
Helped up by husband; X-Ray
Helped up by wife; X-Ray; Pain
management
Up with help of table and walking
stick; X-ray
Up with help of chair; called GP;
sent to A&E
carrying something
• Standing – bending,
reaching, washing or
dressing or completing
another task
Ambulant
45%
Standing
32%
Up with wife’s help; A&E
Strangers helped me up; medics
came out; treated at home
Two ambulance men helped me up
and cleaned up
2
carrying something
• Standing – bending,
reaching, washing or
dressing or completing
another task
• Transfers
• Slipped out of chair or
Transfers
21%
Ambulant
45%
Standing
32%
rolled out of bed (2%)
Stack et al Phys Res Inter 2005; 10: 146-153
Perceived Cause
•
•
•
•
•
Tripped
Freezing/festinating
Bending or reaching
Transfer
Walking: Loss of
balance
• Washing and dressing
• Misjudgment
• Others
Injurious Falls
Tripped
Others
Freeze
Bend
Misjudgment
Transfer
Wash Walk
Study Summary
• Over 600 falls were surveyed
• All participants were repeat fallers
• Validates previous findings
– Most falls happen at home
– Tripping is biggest single cause
– Turning reaching and rising are key challenges to
stability
• Additional finding - people fall when stationary –1 in 3
falls from standing posture
• Diaries have strengths & weaknesses but rely on
individuals’ perceptions
• 17 injurious falls
• 11 at home 4 outdoors & 1 in hotel & 1 in
shop
• Turning implicated in 6 serious falls (5 had
backward or sideways landing)
• 8 fractures (hip, pelvis, tibia, hand, three
ribs and a nose) and 5 facial injuries
• Further 4 had x-rays, 2 attended A&E and
3 required paramedic assistance
Retrospective or Prospective
Recording
• Comparison of retrospective and prospective
recording (stroke)
• 76 subjects
• 83% agreement but more information from
retrospective
• Frequent fallers – less likely to report falls
monthly
• Recommend prospective plus face to face
interview
Kunkel et al, Age & Ageing 2011; 40 (2): 277-280
3
Implications for practice
• Most PwPD can complete fall diaries
• Recommend use of diaries in rehabilitation as
an aid to assessment & interventions
Funding from
• Action Medical Research and
• John & Lucille Van Geest Foundation
• Identify individual fall related activities and teach
physical and cognitive skills to counterbalance
• Consider environmental adaptations
• Encourage ways of making standing tasks safer
4
11/07/2011
Summary
• Epidemiology and
consequences
• Risk factors
• Exercise and falls in PD
Exercise to alleviate falling in
Victoria Goodwin
Are falls common in PD?
Risk factors for falls in PD
80
70
60
50
40
% fallers
% recurrent fallers
30
20
10
 Prior falls
 Cognitive impairment
 Freezing
 Postural instability and
reduced balance
 Reduced strength and
power
 Fear of falling
0
Ashburn 2001
Wood 2002
Allcock 2009
Kerr 2010
Matinolli 2011
Risk factors for falls in PD
 Prior falls
 Cognitive impairment
 Freezing
 Postural instability and reduced balance
 Reduced strength and power
 Fear of falling
PD
Motor impairments
Cognitive impairments
FALLS
FRACTURES
Decline in physical ability
(strength, balance)
Fear of falling
Reduced physical activity
1
11/07/2011
Targeting modifiable risk factors
•
•
•
•
Exercise for strength and power
Strength
Power
Balance
Fear of falling
Balance and the ICF framework
Exercise for balance impairment
PD
Body structure
and function
(impairment)
Activities
(functional
limitations)
Participations
(Disability)
Balance
responses
Functional
balance tests
Falls, fear of
falling
Exercise for functional balance
(activity)
Participation (falls and fear of falling)
2
11/07/2011
Ashburn et al (2007)
• N=142
• 6 sessions of home-based physiotherapy vs.
usual care
– Strength, ROM, balance, movement strategies
– Individually tailored and progressed
• Reported no difference in fall risk, Berg
balance or PD-SAS
• Significant difference in ‘near’ falls, functional
reach and QOL at 6 months
Ongoing studies
Watts et al (2008)
• Movement strategies vs. Strength training vs.
Social activity/education group
– 1 supervised and 1 unsupervised session pw for 8
weeks
Canning et al (2009)
• Strength and balance training plus cueing
strategies vs. Usual care
Goodwin et al (2011)
• N=130
• 10 sessions group strength and balance
training vs. usual care
– Individually tailored and progressed
– Home exercises twice weekly
• Non-significant difference in fall rate, QOL,
TUAG or household physical activity
• Significant difference in Berg balance,
recreational physical activity and FES-I
Conclusions
• Falls are a common problem for PwP
• There is evidence that some fall risk factors
can be improved with exercise interventions
• To date, there has been limited research into
reducing falls among PwP
– 3 unsupervised home exercise sessions pw for 6 months
with choice of monthly group or home visit to progress
Thank you for listening!
[email protected]
3
9/15/2011
Targeting Muscle Force Production to
Reduce Hypokinesia in PD
Acknowledgements
• Participants
• Movement Disorders Team
–
–
–
–
–
Bo Foreman, PT, PhD
Jim Ballard, PT, DPT
A
Amy
Bl
Black,
k PTA
John Steffens, MD
Paul House, MD
• Funding Agencies
– Davis Phinney Foundation / PDF
– APDA
– NIH
Muscle function is reduced in older
adults
• Skeletal muscle
sarcopenia is epidemic
– Reduced muscle size and
strength
g
Weakness in neurologic disease
• Stroke
– (Canning et al., 2004;
Nadeau et al, 1999)
• Multiple Sclerosis
– (Lambert et al., 2001;
Petajan et al., 1996)
• Amplified in weightbearing extensor muscles
• Cerebral Palsy
• Inactivity plays an
important role
• Parkinson’s Disease
Hypokinesia
Dromey et al., 2010
– (Fowler et al, 2001; Dodd et
al., 2003)
• Weakness in PD:
– In multiple muscle groups
(quads, hamstrings, PF, DF)
– At varied contraction
velocities, contraction types
– Glendinning & Enoka,
1994; Nogaki et al.,
2001; Pedersen et al.,
1997; Yanagawa et al.,
1990
Our view of hypokinesia
Morris et al.; Falvo and Earhart, 2008; Allen et al., 2010
1
9/15/2011
Does LE resistance training work?
Alterations of Muscle Structure
and Function
• Mild PD
– Force increases with hypertrophy
• Moderate PD
– Force increases without hypertrophy
• In-direct support for better PNS/CNS
function?
Additional references: Falvo et al., 2008; Allen et al., 2010; Schilling et al., 2010
Specific alterations of muscle
structure
Lean / AT asymmetry between limbs
Lean tissue AND intramuscular AT may respond to resistance training
Health status changes
Clinical Implementation
• Mode of contraction
(concentric / eccentric?)
• Intensity (high speed,
60% 1 RM, 80% 1 RM?)
• Frequency (2x/wk,
(2x/wk
3x/wk?)
• Duration (8, 12, 16
weeks, on-going?)
Hirsch et al., 2003; Dibble et al., 2006, 2009; Falvo et al., 2008; Hass et al., 2007;
Allen et al., 2010; Schilling et al., 2010
2
9/15/2011
Clinical implementation
Efficacy across muscle groups / tasks
• Underdosing is the standard of care
• Optimal mode & intensity unclear
Vaughn et al., 2011
– High intensity or High Speed
– Eccentric / Concentric
• Disease severity may limit response*
Troche et al., 2010; Pitts et al., 2009
*Dibble et al 2006, 2009; Foreman et al., 2011
Resistance exercise: Training the
muscle and the brain
Questions and Discussion
3
7/11/2011
Physical Therapy in Parkinson’s disease:
Issues for consideration and how to proceed?
Prof. Gert Kwakkel
Chair ‘Neurorehabilitation’, VU University
Medical Center, Amsterdam
( [email protected] )
Aim of physical therapy in PD
The role of the physical therapist is to maximize
functional ability and minimize secondary
complications by using movement therapy based on a
framework of education and support for the whole
person
.
Deane KHO et al, , The Cochrane Database of Systematic Reviews, 2001, Issue 3.
The multidisciplinary Parkinson-team
• Neurologist
• Parkinson nurse
Permanent members
„Relational
coordination‟
• Social worker
• Speech therapist
• Physical therapist
• Occupational therapist
• Rehabilitation physician
• Neuropsychologist/psychiatrist
Elective members
• Dietitian
• Sex therapist
•…
Dimensions that determines quality of ‘relational
coordination’ between professionals working in a PD
team
Surgical Performance Index: Is an quality index reflecting patients’
satisfaction, post-operative freedom from pain and post-operative
functioning, as well as efficiency: number of inpatient days in the hospital
 Shared goals
 Shared knowledge
 Mutual respect
 Helpfulness
 Frequent communication (timely,
accurate, problem solving)
Increment in shared goals, shared knowledge, helpfulness and mutual respect of surgical team
Hoffer Gittell et al, Medical Care 2000:38:807-819
Hoffer Gittell et al, Medical Care 2000:38:807-819
1
7/11/2011
How to proceed?
Identified RCTs in the domain of PT
(n=46; 2647 subjects)
• …understand the dimensions that defines the quality of a PD
team
• …more trials in particular neglected fields such as upper limb
function, bed mobility, prevention of falls in PD
Focus of identified RCTs (no of subjects N=46):
How to proceed?
team
• …further improve methodological quality of trials and future
designs
Number of RCTs (n=46) satisfying the 10 items of the PEDRO-scale
PEDRO score
Positive association between year of publication
and PEDro score = 0.319 (p=0.031)
Other main flaws of submitted clinical trials:
• A number of submitted trials reported and discussed the withingroup changes and not the between group-differences.
• A number of submitted trials failed to discuss the clinical relevance
of their significant outcomes.
• Number of studies failed to define the primary measurement of
outcome and suffer from multiple testing (i.e., type I error).
• Almost all RCTs are underpowered and suffer from type II error.
2
7/11/2011
Daily (dopamine-dependent) activity
levels between patients A, B and C
On / Off phenomena in patients with PD.
assessment 1
Statistical power of a study with 2 groups in which
patients are randomized into a 1:1 ratio (r):
assessment 2
With one post-intervention assessment after randomisation:
(Z (1-α /2 ) + Z (1 – β ) )2 x σ2 x ( r + 1)
N=
v2 x r
With repeated assessments (T) after randomisation:
(Z (1-α /2 ) + Z (1 – β ) )2 x σ2 x ( r + 1) x { 1 + T-1) x ρ}
N=
v2 x r x T
Applied measurements for evaluating PT interventions in 46 RCTs
How to proceed?
team
• …improve methodological quality of trials and future designs
• …need for consensus on a core set of outcomes according to
constructs of ICF
How to proceed?
Pathology
Body function &
structure
(impairments)
UPDRS II and III
Modified Hoehn &Yahr
MDS
MMSE
Brixton
Cognistat
ROM
Muscle Strength
Dynamometry
Sensory Orientation Test
Physical condition
Finger and heel taps
BORG Scale
VO2-peak
Respiratory Exchange Ratio
Zung Depression Scale
FSS, MFIS
Becks Depression Scale
HADS
SPES/SCOPA
Activities
(limitations)
participation
(restrictions)
•UPDRS-ADL
•PDQ-39
•Posture & Gait
•SIP-68
•Turning in bed
•SF-36
•Berg-Balance Scale
•PSI-PD
•Timed-Get-up & Go test
•M-PAS
•10-mWMT (max. or comf.)
•Care Giver Strain
•Step and stride length
Index
•Cadence / Stepping frequency •EQ-5D;
•Nine Hole Peg Test
•PDQL
•FOGQ,
•SA-SIP
•(Near) falling, FES
•SPES/SCOPA
•NE-ADL
•BI, FIM, PAS, HAP,
•SPDDS (Self Assessment PD
Disability scale); PPOS
•2 and 6 min. walking test
•Functional Reach test
•Webster rating scale
•North Western University
Disability Scale
•Browns Disability Score
•Becks Disability Inventory
Posture & Gait Score (0-20)
• …need for dose-response trials
constructs of ICF
• …need for better understanding the underlying construct of
most measurements in terms of body functions, activities and
participation (e.g., parts of the UPDRS)
Stebbins GT, Goetz CG, Flournoy T. Unified Parkinson's Disease Rating Scale: reliability and factorial validity of the motor exam
section. Annals of Neurology, 1991;30:298-298.
3
7/11/2011
Posture & Gait Score (0-20)
standing
lying
walking
sitting
% of walking periods > 10 seconds
24 hour activity profile
Lim et al, Neurorehabil Neural Repair. 2010 Jun;24(5):469-77.
What is changing when PD patients benefits from PT?
How to proceed?
constructs of ICF (allowing meta-analysis)
• …need for better understanding the underlying constructs in
terms of ICF
 …understand what patients learn when they improve in terms
of activities such as gait, turning and sit-to-stand activities.
Behavioral
compensation
Substitution
Improve motor
performance
Restitution / Substitution
What is changing when PD patients benefits from PT?
Lack of
execution
of
automatic
motor
control
Rerouting
through nonautomatic
pathways
Neural repair
Behavioral
compensation
Substitution
Restitution
Improve motor
performance
4
7/11/2011
Effects of treadmill training (18 cm/s, 1 h per day for 5d
/week) in MPTP-lesioned mouse (n=12) may upregulation
of DA-D2R expression in dorsal striatum
Exercise-induced neuroplasticity in MPTP-lesioned adult animals
TH-cells↑
Dopamine↑
BDNF↑
Striatal receptor
expression↑, Striatal
Dopamine transporter
(DAT)↑
synaptogenesis↑
IGF-type 1↑
Neurogenesis↑
DA-D2R↑
Exercise/
Training
VEGF↑
Exercise-induced neurotrophic
factors and signaling cascades
Motor behavior ↑
Neurocognition ↑
Angiogenesis↑
Adaptive neuroplasticity
Improved
outcome
e.g.: Vuckovic et al, Movement Disorders, Vol. 25, No. 16, 2010, pp. 2777–2784
Smith et al, Brain Research 2011; 1386:70-8
Cobett & Murphy, Narture reviews 2009 Dec;10(12):861-72
Vuckovic et al, Movement Disorders, Vol. 25, No. 16, 2010, pp. 2777–2784
Smith et al, Brain Research 2011; 1386:70-80
‘Need for translational research in PD’
Thank you for your attention!
Basic
science
Experimental
medicine ‘proof
of concept’
Clinical Trials
& Monitoring
change
Clinical
Practice
‘What do patients with PD
learn?’
“Integrating pre-clinical and clinical evidence from scientists working
together in the field of neuroscience & neurorehabilitation.”
Kwakkel G. Towards integrative neurorehabilitation science. Physiother Res Int. 2009 Sep;14(3):137-46.
5
11-7-2011
Broad range of symptoms
Requires expertise
Different clinical presentation
Evidence into practice:
the ParkinsonNet concept
Maarten J. Nijkrake, PhD, PT
Parkinson Centrum Nijmegen (ParC)
UMC St Radboud, Nijmegen, The Netherlands
High impact on QoL (both physical and mental)
Involvement of many professionals
Extensive use of health system
Expensive disease
?
Requires evidence
for interventions
Requires collaboration
and integration of care
Improving allied health care in PD
1. Evidence for allied health
2. Barrier: referrals
2. Barrier: expertise of professionals
Low use of care for problems that potentially can be treated
Nijkrake et al, Mov Disord. 2009
Maarten Nijkrake Copyright UMC St
Radboud 2011
Not many PD experts, low PD patiënt volumes and unfamiliarity
with other disciplines
1
11-7-2011
3. ParkinsonNet concept
1. Selection of
professionals
3. ParkinsonNet concept
1. Selection of
professionals
2. Increase
expertise
3. Stimulate
collaboration
= area
= physiotherapist
= neurologist
3. Increase expertise
4. Make
expertise visible
= area
= physiotherapist
= neurologist
3.Web-based communication (www.parkinsonnet.nl)
Expertise
Decision supporting
health record for
physiotherapists
Visible expertise by
using a search engine
Communication
- secure mail option
- disussion forum
- wiki’s
- blog’s by PD experts
- Basic course
- Ongoing seminars
- Structured referrals
3. Pilot results
4. Cluster randomized trial
Randomisation of
16 area’s
Significant increases in guideline adherence and patiënt volumes
Number of patients
Patiënt volume (mean
ParkinsonNet area’s
S.E.M.)
1 Haarlem
2 ‘t Gooi
3 Delft
4 Gouda
5 Den Bosch
6 Eindhoven
7 Oss-Uden-Veghel
8 Doetinchem
25
20
15
10
5
0
2003
2004
2005
Control area’s
9 10
1
11 12
2
3 4
13
14
15
5 7
6 16
8
9 Alkmaar
10 Hoorn
11 Den Haag
12 Zoetermeer
13 Ede
14 Apeldoorn
15 Deventer-Zutphen
16 Venlo
2006
Radboud 2011
2
11-7-2011
4. Flowchart ParkinsonNet trial
4. Outcomes and endpoints
Follow up of 6 months
Health benefits
Quality of care
Control area’s
358 patients
341 patients
Visit
neurologist
Total health costs
No
physiotherapy
4. Results
Parkinson-Net area’s
ParkinsonNet
physiotherapy
Visit
neurologist
General
physiotherapy
No
physiotherapy
General
physiotherapy
5. Nationwide implementation
Significant reduced costs and no effects on health status
65 ParkinsonNet networks
748 physiotherapists
289 speech therapists
€ 200
€0
-€ 200
-€ 400
-€ 600
-€ 800
-€ 1.000
-€ 1.200
-€ 1.400
265 occupational therapists
€727 saved for each
patient over 6 months
82 dieticians
54 psycho-social professionals
Munneke et al, Lancet Neurol. 2010
5. Patient empowerment (www.mijnzorgnet.nl)
Connect
Get in contact with
patients, caregivers and
professionals
Share
Share knowlegde,
information and
experiences
Radboud 2011
5. Worldwide implementation
Find
Find information
concerning PD
3
11-7-2011
Contact information
Maarten Nijkrake
[email protected]
Radboud 2011
4
14-7-2011
• Patients rarely empowered as treatment providers
• Patients as “subjects” or “objects” of research
• PT conducted in hospital settings
Community-based
participatory
rehabilitation and
research: peer approach
Carolinas Medical Center
Charlotte, North Carolina 28203, USA
[email protected]
www.ccph.org
YES
administered by
Peer-topeer?
Resistance
Student nurse
No
Comella 1994
2-3
OP
Martial arts
PT
No
Bridgewater 1997
1-3
OP
Aerobic dance
PT
No
Bridgewater 1996
1-3
OP
Aerobic dance
PT
No
Schenkman 1998
2-3
OP
Spinal Flexibility
PT
No
Miyai 2002
2.5-3
OP
Treadmill
PT/OT
No
Protas 2005
2-3
OP
Treadmill
PT
No
Ellis 2005
2-3
OP
Motor training
PT/PT Student
No
-
OP
QiGong
MD
No
Burini 2006
2-3
OP
QiGong/ ergometer
PT
No
Toole 2006
1-4
CommunityPlaced
Treadmill
professional
No
Toole 2000
1-4
CommunityPlaced
Resistance/
balance
professional/ PT
No
Ashburn 2007
2-4
Home-Placed
Motor training
PT
No
Hirsch 2003
1-2
CommunityPlaced
Resistance/
balance
Trained
care-partners
Yes
Failure to involve patients
as partners in
research or delivery of communitybased exercise
NO
Model 1
Model 2
Using principles of
CBPR to plan the
exercise intervention
Traditional approach (healthcare
professional) to plan the exercise
intervention.
Using peer-to-peer
approach to administer
the exercise intervention
Using peer-to-peer approach to
administer the exercise
intervention
Model 3
NO
Exercise
Intervention
Out patient
Schmitz-Hubsch 2005
Community-Based Participatory Research Approach
Peer-ToPeerApproach
Setting
2-4
Author
Mark A. Hirsch, PhD
Department of Physical Medicine and
Rehabilitation
YES
H&Y
Palmer 1886
Traditional approach (healthcare
professional) to plan the exercise
intervention.
Using traditional
approach
(physiotherapist/ fitness
professional) to
intervention
Using traditional approach
professional) to administer the
CBPR approach to community change
Command/ control
Collaborative/ peer
involvement
Organizational Hierarchy
Dispersed/ network
structure
Who has relevant Health professionals Patients
information?
Who has
The people at the top of Community
authority to make the organization
final decisions
What is the basis Dictated by leaders Performance on achieving
for accountability
shared goals
and control?
Where does it Works well in defined Works well for diverse
work best?
hierarchy; works
groups and when
poorly when innovation innovation and creativity
is important
are critical
TAKE HOME POINTS
Model 4
Using principles of
CBPR to plan the
Failure to involve physiotherapists
and researchers in delivery of
community-based exercise
Why Peer-to-Peer?
Why CBPR?
Failure to involve care-partners
as collaborators in
Models to plan and deliver community-base d exercise
interventions for people living with Parkinson’s disease
Failure to engage community
partners as collaborators in
Potential mechanisms of exercise-induced recovery of
function in animal models of exercise and PD
YES
YES
PeerToPeerAppro
ach
NO
NO
Model 1
Model 2
Using principles
of CBPR to plan the
exercise
interv ention
Traditional approach
(healthcare professional) to
plan the exercise
interv ention.
Using peer-to-peer
approach to
administer the
exercise
interv ention
Using peer-to-peer
approach to administer the
exercise interv ention
Model 3
Model 4
Using principles
of CBPR to plan the
exercise
interv ention
plan the exercise
interv ention.
Using traditional
approach
(physiotherapist/
fitness
professional) to
administer the
exercise
interv ention
professional) to administer
the exercise interv ention
Source: (1) Fisher BE. J Neurosci Res. Aug 1;77(3), 378-90 (2004); (2) Petzinger GM. J Neurosci. May 16;27(20), 5291-300 (2007) ;
(3)Vuckovic MG. Movement Disorders. 25(16), 2777-2784 (2010) ; (4) Tillerson JL. J Neurosci. Jun 15;21(12), 4427-35 (2001) ; (5) Tillerson
JL. Neuroscience. 119(3), 899-911 (2003) ; (6) Mabandla M. Metab Brain Dis. Jun. 19(1-2), 43-50 (2004); (7) Lau YS. Neuroscience. 33(7),
1264-1274 (2011) ; (8) Al-Jarrah M. 26(4), 369-373 (2010) ; (9) Poulton NP. Exper Neurol. 193,181-197 (2005). Cited in: Hirsch et al.,
Neurodegenerative Disease Management, October 2011, in press
1
14-7-2011
Our unique opportunity
Our unique opportunity
•
•
•
•
•
•
•
•
33 hospitals
Expansive geography
6000 physicians
Ethnic, socioeconomic and
demographic diversity
• > 9,000,000 annual patient
encounters
Traditional research model
• Scientists/ healthcare
professionals as “experts”
Community-based participatory approach
• Public disconnected from
research agenda
YES
• True community needs unknown
• Patients as “subjects” or
“objects” of research
PeerToPeerAppro
ach
NO
Growth in funding
12,500+ patients enrolled
900+ clinical trials
< 2% use principles of
community-based
participatory research
(CBPR) or participatory
action research (PAR)
methodologies
YES
NO
Model 1
Model 2
Using principles
of CBPR to plan the
exercise
interv ention
plan the exercise
interv ention.
Using peer-to-peer
approach to
administer the
exercise
interv ention
Using peer-to-peer
Model 3
Model 4
Using principles
of CBPR to plan the
exercise
interv ention
plan the exercise
interv ention.
Using traditional
approach
(physiotherapist/
fitness
professional) to
administer the
exercise
interv ention
“A collaborative approach to
research that equitably
involves all partners in the
research process and
recognizes the unique
strengths that each brings”.
YES
YES
-- W.K. Kellogg Foundation, 2001
“Research on health
promotion, disease
prevention, and health
disparities that is jointly
conducted by communities
and researchers”
PeerToPeerAppro
ach
NO
NO
Model 1
Model 2
Using principles
of CBPR to plan the
exercise
interv ention
plan the exercise
interv ention.
Using peer-to-peer
approach to
administer the
exercise
interv ention
Using peer-to-peer
Model 3
Model 4
Using principles
of CBPR to plan the
exercise
interv ention
plan the exercise
interv ention.
Using traditional
approach
(physiotherapist/
fitness
professional) to
administer the
exercise
interv ention
-- NIH, 2004
CBPR - Involving patients, care-partners and other
community partners in all aspects of conducting the
research
Collaborative Framework
Identify
Health
Concerns
Disseminate
Information
Study Design
1. Developing the question.……focus groups
2. Writing the research protocol
Community
Participation
3. Community Advisory Board
Data
Collection
Recruitment
4. Administering the treatment (peer-to-peer)
5. Data interpretation (member check)
6. Data dissemination (town hall meeting)
7. Sustainability of the program
Peer-topeer
approach
Intervention
Design
Develop
Measuring
Instruments
2
14-7-2011
Carolinas ParkinsonNet Initiative
Parkinson
Association
Carolinas
NIH studies with CBPR component
45 Parkinson
Support Groups
263 studies / $114 million
300
33 CHS
facilities
Research Core
200
N
Community
Advisory Board
Mecklenburg
Department
of Health
University of North Carolina
Department of Communication
Department of Kinesiology
Department of Biology
38
10
09
20
08
20
07
20
06
20
05
20
20
20
20
04
0
02
YMCA’s
Of
Greater
Charlotte
100
03
PM&R
&
Neurology
20
Area YMCA’s
YEAR
Source: RePORT (Research Portfolio Online Reporting Tool). NIH, 03/24/2011.
Key Principles of CBPR
Why Peer-to-peer?
– More patients than
physiotherapists
YES
– Patients / care-partners
rarely empowered
– Importance of social
networks in exercise
adherence
NO
Model 1
Model 2
Using principles of
CBPR to plan the
(healthcare professional) to plan
the exercise interv ention.
Using peer-to-peer
approach to
administer the
Using peer-to-peer approach to
interv ention
Model 3
Model 4
Using principles of
CBPR to plan the
(healthcare professional) to plan
the exercise interv ention.
Using traditional
approach
(physiotherapist/
fitness professional)
to administer the
professional) to administer the
YES
PeerToPeerApproa
ch
NO
– Sustainability
• Fostering trusting
relationships
• Building on strengths and
resources within the
community
• Promoting co-learning and
capacity building among
all partners
• Utilizing equitable
processes and procedures
Models to plan and deliver community-base d
exercise interventions for people living with
Community-Based Participatory Research
Approach
YES
YES
PeerToPeerAppro
ach
NO
NO
Model 1
Model 2
Using principles
of CBPR to plan
the exercise
interv ention
(healthcare professional)
to plan the exercise
interv ention.
Using peer-topeer approach to
administer the
exercise
interv ention
Using peer-to-peer
approach to administer
Model 3
Model 4
Using principles
of CBPR to plan
the exercise
interv ention
(healthcare professional)
to plan the exercise
interv ention.
Using traditional
approach
(physiotherapist/
fitness
professional) to
administer the
exercise
interv ention
Using traditional
approach
professional) to
interv ention
Source: Viswanathan M et al. Community-based participatory research: assessing the evidence. Evidence report/technology assessment
(Summary) 2004. pp. 1–8.
Reference:
Hirsch MA, Iyer S, Englert D, Sanjak M.
Promoting community-based participatory research
exercise programs in Parkinson’s disease.
Neurodegenerative Disease Management, in press.
Thank you!
3
11-7-2011
Evidence-based PT guidelines
2004
• Decision supporting
• Graded recommendations
• 4 Quick reference cards
European guideline for
Physiotherapy in Parkinson’s disease
High quality
In English, for free!
www.appde.eu
Amsterdam, 20 June 2011
14.30-17.30u
Core areas PT in PD
VIDEO: Cueing
Keus, Bloem et al., Mov Disord 2007;22:451-460
Quick reference cards
Gait
Dexterity
Balance
& falls
Transfers
Physical
capacity
Posture
Graded recommendations
According to the level of evidence
Main recommendations
Cognitive movement
strategies
Compensation to improve
transfers
Cueing
Use of external rhythms
to improve gait
Exercise
To improve strength,
aerobic capacity, range of
movement and balance
Exercise
Cues
Cognitive
movement
strategies
(Level 2 = 2 controlled studies)
1
11-7-2011
www.APPDE.eu
Guideline Implementation Europe
Nijmegen (NL), 4 & 5 June 2010
Need for update
Update into European guideline?
70
60
Publications
50
40
30
20
10
0
1980
1985
1990
1995
2000
2005
2010
Year
European guideline!
Steps guideline development
Project leaders: Samyra Keus & Marten Munneke
Grant:
KNGF, Royal Dutch Society for Physical Therapy
Support:
•European Region WCPT
•APPDE
•EPDA
18 countries!
Available: 2012
Unmet
needs &
barriers
Key
questions
Systematic
literature
search
Conclusions
Other
considerations
Recommendations
New: patient involvement from start
• Writing group
• Reading Group
• Web-based (open)
2
11-7-2011
Guideline products
1. Guideline
•
Clinical practice guidelines
•
Review of the evidence
•
•
•
MDS referral criteria
Barriers in current care
Patients
•
Focus groups with patients (Vd Eijk, Faber)
Appendices
•
Referral PT survey patients (Ketelaar)
QRC
•
EPDA collaboration
2. Quality indicators
3. Patient information
4. Advice for national guideline adaptations
PTs
•
Focus group interviews & web-based forum
•
European survey
5. Publication
Main patient barriers
EU survey - Goal
•
self-management support
•
active involvement decision taking
•
Identify knowledge barriers
•
multidisciplinary collaboration
•
Identify gaps in the KNGF-guideline
•
PD experts
1. European guideline: new key questions
2. Guideline implementation
•
Identify future experts
•
Indentify barriers in care organisation
•
Identify knowledge barriers (education)
EU survey – Development process
EU survey – Contents
Aug – Nov 2010
Part 1 – General
Based on:
•
PT characteristics
•
existing questionnaires: Dutch evaluation of care
•
PD expertise (also 1 question GoogleDocs = Part 0)
•
KNGF guideline: competences
•
Barriers in care
•
>0 PD pts/yr: what would you like to see (different) in the
Feedback: APPDE members
guideline?
Pilot web-based form: international PT students
3
11-7-2011
EU survey – Contents
EU survey – Results
Countries participating: 16 / Languages: 10
Part 2 – Expert (>4 PD pts/yr)
•
Measurement tools: frequency & barriers
•
Diagn. & therap. Process: frequency & competences
•
Use of KNGF guideline
Time week 0: Feb 2011 (Ireland) - June 2011 (Cyprus – not
included yet)
Response random sample (n=9,000): 3137 (34.9%)
PD pts 1-4:
4 PD pts / yr: 632 (23.0%)
+ 842 experts
General barriers optimal care
•
limited experience treating PD
•
limited time session
•
limited availability local exercise groups
•
limited opportunity to discuss w/o health professionals
•
referral too late
Hoehn & Yahr stages patients treated
40%
35%
30%
25%
20%
15%
10%
5%
0%
Use of KNGF guidelines: 4%
1
2
3
4
5
Hoehn & Yahr
Measurement tools
Use of measurement tools 2
UPDRS, part 3: Motor Examination
Do you use measurement tools?
(n= 628 ‘experts’)
Unified Parkinson’s Disease Rating Scale (UPDRS), part 2: ADL
Yes
No
55%
45%
Tinetti-Balance and Gait Evaluation, Part 2: Gait
Tinetti -Balance and Gait Evaluation part 1: Balance
Timed up and go test (TUG)
Sickness Impact Profile (SIP)
Because:
•
Supports diagnostic process
•
Supports clinical reasoning & treatment planning
•
Important to present treatment results
Sensory Orientation Test (SOT)
Self-assessment Parkinson’s Disease Disability Scale (SPDDS)
1 always
Retropulsion test
2 usually
3 sometimes
Phone FITT
4 Never
Parkinson’s Disease Questionnaire-39 (PDQ-39)
Parkinson’s Activity Scale (PAS)
Patient Specific Index for Parkinson’s Disease (PSI-PD)
Parkinson’s Disease Quality of Life Scale (PDQL)
But:
Medical Outcomes Scale Short Form-36 (SF-36)
Lindop Parkinson's Assessment Scale (LPAS)
•
Time consuming
•
> 75 different measurement tools used!
LASA Physical Activity Questionnaire (LAPAQ)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90% 100%
4
11-7-2011
Other specific barriers
•
Optimum time referral
•
Patients expectations
•
Cognitive limitations: implications for PT treatment
•
Late stage treatment
•
Use and interpretation results measurement tools
•
Continuity of care: what, when, hoe to discuss?
•
Collaboration with other health care providers
Launch New European Guideline
Stay informed, get involved!
www.appde.eu
[email protected]
5
11-7-2011
All participants
The presenters
1
11-7-2011
Fruitful discussions
We thank you
for your participation!
2

information - Association of Physiotherapists in Parkinson`s Disease

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