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HELP PD is a unique exercise protocol designed to delay mobility losses in Parkinson ’s disease. Developed at OHSU’s Neurological Sciences Institute by Dr. Fay Horak and her team of researchers, including lead trainer, Sue Scott, MS. HELP PD uses 6 specific physical activities (parts of Tai chi, Kayaking, Pilates, Lunges and obstacle courses) to target 5 key mobility constraints of PD: rigidity, freezing, bradykinesis, poor coordination and sensory integration. This program was presented for the International Council for Active Aging, ICAA, in December 2009
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Renewable Fitness & ABLE Bodies
Research: A unique way to share your story
Tough Love vs Spanking
Renewable Fitness & ABLE Bodies
Sue Scott, MS
Renewable Fitness
Parkinson’s-SpecificAgility Training
Continuous feedback loops
Automaticity of balanceSelect, initiate & maintain movementSequencing and pace Sensory IntegrationMulti-tasking
Renewable Fitness & ABLE Bodies
Role of Basal Ganglia
Today’s presentationis the work of many
• Fay B Horak, PT, PhD• Laurie A King, PT, PhD
• Researchers• Physical Therapists• Three PD-focused PhD• Six Certified Trainers
With permission: ABLE Bodies Balance Training,
2008; Human Kinetics
Renewable Fitness, LLC
Achieving Better Living with Exercise
Postural instability 5X age-matched
38% fall each year18% falls are fractures
Exercise helps avoid falls and fractures Medications don’t help reduce falls
Renewable Fitness & ABLE Bodies
Falls are Leading Cause of Death
Immobility impairs heart, muscles, social relations, independence
Renewable Fitness & ABLE Bodies
Cardiovascular Events 2nd -leading Cause of Death
Aerobic Exercise• CV System & Endurance• Strength & Balance • Flexibility • Social Ties • Attitude
Regular
3
HOW does exercise help PD?
Prevention
Compensation
Neuroprotection
Renewable Fitness & ABLE Bodies
Renewable Fitness & ABLE Bodies
Prevention
Falls Cardiovascular events Poor coordination Back pain, stiffness Fatigue, inactivity Apathy, depression
Renewable Fitness & ABLE Bodies
Compensation
Improved motor function
“Useful tricks” External cues Visual, sound, somatic
Cognitive strategies Break down task into parts Mental rehearsalThink BIG
Use alternative parts of the brain
Neuroprotection
Increase brain transmitters Reduce cell death Improve cell function Increase brain plasticity
Start exercise early in PD to PROTECT &
PRESERVE neurons and function Renewable Fitness &
ABLE Bodies
Aerobic: Treadmill running vs: Dopamine More neural transmitter Better motor function
Renewable Fitness & ABLE Bodies
Exercise & Neuroprotection in PD Rats
Balance & Agility training vs: Strength or Aerobic Larger improvements in
motor function More new synapses
Renewable Fitness & ABLE Bodies
Task Specific AgilityTraining for Rats
Sensori-motor Tasks Largely controlled by
basal ganglia
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Human PD StudiesRandomized Controlled Trials
• Increased kinematics of gait• Walking speed • Stride Length
• Improved • Flexibility• Strength & Mobility• Functional abilities• Quality of life
•Reduced • Medications • Falls
What type of exercise is best for PD?
Lance Armstrong (Endurance)?Muhammad Ali (Agility, quickness/power)?
Arnold Schwarzenegger (Strength)? Guru? (Tai Chi, Yoga, Pilates)
Renewable Fitness & ABLE Bodies
Renewable Fitness & ABLE Bodies
EXERCISE IS MEDICINE
Active Ingredient: ModeStrength: IntensityHow often: FrequencyHow long: Duration
Renewable Fitness & ABLE Bodies
Exercise can target . . .
Physical Activities/Challenges Improve specific problems
with mobility
Mobility Constraints of PD
Renewable Fitness & ABLE Bodies
HELP PD Targets Constraints of Mobility
Rigidity - Stiffness; flexed posture
Brady- & hypo-kinesia - Slow, small movements
Freezing -Initiating movement
Coordination - Turning, rolling, quick switching
Sensory Integration - Coordinate sensory input
Executive function – Tasks & attention
Characteristics – increased muscle tone, stiffness◦High tonic background activity (flexors)◦Co contraction (axial muscles)
Results/Symptoms◦Joint pain, stiffness◦Flexed Posture◦Lack of trunk rotation
Vertebral flexibility, ROM Difficulty turning while walking, rolling over in bed Enbloc movement
Renewable Fitness & ABLE Bodies
RIGIDITY
Tai chi Pilates/yoga
Think BIG Reciprocal, Whole-Body
Movement LungesRenewable Fitness &
ABLE Bodies
Strategies to HELP RigidityLarge, flowing moves
Spinal suppleness Lengthen flexors
Strengthen extensorsSomatic self-awareness
Practice difficult transitions
Slow, small, weak movements/responses Inefficient muscle recruitment patterns Reduced postural stability Gait
◦Weak push-off ◦Delayed, reduced lift-height of swing limb◦Small stride length, slowed turning ◦Multi-joint reaching, absent arm swings
Not improved by medications
BRADYKINESIA
Cognitive or central strategies Self initiated & paced
Get their imaginations to help Go BIG, rehearse
Require postural control & adjustments Voluntary, reactive, anticipatory, quick Practice large protective steps Lunges, boxing
Renewable Fitness & ABLE Bodies
Strategies for Bradykinesia
Movement hesitation Not well understood Major contributor to falls Executive (central) disorder
• Preplanning movement • Quickly selecting motor program
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FREEZING
Difficulty/symptoms: • Shifting attention• Crowded rooms, doorways
Safe practice for difficult scenarios Environments where freezing typical Obstacle Courses
Quick turns, negotiating narrow or tight spaces – corners or near walls
Ducking , stepping over obstacles Picking up objects while walking Quick changes in directions and foot
placement
With permission: ABLE Bodies Balance Training,
2008; Human Kinetics
Strategies to HELP Freezing
CharacteristicsSelection & sequencing Inflexible program selectionDifficulties/symptomsComplex motor actionsPostural transitions New and challenging environmentsNot improved by dopamine
replacement
SEQUENTIAL COORDINATION
Complex, sequential patterns Whole Body Multi-segmental
Quick selection
Renewable Fitness & ABLE Bodies
HELP for Sequential Coordination
Characteristics Abnormal kinesthesia Associated w/Bradykinesia
–o/estimation of motionPoor use of proprioceptionDecreased perception of movementOverdependence on vision
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SENSORY INTEGRATION
Reduce visual input Wear dark sun glasses No-body glasses Dim room, slightlyUse variety of surfacesReduce external feedback & cues
Strategies for Better SI
With permission: ABLE Bodies Balance Training, 2008; Human Kinetics
With permission: ABLE Bodies Balance Training, 2008; Human
Kinetics
Renewable Fitness & ABLE Bodies
External Cues
Use initially, then limitAs disease progresses, use again
Characteristics & SymptomsMulti-tasking difficult High stress Increased fall risk
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COGNITIVE CONSTRAINTS
No math
Math
40
30
0
10
20
% o
f Tria
ls w
ith F
alls
CONTROLS PARKS ON PARKS OFF
No
Fal
ls
Doing Math Increases Falls During Balance Disturbances
PD Affects Automaticity of Balance Control
Used with permission; Presented at the Movement Disorders Conference in Paris June 7-11, 2009: We-215. Effect of cognitive dual-task on balance in
Parkinson’s disease, R.M. Allen, P. Carlson-Kuhta, J.V. Jacobs, J.G. Nutt, F.B. Horak.
Addition of a second task
Dual tasks improve Attention skills Automatic Balance
Renewable Fitness & ABLE Bodies
Cognitive Strategy:Dual Tasks
With permission: ABLE Bodies Balance Training,
2008; Human Kinetics
Verbal Tasks◦ Engage in conversation◦ Easy recitation
Motor Tasks◦ Balance something on a tray◦ Toss/catch a ball◦ Pick up object from the floor in passing
Cognitive Tasks◦ Word Winks/Tongue Twisters◦ Math◦ Alphabetize words, order numbers
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Order of Difficulty
Constraints
Rigidity
Bradykinesia
Freezing
Sequential Coordination
Sensory Integration
Executive/Cognitive Processing
Constraints & Strategies
StrategiesBIG, Flowing, Reciprocal, Sequential
Multiple directions, quick
Dual Task
Upright posture, supple spine; strengthen extensors, trunk rotation,
Reduce external cues, vision
Require plan, quick changes
Negotiate obstacles & difficult tasks
Develop somatic awareness
Click icon to add picture
Renewable Fitness & ABLE Bodies
HELP PD
Strategies
Exercises
Constraints
Basal gangliaNeural plasticity
protection
Physical Activities Large, flexible,
reciprocal, upright Whole-body CoM movements in all
directions
Task Specific Functional, require planning, change, sensory
integration Dual tasks
Self
initiated
Self paced
Renewable Fitness & ABLE Bodies
Renewable Fitness & ABLE Bodies
Assembly Required
Tai ChiKayakingBoxingLungesObstacle CoursesPilates & misc.
Renewable Fitness & ABLE Bodies
HELP PD Rx for Agility
Research Big, flowing, sequential Coordinated, multi-
segmental (upper/lower) Weight shifts in multiple
directions Sensory integration Mindful of movement,
breath, body Upright posture
Renewable Fitness & ABLE Bodies
TAI CHIPrayer WheelCat WalkingCloud Hands
Repulsing the Monkey
KAYAKING
Pictures with permission: ABLE Bodies Balance
Training, 2008; Human Kinetics
BIG, flowing, reciprocal, multi-segmental, whole body Axial mobility, rigidity
Renewable Fitness & ABLE Bodies
Obstacle CourseQuick, fast,
flexible Quick weight changes Quick task changes Plan ahead, manage
obstacles, decisions Multiple directions,
environments Practice difficult
situations
As comfortable . .
.
High KneesTire Course
Lateral shuffleGrapevine
Renewable Fitness & ABLE Bodies
BOXING
Quick, light, powerful, flexible, sequential, BIG, endurance, backward walking, mental agility,
Float like a butterfly . . .Sting like a bee!
Jab, Cross Hook Ducking Footwork KicksShouting!
Renewable Fitness & ABLE Bodies
Lunges
With permission: ABLE Bodies Balance
Training, 2008; Human Kinetics
In-PlaceWalking
Corrective
With permission: ABLE Bodies Balance
Training, 2008; Human Kinetics
BIG, flowing, multi-
directional Reciprocal arms, legs
Vary direction, size, speed,
environment, Trunk rotation
BIG Lunges Multiple directions
Coordinate legs/arms
Pictures with permission: ABLE Bodies Balance Training; 2008;
Human Kinetics
Arm SwingsReciprocal limb motion around spine
Develop: Extensor Strength Spinal Suppleness Somatic awareness, breathing, relaxation Transitional skills (ADLs)
From: Low Back Disorders; Stuart McGill; Human Kinetics, 2007
Pilates, misc.
◦Bridges◦Bird Dog◦Heel Slides ◦Paddle arms
ABLE Bodies Balance Training
Extensor (Axial)Strength & Length
Pilates Plus; Alan Herdman
From: Low Back Disorders; Stuart McGill; Human Kinetics, 2007
Renewable Fitness & ABLE Bodies
Spinal SupplenessKnee rolling & Cossack armsTelescoping ArmsCat & Camel & Shell poseThread the Needle
Undulate, Undulate!
Chair StandsHalf kneeling to standGet up from floorRolling on floor
Practice difficult ADLs
Tai chiKayakingObstacle CourseBoxingLungesPilates, etc.
Renewable Fitness & ABLE Bodies
The BIG Six
• Develop form, skill• Increase complexity
My pizza is cold 4 31 19 7 T__ L__ S__ B__ __ F__V __G __R
Attention Training
Renewable Fitness . . .imagine the
possibilities
TTTT
Word Winks:Mental Agility
Think
Renewable Fitness . . .imagine the
possibilities
fry fry
Word Winks
Renewable Fitness . . .imagine the
possibilities
What noise annoys an oyster most? Noisy noise annoys an oyster most
(Google has bazillions of ideas)
Renewable Fitness . . .imagine the
possibilities
Tongue Twisters
Require concentration
Help diminishing verbal skills -
BIG enunciations, loud voice
Renewable Fitness & ABLE Bodies
Other ways to assemble HELP PD strategies
Focus on ExtensorsStretch FlexorsUpper/Lower bodyThink BIGFunctional
Strength Training
Renewable Fitness . . .imagine the
possibilities
Safely make it more PD-Specific? Involve more balance
◦Elliptical, treadmill vs: recumbent bike◦Changes in direction, environment, surface, tasks
Go BIG! – try trekking poles Mix it up, variety
Endurance Training
Renewable Fitness . . .imagine the
possibilities
Pilates Tai Chi Yoga Aerobics Dance Martial Arts Others (Zumba Gold is
Big, quick, imaginative & fun)
Community Programs
Renewable Fitness . . .imagine the
possibilities
As PD Progresses . . .make changes
All stages: Flexibility, postural alignment, BIG movements, deep breathing, kinesthesia,
mind body connectionsEarly: Sports—physical & mental agility,
stamina, strength (neuroprotective)
Later: Walking, transitions, useful tricks, external cues, fall prevention
Renewable Fitness & ABLE Bodies
Fall Risks ◦ Backwards◦ Obstacles, hazards◦ Low vision◦ Dual tasks
Light Headedness: Quick postural changes Musculoskeletal Injuries: Rigidity, difficulty
initiating movementRenewable Fitness & ABLE
Bodies
Safety Considerations for Exercise with PD
BIG, Flexible, Reciprocal, Sequential Self initiated, Self paced Upright & Supple Posture Mind-Body Connections Sensory Integration Arm and leg coordination Quickness Endurance
Renewable Fitness & ABLE Bodies
Strategies for basal ganglia and neuroplasticity
Preserve/protect/enhance function & behavior Adapt, behave, function Increase neuro –transmitters Neuro-plasticity Increase number of synapses Cell proliferation?
Prevent falls Reduce cardiovascular events Improve, motor function Maintain quality of life, social ties, independence,
connections to community, Renewable Fitness & ABLE Bodies
Sensori-motor Activities:Benefits & Mechanisms
. . . Imagine the Possibilities
Renewable Fitness & ABLE Bodies
What’s the Best Exercise?
The one they’ll do!
Thank You!
Sue Scottemail
Ph: 503-720-9161
I think my work here is done
Physical Therapy April 2009; v89:4
Active Aging Today January 2010
UprightControl
Parkinson'sDisease
Upright posture requires good kinesthesiaStooped posture reduces stability
Hip Flexor(Abs)
Knee Flexor(Hamstring) Ankle
Flexor(Tib)
Knee Extensor(Quad)
Hip Extensors(back/hip)
AnkleExtensors(Calf)
StrengthenExtensors
LengthenFlexors
Renewable Fitness & ABLE Bodies
Strength & Endurance w/ Dual Task
Renewable Fitness & ABLE Bodies
Exercise preserves neural function
No Exercise
Improved function!
Neuroprotective . . . Can exercise slow
progression?Function/Neurons
Years after Diagnosis
More
Less
Gentle, lithe rotation along long axis of spine
Renewable Fitness & ABLE Bodies
Spinal Rotation
Renewable Fitness & ABLE Bodies
Exercise is especially importantbecause it works!
Prevents anticipated problems
Reduces depression and apathy
May slow disease progression . . . ?
Kinesthesia Breath tied to movementSelf awarenessDual TasksUseful tricks
Renewable Fitness & ABLE Bodies
Mind/Body Connections
Unknowns about Exercise for PD
What is the best kind? How intense and often? How long does it last when you stop? Does it reduce the rate of decline? Who would benefit the most?
Both young and older benefit Start: The earlier the better
Renewable Fitness & ABLE Bodies
Renewable Fitness & ABLE Bodies