LSVT BIG, dance, and other recreational interventions Based on the finding that hypokinesia or small amplitude movements are the underlying impairments leading to decreases in movement speed, the Lee Silverman Voice Treatment (LSVT ® ) focuses on movement amplitude for training speech (Fox et al., 2012). Because of evidence for the efficacy of this technique (Fox et al., 2012), a program for movement based on the same principles was developed. Called the LSVT BIG™ intervention , the program emphasizes the need to practice large-amplitude movements in order to obtain long-term changes in movement size (Ebersbach et al., 2015; Farley & Koshland, 2005). The program involves intensive therapy lasting 60 minutes and taking place 4 days per week for 4 weeks, with additional work completed at home as well. A key component of the program is focusing awareness on the movement in order to increase sensory awareness of movement amplitude. Therapists interested in becoming certified in this technique can consult the “Resources” section for additional information. Several randomized clinical trials have examined the effects of recreational activities such as dancing, video games, and tai chi on improving movement in individuals with PD. One dance study used the tango to capitalize on partnering to improve movement and the use of music to set the pace and cue movement. Tango participants improved on both the BBS and the UPDRS, whereas those who performed only traditional exercise improved on the UPDRS but not the BBS (Hackney et al., 2007). Improvement on the BBS indicates that tango dance improves functional balance, whereas the UPDRS items test balance only at the body structure level. A large randomized trial comparing tai chi to stretching and resistance exercise demonstrated that tai chi improved stride length and functional reach and lowered fall incidence and that these improvements were maintained at 3 months’ follow- up (Li et al., 2012). Strength training also resulted in lowered fall incidence (Li et al., 2012). There is increasing interest in the use of video games for exercise and balance training, but few studies exist to validate their effectiveness. Wii Fit™ is a popular gaming system that comes with a balance board and a wide selection of programs that lead players in anything from basic yoga and strengthening programs to high-level balance activities. A small study utilizing the Wii Fit™ balance board demonstrated significant improvement among individuals with moderate PD, as indicated by scores on tests such as TUG, Sit to Stand, single-limb stance, gait velocity, and the TMT (Esculier et al., 2012). Game selection is key; therapists should select games that practice the particular skills that the client is having difficulty performing. Research shows that the ability of patients with PD to learn, retain, and transfer performance improvements after training depends largely on the demands, particularly cognitive demands, of the games involved (dos Santos Mendes et al., 2012). This finding reinforces the importance of appropriate game selection for rehabilitation purposes. It is highly recommended that a therapist be present the first time games are played by those with demonstrated deficits in mobility or balance; this will ensure that appropriate and safe games are chosen for each individual. Fitness The current recommendation for individuals with neurologic disease is to engage in fitness activities to prevent secondary problems such as cardiopulmonary disease and diabetes (Gretebeck et al., 2012; Langhammer & Lindmark, 2012; Motl & Goldman, 2011). However, individuals with degenerative diseases encounter numerous obstacles to exercise. Common barriers to exercise include difficulties finding transportation, pain that limits participation, and functional limitations that preclude participation in many common exercises offered in community centers. Fortunately, many communities have recognized the importance of accessible fitness programming and offer it for the elderly and those with PD. Studies show that fitness programming can extend the life expectancy of individuals with PD (Kuroda et al., 1992) and improve quality of life (Rodrigues de Paula et al., 2006). To institute a successful
Cycling has shown to be promising as a rehabilitation technique for mobility and even improving upper extremity tremor and reducing bradykinesia in clients with PD (Ridgel et al., 2015). Initially the study used a tandem bike with an experienced cyclist setting a pace of 80 rpm. More recent studies have examined the use of a motorized bike to set the pace such that it is averaging 80 rpm but has some inherent variability in the pace to challenge the rider (Ridgel et al., 2015). These studies have shown an improvement in UPDRS motor scores indicating less bradykinesia and tremor. It is important to note that these are very specific, pace-controlled protocols and not over-ground cycling or use of a stationary bike with an external pacesetter. It is not possible at this time to say whether other forms of cycling are beneficial. Transfers Individuals with PD typically experience significant difficulties with transfers; these difficulties are exacerbated when seated surfaces are lower, or softer, or when arm support is not available (e.g., toilet seats and car seats). Many underlying symptoms can contribute to deficits in transfer ability, including: ● Movement initiation difficulty. ● Bradykinesia. ● Hypokinesia. ● Rigidity and loss of ROM. Underlying impairments of body structure should be identified and addressed as part of the process of providing an individualized functional training program. Cueing, along with repetitive practice, can be used to aid in movement initiation (Maitra, 2007). Based on recent evidence, the client should be taught to give himself or herself a verbal cue (Maitra, 2007). Another common movement deficit during transfers from a lower surface stems from the failure to sufficiently shift body weight over the feet. Physical therapists should instruct patients to get their “nose over the toes” as the patient comes to standing. It may be difficult for many individuals to stand erect from extreme postures of forward flexion; instruction to keep the head and eyes up, aiming for a point in the distance while leaning forward, ensures that the transfer is done with an erect and active spine that allows for an easy transition to an upright position once the move from sit to stand is initiated. As shown in Figure 6, many individuals with neurodegenerative diseases do better with transfers if they place their hands on their thighs both to assist in pushing off for sit to stand and for support during lowering for stand to sit. This posture allows for support from the arms while promoting safe and appropriate body mechanics during the transfer. Individuals with balance deficits should not be told to reach back for the seat of the chair for stand-to-sit transfers; doing so before the knees are flexed promotes an abnormal movement strategy and produces an early posterior weight shift that can result in loss of balance and a fall into the chair. If clients tend to sit too quickly, they should be told to touch the chair with their thigh or put their hand on the armrest (if there is one) rather than reach for the seat of the chair. Figure 6: Sit-to-Stand Transfer
Note. From Western Schools, 2018.
EliteLearning.com/Physical-Therapy
Page 118
Powered by FlippingBook