I have started to add exercises and educational handouts to an online program for Physical Therapists and Occupational Therapists. It’s called HEP2go and allows therapists to upload exercises or have access to exercises or educational materials which other individuals have uploaded. You can join for free or become a member for a reasonable annual fee. HEP2go.com You can search for exercises or for individual members who have uploaded exercises. You can search my uploads by searching Miriam ‘Mia’ Boelen.
Parkinsonism is an umbrella term used for individuals who present with some of the symptoms of Parkinson’s with the main feature being slowness of movement. Idiopathic Parkinson’s disease is the most common form of Parkinsonism and the most treatable. It is typically referred to as: Parkinson’s disease or Parkinson’s or PD. The ‘Atypical Parkinson’s’ (also known as Parkinson’s Plus Syndromes) houses 4 diagnostic categories. Each category has it’s own distinguishing features. Secondary Parkinsonism is caused by something other than a lack of dopamine but can effect the dopamine system. An example of a secondary Parkinsonism is the result of medications which block the action of dopamine. This type of secondary Parkinsonism can be reversible by removing the medication causing the symptoms. Click on link for listing of medications: https://www.parkinsons.org.uk/sites/default/files/publications/download/english/fs38_druginducedparkinsonism.pdf
When someone is diagnosed with Parkinsonism there is often uncertainty what that means. ‘Does that mean I have Parkinson’s disease?’ You may, or you may have something else that currently looks like Parkinson’s but over time your symptoms will become more clear. Also, your response to Parkinson’s medications will offer more information to help with a more definitive diagnosis. This process can take some time to unfold depending on how pronounced the individual symptoms present themselves and if medications offer substantial relief or not. Click on the chart to see a larger version.
As you look at the chart, the terms falling and dementia can be disconcerting. When looking at information which condenses an entire diagnoses in a few words, you should view it with caution since the degree which an individual can experience symptoms is largely variable and not everyone experiences all symptoms. The autonomic symptoms experienced by the ‘Atypical Parkinson’s’ category may also effect people with PD but to a lesser degree and only contributes to the sometimes daunting task of establishing a definitive diagnosis. A Movement Disorder neurologist is the most knowledgeable in sorting out Parkinsonisms.
I recently gave a talk for the APDA annual symposium, Midwest Chapter. It explains the physical therapy evaluation process and how physical therapy can help individuals with Parkinson’s. There are still many people with Parkinson’s who have never been to physical therapy and many others who only start seeing a physical therapist once there are balance problems. Being informed and proactive can impact how well you live and substantially reduce stress. This video offers practical tips and guidance. Click on picture below to view.
- Get a baseline – How long can you walk before you need to rest? Also, if you have a pedometer – how many steps do you take during the day?
- Problems with balance or arthritis? You may need a walking device to help you to walk safer and with less pain. Consult your physical therapist.
- History of cardiac problems, low blood pressure or diabetes? Consult with your doctor and/or physical therapist. We want you to be successful!
Which category do you fit into? (Don’t let these numbers discourage you! You should try to compete with yourself AND use a pedometer that really counts every step!)
- Sedentary Lifestyle – < 5,000 steps/day
- Low Active – between 5,000 to 7,499 steps/day (typical of daily activity excluding sports/exercise)
- Somewhat Active – 7,500 to 9,999 steps/day
- Active – > 10,000 steps/day
- Highly Active – > 12,500 steps/day
Norms – Steps by age:
- Younger than 65 years old – between 8,899 to 9,996 steps/day
- > 65 years old – between 6,565 to 8,233 steps/day
- Start walking more than your baseline but perform to your tolerance. Do this daily.
- Build up gradually with your walking time, steps and intensity
- Goal: 30 minutes of walking most days of the week at increments not less than 10 minutes
- Use a walking device if needed for balance or pain to allow you to walk more
- Pedometers are motivational to increase walking steps/day. This can result in improved walking speeds and stamina. You can track progress.
- To find information on pedometers go to this website: http://pedometers-review.toptenreviews.com
Bohannon, R. W. (2007). “Number of pedometer-assessed steps taken per day by adults: a descriptive meta-analysis.” Phys Ther 87(12): 1642-50.
Bravata, D. M., C. Smith-Spangler, et al. (2007). “Using pedometers to increase physical activity and improve health: a systematic review.” JAMA 298(19): 2296-304.
Ellis, T., N. K. Latham, et al. “Feasibility of a virtual exercise coach to promote walking in community-dwelling persons with Parkinson disease.” Am J Phys Med Rehabil 92(6): 472-81; quiz 482-5.
Nelson, M. E., W. J. Rejeski, et al. (2007). “Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association.” Circulation 116(9): 1094-105.
Tudor-Locke, C. and D. R. Bassett, Jr. (2004). “How many steps/day are enough? Preliminary pedometer indices for public health.” Sports Med 34(1): 1-8.
I am always in search of rollators which will fit the needs of my patients. (A rollator is a ‘walker’ with 4 wheels, seat and handbrakes). Recently I attended an ‘Ability Fair’ which featured items that can help people live more independently. Included in this fair were rollators. A particular rollator caught my eye and is called the ‘Gemino 30’. There is a website called ‘Elderluxe’ which showcases many quality walkers AND the Gemino. Click on this link: http://www.elderluxe.com/mobility/walkers-and-rollators/all-walkers-and-rollators/ This walker is made in Germany and has won awards for its design.
When buying a rollator, the approximate size should NOT be determined by your height. Instead, the proper way to determine the proper size is to measure the distance from your wrist to the floor. Try to match that distance to the handle height. The handle height information is typically found in the ‘specs’ section. If possible, pick a rollator which has the capability of adjusting above and below your (wrist to floor) measurement for fine tuning. Establishing the best walker/rollator for your needs is best performed with the guidance of a physical therapist who is familiar with Parkinson’s. For some individuals a rollator may not be safe for various reasons and a physical therapist can help guide you.
(click on the title ‘Pedometers and physical activity to see full posting)
Pedometers have been commercially available since the 1980’s and have been a source of motivation to increase steps/day for health benefits such as reducing blood pressure, improving insulin sensitivity, osteoporosis and depression. There is mounting evidence regarding the benefits of exercise to control Parkinson’s symptoms and lack of exercise can worsen Parkinson’s symptoms. It is often difficult to motivate individuals to be more active but a pedometer has shown to be one effective tool.
Initially, when someone hears they must walk 10,000 steps/day, it can make them give up before even starting. I tried to walk 10,000 steps with an inexpensive pedometer and had great difficulty attaining that goal. Positioning the pedometer just right so that every step is counted is a common problem which I have observed and personally experienced. Often, the first few steps are not counted.
There is a new generation of pedometers which seem to count EVERY step and the placement is not critical. In fact you can just throw it in your pocket, clip it to any part of your clothing at any angle or wear a wrist bracelet. I recently purchased a ‘fitbit‘ which monitors your activity (steps, stairs and calories burned) which can be wirelessly downloaded to a computer or app and graphed so you can follow your progress effortlessly. It resets on it’s own everyday and needs to be recharged on a weekly basis for a brief period. You can find the ‘Fitbit’ on Amazon however there are also other companies which manufacture similar devices such as Nike and Jawbone. Looking at the reviews on Amazon, the Fitbit is showing the best rating.
Below are some guidelines to compare your steps/day and level of physical activity with healthy adults:
‘Sedentary lifestyle’ = less than 5000 steps/day
‘low active’ = 5000 to 7499 steps/day
‘somewhat active’ = 7500 to 9999 steps/day
‘active’ = 10,000 or more steps/day
‘highly active’ = greater than 12,500 steps/day
I am excited to announce my newly published book, ” How To Live Well With Parkinson’s: Advice From a Physical Therapist”. It is intended for the person who has Parkinson’s and their Caregiver. Physical therapists can also benefit from this book since it is filled with interventions specific for this population. There are over 200 illustrations. Click on book cover to see more details on Amazon. Table of Contents below.
Chapter 1 “I have PD – Now Who is in Charge of What?”
Chapter 2 Exercising With Purpose
Chapter 3 The Bed Challenge – Is it You or the Bed (or both)?
Chapter 4 Chairs – Sitting is the Easy Part.
Chapter 5 Walking Problems and Remedies
Chapter 6 Walkers/Rollators: Choosing and Using Them
Chapter 7 Balancing Act – Tips On Staying Balanced
Chapter 8 Caregivers Corner
Appendix – Helpful devices
As a physical therapist, I am always searching for ways to ensure my patients receive the most effective interventions which are targeting their individual needs. A recent research article published in 2012 discusses benefits from various interventions: ‘Physiotherapy Intervention in Parkinson’s disease: systematic review and meta-analysis’ (click on the title, once you are on the website you can download the full article for free). This type of research article can save clinicians time since it reviews a number of relevent research studies and synthesizes outcomes. Categories of interventions were: physiotherapy (gait and balance, hands-on techniques and education regarding body mechanics with transfers, posture and physical fitness), exercise, treadmill, cueing, dance (tango, waltz and foxtrot) and martial arts (tai chi,qigong). Listed are outcomes established from these various interventions:
1) Improved gait velocity (increased stride length)
2) No change in cadence (cadence tends to be preserved in people with Parkinson’s (PwP))
3) No change in balance confidence (Activity Specific Balance Confidence Scale – ABC; Falls Efficacy Scale)
4) Fall reduction
5) Significant improvements in the Unified Parkinson’s Disease Rating Scale (UPDRS) – subscore for activities of daily living
6) No change in the mobility section of the Parkinson’s Disease Quality of Life Questionnaire (PDQ-39)
7) There was no difference reported between type of physical therapy intervention and outcome.
As you can see, there are a variety of interventions to accommodate a wide spectrum of motor problems experienced by PwP. It is important to recognize the individual needs of PwP and apply interventions accordingly. It has been my experience that unless we educate our patients to continue to practice what was learning in therapy including staying active and exercising/walking, benefits will be lost.
Dual tasking is doing more than one thing at a time. People with Parkinson’s (PwP) often have greater difficulty doing 2 things at the same time. This is in part due to the increased concentration required to perform activities. Disruptions with walking when dual tasking is often used as an example due to potential fall risk involved.
Over the years I have focused interventions on redirecting primary focus on gait with less attention to the secondary task. Patient education regarding increased attention demands on gait helps the individual understand the need for redirected focus. Also, educating PwP to place balance as a priority over the task at hand can be helpful for self-management with balance control. Conditioning exercises and gait training utilizing compensatory strategies to maximize stride length can prepare individuals when there are more distractions. I have found benefits in this comprehensive approach.
Only occasionally have I attempted dual task training with individuals with mild PD : walking + cognitive task or walking + manual or walking + manual + cognitive. I have observed either short term or no improvements but have to admit that perhaps not enough time was spent on these activities (4 sessions for 30 minutes).
I have often wondered if I should work more on dual tasking to prepare an individual for the real world but have felt it would require an inordinate number of treatment sessions to become successful. Dual tasking, I find also requires an individual to have the capability or capacity to learn to filter distractions. So, would exposing an individual to numerous distractions help to desensitize and improve focus in dual tasking conditions? If this is so, I would think community Parkinson’s classes could help an individual in this area more economically. Community classes can be ongoing and definitely distracting! Two community based exercise programs which come to mind which specialize in PD and comprehensively address the needs of PwP are:
1. The PWR (Parkinson’s Wellness Recovery) Exercise classes – founded by Becky Farley PT, PhD . Dr Farley is currently doing work in dual task function in early PD. http://www.pwrgym.org/
2. Delay the Disease http://delaythedisease.com/
It appears there are various sources which are currently investigating interventions and outcomes in the area of dual tasking. I look forward to the completion of these studies!
Recently discovered a website which has a comprehensive listing of tests to measure the status of our patients. It shows the name of the test, how long it takes to perform a particular test, diagnoses appropriate for a particular test. It links you to the instructions of the test and any useful information you need to know. I have added the link to this website for physical therapists. click on outcome measures. Or, you can click here. It also has definitions of statistical terms – bonus!