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expectation of progress
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expectation of progress - April 9, 2008 3:50:50 PM
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buckeye
Posts: 170
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How do you all handle the expectation of progress in a reasonable and generally predictable period of time for the neurologically involved patient such as Parkinsons?
Do we 'test the waters' and see the patient for a period of time then discharge?
Do we not start PT at all because improvement is not likely?
Thoughts from anybody?
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RE: expectation of progress - April 9, 2008 6:34:31 PM
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annpsu25
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I think that patients with Parkinson's should be treated in the clinic. Once they start to plateau send them home with a home program. If any improvement is made, or the patient starts to deteriorate, then the patient should be re-evaluated and PT should be started again. Function is probably the most important factor for these types of patients. If this is a patient newly diagnosed with Parkinson's, PT should benefit.
< Message edited by annpsu25 -- April 9, 2008 6:41:14 PM >
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RE: expectation of progress - April 9, 2008 9:40:35 PM
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SJBird55
Posts: 2430
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From: Michigan
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Prescribed medication is very important for individuals with Parkinson's. The few times I worked with people with Parkinson's, they did progress with physical therapy intervention - (gait training, lower extremity strengthening, balance activities and functional activities) particularly with ambulation and controling movement patterns to safely move from sit to stand and stop walking with better timing so they didn't overshoot say the chair. But medications were extremely important - the right dosage and the timing of the effect of the medications were factors that did affect physical therapy intervention. I also tried to create continuity with the speech therapist - the speech therapist would give me tidbits of insight to assist with improving communication skills for the patient. From my experience, huge progress isn't achieved in 4 weeks. The beginnings of improvement seem to be noted around 8 weeks. As long as the patient is progressing and you are noting change, you can continue treating. Make sure you document the improvements so that treatment is justified. Below are just a few abstracts. We can offer a lot for these patients....
Arch Phys Med Rehabil. 2007 Sep;88(9):1154-8.
Six weeks of intensive treadmill training improves gait and quality of life in patients with Parkinson's disease: a pilot study.
Herman T, Giladi N, Gruendlinger L, Hausdorff JM.Movement Disorders Unit, Tel-Aviv Sourasky Medical Center, Department of Physical Therapy, Sackler School of Medicine, Tel-Aviv University, Israel.
OBJECTIVE: To evaluate the effects of 6 weeks of intensive treadmill training on gait rhythmicity, functional mobility, and quality of life (QOL) in patients with Parkinson's disease (PD). DESIGN: An open-label, before-after pilot study. SETTING: Outpatient movement disorders clinic. PARTICIPANTS: Nine patients with PD who were able to ambulate independently and were not demented. Mean age was 70+/-6.8 years. Patients had mild to moderate PD (Hoehn and Yahr stage range, 1.5-3). INTERVENTIONS: Patients walked on a treadmill for 30 minutes during each training session, 4 training sessions a week, for 6 weeks. Once a week, usual overground walking speed was re-evaluated and the treadmill speed was adjusted accordingly. MAIN OUTCOME MEASURES: The 39-item Parkinson's Disease Questionnaire (PDQ-39), motor part of the Unified Parkinson's Disease Rating Scale (UPDRS), gait speed, stride time variability, swing time variability, and the Short Physical Performance Battery (SPPB). RESULTS: A comparison of the measures taken before and after the treadmill intervention indicates general improvement. QOL, as measured by the PDQ-39, was reduced (improved) from 32 to 22 (P<.014). Parkinsonian symptoms, as measured by the UPDRS, decreased (improved) from 29 to 22 (P<.043). Usual gait speed increased from 1.11 to 1.26 m/s (P<.014). Swing time variability was lower (better) in all but one patient, changing from 3.0% to 2.3% (P<.06). Scores on the SPPB also improved (P<.008). Interestingly, many of the improvements persisted even 4 weeks later. CONCLUSIONS: These results show the potential to enhance gait rhythmicity in patients with PD and suggest that a progressive and intensive treadmill training program can be used to minimize impairments in gait, reduce fall risk, and increase QOL in these patients.
Arch Phys Med Rehabil. 2001 Apr;82(4):509-15.
The effects of physical therapy in Parkinson's disease: a research synthesis.
de Goede CJ, Keus SH, Kwakkel G, Wagenaar RC.Department of Physiotherapy, University Hospital Vrije Universiteit, Amsterdam, The Netherlands. fysiother@azvu.nl
OBJECTIVE: To present a critical review and meta-analysis of studies evaluating the effects of physical therapy in patients suffering from Parkinson's disease (PD), in terms of neurologic signs, activities of daily living (ADLs), and walking ability. DATA SOURCES: Articles published from 1966 to May 1999 were compiled by means of MEDLINE, Cochrane register of controlled trials, and CINAHL using combinations of the key words Parkinson's disease, exercise, exercise therapy, physical therapy, and group training. References presented in relevant publications were also examined. Articles written in English, German, or Dutch were included. STUDY SELECTION: Studies had to meet the following selection criteria: (1) patients with PD were included in the intervention study, (2) the effects of physical therapy (PT) were evaluated, (3) the study could be classified as true or quasi-experiment, and (4) the study was published in a journal or book. DATA EXTRACTION: Two reviewers assessed independently the methodologic quality of the data of each included study. One reviewer extracted relevant meta-analysis data. DATA SYNTHESIS: For each outcome measure the estimated effect size and the summary effect size (SES) were calculated, using fixed (ie, Hedges's g) and random effects models. The meta-analysis resulted in a significant homogeneous SES with regard to ADLs (.40; confidence interval [CI] = .17-.64) and stride length (.46; CI = .12-.82). The SES with regard to walking speed showed a significant heterogeneous SES, which remained significant after applying a random effects model (.49; CI = .21-.77). The SES with regard to neurologic signs was not significant (.22; CI = -.08 to .52). The small number of studies included and the shortcomings of the methodologic quality of these studies, however, bias the results of the present study. CONCLUSIONS: The results of the present research synthesis support the hypothesis that Parkinson patients benefit from PT added to their standard medication.
Clin J Sport Med. 2006 Sep;16(5):422-5.
Is physical exercise beneficial for persons with Parkinson's disease?
Crizzle AM, Newhouse IJ.Department of Public Health, Lakehead University, Thunder Bay, Ontario, Canada.
OBJECTIVE: To review existing studies evaluating the effectiveness of physical exercise on mortality, strength, balance, mobility, and activities of daily living (ADL) for sufferers of Parkinson's disease (PD). DATA SOURCES: The following databases were searched (1) Cochrane Database of Systematic Reviews, (2) Cumulative Index to Nursing and Allied Health Literature (CINAHL), (3) PubMed and (4) Medline/NARIC (National Rehabilitation Information Center) using combinations of key words Parkinson's disease and physical exercise. Only articles written in English were included. References cited were also examined. STUDY SELECTION: Studies were eligible if (1) only patients with PD were included in the intervention study (there were many studies that evaluated the benefits of exercise after stroke, cardiac arrest, sports injuries, surgery, and arthritis, but only a few for patients with PD), (2) the intervention included some form of physical or therapeutic exercise, (3) the effects of the physical exercise were evaluated, and (4) the studies were published in a refereed journal. Because few studies were found that dealt with PD patients exclusively, all studies that evaluated the effectiveness of physical exercise for only PD patients were included. Seven studies met our criteria and were selected. Three of the selected studies were randomized controlled studies, 1 was an open trial, and the other 3 relied on patients' own assessments. DATA SYNTHESIS: Outcomes in the studies were measured in terms of physical improvements in patients with PD, such as improved axial rotation, functional reach, flexibility, balance, muscle strength, short-step gait, and mobility. All studies reviewed show that exercise improves overall performance in PD patients. Improvements were measured using standardized tests and other measurement scales. CONCLUSIONS: The results of the present research synthesis support the hypothesis that patients with PD improve their physical performance and activities of daily living through exercise. Future studies should include the development of standardized exercise programs specific for problems associated with PD as well as standardized testing methods for measuring improvements in PD patients. There is also a need for longer term studies (over 1 year) to assess if improvements achieved during the intervention stage are retained long term.
Eura Medicophys. 2006 Sep;42(3):231-8.
A randomised controlled cross-over trial of aerobic training versus Qigong in advanced Parkinson's disease.
Burini D, Farabollini B, Iacucci S, Rimatori C, Riccardi G, Capecci M, Provinciali L, Ceravolo MG.Neurorehabilitation Clinic, Department of Neurosciences, Politecnica University of Marche, Azienda Ospedali Riuniti, Ancona, Italy.
AIM: To investigate the effects of an aerobic training in subjects with Parkinson's disease (PD) as compared to a medical Chinese exercise (Qigong). METHODS: Design: randomized controlled trial with a cross over design. Setting: PD out-patients referred to a Neurorehabilitation facility for the management of motor disability. Subjects: 26 PD patients in Hoehn and Yahr stage II to III under stable medication were randomly allocated to either Group AT1+QG2 (receiving 20 aerobic training sessions followed by 20 ''Qigong'' group sessions with 2 month interval between the interventions), or Group QG1+AT2 (performing the same treatments with an inverted sequence). Main outcome measures: clinical effects of treatment were sought through the Unified Parkinson's Disease Rating Scale (UPDRS), Brown's Disability Scale (B'DS), six-Minute Walking Test (6MWT), Borg scale for breathlessness, Beck Depression Inventory (BDI) and Parkinson's Disease Questionnaire-39 items (PDQ-39). A spirometry test and maximum cardiopulmonary exercise test (CPET) were also performed to determine the pulmonary function, the metabolic and cardio-respiratory requests at rest and under exercise. All measures were taken immediately before and at the completion of each treatment phase. RESULTS: The statistical analysis focusing on the evolution of motor disability and quality of life revealed a significant interaction effect between group and time for the 6MWT (time x group effect: F: 5.4 P=0.002) and the Borg scale (time x group effect: F: 4.2 P=0.009). Post hoc analysis showed a significant increase in 6MWT and a larger decrease in Borg score after aerobic training within each subgroup, whereas no significant changes were observed during Qigong. No significant changes over time were detected through the analysis of UPDRS, B'DS, BDI and PDQ-39 scores. The analysis of cardiorespiratory parameters showed significant interaction effects between group and time for the Double Productpeak (time x group effect: F: 7.7 P=0.0003), the VO(2peak) (time x group effect: F: 4.8 P=0.007), and the VO(2)/kg ratio (time x group effect: F: 4.3 P=0.009), owing to their decrease after aerobic training to an extent that was never observed after Qigong treatment. CONCLUSIONS: Aerobic training exerts a significant impact on the ability of moderately disabled PD patients to cope with exercise, although it does not improve their self-sufficiency and quality of life.
Clin Rehabil. 2007 Aug;21(8):698-705.
The effects of incremental speed-dependent treadmill training on postural instability and fear of falling in Parkinson's disease.
Cakit BD, Saracoglu M, Genc H, Erdem HR, Inan L.2nd Department of Physical Medicine and Rehabilitation, Ankara Education and Research Hospital, Turkey. burcudcakit@yahoo.com
OBJECTIVE: To detect the effectiveness of incremental speed-dependent treadmill training on postural instability, dynamic balance and fear of falling in patients with idiopathic Parkinson's disease. DESIGN: Randomized controlled trial. SETTING: Ankara Education and Research Hospital, 2nd PM&R Clinic, Cardiopulmonary Rehabilitation Unit. SUBJECTS: Fifty-four patients with idiopathic Parkinson's disease in stage 2 or 3 of the Hoehn Yahr staging entered, and 31 patients (21 training, 10 control) had outcome data. INTERVENTIONS: Postural instability of patients with Parkinson's disease was assessed using the motor component of the Unified Parkinson's Disease Rating Scale (UPDRS), Berg Balance Test, Dynamic Gait Index and Falls Efficacy Scale. Twenty-one patients with Parkinson's disease participated in an eight-week exercise programme using incremental speed-dependent treadmill training. Before and after the training programme, balance, gait, fear of falling and walking distance and speed on treadmill were assessed in both Parkinson's disease groups. MAIN MEASURES: Walking distance and speed on treadmill, UPDRS, Berg Balance Test, Dynamic Gait Index and Falls Efficacy Scale. RESULTS: Initial total walking distance of the training group on treadmill was 266.45 +/- 82.14 m and this was progressively increased to 726.36 +/- 93.1 m after 16 training session (P < 0.001). Tolerated maximum speed of the training group on treadmill at baseline was 1.9 +/- 0.75 km/h and improved to 2.61 +/- 0.77 km/h (P < 0.001). Berg Balance Test, Dynamic Gait Index and Falls Efficacy Scale scores of the training group were improved significantly after the training programme (P < 0.01). There was no significant improvement in any of the outcome measurements in the control group (P > 0.05). CONCLUSIONS: Specific exercise programmes using incremental speed-dependent treadmill training may improve mobility, reduce postural instability and fear of falling in patients with Parkinson's disease.
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RE: expectation of progress - April 10, 2008 1:30:47 PM
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buckeye
Posts: 170
Joined: May 24, 2007
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Thanks for the replies. I had more to my post but lost it during a copy and paste, then did not read the message again until today. I apologize for the miscommunication.
I wondering more specifically about the advance Parkinson's or perhaps other progressive neurologic pathology patient. Someone who no longer walks and is dependent for transfers, or who is dependent for transfers but walks with maximum assistance - for many months. We will suppose there are no other medical reasons for the decline and no acute ro sub-acute medical/orthopedic problems - just a family/doc who wants the patient to have therapy.
Is it reasonable to expect this patient to improve mobility? Do we have a trial of therapy?
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RE: expectation of progress - April 10, 2008 7:18:11 PM
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SJBird55
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From: Michigan
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It's always reasonable to have a trial of physical therapy services. Where is the information coming from with regard to the current functional level? Maybe no one has actually taught the patient how to transfer? Did the patient get this way because others were doing the physical labor? Is the patient really so advanced nothing will help? Can a strengthening program be initiated that might somewhat assist with function? Could a maintenance program be designed and then a list of indications as to when physical therapy services could be initiated again? The only way to know is to evaluate and do a trial of physical therapy.
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RE: expectation of progress - April 11, 2008 7:51:51 AM
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buckeye
Posts: 170
Joined: May 24, 2007
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sjbird - All valid points. Thanks. I usually will go the route of examination/evaluation and a trial for these types of reasons. Also try to gather a strong history of previous therapies and time frames. Most of the time, I suggest patients be re-evaluated on a regular basis to monitor status.
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