clincal practice guidelines parkinsons

Question 1

Aerobic exercise

Answer 1

Physical therapists should implement moderate- to high-intensity aerobic exercise to improve VO2, reduce motor disease severity and improve functional outcomes in individuals with Parkinson disease

Question 2

Resistance training

Answer 2

Physical therapists should implement resistance training to reduce motor disease severity and improve strength, power, nonmotor symptoms, functional outcomes, and quality of life in individuals with Parkinson disease

Question 3

Balance training

Answer 3

Physical therapists should implement balance training intervention programs to reduce postural control impairments and improve balance and gait outcomes, mobility, balance confidence, and quality of life in individuals with Parkinson disease

Question 4

Flexibility exercises

Answer 4

Physical therapists MAY (evidence is low in this part) implement flexibility exercises to improve ROM in individuals with Parkinson disease

Question 5

External cueing

Answer 5

Physical therapists should implement external cueing to reduce motor disease severity and freezing of gait and to improve gait outcomes in individuals with Parkinson disease

Question 6

Community-based exercise

Answer 6

Physical therapists should recommend community-based exercise to reduce motor disease severity and improve nonmotor symptoms, functional outcomes, and quality of life in individuals with Parkinson disease

Question 7

Gait training

Answer 7

Physical therapists should implement gait training to reduce motor disease severity and improve stride length, gait speed, mobility, and balance in individuals with Parkinson disease

Question 8

Task-specific training

Answer 8

Physical therapists should implement task-specific training to improve task-specific impairment levels and functional outcomes for individuals with Parkinson disease

Question 9

Behavior-change approach

Answer 9

Physical therapists should implement behavior-change approaches to improve physical activity and quality of life in individuals with Parkinson disease

Question 10

Integrated care

Answer 10

Physical therapist services should be delivered within an integrated care approach to reduce motor disease severity and improve quality of life in individuals with Parkinson disease

Question 11

Telerehabilitation

Answer 11

Physical therapist services MAY be delivered via telerehabilitation to improve balance in individuals with Parkinson disease

Question 12

It has been suggested that dopaminergic replacement medications may ______the benefits of exercise, thus potentially accounting for lack of effects of aerobic exercise on motor symptoms when measured in the “on” state

Answer 12

mask

Question 13

Improvements at the impairment level have been demonstrated in many aerobic exercise trials in PD. High- and moderate-quality studies found that aerobic exercise compared with control (eg, usual care, stretching, strengthening) improved VO2, suggesting a _______ of training effect.

Answer 13

specificity

Question 14

Most aerobic exercise studies in individuals with PD consisted of walking on a treadmill or stationary cycling. Few studies have directly compared different modes of aerobic exercise, though no differences have been revealed when direct comparisons were made.18 Results across studies using different modes of aerobic exercise were comparable,24,26 suggesting no single form of aerobic exercise was ________ to another.

Answer 14

superior

Question 15

cycling rather than treadmill walking may be a safer aerobic exercise option in those who are at high risk of falling and/or with freezing of gait (FOG)

Answer 15

true

Question 16

Aerobic exercise has also been shown to improve various aspects of function and quality of life in individuals with PD. Two high-quality19,25 and 2 moderate-quality studies29,32 revealed improvements in gait-related outcomes, including the _________ test

Answer 16

6 minute walk test

Question 17

Given the potential benefits of moderate- to high-intensity aerobic exercise to reduce motor disease severity in PD, the GDG recommends that physical therapists prescribe aerobic exercise very ______ in the course of the disease.

Answer 17

early

Question 18

Given the variability in the dosing of aerobic exercise across studies, the optimal dosing of aerobic exercise has not been determined but many studies reveal a benefit of aerobic exercise when implemented at least ___ days per week for ____ to _____ minutes each at moderate to high intensity

Answer 18

3 days a week for 30 to 40 minutes at moderate to high intensity

Question 19

Due to autonomic dysfunction leading to a blunted HR response in some individuals with PD, ______________ should also be considered as a means of monitoring exercise intensity

Answer 19

rate of perceived exertion

Although the length of the trials and timing of follow-up assessments vary considerably among studies, it appears that gains dissipate if exercise is discontinued. This suggests that regular, long-term engagement in aerobic exercise is needed to sustain a benefit.

Question 20

Most aerobic exercise studies include individuals with mild to moderate PD (H&Y stages 1–3). These recommendations may not apply to those with _____ PD who do not have the capacity to engage in moderate- to high-intensity aerobic exercise

Answer 20

severe

Question 21

progressive resistance training program was shown to be more effective than a __________ exercise intervention (modified from the Fitness Counts Booklet, Parkinson’s Foundation) for improving elbow flexion and extension torque66 and elbow flexion torque

Answer 21

non progressive

A progressive resistance training protocol using a weighted vest and ankle weights (60-minute class, twice weekly for 24 weeks) was superior to either tai chi or a stretching program to improve knee flexion and knee extension peak torque value as measured with use of isokinetic dynamometer

Question 22

Resistance training with instability (RTI) was favored compared with ______ to improve strength/power of the plantar flexors and knee extensors as measured via surface electromyography signals identified during submaximal isometric contractions on an isokinetic dynamometry

Answer 22

resistance training alone

RTI is described as resistance training (leg press, latissimus dorsi pulldown, ankle plantar flexion, chest press, and half squat) with an added progressive and concomitant increase in resistance and instability applied via unstable devices (eg, balance pad, dyna discs, balance discs, BOSU, and Swiss ball).

Question 23

Resistance training was favored over usual physical activity to improve fast gait speed on the 10-Meter Walk Test (10MWT),86,87 and progressive RTI was favored over a nonexercised, education-based intervention to improve balance (BESTest) and stability (Biodex Balance system)

Answer 23

Progressive resistance training plus movement strategy training and falls education was favored over a control group that engaged in guided education and discussion to improve fall rate over 12 months and activities of daily living (UPDRS activities of daily living score). All 5 of these high-quality studies followed a systematic progression of resistance, with 4 of them following recommendations from the ACSM on progression of resistance.

Question 24

One high-quality study79 and 3 moderate-quality studies61,80,81 addressed 3 different modes of resistance training to improve balance and stability in people with PD. RTI was favored over resistance training to improve balance on all domains of the BESTest except reactive postural responses and sensory orientation.

Answer 24

RTI was also favored over resistance training to improve stability as measured by an overall stability index on the Biodex Balance System

Question 25

Physical therapists should implement resistance training, either alone or as a part of a _______ intervention, to improve function.

Answer 25

multimodal interventions Three high-quality studies22,47,72 favored multimodal interventions that included resistance training compared with control to improve balance as measured by the Mini BESTest,88,89 the Functional Reach Test, and the Berg Balance Scale (BBS). One of these studies identified these improvements both in the “on” and “off” medication state for individuals with PD

Question 26

There was variation in the intervention approaches used to target balance, but most studies included multimodal balance training that incorporated elements of strengthening, sensory integration, ________ postural adjustments, ________ postural adjustments, gait, and functional task training.

Answer 26

anticipatory postural adjustments, compensatory postural adjustments .... The Mini-BESTest88,89 was the most frequently used primary outcome measure (4 out of 7 high-quality studies). Additional balance measures reported in the high-quality articles included BBS and single-leg stance. High-quality studies that demonstrated favorable outcomes ranged in frequency (2–3 times per week) and duration (10–30 total hours: 5–12 weeks)

Question 27

Mobility improved in individuals with PD when a supervised multimodal balance program was implemented __ to __ times per week, 16 to 30 total hours, for at least 5 and up to 10 weeks.

Answer 27

2 to 3 Due to variability in settings, frequency, and delivery patterns, session durations ranged from 30 to 120 minutes. Common among these intervention programs was an emphasis on multidirectional stepping, motor agility, anticipatory postural control, and reactive balance. However, balance training that was a primarily home-based, minimally supervised intervention did not show significant improvements in mobility

Question 28

Improvements in gait outcomes, including gait velocity, Functional Gait Assessment,138,139 Freezing of Gait (FOG-Q),140 and spatiotemporal measures (step length and stride) were found in 4 high-quality studies.

Answer 28

Outcomes related to balance confidence including the Falls Efficacy Scale-International and Activities Specific Balance Confidence Scale improved in 2 high-quality studies41,47 and 3 moderate-quality studies119,121,137 compared with control. Changes in balance confidence were not significant in 3 high-quality studies40,95,108 and 1 moderate-quality study

Question 29

Quality of life outcomes

Answer 29

Parkinson’s Disease Quesionnaire-39 (PDQ-39) Euro-QoL-5 Dimension (EQ-5D) Short-form Health Survey – 6 Dimension 12-item Short Form Health Survey Positive Affect Scale Of these, balance intervention was favored over control in PDQ-3940,141,142 and EQ-5D.91 This finding should be interpreted cautiously, because the other studies that measured quality of life either favored control104 or showed no significant difference between balance intervention and control

Question 30

The effect of balance training on falls outcomes is _____

Answer 30

mixed Several studies have examined the effect of balance training on fall rate and found no significant effect.41,47,91,115,116,119 Interestingly, 1 high-quality study using a 6-month duration, primarily home-based, minimally supervised exercise program targeting fall risk factors found that falls were reduced in individuals with mild PD, but not in people with more severe PD.41 Similarly, another moderate-quality study found in a secondary analysis that individuals with more moderate disease but not severe disease had decreased fall rates in the experimental group.121 This would suggest that physical therapists may consider intervening earlier in the disease process with balance interventions intended to reduce fall rates.

Question 31

Nonmotor symptom outcomes

Answer 31

Moderate-strength evidence suggests that balance training could be used to improve nonmotor symptoms compared with usual medical care or control interventions. Two moderate-quality studies supported improvements in depression as measured by the Geriatric Depression Scale.119,121 One moderate-quality study supported improvements in cognition as measured by the Wechsler Memory Scale difficult III subscore when balance interventions were performed for at least 4 months.

Question 32

The dosing of balance interventions varies across studies. However, many studies reveal a benefit of balance training when implemented 2 to 3 times per week for 16 to 30 total hours over 5 to 10 weeks.

Answer 32

Given that falls are multifactorial in PD, balance training may need to be combined with other interventions to reduce fall rate, particularly those with greater disease severity.

Question 33

Four high-quality studies93,111,148,154 and 1 moderate-quality study159 identified that external cueing was superior to other modes of intervention or no cueing training at all for reducing motor disease severity as measured by the UPDRS III.

Answer 33

Gait training with visual cues was superior to overground training without cues,148 and visual feedback during balance training was superior to conventional balance training without visual feedback.111 Rhythmic auditory stimuli (RAS) provided during balance training was superior to a general educational program,93 RAS during treadmill training was superior to treadmill training without RAS,159 and cueing training that included visual, auditory, or somatosensory cues during standing balance and gait tasks154 was superior to no cueing training. Cueing in all these studies was delivered between 20 minutes to 1 hour, 2 to 5 times per week for 3 to 8 weeks.

Question 34

Three high-quality studies145,150,152 and 1 moderate-quality study157 identified reductions in motor disease severity when different modes of external cueing were compared, indicating that no one mode of external cueing is superior to another.

Answer 34

An additional high-quality study155 and a moderate-quality study167 also identified no difference in motor disease severity when external cueing was compared with conventional physical therapy. External cueing in these studies included visual and auditory cues delivered during gait training on a treadmill instrumented with a visual display,150 visual and auditory cues provided during overground gait training,150,152,155 cues with an internal focus of attention,145,157 visual cues placed on the limbs with emphasis on an external focus during limb movements,145,157 and active music therapy.

Question 35

One moderate-quality study identified that ______ delivered continuously during overground walking was superior to _______ that played only if the participant achieved a predetermined stride length via a preprogrammed wearable sensor.

Answer 35

Music

Question 36

Two moderate-quality studies favored an attentional strategy using cues to produce large amplitude whole body movements Lee Silverman Voice Treatment physical or occupational therapy improves mobility and movement used in everyday function (LSVT BIG) delivered for 1 hour, 4 times per week for 8 weeks compared with 1 hour of Nordic walking 2 times per week for 8 weeks.

Answer 36

LSVT BIG was also favored over a shortened amplitude-oriented training delivered 5 times per week for 2 weeks

Question 37

Spatiotemporal parameters of gait Four high-quality studies149,153–155 and 2 moderate-quality studies159,168 identified that ________ cueing was superior to usual physical therapy care,149,155 overground gait training without cues,153 treadmill gait training without cues,159 and no treatment154,168 to improve gait speed as measured by an instrumented treadmill149,155 during a 20-m walk153 and during the 10MWT.86,87,154,159,168

Answer 37

External External cueing in these studies included augmented proprioceptive stimuli applied to the feet through shoe sensors during treadmill training149 and overground gait training using visual cues153; a multimodal exercise program that included overground gait training with visual cues155; cueing training that included visual, auditory, or somatosensory cues during standing balance and gait tasks154,168; and treadmill training using RAS.159 Cueing interventions in all of these studies was delivered 2 to 5 times per week for 3 to 8 weeks.

Question 38

An additional high-quality study150 identified that visual and auditory cues delivered during gait training on a treadmill instrumented with a ____ display were superior to visual and auditory cues provided during overground gait training to improve gait speed, measured using an instrumented treadmill, and delivered 7 times per week for 4 weeks.

Answer 38

visual

Question 39

Made it to gait outcomes at spatiotemporal parameters of gait on CPG

Answer 39

Made it to gait outcomes at spatiotemporal parameters of gait on CPG