Let’s bottle this

Far too often, physical therapy for the gait problem of PSP uses the techniques designed for Parkinson’s disease – targeting strength, flexibility, endurance and balance.  But much of PSP’s gait problem arises from the loss of monitoring by the visual sense.  The eyes can’t move well enough to maintain awareness of the spatial environment and to communicate that to the movement circuits in the brain.

Cris Zampieri, PT, PhD is a physical therapist at the NIH with an ongoing, published interest in PSP.  Since 2006, she has been a pioneer in devising special gait re-training for people with PSP by adding eye movement tasks to standard PT measures for Parkinson’s disease, in this case boxing, stepping and treadmill use.  

The patient reported now was a 63-year-old courtroom lawyer with a symptom duration of 11 years but a PSP Rating Score of only 24, where 0 is normal and 100 is the worst.  Such a mild score is typical of someone with PSP of only 2 or 3 years’ duration and to me suggests the subtype called PSP-parkinsonism.  The patient still enjoyed hikes in the woods and his specific goal for the therapy was to improve his ability to walk over rocks.  The regimen of one hour twice a week for a total of 15 hours produced satisfying improvements in formal measurements of gait and balance as well as in his subjectively reported ability to hike safely. A small but useful fraction of the benefit was still present at 6 months.

The novelty of this case report was that the patient was relatively high-functioning, allowing him to comply with more complicated instructions, and also that his treatment goals were different from those of the typical patient with PSP, who is merely seeking greater independence at home.  For me, the publication served as a reminder that there are specific PT measures for PSP that most physical therapists don’t know about.

Working with Dr. Zampieri on the current project were her NIH colleagues Earllaine Croarkin, Krystle Robinson and Christopher Stanley.  I emailed the lead author, Ms. Croarkin, to ask if this PT regimen could be applied at most PT practices.  Here’s her reply:

“The assessments and interventions we used for physical therapy in this case report can absolutely be repeated in typical physical therapy clinics . . . Our intent was to publish information in a manner that therapists could use to replicate the activities. For example, physical therapy interventions for gaze shifting, postural stability and step response employed low-cost equipment readily found in clinics, i.e.,  punching bag, laser light, stool, and treadmill.”

Citations of Dr. Zampieri’s earlier work on PT with accompanying eye movement retraining appear in my 2019 book on PSP management and in the 2021 Best Practices consensus document published by the CurePSP Centers of Care.  Now we need patients and caregivers to ask about it, neurologists to prescribe it, and physical therapists to know how to administer it.

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