Physical therapy for parkinsonism
Definition:
Parkinson's disease is a chronic, progressive disease of the nervous
system involving the basal ganglia, characterized by disturbances of
tone, abnormal postures and involuntary movements. Clinically, the
patient usually exhibits some combination of three classic signs: rigidity,
bradykinesia and tremor.
Clinical manifestations:
1. Postural changes: They include the development of abnormal fixed
posture , typically flexed or stooped posture. Flexor and adductor muscles
become selectively more contracted in both upper and lower extremities.
In addition, pronators, plantar flexors, neck and thoracic flexors are also
involved.
Fig. (2): Abnormal postural changes in parkinsonism.
2. Postural reflexes: All postural reflexes (righting , equilibrium , and
protective extension reactions) are diminished. When balance is lost, the
immediate compensatory adjustments needed to regain equilibrium are
reduced. If the patient falls, protective responses may be lacking, resulting
in frequent injury. Automatic postural responses are particularly impaired
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if rigidity of the trunk is severe.
3. Rotatory movements: Movements around the longitudinal axis are also
impaired. Thus, the patient finds turning and rolling movements difficult .
Deficits in axial rotation are particularly disabling, impairing many simple
functional activities such as rolling over and getting out of bed.
4. Automatic or unconscious movements are impaired or lost: An example
of this is the loss of reciprocal arm swing during gait. The patient is required
to think about each movement in order to execute it successfully.
Constantly, combating the effects of bradykinesia and rigidity can lead to
mental fatigue and loss of motivation.
5. Fatigue: In patients with fully developed parkinsonism, fatigue is one of
the most common symptoms reported. The patient has difficulty in
sustaining activity and experiences increasing weakness and lethargy as the
day progresses. Repetitive motor acts may start out strong but decrease in
strength as the activity progresses. Thus, the first few words spoken may be
loud and strong but audibility of succeeding words diminishes rapidly as
speech continues. Performance decreases dramatically after great physical
effort or mental stress. Rest or sleep may restore mobility.
6. Gait pattern: Gait of the patient with parkinsonism is highly stereotyped
and characterized by poverty of movement. Hip, knee and ankle motions
are decreased with a generalized lack of extension at all three joints. Trunk
and pelvic motions also are diminished, resulting in a decrease in step
length and reciprocal arm swing. Patients characteristically walk with a
slow and shuffling gait. Persistent posturing of a forward head and trunk
typically displaces the patient's center of gravity forward and may result in
a festinated gait pattern. The patient takes multiple short steps in order to
avoid falling forward. Propulsive gait pattern has a forward accelerating
quality, and a retropulsive gait has a backward accelerating one. Many
patients are able to stop only when they come in contact with an object or a
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wall. Patients who are toe walkers owing to plantar flexion contractures
exhibit an additional postural instability because of a narrowing of their
base of support. Movements that involve turning or changing direction are
particularly difficult to accomplish.
7. Facial expression: It is described as mask-like, with infrequent blinking
and lack of expression. Smiling may be possible only on command or with
volitional effort. sialorrhea and drooling may be present along with
impaired swallowing (dysphagia) and speech . The predominant finding is
usually hypo-phonia or decreased volume of speech secondary to rigidity
and bradykinesia of the speech musculature and decreased excursion of the
chest. In some advanced cases, the patient speaks in whispers and the
speech is monotonous.
8. Mental changes: They may result from severe parkinsonism, drug
toxicity or from concurrent multiple cerebro-vascular accidents. There
is consistent deficits in short-term memory and in problem solving, which
tend to be slow and confused that is termed bradycognition .
9. Sensation: Parkinsonians do not suffer from primary sensory deficits
but many experience discomfort or pain, which is cramp-like and poorly
localized. These sensations may result from lack of movement, sustained
muscle spasms, faulty posture or ligamentous strain.
Secondary complications:
Most patients with parkinsonism are elderly and show the effects of
generalized musculoskeletal deconditioning. Secondary problems and
complications include:
1. Muscle atrophy and weakness, secondary to disuse.
2. Respiratory changes: Vital capacity is markedly reduced owing to
decreased thoracic expansion, resulting from rigidity of the intercostals
and the upper trunk and upper extremity positions of flexion-adduction.
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Energy consumption is increased secondary to the increased muscular
effort required for normal breathing. These patients are in constant danger of
respiratory complications as pneumonia, which is one of the leading
causes of death .
3. Nutritional changes: Late in the disease, some patients become
malnourished because of problems of eating chewing and swallowing. This
contributes to the fatigue and exhaustion they often experience from
ordinary activities of daily living.
4. Osteoporosis: It is often a serious problem in parkinsonism because of
prolonged inactivity and old age. Poor diet also may contribute to this
problem. Loss of automatic movement, poor balance reactions and
osteoporosis may result in frequent falls and fractures with delayed
healing.
5. Circulatory changes: The lower extremities exhibit circulatory changes,
secondary to the venous pooling that results from decreased mobility. These
patients present with edema of the feet and ankles during the day which
disappears when in bed.
6. Contracture and deformity: Lack of movement in any body segment
leads to shortening of muscles and soft tissues. Typical contractures occur in
hip and knee flexors, hip adductors, plantar flexors, upper chest, dorsal
spine and neck flexors, shoulder adductors and internal rotators, forearm
pronators and wrist and finger flexors.
7. Decubitus ulcers: In advanced cases, prolonged inactivity and bed
rest may lead to the decubitus ulcers.
Physical Management
The treatment of patients with parkinsonism involves medical,
surgical and rehabilitative managements. An estimate of the stage and
severity of the disease is made using many scales such as “Yahr
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Classification of Disability”.
Table (1): Yahr Classification of Disability.
Stage
I
II
III
IV
V
Character of Disability
Minimal or absent; unilateral if present.
Minimal bilateral or midline involvement; balance is not impaired.
Impaired righting reflexes. Unsteadiness when turning or rising from chair. Some
activities are restricted but patient can live independently and continue some
forms of employment.
All symptoms present and severe; patient requires help with some ADL.
Patient is confined to bed or wheelchair unless aided.
Rehabilitative management:
Assessment:
* The examination begins with a thorough assessment of tone including
severity , distribution and their impact on movement.
* Movement transitions (e.g. rising from a chair or rolling in bed)
should be stressed.
* Postural reactions: A thorough assessment of righting, equilibrium
and protective reactions is indicated.
* Unequal distribution of tone also leads to contractures and deformity.
Objective measurement of both active and passive range of motion
using goniometry is helpful in quantifying these deficits.
* Postural and gait assessments are also routinely performed.
* An assessment of the patient's functional abilities can be determined
using a disability scale. The influence of rigidity, bradykinesia and
tremor on functional performance should be noted for each skill tested.
Problems will often be noted in those activities having a rotational
component, such as rolling or turning. Fine motor skills such as feeding
or dressing will also be difficult; time it takes to initiate and to
complete an activity should be recorded. Because these patients
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experience increased fatigue with resultant fluctuations in performance,
examinations should be kept brief (i.e. 10 to 15 minutes) and repeated
at different times during the day. A videotape of functional movement
patterns can provide an objective record of dysfunction. Functional
assessment in the home environment is also indicated.
* The therapist should focus on assessing the patient's cardio-respiratory
status. Cardiovascular endurance is usually decreased from long-standing
inactivity and poor respiratory function. Excessive fatigue, shortness of
breath and high heart rate response to exercise indicate marked
deconditioning and exercise intolerance. Diaphragmatic movements and
thoracic expansion and mobility also should be assessed. Respiratory
function tests (vital capacity and forced expiratory volume) should be
routinely performed .
* Finally, it is important to assess the patient's pre-morbid interests, abilities
and daily activities in order to translate them into a treatment program that
will engage the patient's full cooperation.
Formulating treatment plan:
Long-term goals:
- To delay or minimize the progression and effects of the disease symptoms.
- To prevent development of secondary complications and deformity.
- To maintain the functional abilities of the patient to the fullest extent.
Short-term goals:
- To maintain or increase range of motion in all joints.
- To prevent contractures and correct faulty posture.
- To prevent disuse atrophy and muscle weakness.
- To promote and improve motor function and mobility.
- To improve gait pattern.
- To improve speech, breathing patterns, chest expansion and mobility.
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- To assist in psychological adjustment and lifestyle modification.
Methods:
1. Relaxation exercises: Gentle rocking and rhythmic techniques that
emphasize slow vestibular stimulation can produce generalized relaxation
of the total body musculature. Through the use of rocking or rotating
chair, inverted head position as prone on large ball with caution for
patients with hypertension and respiratory complications can be
accomplished. Slow rhythmic rolling can also be accomplished on a mat.
2. Range of motion exercises:
Active and passive range of motion exercises should be completed
several times a day. Active ROM should focus on strengthening the
patient's weak and elongated extensor muscles, while stretching the tight
flexor muscles. Muscle hypertonia or spasm may respond to autogenic
inhibition techniques, such as PNF contract-relax techniques. Passive
stretching at the maximum tolerated muscle length also increases range
through manual or mechanical stretching.
3. Mobility exercises:
An exercise program for the patient with parkinsonism should be
based upon functional movement patterns that engage several body segments
at once. Extensor, abduction and rotatory movements should be stressed.
Movements should be rhythmic and reciprocal; progressing toward full
ROM. Exercises that are related to functional skills, such as self-care and
pre-morbid skills will help increase motivation and reduce the depression
that is commonly seen in these patients. The use of verbal, auditory and
tactile stimulation provides sensory reinforcement and helps increase patient
awareness of movement. Verbal commands, music, clapping, marching,
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metronomes, mirrors and floor markings are examples of effective aids in
promoting successful performance of an activity.
Exercise techniques and approaches include PNF and rhythmic
activities. The use of diagonal limb and trunk PNF patterns accomplishes
several exercise goals at once. Because these patients have a minimum of
energy to expend and multiple clinical problems, they benefit from
exercising in total-body physiologic patterns that combine several motions
at the same time . PNF patterns also emphasize rotation; a movement
component that is typically lost early in parkinson's disease. Particular
emphasis should be placed on activating extensor muscles to counteract the
tendency for a flexed stooped posture. In the upper extremities, bilateral
symmetrical flexion patterns (shoulder flexion, abduction and external
rotation) are useful in promoting upper trunk extension and in counteracting
kyphosis. During this exercise, coordination with respiratory movements
emphasizing increased chest expansion should be encouraged. In the lower
extremities, hip and knee extension should be emphasized, ideally in hip
extension, abduction and internal rotation to counteract the typical flexed
adducted posture.
The PNF technique of choice is rhythmic initiation, aiming
specifically at overcoming the debilitating effects of bradykinesia. The
therapist begins by moving the limb through the pattern passively,
gradually increasing the range and setting up a rhythm to the movement.
As relaxation occurs and the movements are more easily accomplished, the
patient is asked to participate in the movement, first with assistance and
then gradually against slight resistance. After several repetitions, the patient
moves actively through the pattern. This “pumping up” sequence can be
used as an effective start to many activities. For example to stand up from a
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chair , the patient can begin by swaying back and forth, until a rhythm is set
up and tone reduced. The active movement of standing up can then be
superimposed upon the more relaxed body state. Thus, the patient
progresses from passive reversals to active assistive to resistive and finally
to active movement.
Developmental mat activities that emphasize the mobility stage of
motor control, rotational movements and extensor antigravity muscles are
also helpful . Rolling is a problematic activity, which should receive early
and intensive emphasis in treatment.
4. Oro-facial treatment:
Facilitating movement of facial and tongue muscles is an important
goal because patients may have limited social interaction and poor eating
skills in the presence of marked rigidity and bradykinesia. Use of stretch,
PNF patterns for head and neck combined with facial, rhythmic initiation
technique, verbal commands may enhance facial movement greatly. Icing to
facial muscles can relax it. Eating from sitting position with appropriate
position of head and neck should be emphasized. Use of mirror for visual
feedback is also advisable. Respiratory exercises and mobilization of chest
wall as well as instructing patients to take deep breath before talking, to
increase the volume of speech, should be carried out .
5. Respiratory exercises:
Breathing exercises are taught to patients to increase mobility of
the chest wall and improve ventilation.
6. Gait training:
It attempts to overcome festinant and shuffling gait, poor postural
alignment and defective postural reflexes. Specific goals are to lengthen the
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stride, to broaden the base of support, to increase contralateral trunk
movement and arm swing, to encourage a heel-toe gait pattern and postural
reactions and to provide a program of regular walking. Stride length and
width may be controlled through use of floor markings. Small blocks of 2 to
3 inches may be used to encourage picking up the feet to avoid shuffling.
Two sticks (held by the patient and therapist one in each hand) may
facilitate reciprocal arm swing during gait. Stopping, starting, changing
direction of movement pattern should be emphasized. Balance reactions in
standing and walking should be practiced daily. Turning movements
emphasizing small steps and wide base also should be stressed. The
overall rhythm of the gait pattern can be improved by using voice
commands (counting), music or a metronome. A festinant gait may be
alleviated by addition of shoe wedges (toe or heel wedges for propulsion or
retropulsion respectively).
7. Group therapy:
Group exercise classes are often organized for patients with
parkinson's disease. Patients benefit from positive support
and
communication with groups. Careful assessment of each prior to admission
into a group is essential. Select patients with similar levels of disability
because the sense of competition can be a key factor in motivating
groups.
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