Parkinson's Physiotherapy for Improved Mobility

Parkinson’s Disease

Parkinson’s Disease (PD) is one of the fastest growing neurodegenerative diseases in the world and the second most prevalent neurodegenerative disease next to Alzheimer’s Disease. What causes it has yet to be discovered, but researchers say that people who are more prone to developing PD are mostly men, aged around 60 or older, and have relatives affected by the disease as well (Brazier, 2018). As the cause of this is unknown, preventive measures have also yet to be developed. Some studies have shown that consumption of caffeine and regular aerobic exercise might be able to reduce the risk of developing this disease, but none of these are conclusive.

Since it is a neurodegenerative disease, symptoms occur almost unnoticeably at the start, usually small tremors in one hand and rigid facial expressions. Some other early signals of developing PD are difficulties in writing, involuntary movements throughout the body, even while asleep, slowed movement and stiffness of limbs (bradykinesia), and a stooped posture (Lava, 2017). While the disease progresses, symptoms of the disease change drastically, most notably in intensified and uncontrollable tremors. It causes major inconveniences in basic daily activities, mostly due to a loss of balance, agility, and flexibility. In terms of gait, people with this disease experience a reduced bilateral arm swing, smaller length in steps and a significantly stooped posture (Pirker & Katzenschlager, 2017).

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There are many ways by which researchers and doctors suggest and recommend to treat Parkinson’s, including surgeries, medications and physiotherapy interventions. However, this study will be focusing on discussing the mechanism by which this disease works, and how physiotherapy intervention is the best course of action when addressing the disease. There are many forms of physiotherapy, including that of martial arts, aerobics and yoga, but this study discusses a specific balance training program proposed in 2012 by Conradsson. This study finds its significance in the need to direct attention and increase efforts for developing cures for PD, as the number of people with this disease is rapidly increasing. This study is also significant as it shows how physiotherapy interventions pose a lot of potential with the proper design specific to patients and proper implementation.

Motor dysfunction as a result of the loss of dopaminergic neurons in the substantia nigra pars compacta and depletion of dopamine in the nigrostriatal pathway

Movement control is achieved with the help of complex interactions among various groups of nerve cells in the central nervous system. Parkinson’s disease (PD) is characterized by the loss of noradrenergic neurons of the locus coeruleus, depletion of dopamine in the nigrostriatal pathway and most importantly, the loss of the dopaminergic neurons in the substantia nigra pars compacta (Alexander, 2004). The substantia nigra is found in the ventral midbrain. Neurons from the substantia nigra create a network of axonal processes that innervates the basal ganglia, producing mostly symmetrical synapses with dendritic spines and shafts of spiny projection neurons (Iravani, Sadeghian, Rose & Jenner, 2014). Neurons of the basal ganglia interact with neurons of the substantia nigra through the liberation of the neurotransmitter dopamine (DA). The functions of the basal ganglia involve motor program selection and adaptation, pertaining to motor agility and involving the maintenance of coordination between body parts, task-specific adjustments of movement and quick shifts from one task to the next (Conradsson, 2012).

As earlier stated, dopamine plays a huge role in Parkinson’s Disease as it assumes the role of relaying information to the brain that controls movement and coordination. The biochemical imbalance from the loss of dopamine results to the typical clinical symptoms that include rigidity, tremor, bradykinesia, and a gradual slowness of spontaneous movement, loss of postural reflexes or, in other words, poor balance and motor coordination (Tiarrhou, 2013). Also as the disease progresses with age, there is a continuous decrease in dopamine levels. The succeeding figure shows PET scans comparing the basal ganglia of a normal person and one with Parkinson’s Disease. The orange areas in the scan of the normal person show higher uptake of the radiotracer, fluorodopa, in the striatum, signifying normal dopamine function. The image on the right shows a smaller orange area and much less uptake of the fluorodopa, indicating decreased dopamine activity as a result of PD.

Another symptom of this disease is the deficiency in motor regulation. This is usually exhibited as delayed change of motor commands when shifting from one task to another, poor intersegmental coordination, and problems in maintaining proper posture (Bertram, 2005). These factors are believed to contribute to freezing of gait and increased instability during fall-related incidents (Sawada et. al., 2012). Another critical aspect of balance control in PD is the ability to multi-task by dividing attention and simultaneously processing multiple tasks (motor or cognitive). In activities involving multi-tasking, individuals with PD are inclined to shift attention away from the balance task, thus leading to falls (Bloem, Grimbergen, van Dijk & Munneke, 2012).

Physiotherapy intervention

To target these motor functions, especially balance control, physiotherapy is most recommended to those with Parkinson’s as a means to improve their quality of life. Other methods may be available but pose life-threatening side effects. For example, there is the usage of prescribed medication, which is less recommended as a remedy since motor symptoms often worsen alongside the effectiveness of the prescribed drugs. Furthermore, long-term use of specific anticholinergic drugs and dopamine agonists have been found to cause motor complications such as involuntary movements and fluctuations in responses (Goldenberg, 2008). Another method is deep brain stimulation, which may help relieve some of the symptoms, but it often requires additional treatment methods, specifically physiotherapy to fully improve mobility and boost independence. This method also involves side effects like stroke symptoms and seizures (Machado & Repold, 2015). On the other hand, physiotherapy mainly focuses on improving range of movement and physical capacity in daily activities through walking, as well as practice of manual activities such as grasping (Borrione, 2014). With the chance to design customizable physiotherapy programs catered to specific individuals, this intervention presents the least risk and at the same time promising potential amongst all options.

The program to be discussed will incorporate different principles of balance training geared towards improving gait. Firstly, exercise variation will be increased as the program develops, to enhance motor learning and promote balance skills applicable to everyday activities. Variation in training will also help increase the difficulty of the training helpful for learning unconscious coordination of movements (Stergiou, Harbourne & Cavanaugh, 2006). Secondly, the exercises will be specifically targeting certain functions. Lastly, the intensity and regularity of the exercises will be challenging.

Each exercise session will start with a 5-minute warm-up session, consisting of varied walking tasks with the target of boosting the cardiovascular system. For the next 50 minutes, highly challenging exercise blocks of standing and walking conditions will be done with a few rest intervals. (Conradsson, 2012). In this program, standing exercises will be addressing the balance components of stability limits, and the balance components of sensory integration and motor agility will mainly be addressed through the walking exercise (Conradsson, 2012). Finally, there will be a 5-minute cool-down through breathing exercises, stretching and some final walking as well. The training proper and targeted functions are stated below.

Balance Components Constraints in PD Exercise principles Exercise objectives

SENSORY INTEGRATION:

Integration of sensory information (somatosensory, visual and vestibular) for estimation of body position - Impaired somatosensory integration

• Poor proprioception
• Visual depedency Walking tasks on varying surface with or without visual constraints Improve interpretation of and reliance on somatosensory information

ANTICIPATORY POSTURAL ADJUSTMENTS

Prediction and control of perturbation related to voluntary movements - Poorly timed and scaled APAs

- Bradykinesia Voluntary arm/leg/trunk movements focusing on movement velocity and amplitude and postural transitions Improve APA strategies regarding timing amplitude and task-specific adaptation

MOTOR AGILITY

Coordination between body parts and movement adaptation, e.g. regulation of movement and quick shifts between tasks - Bradykinesia

• Impaired whole-body coordination
• Biomechanical constraints
• Inflexible motor programming - Whole-body coordination during varying gait conditions and reciprocal movements
• Quick shifts of movement characteristics (velocity, amplitude and direction) during predictable and unpredictable conditions Improve whole-body coordination, ability to adapt movement and quick shifts between different tasks

STABILITY LIMITS

Whole-body regulation relative to the base of support - Reduced functional stability limits

• Biomechanical constraints
• Poor proprioception
• Impaired somatosensory integration Voluntary learning tasks in standing with varying base of support-stimulating weight shifts in multiple directions through arm and trunk movem`ents Improve the ability to safely control center of mass within base of support to increase functional limits of stability

During the initial phase, the exercise for each balance component will be trained separately on a weekly basis, to establish the foundations and promote familiarity of the principles and objectives and task-specific motor learning. In the later stages of the program, generalization of motor skills will be focused on. In the second stage, increasing variation with regard to characteristics of exercise in each balance component, including variation of body position and changes in movement direction and velocity will be the focus. Integration of exercises from different balance components will be the focus of the last stage. This framework may have huge potential due to the fact that, intensities and variations can be conveniently modified depending on the progress exhibited by the patient. The proposed training progression and its targeted balance component is stated below.

Training Principle and objectives Week Balance components

1. Introduction of performance of each balance component separately and emphasizing quality of performance to accomplish familiarity and task-specific motor learning 1 Motor agility and stability limits
2. Sensory integration/APAs
3. Improvement of balance performance and strategies of attention in varying balance conditions through increased level of difficulty and task variation for each balance co 3 Motor agility or stability limits Cognitive dual-task training
4. Sensory integration or Anticipatory postural adjustments Motor dual-task training
5. Motor agility/stability limits Cognitive dual-task training
6. Sensory integration or Anticipatory postural adjustments Motor dual-task training
7. Further challenging of movement complexity through increased levels of difficulty, task variation by successively integrating the balance components, and increasing demands of multi-tasking
8. Sensory integration/APAs/motor agility/stability limits Mixed cognitive and motor dual-task training
9. Sensory integration/APAs/motor agility/stability limits
10. Sensory integration/APAs/motor agility/stability limits
11. Sensory integration/APAs/motor agility/stability limits

Unlike majority of training regimes that emphasize general physical training or target single physiological systems (e.g. muscular strength, reactive postural adjustments), elements in this intervention cover traditional training principles of specificity, progressive overload and random training (Conradsson, 2012). These principles are specifically designed to promote motor learning in PD through specific balance components related to PD symptoms during highly challenging and varying exercise conditions.

To conclude, continuous training involving proper balance and walking improve mobility of people with Parkinson’s Disease. As there is still no cure in sight for completely removing Parkinson’s, physiotherapy, which has the potential of improving one’s quality s the best course of action. Exercises involved in this program will help add to the knowledge of how to set-up programs for Parkinson’s Disease, especially with the effects of varying exercise components and training intensity. For optimum results, it is best that a team of neurologists and physical therapists be the ones to design a specific training program to a patient with Parkinson’s disease for easing mobility.

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