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The contemporary look on physiotherapy in Parkinson's disease - Some chosen questions
Abstract
Morbus Parkinsoni (Parkinson's disease, PD) is the neurodegeneration illness of the central nervous system, which characterizes tricky beginning and slow progress of the symptoms, meanwhile pathomorphology - the degeneration of the cells of part compact black matter including the dye neuromelanin. Clinical symptoms appear after destruction about 50% cells of the black matter and the fall down of production dopamine. This disease belong to the extrapyramidal system diseases, in which applies symptomatological treatment (pharmacotherapy, rehabilitation) what permits lengthen and bear current efficiency and physical condition. In the treatment comply also the operating treatment - neurosurgical, which the aim is the improvement patient's quality of life. Complex rehabilitation should be initiate on every stage of the disease and hold in continuous way, not just in hospital term, as well as ambulatory too. The use of the different possibilities and the therapeutic methods in significant modus accelerate return to optimum functional patient's efficiency in dependence from the degree of advanced disease, and this is the succession of improving. Rehabilitation in neurological diseases state very important and wide question. At that time it is the most important elements in the treatment of those patients. In this review article the authors introduced some chosen forms and methods of motor exercises, physical procedures and some conduct physiotherapy principles patients with Parkinson's disease, which should be realized as a main part of comprehensive treatment.
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Objective: To critically review studies evaluating the effects of external rhythmical cueing on gait in patients with Parkinson's disease.
Methods: Articles published from 1966 to January 2005 were searched by two physiotherapists in MEDLINE, PiCarta, PEDRo, Cochrane, DocOnline, CINAHL and SUMSEARCH. To be included, articles had to investigate the effects of external rhythmical cueing (i.e., auditory, visual or tactile cueing) on gait parameters in patients with idiopathic Parkinson's disease. Both controlled and noncontrolled studies were included. Based on the type of design and methodological quality a meta-analysis or best-evidence synthesis was applied.
Results: Twenty-four studies (total number of patients = 626) out of the 159 screened studies were evaluated in this systematic review. Two out of 24 were randomized controlled trails (RCT), both of high methodological quality. One RCT did not focus specifically on external rhythmical cueing of individual patients with Parkinson's disease, but on group exercises in general, including walking with cues. All other studies were pre-experimental studies. Best-evidence synthesis showed strong evidence for improving walking speed with the help of auditory cues. Insufficient evidence was found for the effectiveness of visual and somatosensory cueing.
Conclusion: Only one high-quality study, specifically focused on the effects of auditory rhythmical cueing, suggesting that the walking speed of patients with Parkinson's disease can be positively influenced. However, it is unclear whether positive effects identified in the laboratory can be generalized to improved activities of daily living (ADLs) and reduced frequency of falls in the community. In addition, the sustainability of a cueing training programme remains uncertain.
This study investigated the effect of Parkinson's disease (PD) on the time course for postural control following the removal and reinsertion of visual information. Twelve medicated PD patients (PD) and 12 age matched control (CTRL) subjects performed two 45-s quiet standing trials, during which visual feedback was available (0-15s), deprived (15-30s), and then restored (30-45s). The 45s test trial was divided into 5s time bins to compare the time-based effect of sensory reorganization during deprivation and reintegration. Results revealed an increase in Elliptical Sway Area (ESA) following visual deprivation for both groups; this increased ESA remained significantly higher than the baseline level for the duration of the deprivation period among PD patients and returned to baseline the level among CTRL. Despite elevated ESA at the end of visual deprivation among PD patients, neither group showed a change in ESA after visual information was restored. These results indicate a PD-associated deficit with the reorganization of sensory priorities for postural control, and may implicate the basal ganglia as being critical for integration of sensory information for postural control.
Postural instability is a common impairment in idiopathic Parkinson's disease (PD). People with PD are prone to balance and walking difficulties. This study analyzed the feasibility of a prospective investigation of Computerized Dynamic Posturography (CDP) and standard Physical Therapy (PT) treatments in individuals with mild-moderate PD. Treatment took place at two sites: 1) CDP therapy at the Southeast Parkinson's Disease Research Education and Clinical Center (PADRECC) within a Veterans Affairs Medical Center and 2) standard physical therapy at a community outpatient rehabilitation center. Final analysis compared 15 patients randomly assigned for therapy to either the CDP or PT treatments. Therapy time was eight weeks (four weeks of CPD or PT followed by home therapy for four weeks). The CDP therapy included gradually intensified closed chain and mobility training. Standard PT consisted of upright, mat, and theraball exercises and gait training. The home exercise phase was identical for both groups. The pilot data demonstrated treatment was tolerated by 68 percent of the sample despite the occurrence of a progressive neurological condition and medical comorbidities. While results failed to reveal any differences between treatment groups, both groups demonstrated improvement on selected outcome measures. An expanded prospective study with methodological improvements appears warranted.
The interest in new, non-invasive methods of therapy has been growing in the recent years. Undoubtedly, magnetotherapy - stimulation with variable magnetic field - is one of those methods. There are documented positive effects of magnetotherapy in fighting pain, acceleration of wound healing and strengthening of the immune system, which have significant impact on social costs of treatment, and the vitalising and anti-stress effect enhances physical and mental fitness of patients. This paper presents, in a clear and practical way, the use of magnetotherapy.
Outcome measure in rehabilitation constitutes one of the most important and difficult question. Different kinds of tests and scoring scales are often applied for the purposes of the outcome measure in rehabilitation. The scoring scales mainly relate to the functional condition and predominantly estimate the degree of independence in the Activities of Daily Living (ADL). Many authors are of the opinion that the assessment of quality of life is the best measure of effectiveness of rehabilitation. Hereof paper presents an overview of the questionnaires of quality of life that are most commonly applied in rehabilitation.
The important role of the physiotherapy in the treatment of elderly patients was recognized in the second part of the 21st century. Physiotherapy facilitates adaptation to the problems of the old age. Physiotherapeutic management includes the development of motor programmes which help elderly people to function normally and independently. Aging is a natural part of human life. Man's role is to make it as comfortable as possible. Geriatric rehabilitation is concerned with treating elderly patients and keeping them fit, helping them to avoid some of the symptoms of chronic old age ailments. Nowadays age 65 is regarded as the beginning of old age. Some of the most characteristic features of this part of life are: difficulties in maintaining homoeostasis in the presence of stress stimuli, lower capability to carry out activities of daily living and reduced physical activity. In fact, elderly people are increasingly dependent on the help of others. Therefore there is a great need for preventative rehabilitation, whose purpose is to prepare for a physiological and healthy old age. This article describes problems connected with rehabilitation of the elderly. Currently employed physiotherapeutic and kinesitherapeutic methods are described together with state-of-the-art treatment options in physical therapy. The latter include magnetic field stimulation, which is remarkably useful in the treatment of depression, injuries and other musculoskeletal conditions and magneto-LED-therapy, a novel combination of fluctuating magnetic field and visible light irradiation possessing anti-inflammatory, antibacterial and analgesic effects.
Primary objective: The plastic changes described in this study enable regeneration and compensation of damage to the nervous system. They can also explain the capacity for adaptation, modification, and organization, as well as the strength of neuronal connections when stimulated. The adaptive ability of the brain and its plasticity are more and more frequently used in post-stroke rehabilitation in order to reactivate all the regenerative capacities of the nervous system. In this review article the authors undertake an analysis of works on cerebral plasticity in the rehabilitation of patients after stroke. Main outcomes and results: Methods based on cerebral neuroplasticity give significantly better results than traditional therapy. Recent studies confirm the beneficial effect of physical activity, such as early poststroke rehabilitation, on the processes of compensation and cerebral activation, as indicated by plastic changes taking place in the brain. Conclusions: Cerebral neuroplasticity based on intensification of natural plastic processes is an important aspect of post-stroke therapy. It gives a new perspective for scientific development in treating these patients. The challenge for contemporary medicine is to understand the mechanisms connected with cerebral plasticity and their modification in order to obtain the best behavioral results.
Swimming is one of modern methods of therapy and recently it has been gaining wide popularity, as there are no age limits to its use. Therapeutic and corrective swimming and water-based exercises are one of many forms of physical exercising in sport and physiotherapy, which enable harmonic development of the entire body with minimum risk of injuries. Benefits of this type of physical activity should encourage people to learn swimming and exercise in the water regardless of the degree of their disability. The purpose of this paper is to describe the methodological basics and benefits of this kind of therapeutic activity and present selected methods and techniques of corrective swimming.
Levodopa-induced dyskinesias are a common complication of chronic dopaminergic therapy in patients with Parkinson's disease (PD). The overall prevalence of levodopa-induced dyskinesias ranges from 40%-90% and is related to the underlying disease process, pharmacologic factors, and to the duration of high dose levodopa therapy. The mechanisms underlying the emergence of levodopa-induced dyskinesias are unknown, although most investigators favor the theory that striatal dopamine receptor supersensitivity is directly responsible for the development of these abnormal movements. In laboratory animals, the pineal hormone melatonin has been shown to regulate striatal dopaminergic activity and block levodopa-induced dyskinesias (Cotzias et al., 1971). Since the pineal gland is known to be a magnetosensitive organ and as application of external magnetic fields has been shown to alter melatonin secretion, we studied the effects of application of external artificial weak magnetic fields in a Parkinsonian patient with severe levodopa-induced dyskinesias ("on-off"). Application of weak magnetic fields with a frequency of 2 Hz and intensity of 7.5 picotesla (pT) for a 6 minute period resulted in a rapid and dramatic attenuation of Parkinsonian disability and an almost complete resolution of the dyskinesias. This effect persisted for about 72 hours after which the patient regressed to his pretreatment state. To ascertain if the responses elicited in the laboratory were reproducible, the patient was instructed to apply magnetic fields of the same characteristics daily at home. These subsequent treatments paralleled the initial response with a sustained improvement being maintained during an observation period lasting at least one month. This case demonstrates the efficacy of weak magnetic fields in the treatment of Parkinsonism and motor complications of chronic levodopa therapy.
Surgery of Parkinson's disease started in the middle of the last century. At the same time this treatment was introduced in Poland. Choróbski removed Broadsman's area 4 through craniotomy. In 1961 Liszka in Kraków introduced the stereotactic procedures, thalamo- and pallidotomy. This type of surgery was soon introduced in two other neurosurgical centers. For the next several years treatment was mostly pharmacological. However, stereotactic treatment was used in patients poorly tolerating drugs. In the meantime first attempts were made at implantation of fetal substantia nigra, with good results. At the end of the century in several patients electrostimulators were implanted. In the last century all known methods of surgical treatment were applied in Poland.
In this review report current possibilities of evaluation of quality of life in Parkinson's disease has been critically presented. Health Related Quality of Life (-HRQoL) comprise wide spectrum of consequences of disease. Measurement of quality of life has become increasingly relevant as an outcome parameter, especially in long-term trials. Most of the available QoL instruments depend on patient self-reports. The data can be collected by written questionnaires. There are universal questionnaires of QoL--for many diseases and the specific ones--specially created for one disease. Among universal questionnaires the Sickness Impact Profile (SIP) and the Short-Form Health Status Survey (SF-36) are most popular in Parkinson's disease. As for specific questionnaires: the Parkinson's Disease Questionnaire (PDQ-39) (by Peto and Jenkinson, 1995) and the Parkinson's Disease Quality of Life Questionnaire (PDQL) (by de Boer and al., 1996) has been described.
The treatment of patients with Parkinson disease should consist of early, complex and continuous rehabilitation connected with reasonable drug therapy. Rehabilitation carried out in hospital, rehabilitation center, sanatorium and outpatient rehabilitation clinic enables better education of patients and their families. Patients' self-consciousness of necessity of continuous daily physical activity at home has a great influence on the length and quality of their life. Physical activity is the best way of prevention of disability and secondary complications caused by immobilization in movement and other systems. It improves also patients' protective forces. Rehabilitation, on the contrary to drug therapy, is cheep, has no adverse effects and can be carried out at home. I this paper are presented the following principles of complex rehabilitation: patients' self-education of Parkinson disease, the proper way of life and work as well as the most effective ways of physiotherapy, occupational therapy and art therapy.
Planning and verification of progress of efficacious physiotherapeutic effect on Parkinson's disease depends notably on the right identification of areas and scope of dysfunction of motoric systems. Biomechanical evaluation of motoric organ disability made by means of three-dimensional motion analysis using the "Vicon" system can make it considerably easier. A sample of three patients (two women and one man of average age of sixty-four) with idiopathic parkinsonism has been examined for the purpose of this evaluation. Based upon results of the three-dimensional motion analysis of these patients, dominant individual movement disorders were determined and individual therapeutic rehabilitation using the PNF method was planned. Within therapy, using the PNF method, they applied special techniques using motor patterns for the pelvis, upper and lower limbs in order to improve movement through an approach of assessed parameters to the biomechanical standard. After three weeks of therapy, specific characteristics of gait were examined again. On the basis of research results before therapy, it was found that these patients had none or limited scope of plantar flexion of feet, excessive dorsal flexion of feet, lengthened duration of stance phase, considerable excessive external rotation of shanks and excessive anteversion of the pelvis during gait cycle. Also big differences in values for spatiotemporal parameters (such as walking speed and frequency, stride length and time of single limb support) between the patients and healthy people were observed. After therapy, there has not been a marked variability in the scope of angular changes to the above-mentioned dysfunction. Only proportions between the duration of stance phase and swing phase have improved noticeably, so that they have directly resulted in better rhythm of gait. They have considerably approached the standards of frequency and speed (p = 0.05). However, stride length and duration of single limb support has not changed significantly.
Rehabilitation plays an important role in treatment of Parkinson's disease (PD). The influence of rehabilitation on balance and gait in PD hasn't been widely investigated. There is general agreement about positive influence of rehabilitation on postural instability and prevention of falls, but therapeutic program prevention of falls hasn't been worked out. Ambiguous results of studies indicate necessity of further investigations.
61 patient were included (H&Y 1, 5-3) and randomly assigned to two groups with and without rehabilitation. The balance test battery included: Functional Reach Test, Balance Performance-Oriented Mobility Assessment (Tinetti), assessment on force platform of quiet standing and active standing with Rhythmic Weight Shifts Test and dynamic task (reaction time, number of hitted targets). Gait was assessed with: timed Up&Go test, 10 m walk, locomotion test and 360 degrees turn. Patients were assessed 3 times, at month intervals. Between 1 and 2 assessment, exercising group took part in 1 month complex rehabilitation, consist of the 28 therapeutic sessions.
The group, which took part in rehabilitation significantly improved in quiet standing with closed eyes after rehabilitation in comparison with initial status. All of the rest variables significantly improved in exercising group after rehabilitation both in comparison between evaluations and in comparison with the nonexercising group.
Rehabilitation significantly influences balance and gait of patients with PD.
To examine the association between Parkinson's disease (PD) and bone mineral density (BMD) and risk of falls.
Cross-sectional and prospective cohort study.
Six U.S. clinical centers.
Five thousand nine hundred ninety-five community-dwelling, ambulatory men aged 65 and older.
History of physician-diagnosed PD was ascertained from participant self-report. BMD was measured at the hip and spine using dual energy x-ray absorptiometry (DEXA) and quantitative computed tomography (QCT). Incident falls were ascertained for 1 year using mailed queries.
Fifty-two participants (0.9%) reported a history of PD. In multivariate models, PD was associated with significantly lower BMD at the spine (-4.9%, P=.04) and total hip (-5.3%, P=.007) using DEXA and at the spine (-6.7%, P=.05) and total hip (-8.2%, P=.03) using QCT. PD was associated with a nearly three times greater age-adjusted risk of multiple future falls (odds ratio (OR)=2.91, 95% confidence interval (CI)=1.55-5.46). Further adjustment for history of multiple falls in the year before baseline attenuated this risk, but it remained significant (OR=2.30, 95% CI=1.15-4.59).
In this cohort of older men, PD was associated with lower BMD at the hip and spine, measured using areal and volumetric BMD, as well as increased falls. Clinicians should consider screening older men with PD for osteoporosis.
Thera-Band (TB) exercises are commonly utilized in ankle rehabilitation, but previous studies have shown inconsistent results.
To compare two TB protocols among healthy subjects in improving postural control.
Mixed model design.
Research laboratory.
Thirty healthy subjects divided into a control (CON), three times/week (TB3) or five times/week (TB5) group.
Training groups completed TB quick-kick protocols for six weeks either three (TB3) or five times (TB5) per week.
Center of pressure velocity in the anterior/posterior (COPVX) and medial/lateral (COPVY) directions.
There were no differences related to Group or Side. COPVX in the eyes open (EO) condition increased pre-post. COPVY decreased pre-post.
The lack of differences between Groups and Side indicates these specific TB training protocols did not impact static postural control differently among healthy subjects.
We evaluated the relationship between upper extremity (UE) and lower extremity (LE) motor impairments in Parkinson's disease (PD) to overall disability and quality of life (QoL) measures. A total of 639 patients who were diagnosed with idiopathic PD were administered the Unified Parkinson's Disease Rating Scale (UPDRS), QoL, activities of daily living (ADL), and behavioral scales. Composite UE and LE scores from the motor section of the UPDRS were correlated with ADL, QoL, and behavioral measurement scores while controlling for disease duration. Patients with greater UE and LE motor impairments had lower QoL scores. However, LE impairments had a greater influence than UE impairments across all QoL measures.