Physical Therapy for Parkinson's Disease

Parkinson's disease is a neurodegenerative disease caused by lack of dopamine. The three leading symptoms in diagnosis are bradykinesia, tremor, and rigidity. With Parkinson's simple tasks like walking around the house become hard. The diagnosis is based on neurological exam findings and there is no specific test that can clearly identify the disease. Some patients present with primitive reflexes because of a problem in the frontal lobe. Some of the clinical signs include bradykinesia, resting tremor, and rigidity. There is currently no cure just processes aimed at slowing down the progression. It is important that Parkinsons is diagnosed early so that the progression can be slowed.

A few symptoms in the early stage are unilateral tremor, rigidity, and gait hypokinesia. Balance and gait deficits occur in the middle of progression symptoms. In the late stage there are severe voluntary movement impairments, swallowing compromised, and the person is dependent. A patient with Parkinson's Disease needs a well rounded program focusing on aerobic exercise and resistance. Higher intensity training shows greater benefits. Aerobic and resistance exercises are the most studied but other exercises should not be neglected. Some research shows that early stretching can slow rigidity progression.

The main treatment is Levodopa and it must be combined with other drugs and delivered in high doses because most of it is metabolized before reaching the brain. In the beginning levodopa can be very effective at reducing motor symptoms but it can become less effective with time. Levodopa can also lead to side effects such as dyskinesia which is involuntary muscle movements and orthostatic hypotension which should be noted by the physical therapist because it can lead to fainting and injury. In newly diagnosed patients dopamine agonists may be used prior to levodopa to delay use of levodopa because of the side effects associated with long term levodopa use.

A recent study published June 21, 2019 found a different route of activation. Treatment using the previously thought system yielded mixed results. This study found a new direct drug target. It was previously thought the enzymes were activated in the glial cells but this new research suggests that it is activated in the dopamine producing neurons. 'Mitochondrial targeting of such compounds is likely to be effective in treating Parkinson's patients, and pursuing that is our future strategy.'

Physical therapy can help with activities of daily living. Exercise is medicine and positively impacts cognition even in healthy individuals. As soon as the patient is diagnosed focus should be put on maintaining and improving flexibility with focus on rotation, specifically trunk rotation and extension because it is vital to functional activities. There is no specific type of strength training but strength training is crucial. Balance is also vital to prevent falls and stepping backward should be avoided, stepping sideways should be implemented. Patients respond well to external cues. A recent study showed that there were functional gait performance benefits in an auditory cueing program. Some recommended exercises are yoga, tai chi, dance, balance, and amplitude training. Stretching should be incorporated because it fights rigidity.

Virtual reality is the future and is being adapted to be used in rehabilitation. The main purpose of this study was to be able to test Parkinsons patients in a safe environment. The patients are put on a treadmill with virtual reality equipment and are required to step over objects and as a step is successfully completed the object becomes larger. This provides a relatively safe environment since the object doesn’t actually exist. The program showed increased navigation skills and range of motion of lower extremities which should lead to a lower fall risk.

Aerobic training along with pole walking can benefit the whole body by forcing different parts to work. The patient must swing the arm to take a step as well as maintain posture and take proper steps. Each step makes the patient realize where they are in space and organize themselves to take another proper step. This training also increases endurance and creates brain/muscle connections. Some key movements according to Parkinson Wellness Recovery are posture, weight shift, trunk rotation, and transition (sit to stand). A recent study found that aerobic exercise can delay neurodegenerative disease. While it is known that aerobic exercise and resistance training is beneficial, it is unknown the exact underlying reasons these are so beneficial.

Exercise can be used to reduce or decrease the risk of mitochondrial disorders. Mitochondria are the powerhouse of the cell and diseases can make the mitochondria fail to produce enough energy for proper functioning. According to a study from the Journal of Physical Activity and Health effects on cognition were exercise intensity dependent and acute aerobic exercise promoted better cognitive performance in people with Parkinsons Disease(6). Another study showed that consistent exercise with executive challenges such as dual tasks can counteract the advanced motor symptoms of parkinsons disease neurodegeneration.

Regular exercise combined with executive challenge such as dual-task may counteract the advanced motor symptoms of Parkinson's disease neurodegeneration. Acute aerobic exercise was able to promote better cognitive performance in people with PD. The effects on cognition were exercise intensity dependent.

LSVT is an intense treatment that was designed to help people with Parkinsons. This treatment revolves around the concept of neuroplasticity which is the ability of the brain to adapt. There are two programs: LSVT-LOUD and LSVT-BIG. LSVT loud focuses on voice and swallowing. LSVT-BIG focuses on functionality and movements. The one month program includes four one hour sessions a week for four weeks in a row. A therapist must be certified in LSVT to provide this intensive one on one treatment. High effort must be done in each session and homework must be done every day in order for the program to be effective. LSVT exercises are done starting in the seated position. The program begins seated and arms are put out in front then down then up then out to the side and count to 10 out loud then clap the hands on thighs and begin again.

The next exercise is seater and the patient reaches out in neutral seated then reaches arm to other side of body and turns body almost to a lunge while still seated and arm out in front with rotated body and count to 10. It is then repeated in the other direction. The patient then puts one foot at a time out alternating feet and put both hands out to side at the same time then claps thigh. This is then progressed with a side step. The next exercise the hands are put out in front of the body then brought behind the body as the leg takes a step back then return to neutral and alternate legs but continue with arms.

Rocking with arms and legs is then done. A twisting exercise is then done by rotating the body with the one arm in front and one arm behind and legs turning in direction of twist a clap is done to return to neutral then the other side is done. These exercises can also be done in standing. The physical therapist can also discuss aids for activities of daily living such as anti slip mats, shower seats, handrails, light weight kitchen equipment are just some examples.