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A combined approach of physical therapy and pharmacological intervention plays a key role in the management of the patient with PD. Despite best efforts, progressive disability develops and affects the patient's quality of life. A variety of interventions to maximize functional ability and minimize secondary complications are used to achieve goals and outcomes, including direct interventions, supervision of assistive personnel, patient/family/caregiver instruction, environmental modification, and supportive counseling. Early intervention is critical in preventing the devastating musculoskeletal impairments these patients are so prone to develop. Interventions also focus on improvement of motor function, exercise capacity, functional performance, and activity participation. Education and support of patients, family members, and caregivers at each stage of the disease is critical to attaining optimal outcomes. The research team for the Cochrane Database of Systematic Reviews found that there was insufficient evidence to support or refute the efficacy of any given form of physical therapy over another in PD. The researchers stressed the need for improved research in this area, including large well-designed placebo-controlled randomized controlled trials (RCTs) to demonstrate the efficacy and effectiveness of "best practice" physical therapy in PD.161,162
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Motor Learning Strategies
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Patients with PD typically demonstrate motor learning deficits, including slower learning rates reduced efficiency, and increased context-specificity of learning. Learning complex movement sequences and movements dependent on internally generated cues are more difficult than those dependent on external cues. In the early and middle stages of the disease, patients can improve their performance through practice and by using additional sensory information. The amount and persistence of learning are variable and can be expected to be lower than in healthy age-matched people. In more advanced stages and in the presence of pronounced cognitive deficits, training will likely be less successful.163,164,165 The therapist needs to structure treatment sessions to optimize motor learning.
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Critical elements of practice include a large number of repetitions to develop procedural skills. The therapist should instruct the patient to deliberately focus his or her full attention on the desired movement. The environment should also be modified to reduce clutter and competing attentional demands that may trigger freezing episodes. The task should be modified to minimize competing cognitive demands (e.g., dual tasking). Long and complex movement sequences should be avoided or broken down into component parts. Initially, random practice order (i.e., practice in which the patient switches back and forth between tasks) should be avoided in favor of a blocked practice order, thereby reducing the effects of contextual interference. Use of structured instructional sets has been shown to improve movement speed and consistency.166 For example, walking patterns can be improved with focused instructions of "swing your arms," "walk fast," or "take large steps." For the patient with advanced disease and cognitive deficits, repetitive drill-like practice should be used together with an increased focus on caregiver training to ensure safety.
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External cues have been shown to be effective in triggering sequential movements and improving movement characteristics in individuals with mild to moderate PD.167 Box 18.5 Evidence Summary presents a review of selected research in this area. Visual cues include stationary floor markings (e.g., brightly colored lines on the floor placed perpendicular to the gait path and spaced about one step length apart) and dynamic transportable cues (e.g., laser light signals). A laser light that projects a line onto the floor in front of the patient can be mounted on an assistive device (cane or walker) or on a subject's chest harness. 168 Visual cues have been shown to improve stride length and velocity while cadence was relatively unchanged. Freezing episodes are also reduced.169 Rhythmic auditory stimulation (RAS) includes use of a metronome beat or a steady beat from a musical listening device. RAS has been shown to improve gait speed, cadence, and stride length.170,171,172 The beat is typically set 25% faster than the patient's preferred pace. Auditory cues such as "Big step" have also been shown to improve gait. Examples include "1, 2, 3 stand, ready set go, big first step." Cues should be consistent, not rushed and have a rhythmical quality to them. Auditory cues appear to have a greater influence on the temporal components of movement (e.g., gait cadence, stride synchronization) rather than on spatial components. Multisensory cueing (use of both visual and auditory cueing) has been used for patients with PD. When sensory enhanced therapy using multisensory cueing was compared with conventional therapy, significant improvements were found in the sensory training group.173,174,175,176,177,178,179,180,181,182
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Box 18.5 Evidence Summary Effect of Visual and Auditory Cues on Gait in Individuals with Parkinson's Disease
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External cues appear to facilitate movement by utilizing different brain areas. For example, the premotor cortex is active in the generation of movement in response to visual or auditory stimuli. Normally the supplementary motor area (SMA) with inputs from the BG is involved in the initiation of self-generated movements and the performance of well-learned, repetitive movement sequences. External cues heighten patient attention through a common mode of action, that is, to bypass the diminished internal cueing of the BG. Thus, focus is shifted to less automatic movement using alternative, more conscious motor control pathways. This is supported by the finding that when patients were requested to carry out a secondary task while walking (dual-tasking), the beneficial effects of visual and attentional cues was reduced.183
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Selection of the type of cue and successful use will depend on the individual patient with predicted long-term benefit of a particular type of cue linked to its initial success. External cues are clearly not effective for all patients with PD. For patients with advanced disease and severe reductions in stride length, cueing is not effective. When cueing is withheld, performance can be expected to deteriorate. Focused attention with cueing requires constant vigilance and is cognitively demanding. Thus, cueing is not suitable for patients with dementia.
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Cueing may also not be effective when medication instability and disease fluctuations are present. However, for many patients, use of external cues is a valid treatment strategy and one in which improved performance can be anticipated.
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Amplitude-based behavioral intervention is a concept that can be applied in different contexts in the treatment of PD.184 The "Training Big" program, also known as the Lee Silverman Voice Treatment (LSVT) Big program, is based on the concept that repetitive high-amplitude movements yield greater improvements in motor performance and possibly have a neuroprotective effect.185 Patients are guided by a physical therapist to exercise at a high intensity (8/10 Borg's RPE Scale) for 1 hour 4 times a week for 4 weeks with large amplitude, multiple repetitions, and whole body movements that increase in complexity (Fig. 18.6). Examples of the exercises and patient directions include the following:
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"Reach left arm across the body to opposite side, keep hand open, palm up, right leg fully extended, toe pushing into the floor. Repeat on other leg and alternate."
"Step out and land 'Big,' pushing the left foot into the floor while reaching with bilateral 'Big arms,' open hands, palms up (Fig. 18.7). Return the foot back to the start, end 'Big.' Repeat on other leg and alternate."186
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These vigorous large movements of the trunk and extremities are counter to the paucity of movement normally associated with PD. After a 4-week program of LSVT "Big" training the subjects had significant improvements in UPDRS motor scores, TUG, and timed 10-m walking.187
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Gentle rocking can be used to produce generalized relaxation of excessive muscle tension owing to rigidity. Professor Charcot, who noted dramatic improvement in patients with PD following rides in bumpy, horse-drawn carriages, first described this effect almost 100 years ago in Paris. Following this observation he constructed a vibrating chair to use with his patients.188 Although the exact mechanism underlying rigidity has not been identified, the beneficial effects of slow rocking on excess tone have been demonstrated.189 Following Charcot's lead, a rocking chair can be used to temporarily relax the patient and enhance sit-to-stand transfers. During therapy, slow, rhythmic, rotational movements of the extremities and trunk can precede interventions such as ROM and stretching, and functional training. For example, hook-lying, lower trunk rotation, or side-lying rolling can be used to promote relaxation. The proprioceptive neuromuscular facilitation (PNF) technique of rhythmic initiation (RI), in which movement progresses from passive to active-assistive to lightly resisted or active movement, was specifically designed to help overcome the effects of rigidity in PD.190,191
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Another strategy to promote relaxation is emphasis on diaphragmatic breathing during exercise. For example, bilateral symmetrical PNF D2 flexion patterns are important patterns that can be used to expand the restricted chest and promote shoulder ROM (Fig. 18.8). The patient's attention can be focused on deep inspiration during D2F ("breathe in deeply") while during D2E patterns attention is focused on expiration ("breathe out deeply").191 Patients may also benefit from cognitive imaging or meditation techniques (e.g., the relaxation response of Benson192). Relaxation audiotapes can be used at home as part of the home exercise program (HEP). Stress management techniques are an important adjunct to relaxation training. A daily schedule needs to be planned to accommodate the restrictions of the disease and the functional needs of the patient. Lifestyle modifications and time management strategies reduce anxiety associated with movement difficulties and prolonged times required to complete basic functional tasks.
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The purpose of flexibility exercise (stretching) is to improve ROM and physical function. A combination of static (PROM), dynamic (AROM), and facilitated PNF exercises is used to achieve maximum ROM. Flexibility exercises should be performed a minimum 2 to 3 days per week and ideally 5 to 7 days per week. A minimum of 4 repetitions per stretch held for 15 to 60 seconds is recommended.54 Special consideration should be given to stretching common areas of limitation (Table 18.4). Stretching can be combined with joint mobilization techniques to reduce tightness of the joint capsule or of ligaments around a joint (Fig. 18.9). By using selected grades of accessory movement, both improved ROM and decreased pain can be achieved. The stretching will be more effective if the muscles have been warmed with active exercise or with an external heating modality. Stretching exercises are an important component of the HEP. The patient and caregiver should be instructed in the appropriate stretching exercises.
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A yoga sequence can be used effectively to focus attention on developmental postures, core stability, and stretching of structures that are traditionally restricted with PD, as well as to promote relaxation (Appendix 18.B).
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Patients with PD have a minimum of energy to expend and multiple clinical problems. They may benefit from ROM exercises in physiological patterns of motion. For example, PNF patterns combine several motions at once while emphasizing rotation, a movement component typically lost early in PD. In the UEs, bilateral symmetrical D2 flexion patterns are ideal in promoting upper trunk extension and in counteracting kyphosis. Unilateral bridging with trunk rotation, bilateral bridging, and high-kneeling with anterior pelvis translation can all be used to stretch tight hip flexors and strengthen spinal and hip extensors. In the LEs, hip and knee extension should be emphasized, ideally in a D1 extension pattern (hip extension, abduction, internal rotation) to counteract the typical flexed, adducted position of the LEs. Muscle contractures typically respond well to PNF facilitated stretching techniques such as the hold–relax (HR) or contract–relax (CR) techniques.191,192 Of the two, CR is the preferred technique because it combines autogenic inhibition from isometric contraction of the tight agonist muscle and active rotations of the limb. A 6-second contraction followed by a 10- to 30-second assisted stretch is recommended for these PNF techniques.54
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Patients with PD benefit from additional attention and cueing strategies during active stretching exercises. Patients are instructed to "Think BIG, and move through the whole range" and maintain full focus and attention during each repetition. Additional tactile or visual cueing can assist in maximizing range during active motions. For example, during active trunk rotation and reaching movements in sitting, the patient can be cued to touch an object or target. Ballistic stretches (high-intensity bouncing stretches) should be avoided because they are linked to increased injury. Muscle tears or ruptures of weakened tissues are especially prevalent in elderly, sedentary individuals. Vigorous stretching can stimulate pain receptors and cause rebound muscle contraction. Patients with PD who are elderly and have long-standing disease must be considered at risk for osteoporosis and therefore must be stretched accordingly. The therapist should also use caution when stretching edematous tissue, a common LE problem associated with prolonged immobility, because risk of injury is also increased in this situation.
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Positioning can also be used to stretch tight muscles and soft tissues. Patients in late-stage PD are likely to demonstrate severe flexion contractures of the trunk and limbs. Early on, the patient may benefit from daily positioning in prone-lying. As the disease progresses and significant postural deformity and cardiorespiratory impairments develop, the patient may not tolerate this position. The patient with a developing lateral curvature can be positioned in side-lying with a small pillow under the lateral trunk. Positional stretching is prolonged, with times typically ranging from 20 to 30 minutes. Additional mechanical stretching can be achieved through the use of a tilt table, for example, the patient is positioned with fixed leg straps to reduce hip and knee flexion contractures and toe wedges to reduce plantarflexion contractures.
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Resistance training is indicated for patients with PD who demonstrate primary muscle weakness with impaired motor unit recruitment and rate of force development and disuse weakness associated with prolonged inactivity. Specific areas of weakness are targeted, such as the antigravity extensor muscles. Weakness of these muscles is associated with poor posture (e.g., a flexed, stooped posture) and functional deficits (e.g., inability to get out of a chair, limitations in gait function).193,194,195 Weakness also contributes to postural instability, falls, and fall injury, as well as increased sense of effort.196 The benefits of strength training in the frail elderly have been well documented by the Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) trials.197 Collectively these studies have shown that the frail elderly improve on measures of strength, functional mobility, balance, gait, fall risk, and quality of life following interventions that include strength training.198,199 Strength training has also been shown to improve muscle force, bradykinesia, and quality of life in patients with PD.200 Hirsch et al201 compared two different exercise training programs for patients with PD. They found significantly greater improvements in balance and strength using a combined program of balance training and high-intensity resistance training for knee extensors and flexors and ankle plantarflexors as compared to balance training alone.
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Resistance training is based on the progressive overload principle. The amount of resistance is increased during training. Load can be applied using resistance machines, free weights, elastic resistance bands, or manually. With older adults the recommendation is to begin at a lower intensity (e.g., using an RPE Scale of somewhat hard, 5 to 6 on a 10-point scale), ensuring that a set of 10 to 12 repetitions per set can be completed.202 Progression is as tolerated. Each repetition should be held for 10 seconds. Strength training can be performed 2 days per week on nonconsecutive days. Exercise machines may be safer than free weights for patients with more advanced disease because the movements are more controlled, especially for the patient who demonstrates dyskinesias at peak dose or cognitive changes.54 Because patients with PD already demonstrate too much stiffness and coactivation, isometric training is generally contraindicated. Functional training activities (see next section) can also be effective interventions to improve strength.
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Corcos et al24 found a significant interaction between medication and strength. Withdrawal of L-dopa during an "off" state period caused a decrease in strength and rate of force development. Exercise training should therefore optimally be timed for "on" periods when the patient is at his or her best (i.e., 45 minutes to 1 hour after medication has been taken). Exercising during an "off" period may not be possible or pose great difficulty for the patient. The patient should consistently exercise at the same time during a medication cycle.
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An exercise program should be based on focused practice of functional skills. The overall emphasis is on improving functional mobility with specific emphasis on improving mobility of axial structures, the head, trunk, hips, and shoulders. Progression to more difficult motor activities should be gradual. The more severely involved patient may benefit initially from assisted movements progressing to active movements (e.g., the PNF technique of RI) to improve initial motor performance.203
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Bed mobility skills (i.e., rolling, bridging, supine-to-sit transitions) are essential skills that are often very difficult owing to truncal rigidity and bradykinesia. Side-lying rolling activities that emphasize segmental rotation patterns (i.e., isolated upper and lower trunk rotations) should be practiced rather than a log-rolling pattern. Patients with very stiff trunks may benefit from compensatory rolling strategies using the UE or LE to reach over and initiate the movement (e.g., D1F patterns of the UE or LE). Rolling should be practiced on different surfaces progressing from firm to soft and finally simulating the patient's bed surface at home. Bridging is an important activity that improves scooting in bed as well as sit-to-stand transfers (Fig. 18.10).
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Sitting can be enhanced through exercises designed to improve pelvic mobility as the patient with PD typically sits with a stiff and posteriorly tilted pelvis (i.e., sacral sitting position) along with a flexed upper trunk. Anterior and posterior tilts, side-to-side tilts, and pelvic clock exercises can be practiced while sitting on a therapy ball, which enhances ease of movement (Fig. 18.11). These activities can then be progressed to sitting on a stationary surface such as a mat table using an inflatable disc to finally no apparatus. Sitting activities should include weight shifting emphasizing upper trunk rotations and reaching. PNF extremity patterns in sitting can be used to enhance trunk mobility. For example, bilateral symmetrical UE D2F and D2E patterns are ideal to promote upper trunk extension. Or a lift/reverse lift pattern can be used to promote upper trunk extension with rotation.
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Sit-to-stand (STS) is a difficult activity for many patients with PD, especially with moderate or advanced disease or when in the "off" state. Issues in poor dynamic stability and inadequate limb support contribute to falls. Patients demonstrate poor timing in controlling their COM forward velocity, which tends to be slower. Insufficient upward momentum (LE extension torques) in standing up is also problematic.194 Other factors include level of agonist-antagonist coactivation and rigidity. STS training begins with the patient scooting to the edge of the mat and placing both feet under the knees and apart. Forward trunk flexion can be enhanced through initial rocking, which encourages relaxation. Cueing strategies (e.g., counting, placing one hand between the patient's shoulder blades) can be used to assist the forward lean. Sitting on an inflated disc can also assist in the forward weight shift and seat-off. Standing-up is enhanced by improved LE muscle strength. Strengthening of the hip and knee extensors can be achieved using modified wall squats. Practice standing up from a firm raised seat decreases the total excursion and work of extensor muscles and promotes ease of rise. Once control is achieved, progression is then to lower, standard height seats. Standing directly in front of the patient should be avoided, because this may block initial standing attempts. Instead, the therapist or caregiver should stand to the patient's side. If safety issues are apparent, a safety gait belt should be used. The more involved patient can practice STS from a chair with both hands on armrests.193
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Standing activities can model the progression used in sitting. The patient needs to first gain the fully upright position with symmetrical weight-bearing over the BOS. Tactile cueing or light resistance can be used on the anterior pelvis to encourage movement of the hips forward into full extension. Once standing, weight shifts and rotational movements of the trunk should be practiced (e.g., reciprocal arm swings or reaching movements). Step-ups using a low platform step (forward, lateral) should be practiced. Backward stepping can be used to strengthen hip and spinal extensors and promote upright posturing. To increase the challenge during stepping, elastic resistive bands can be used (Fig. 18.12). The patient can also practice standing with UEs extended and hands weight-bearing on a wall to promote upper trunk extension.
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Patients with PD typically experience a high number of falls and should be taught how to get up after a fall. To that end, skills in quadruped creeping should be practiced so the patient is able to move to a nearby stable chair or couch at home. The patient should also practice transitions moving from quadruped to kneeling to half-kneeling and finally to standing using UE support.
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Mobilizing facial muscles is another important component of the exercise program because the patient will have limited social interaction and poor feeding skills in the presence of marked facial rigidity and bradykinesia. These factors can greatly influence the patient's overall psychological state, motivation, and social participation. Massage, stretch, manual contacts, and verbal cueing can be used to enhance facial movements. The patient can be instructed to practice lip pursing, movements of the tongue, swallowing, and facial movements such as smiling, frowning, and so forth. A mirror can be used to provide visual feedback. In cases where eating is impaired by immobility, the movements of opening and closing the mouth and chewing should be combined with neck stabilization in a neutral position. Verbal skills should be practiced in association with breath control.
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It is important to recall that learning is task and context specific. Thus, a balance training program should include a variety of activities that alter task demands and expose the patient to varying environmental conditions. Whenever possible the therapist should try to duplicate the conditions the patient will encounter in everyday life. The level of challenge is important. A therapist should know the limitations of the patient and the specific demands of the task and environment in order to select and progress tasks accordingly and ensure patient safety. See Chapter 10, Strategies to Improve Motor Function, for a more complete discussion of balance training.
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An important focus of balance training for the patient with PD is COM and LOS control training. Patients should be instructed in how COM influences balance and how to improve posture in sitting, in standing, and during dynamic movement tasks. Patients should also explore their LOS and practice working toward expanding them in both sitting and standing. In standing, patients with PD typically demonstrate restricted LOS with forward displacement of center of foot pressure. Patients should be instructed in how to improve postural alignment and in ways to avoid postural disturbances and falls. The therapist can assist with postural and safety awareness by using appropriate verbal, tactile, or proprioceptive cues to facilitate the desired responses. For example, the patient is instructed to "sit tall" or "stand tall" and a mirror is used to provide feedback concerning upright posture. A standing platform training device (i.e., posturography system) can be valuable in providing COM position and LOS biofeedback. The patient is instructed in weight shifting that expands the LOS. The Nintendo Wii Balance Board is a widely available and economical force platform and biofeedback system. When compared to a laboratory-grade force platform the Nintendo Wii Balance Board was valid in quantifying center of pressure, an important component of standing balance.204 Subjects with poor positional awareness who trained on the Wii Balance Board with real-time visual biofeedback demonstrated significant improvements in weight-bearing symmetry.205 Elderly subjects who trained with this device over a 4-week period improved on average 9.14 points on the BBS.206
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Balance training should emphasize practice of dynamic stability tasks (e.g., weight shifts, alternating unilateral weight-bearing, reaching, axial rotation of the head and trunk, axial rotation combined with reaching, and so forth). Seated activities can include sitting on a compliant surface (inflatable disc) or a therapy ball. Challenges to balance can also be introduced in quadruped (Fig. 18.13), kneeling (Fig. 18.14), half-kneeling (Fig. 18.15), and standing on a disc (Figs. 18.16 and 18.17). Altering arm positions (e.g., arms out to side, arms folded across chest, reaching); altering foot/leg positions (e.g., feet apart, feet together); or adding voluntary movements (e.g., overhead arm clapping, head and trunk rotations, single leg raises, stepping or marching in place) can all be used to increase difficulty of the activity. Training should focus on achieving faster initiation and execution movement times supported by the use of appropriate cueing strategies.166 Externally induced perturbations in the form of gentle manual displacements of the patient's COM are generally contraindicated for many patients with PD because they can produce an increase in postural stiffness and fixation. Strategies for varying environmental demands include altering the support surface (e.g., standing on foam), visual inputs (e.g., reduced lighting, eyes closed), or challenging the patient with a variable open environment (e.g., busy clinic setting).
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Adequate strength and ROM are important components needed to withstand the challenges of balance. The patient can be instructed in standing exercises to enhance balance, including heel-rises and toe-offs, partial wall squats and chair rises, single-limb stance with sidekicks or back-kicks, and marching in place. Collectively these exercises are sometimes referred to as the "kitchen sink exercises" and are important components of the HEP for patients with balance deficiencies. The patient may require light touch-down support of the hands to start in order to stabilize; progression should be to no support as soon as possible.
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Whole body vibration (WBV) is gaining popularity as a treatment for patients with neurological diseases. It is theorized that the seesaw-like displacement of the platform mimics human gait207 and that postural responses are induced by vibration of the foot soles.208,209 It is also believed that WBV increases efficiency of agonist/antagonist pairs.210,211 Systematic literature reviews reveal insufficient high-quality studies and only minor evidence from the current literature that WBV improves strength, proprioception, gait, and balance.212,213 For people with PD, WBV seated in a physioacoustic chair resulted in improved gait, UPDRS scores, and upper limb control and significant reductions in tremor and rigidity.214 Another study examined the effect of treatment standing on a random multidirectional vibrating platform. After WBV, subjects presented with significantly improved scores on the UPDRS with reductions in tremor and rigidity.215 Additional quality research examining the efficacy of WBV in the treatment of people with PD is needed.
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Locomotor training goals focus on reducing primary gait impairments, which typically include slowed speed, decreased stride length, lack of a heel-toe sequence with forward progression characterized by a shuffling (festinating) gait pattern, diminished contralateral trunk movement and arm swing, and an overall attitude of flexion while walking. Goals also focus on increasing the patient's ability to safely perform functional mobility activities and prevent falls.216 Effective strategies for improving upright alignment and safety include having the patient walk with vertical poles (pole walking) (Fig. 18.18). Strategies to enhance posture, step length, velocity, and arm swing include the use of verbal instructional sets (e.g., "Walk tall," "Walk fast," "Take large steps," "Swing both arms"). Behrman et al217 found that commands for large step and arm swing were more effective instructional strategies than the command to walk fast. As previously discussed, visual and auditory cues are also effective in improving gait speed and step length. Transverse visual–spatial cues (across the gait path) were more beneficial than parallel visual cues (alongside the gait path) in improving gait velocity, stride length, and percentage of leg stance time.218 Strategies to improve foot placement can include use of floor markers or footprints on the floor. Strategies to improve step height include practice marching in place progressing to walking using an exaggerated high stepping pattern. Brisk marching music can be used to enhance pace. Sidestepping and crossed-step walking can be practiced (Fig. 18.19). The PNF activity of braiding, which combines side-stepping with alternate crossed-stepping, is an ideal training activity for the patient with early PD because it emphasizes lower trunk rotation with stepping and side-stepping movements. It can be practiced with the patient holding on lightly to a dowel held jointly with therapist or as a free walking pattern. Advanced stepping and balancing can be achieved by having the patient practice juggling scarves (Fig. 18.20). Reciprocal arm swing during gait can be enhanced by having the patient and therapist hold onto a set of two dowels (one in each hand). The therapist walks behind the patient and uses his or her arm swing to assist the patient's.
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Patients with PD who practiced locomotor training on a motorized treadmill with an overhead harness demonstrated improvements in postural stability, gait (e.g., walking speed, step and stride length), motor function, and quality of life.219,220,221,222,223,224,225,226,227 Both body weight support (e.g., up to 20%)220 and no body support have been used.219 In a long-term study, Miyai et al221 found that gains in walking speed and number of steps following this type of training were maintained at 4 months. The researchers stated that attentional strategies were not used and speculate that the enhancement of gait might be due to activation of central pattern generators as is thought the case in stroke and spinal cord injury (SCI) studies. The treadmill may be acting as an external cue to enhance gait rhythmicity and reduce gait variability.224 The benefits of treadmill training, as with exercise training in general, are dose dependent. More pronounced improvements are noted with high-intensity practice and incremental increases in treadmill speed.225,226 High-intensity treadmill training has been shown to normalize corticomotor excitability in early PD.226 The motorized treadmill has also been used for step training in people with PD. While supported in a safety harness, patients practiced stepping in all four directions in response to suddenly turning the treadmill on and off.228
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Locomotor training should also include task-specific training designed to promote full participation in social roles pertaining to family life, leisure, and community participation. This includes varying the walking task (e.g., walking on a tile floor, on carpet, outdoors on sidewalks and grassy terrain). Additional challenges include walking in the community (e.g., variable open environments), stair climbing, up and down curbs, and ramp walking. Patients with PD often demonstrate difficulties in obstacle stepping due to minimized foot clearance. Foot clearance can be improved with repeated practice of stepping over horizontal floor markers or laser light signals.
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Patients in the advanced stage of the disease will be limited in terms of walking and variations that can be utilized. The overall goal at this stage is to promote regular walking while maintaining safety and preventing falls. Compensatory training strategies are indicated. Caregiver instruction regarding assisted walking and safety is imperative. Freezing episodes are common and are often resistant to drug therapy. The therapist and patient should identify and practice strategies for unfreezing gait.229 For example, cueing or "trick" movements such as dropping a tissue that the patient must step over can be successful in reducing freezing. Some patients, especially those in the postural instability gait disturbed group, can benefit from walking with a therapy dog. The dog provides an assist in balance and momentum, and a source of external cueing of stepping movements (Fig. 18.21).
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Spinal bracing may be an appropriate adjunct to therapy for patients with postural deformities common to PD (e.g., increased thoracic kyphosis, decreased costal expansion, and forward head posture). The Spinomed thoracolumbar orthosis is unique in that it not only corrects faulty posture but also has been shown to increase trunk stability, increase respiratory vital capacity, and improve a patient's self-report of well-being.230,231 When the brace was worn for 6 months the subjects had a 73% increase in back extensor strength and a 58% increase in abdominal flexor strength. These strength gains are attributed to increased muscular activity in response to the proprioceptive biofeedback of the brace.232 A study investigating gait stability and physical functioning in women with postmenopausal osteoporosis demonstrated decreased double limb stance time associated with a beneficial impact on gait stability.233 Further research is warranted to determine if this type of orthotic intervention holds potential for patients with PD.
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Pulmonary Rehabilitation
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The four main classifications of respiratory disorders in patients with PD are medication complications, upper airway obstructions, restrictive disorders, and aspiration pneumonia.234 Since respiratory dysfunction in the neurological movement disorders population is linked to a high rate of disability and mortality, it is critical that the prevention and treatment of these dysfunctions take priority. Components include diaphragmatic breathing exercises, air-shifting techniques, and exercises that recruit neck, shoulder, and trunk muscles. Manual techniques such as vibration and shaking can be used to ensure complete exhalation, distal alveoli opening, and to assist with secretion clearance. The patient should be instructed in deep-breathing exercises to improve chest wall mobility and vital capacity. Air shifts are promoted to lesser-ventilated areas of the lung. For example, basal expansion can be promoted using side-lying recumbent positioning, manual stretch, and resistance to those segments. Upper body resistance training exercises are indicated. These can include raising and lowering a dowel with light weights added to increase resistance (e.g., 1 lb [453.5 g]). Weights are increased as function improves. As previously mentioned, chest wall mobility can be improved by using PNF UE bilateral symmetrical D2 flexion and extension patterns. Light weights (wrist cuffs) can also be added to these exercises. Patients are encouraged to coordinate breathing with UE movement. Exercises are performed in unsupported sitting to promote trunk stabilization. A focus on improving trunk extension is especially important in improving breathing patterns in patients with postural kyphosis. Pulmonary rehabilitation programs have been shown to be safe and effective for patients with PD in improving pulmonary function (i.e., oxygen consumption [VO2], minute ventilation [VE], respiratory rate, inspiratory muscle strength)235,236 and perception of dyspnea.237
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The quality of speech in patients with PD is often a breathy monotone, soft voice that is perceived by the patient to be of normal loudness. Hypophonia is caused by a bradykinetic bellows mechanism (chest wall and diaphragm) and patients' inaccurate perception of their own speech effort. Speech deficits are seen in 80% of patients with PD and have a dramatic effect on function with 30% reporting it as the most disabling part of the disease.239 As mentioned earlier, the Lee Silverman Voice Treatment (LSVT) was designed specifically for patients with PD.239 It focuses on intensive high-effort exercise with a single functionally relevant target (loudness) and a recalibration of self-perception of vocal loudness. This technique effectively increases vocal loudness and improves facial expressions in patients with PD.240,241,242
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An individualized exercise prescription is developed based on the ACSM guidelines for frequency, intensity, duration, and progression.54 Intensities will be less than normal training intensities or submaximal (i.e., 60% to 80% of maximum HR), based on the patient's level of disease, fitness, and lifestyle. When lower intensities are used, longer-duration or more frequent exercise sessions are necessary to improve fitness. Careful monitoring is indicated, because autonomic dysfunction is common. Long-term L-dopa use can produce arrhythmias and OH along with dyskinesias. The therapist should monitor vital signs (HR, RR, BP), RPE, fatigue levels, and symptoms of exertional intolerance (e.g., significant dyspnea, hypotensive response, and so forth).
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Training modes can include leg and arm ergometry and walking. Selection will depend on the specific abilities of the patient; for example, postural instability and increased risk of falls may rule out use of a treadmill without an overhead harness. Recumbent or seated LE ergometry is a suitable alternative. For most patients a program of regular walking is recommended. The duration, speed, and terrain covered can be modified, based on individual ability. Accessibility to a supervised walking program using an indoor walking track is important for some to ensure safety. A shopping mall can provide an acceptable environment for community walkers in case of inclement or extremes of weather. A supervised aerobic pool program can also provide an acceptable mode of exercise for some patients. The warmth of the water may be relaxing and the buoyancy may enhance stepping movements. The minimum recommended aerobic exercise frequency is 3 sessions per week. Daily walking with short multiple bouts (20 to 30 minutes) spaced throughout the day is recommended for individuals with lower functional capacity. Intermittent exercise with adequate rest intervals is indicated for those patients who are elderly and deconditioned, and who present with restrictive pulmonary dysfunction. Aerobic training programs have been shown to be safe and effective for patients with PD in improving aerobic capacity.243,244
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Group and Home Exercises
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Community-based group exercise classes can be valuable for patients with PD. Patients benefit from the positive support, camaraderie, and communication the group situation offers.245,246 Careful evaluation of each patient before admission into a group is essential. Patients should be able to perform the therapeutic core of the class. Selecting patients with similar levels of disability is often advisable because the sense of competition can frequently be a key factor in motivating groups. The ratio of staff to patients should be kept small (ideally 1:8 or 1:10), and extra staff should be added if patients are unable to work on their own. A variety of activities can be used to stimulate and motivate patients. The patients can begin in the seated position and progress to standing, using light, touch-down support of the back of the chair. Stretching exercises or calisthenics involving large muscle groups and multijoint compound movements can be used as an initial warm-up activity. Progression is to combination movements (UEs and LEs with axial trunk rotation). Well-structured, low-impact aerobics are an appropriate focus for a group class. For example, patients can march in place, first in sitting, then in standing. The group can then practice walking with an emphasis on taking large, high steps. Music is used to provide necessary stimulation to movement and movement pacing. Exercise stations (e.g., stationary bicycle, mats, pulleys, and so forth) can also be used. Exercises done by the whole group together should focus on important exercise goals (e.g., improving ROM, mobility, and so forth). Recreational activities can follow the aerobic portion, such as line dancing, ball activities, beanbag toss, and so forth. The activities selected should be interesting and varied. A relaxation segment should be incorporated into each class. Yoga and Tai Chi group classes effectively address multiple components of PD by improving posture, flexibility, core stability, functional mobility, balance, relaxation, and socialization.247,248,249,250,251 King and Horak252 recommend incorporating Tai Chi with other agility exercises (e.g., kayaking, boxing, lunges, agility training, and Pilates exercises) to delay loss of mobility in people with PD.252
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The home-based exercises include exercises designed to improve relaxation, flexibility, strength, and cardiopulmonary function (all previously discussed). A key element is stressing the importance of regular daily exercise and avoidance of prolonged periods of inactivity. The HEP should be realistic and of moderate duration and intensity. The patient should be cautioned against overdoing activity, which could result in excessive fatigue. Early morning warm-up calisthenics are often helpful in reducing the increased stiffness patients may experience on arising. Stretching and strengthening exercises are performed in supine, sitting, and standing positions. Home ROM exercises can often be assisted by use of adaptive equipment. For example, to reduce the effects of forward head and kyphotic posture, the patient can be instructed to hang by the hands using an overhead bar. Standing, corner wall stretches can also be used to provide a maintained stretch on the upper trunk flexors. Use of a wand or cane can be effective in promoting overhead motions. In standing, a countertop or back of a sturdy chair can be used to assist in stabilization during standing calisthenics and balance activities. Home-based exercise programs have been found to be effective in improving postural control and mobility in people with PD.253,254