Table of Contents  

Pinter: Rehabilitation in idiopathic Parkinson’s disease in the focus of the future

Introduction

Idiopathic Parkinson’s disease (PD) is a complex neurodegenerative disorder. It is characterized by motor and non-motor symptoms with a chronic progressive course. The implications for patients and their families are wide-ranging. PD is progressive, so patients face increasing difficulties with activities of daily living and various aspects of mobility. Ultimately, this leads to decreased activity, loss of independence and, finally, social isolation.1

Traditionally the management of PD has treated the symptoms. Drugs such as levodopa are considered the ‘gold standard’, and surgical approaches include deep brain stimulation (DBS).

Despite optimal medical management and well-established therapeutic strategies, the autonomy of patients with PD still deteriorates progressively as their disability increases. Most patients continue to experience a wide range of motor and non-motor symptoms.2 These influence their activities of daily living and affect their quality of life.3,4

Some motor symptoms, such as impairments in speech, unstable posture and freezing of gait, do not respond sufficiently to medication or surgery. In addition, disability arises when non-motor symptoms such as cognitive impairment, depression or psychosis are not optimally controlled with current medical management and surgical procedures.

In the light of these facts, non-pharmacological treatment is a challenge not only in advanced stages of the disease but also in the early stages.5

For this reason, all therapeutic rehabilitation strategies complement medical and surgical treatment. They offer relief of motor and non-motor symptoms that are otherwise difficult to treat. Therapeutic strategies of rehabilitation in PD have been considered as an adjuvant to pharmacological and surgical treatments with the aim of minimizing functional disabilities and improving quality of life.

This article reviews recent achievements in rehabilitation for PD. It focuses on the most critical current and future issues in rehabilitation for PD. First it reflects on rehabilitation therapies for motor symptoms. Then it considers rehabilitation methods for non-motor symptoms.

Search strategy

This review focuses mainly on the evidence underlying rehabilitation in Parkinson’s patients, including the principles of rehabilitation practice, and specific, particularly neurophysiological, interventions. References for this review were identified through searches of MEDLINE, EMBASE and the Cochrane Library using the search terms ‘Parkinson syndrome’, ‘Parkinson’s disease’ and ‘idiopathic Parkinson syndrome’ in combination with ‘rehabilitation’, ‘motor function’, ‘walking ability’, ‘cognitive function’, ‘dysphagia’, ‘participation’ and ‘functional outcome’.

Preference was given to papers published between 1999 and 2016. Only papers published in English were reviewed in detail, selecting studies for evaluating the evidence of therapeutic options and the effectiveness of functional outcome in PD.

The aim was to summarize the available evidence from systematic reviews of randomized controlled trials and Cochrane reviews, and to identify randomized clinical trials for which interventions show promise of efficacy.

Strategies in rehabilitation of motor symptoms

Impairment of gait and balance are important symptoms in PD. The alteration of gait parameters manifests from the beginning of the disease and generally worsens over time.6 Gait disturbances may be classified as continuous (reduction of stride length and gait speed, increased double support time, stride-to-stride variability and left–right asymmetry) or episodic (festination and freezing).7 Both types of gait disturbances – continuous as well as episodic – are strongly disabling because they impair mobility and worsen the quality of life of patients.8

Freezing of gait (FOG), which can lead to falls in PD, is often triggered by environmental constraints requiring a change in gait direction, getting over an obstacle, or reaching a destination. FOG is very difficult to treat pharmacologically, since, while patients with FOG in the ‘off’ phase benefit from an increase in levodopa dosage, patients with FOG in the ‘on’ phase commonly show only a partial or no response to drugs.9 Nevertheless, FOG remains poorly understood and different hypotheses have been proposed to clarify its pathogenesis.10

Furthermore, there is a high prevalence – up to 50%, depending on disease phase – of fear of falling (FoF) in people with PD.1115 Excessive FoF can lead to self-induced restricted mobility, increased risk of falls, social isolation and reduced quality of life for PD patients. An increased level of FoF has been associated with postural instability.11

Moreover, if patients with PD lose the ability to maintain postural control, it adversely affects their function and quality of life.16 As the disease progresses, patients lose postural stability and have gait dysfunction, difficulty managing activities of daily living and frequent falls.17 Nevertheless, characteristics such as postural instability are less responsive to medication and require alternative approaches.18,19

The neural control of posture is compromised in patients with PD.20,21 Automatic postural responses can be influenced by cortical processing related to learning, previous experiences and initial postural conditions.22 The basal nucleus plays an important role in the control of axial tone and postural responses and in the interpretation of somatosensory information.2325

The physiotherapy interventions can be placed into different categories according to the type of treatment administered: general physiotherapy, exercise, treadmill training, cueing, dance and martial arts. However, the content and delivery of the interventions within each category are diverse and vary substantially.

The domain of physiotherapy that has been studied most extensively is exercise that aims to improve both physical and cognitive disabilities.2628 The importance of regular physical activity was supported by a large observational study based on a unique data registry of 4866 patients.29 It analysed how ‘spontaneous’ variations in self-selected physical activity correlated with specific outcomes. It found that regular physical activity was associated with better quality of life, better physical function and lower caregiver burden. Although this study may reflect some bias, these results provide new, complementary support for the possible benefits of physical activity in PD.29

Previous studies of treadmill training for PD have varied the duration and type of intervention, including body weight support,30,31 weight loading32 and visual/auditory cueing.33,34 As a group, treadmill trials for PD have shown consistent improvements in gait and fitness.

The beneficial effects of aerobic training on physical functioning are well known. However, a recent study compared 3 months of treadmill training three times per week at different intensities with a non-aerobic control intervention such as strength training. The effect on cardiovascular functioning, muscle strength and PD symptoms was comparable for high-intensity (80% of heart rate reserve) and low-intensity (40% of heart rate reserve) treadmill training. In fact, the low-intensity group performed better on gait speed than the high-intensity group. These findings emphasise the need to perform more dosage studies, to better understand the influence of training intensity on clinical outcomes.35

Few studies compare higher- and lower-intensity treadmill exercises for PD. Pohl et al.36 studied the immediate effects of 30 minutes of high- and low-speed treadmill training compared with conventional gait training. High- and low-speed treadmill training resulted in similar improvements in gait speed; there were no improvements in the non-treadmill groups.

In general, the use of treadmills has proven useful in the rehabilitation of gait disorders in PD. In particular, the use of treadmill training combined with auditory or visual cues is effective in improving FOG in PD.37,38

Thirty patients with FOG and 30 without FOG, all of whom froze in the ‘on’ phase, underwent a 4-week rehabilitation treatment using a treadmill combined with auditory and visual cues. They were evaluated at enrolment and at the end of rehabilitation. Rehabilitation produced a homogeneous improvement in both groups of patients in all variables except balance, for which greater improvement was observed in patients with FOG. The improvement in FOG patients in the ‘on’ phase was significantly correlated to the improvement in asymmetry of gait. Moreover, these data suggest that asymmetry of gait is directly involved in the development of FOG in PD. Overall, treadmill training is effective in improving gait and balance in PD patients with FOG in the ‘on’ phase. This might be related to a reduction in asymmetric gait.6

Strength training is a relatively new intervention for PD. A recent study showed an associated long-term reduction – lasting more than 24 months – in motor symptoms based on progressive resistance training twice per week.39 It has been suggested that a combined aerobic and strength exercise intervention was even more effective, but this combined intervention has so far not been compared with either strength or aerobic training alone.35 A further study showed that 6 months of resistance training, twice per week, was associated with more perceived health benefits than stretching.40

Another re-emerging development is hydrotherapy for balance problems. It is potentially more effective than land-based therapy, given the problems of PD patients with unloading responses.41 Water buoyancy reduces the effects of gravity, and prolonged microgravity can improve static and dynamic postural control.42,43

The positive effect of water-based balance training compared with land-based training has been demonstrated in a recent study. Patients in the hydrotherapy group showed better postural control and balance, and performed better on balance confidence and falls efficacy.44

Increasing attention is being paid to dance interventions as an alternative to regular exercise or physical activity. Dance has additional components of rhythmic timing and musical cueing. It has the additional advantage of being enjoyable for many patients, which may increase the likelihood of long-term adherence.45 Randomized controlled trials performed in the last few years suggest that different dance interventions, such as tango or virtual reality dancing on a videogame system, are potentially effective on symptoms in different domains. These include motor function, spatial cognition, disease severity, activities of daily living, social participation and depression.4648

Occupational therapy can help PD patients to better manage their problems in daily functioning and to facilitate meaningful activities. Evidence about occupational therapy has long been scarce. Only a few studies demonstrate the effect of occupational therapy in PD.49,50 Taken together, these trials show that occupational therapy is effective in improving daily activities as perceived by patients themselves.49 In addition, caregivers allocated to the occupational therapy group reported lower health care costs. Finally, occupational therapy was associated with a reduction in institutional care.50

Dysphagia is a common problem in patients with PD. In advanced stages of the disease, the incidence of dysphagia can increase to up to 95%.51 According to the literature, the main phenomena of dysphagia in patients with PD are rigidity and bradykinesia of swallowing. Incomplete cricopharyngeal relaxation, reduced cricopharyngeal opening and delayed initiation of the swallowing reflex have been suggested as possible mechanisms of dysphagia in this patient population.52 Dysphagia is associated with malnutrition, dehydration, aspiration pneumonia and sudden death.53

Currently, dysphagia in patients with PD is treated in the traditional way by a speech therapist.54 This includes oral motor exercises, airway-protecting manoeuvres, postural correction to facilitate bolus transition, and thermotactile stimulation. Baijens and Speyer55 and Sharkawi et al.56 describe speech therapy as having a positive effect on patients with PD and dysphagia, but there are methodological issues.55

Strategies in rehabilitation of cognitive and behavioural symptoms

The dopaminergic loss in the basal ganglia not only affects automaticity of movements but also causes cognitive decline in executive functions, especially mental flexibility and set-shifting. This is related to alterations in frontostriatal connectivity.57

Executive function is defined as a set of higher-order cognitive processes that control, integrate, organize and maintain other cognitive abilities. It is often altered in PD patients.5860 Specific deficits include response inhibition, set-switching and updating of working memory.6163

Recent work identifying the locomotor neural network also provides evidence for reduced structural and altered functional connectivity in people with PD.64,65 Although mobility and cognitive function may be related, deficits in them are typically treated separately. In the elderly, there is some evidence that cognitive training may improve motor function while mobility training may improve cognitive function, but a recent meta-analysis on this topic revealed that the studies were limited and of low quality.66

Many individual studies of exercise and rehabilitation interventions report success in improving balance and gait in people with PD. However, the overall effect size of many interventions is sometimes minimal. Often it does not reach the level of minimally important change or minimal detectable change.28,67,68

A study compared cognitive training with movement training. Cognitive training focused on attention, working memory and executive functions, while movement training involved dynamic sports games on a motion-controlled videogame. The movement training resulted in the same level of cognitive improvement as cognition-specific training, and even better attention performance.69,70 The exact mechanisms underlying the cognitive effects of exercise remain unclear, but they may be mediated by increased blood flow or neurotransmitter modulation.71

Another intervention is training cognitive processing using virtual reality. A recent study, which involves tracking and recalling multiple moving visual targets, showed improved speed of processing after 20 hours of self-administered training compared with no intervention. Effects on speed of processing, theory of mind, memory and functional disability were evident in a study on cognitive group training using a structured paper and pencil programme.72

A further study used cognitive behavioural therapy with the aim of reducing impulse control behaviour. It resulted in better outcomes on neuropsychiatric disturbances such as anxiety and depression than no intervention.73

Conclusion

This review illustrates that therapists employ a wide range of approaches to treat PD patients. Growing evidence has been seen for the effectiveness of various types of rehabilitation interventions, particularly the effectiveness of aerobic training, gait training and balance training combined with cognitive training.

A general failing is the fact that the long-term effectiveness of most treatments remains unknown because there has been limited follow-up in most randomized controlled trials, and because of the small sample sizes. Moreover, there is a need to perform more dosage studies, to better understand the influence of training intensity on clinical outcomes.

Despite these remaining gaps in knowledge, current evidence indicates that it is worth routinely prescribing exercise to patients with PD. Interesting new work suggests that emerging technologies, such as virtual reality dancing, may offer tools to improve long-term adherence to a physically active lifestyle. In addition, various ways of using computer games for exercise constitute a promising and rapidly growing field.

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