Physiotherapists draw on techniques from a range of approaches when managing patients with Parkinson’s. For example, they adopt theories of learning, neuro-physiological and biomechanical approaches.
The dominant treatment concept has been termed METERS (Movement Enablement through Exercise Regimes and Strategies). A lot of research is being done evaluating the specific techniques encompassed within this concept.
General physical activity
• Regular exercise can influence the survival rate in Parkinson’s disease (PD) by preventing decline from disuse.
• Individuals with mild to moderate Parkinson’s disease can maintain normal exercise capacity with regular activities such as walking or cycling.
• It is important to maintain an active lifestyle by incorporating physical activity and exercise. This would also ensure optimal drug effect.
Specific exercise programmes
• An individualised home exercise programme focusing on trunk and lower limb can improve functional activities.
• Strengthening exercises specific to the trunk, incorporated into aerobic exercise classes can improve trunk muscle performance.
• A ten-week individualised exercise programme designed to promote spinal flexibility will show improvement in axial mobility and functional performance.
• A ten-week balance and lower limb strength training programme will maintain equilibrium and cut falls.
General exercise programmes
Typical components of a general therapeutic exercise programme, whether delivered individually or in a group format, include:
• Exercises for the trunk, upper and lower limbs and face in lying, sitting and standing positions
• Speech and breathing exercises
• Gait training
• Balance training
• Transfer training
These activities will promote function through strength, flexibility, co-ordination, 58 balance and relaxation.
The basal ganglia, the site of degeneration in Parkinson’s disease, are involved in the performance of complex motor sequences including skilled, largely automatic movement and in providing cues to link the sections of the movement sequence together.
Compensatory movement strategies involve
• Breaking down complex movement sequences, such as rolling in bed, into component parts
• Arranging the parts sequentially
• Performing each part individually at a conscious level
• Avoiding simultaneous motor or cognitive tasks
• Using mental rehearsal of the forthcoming movement
• Using cues to initiate and maintain movement
• External (visual, auditory or proprioceptive) and internal (cognitive) cues utilise cortical mechanisms to activate and sustain movement and in doing so bypass the defective basal ganglia – supplementary motor area circuits.
• Visual cues – White strips of card or tape on the floor can aid step length and initiation problems in confined spaces. A coloured marker at eye level can provide a prompt to maintain large steps in a corridor. Strategically placed cue cards containing keywords or phrases help activation of the movement.
• Auditory – Metronomes can be worn to aid gait initiation. A musical beat or the human voice can also provide a cue.
• Proprioceptive – Taking a step back before starting to walk and rocking gently from side to side may help overcome freezing.
• Cognitive – Memorising the separate parts of a movement sequence andrehearsing them mentally; visualising the appropriate step length and walking with steps that size. Also, using a cognitive cue to emphasise a component of movement such as heel strike may prove helpful.
Compared to programmes centered on exercise and functional activities alone, programmes using compensatory movement strategies and the full range of sensory cues will have longer lasting retention of performance gains. It has been suggested that individuals should perform exercise and strategy training at peak dose in their medication cycle.
A range of other techniques may be employed as appropriate for pain relief, pulmonary rehabilitation etc. A few such techniques are listed below:
• Transcutaneous Nerve Stimulation (TENS)
• Soft tissue massage
• Muscle relearning
• Stress management
• Breathing techniques
• Energy conservation
Benefits of individual, group and combined individual/group therapy
In the absence of clear evidence to support one above the other, expert physiotherapists prefer individual sessions supplemented by group work as the model of service delivery. Most groups are run on a multidisciplinary basis. Some groups are specifically targeted at individuals who are newly diagnosed or in the later stages of the condition, and some cater to individuals at all stages. Particular attention needs to be given to meeting individual needs within mixed ability groups. Caretakers may be included in group work or have their own group. Monitoring, exercise, advice, and the sharing of information, with emphasis on self-management, are key components of group work. Individuals like to have the choice of individual and/or group therapy. They feel that their personal needs are being addressed in individual therapy sessions; they highlight social contact and motivation as benefits of group work. Whether in an individual or group context, individuals highlight their need to:
• Talk privately
• Have their personal needs met
• Be properly supervised whilst exercising
• Have their time in a physiotherapy department maximised
• Involving caretakers in physiotherapy management
The willingness of individuals to involve their caretakers in physiotherapy and the willingness and ability of caretakers to be involved, need to be first ascertained. A physiotherapist can explain to caretakers how Parkinson’s disease has affected the movement of the individual they care for and provide information and advice on the best way to help that individual whilst avoiding injury to themselves.
Caretakers offer high levels of support with activities associated with core areas of physiotherapy practice such as turning in bed. Caretakers find advice on practical handling and cueing, for example in relation to helping individuals out of bed or to overcome freezing, particularly helpful.
If caretakers have good information about the movement consequences of Parkinson’s disease, they can provide important feedback about symptoms and response to physiotherapy, especially if the patient has dementia.