EXPERT OPINION: Parkinson's Disease and Physiotherapy Management - DR. M. G. MOKASHI

James Parkinson described this condition as paralysis agitance in an ‘Essay on the Shaking Palsy’, in 1817. It was after a century that loss of dopaminergic cells was discovered in Parkinson’s diseases (PD) and later on low levels of dopamine in corpus striatum were detected, which gave a boost to medication for PD in 1970. In Parkinson's disease, multiple system atrophy and progressive supranuclear palsy,  the main regulators of the caudate nucleus and putamen (dopaminergic substantia nigra and glutaminergic caudal intralaminar nuclei), as well as the cortical projection from the pre-supplementary motor area, degenerate. Degeneration of the major basal ganglia circuit neurons also occurs in multiple system atrophy, while degeneration of the subthalamus and a widespread loss of inhibitory interneurons within the extrapyramidal system occurs in progressive supranuclear palsy. 

Motor abnormalities: PD is classified as movement disorder. Tremors at rest in distal muscles of jaw, lips, tongue and hand, is an early sign, though the akinesia or slowness in movements, an accompanying sign may be missed, at times. TRAP is the appropriate mnemonics for PD symptomatology i.e. tremors, rigidity, akinesia and postural unsteadiness. Symptoms are unilateral and progressive for even 10 or more years. Tremors at rest in early stage do not interfere with function and they disappear by voluntary effort. To be acceptable cosmetically, a patient holds on to arm of a chair or just tightens the fist. Hand function initially looses finer skills though gross manipulating handling may be retained, for years. For the face, patient may prefer a tight lipped attitude, in order to control tremors. Within years a freezing attitude in consequence to akinesia is added; rigidity progresses in proximal musculature. If present in wrist-hand, it is cog wheel type. Mask like face which is without expressions is another feature to recognize the condition, though with strong emotion, face may be unmasked, suddenly. Therapist must note this since during communications, one should not mistake it for no-response from a patient. However, after 5 years or so cognitive deficit appears. At last, a stooping posture is adopted. Dynamic stability is also affected; the gait is described as festinating type which appears as if one is trying to catch one’s own centre of gravity. Eventually gait becomes short stepped and slow and since the disease is progressive, finally a patient may be non-walker depending on wheelchair ambulation. Likewise, activities of daily living are progressively affected as the hand function as well as the instability, deteriorate.

Distonia is an early presenting symptom in the middle aged patients. Fluctuating tone makes testing difficulties and planter reflexes may present as equivocal, though rigidity is a hypertonic feature. A patient may present dorsiflexed wrist in function which is uncommon in spastic stroke hemiplegia; again, patient may have heel-strike in gait (with dorsiflexion of foot), in spite of other gait abnormalities. This gives false impression that voluntary control over movements is fairly good. It is not a disorder of voluntary movement. Skilled movements cannot be executed due to abnormalities of tone, dyskinesia being a disturbing feature. Non-motor symptoms in the form of autonomic dysfunction, sleep disturbances and mood disorders may precede motor changes and known as pre-motor phase. MRI and other investigative techniques may help in early detection of this phase but this aspect is being validated. Those symptoms become severe only after 5 years or more. Behavior problems are added later on. Autonomic instability, involves modest cardiac and neurological changes  including bradycardiaorthostatic hypotension, and ambient temperature intolerance.   

Parkinson plus syndrome has early cognitive problems in severe form resulting in dementia. Some patients develop urinary obstruction along with autonomic dysfunction, esp. postural hypotension marked by fall of diastolic BP by 10 mmHg. In some patients cerebellar signs and symptoms are manifested. By asking a patient step on marked spots or by tandem walking, condition is revealed. As such dystonia is present. Some develop hallucinations. When Parkinson’s symptoms are associated with dementia, autonomic disturbances and cerebellar ataxia, it is multiple system atrophy. Levodopa may not be effective in some such conditions though in case of some early conditions, it gives good results. Causes are degenerative and 60+ aged population has always a risk. At times, disease appears in middle aged, too. Infective encephalitis is a common cause in our country. Also, PD may be due to vascular lesions, following stroke. Some symptoms may appear due to adverse drug effect and recover as the drug is withdrawn. Barring infective lesions, other risk factors would be similar to stroke and preventive strategies may be employed, in accordance. Parkinsonism is caused by toxic effects of alcohol, pesticides etc, also.  Head injury could result in PD, some times and so due to the neoplastic lesions. Stress is also a contributing factor.

Management: Levodopa is the medication of choice and reduces tremors and akinesia, in early course of disease upto 5 years. Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. The role of physiotherapy is to maximise functional ability and minimizing morbidity. The general aim is optimum independence within safety limits. Well-being, and quality of life as much feasible should be the final goal. It is reported that in the later stages of Parkinson's disease, side effects occur because of the long term  use of levodopa treatment. These consist of involuntary writhing movements (choreoathetosis), painful cramps in the legs (dystonia) and a shortened response to each dose referred to as 'end-of-dose deterioration' or the 'wearing-off effect'. Dopamine agonist drugs act by mimicking levodopa in the brain, but they do not cause these long-term treatment complications when used as initial therapy.Sometimes chorea like movements appear due to psychiatric drugs administered to a patient and a physio should work in co-partnership with a physician in addressing such problems. Some drugs may affect cognition which should not be mistaken due to the disease itself. 

Other medical regime for Parkinson-like diseases and iatrogenic complications due to psychiatric drugs is out of scope of this article. Physical activity must accompany side by side medical interventions. In order to control dyskinnesia, brain stimulation surgery with implanted electrodes is an option. We advocate, physiotherapy should address the problems that interfere with function first. For tremors there is no remedial physiotherapy technique; and for a long period they do not come in way of function. Hence motor learning can be expected. Bernstein proposed systems theory for motor learning. Tasks can be continuous like cycling; discrete tasks are like batting, the skilled ones.  Closed tasks are like a signature or developmental programmes with the environment, stable. Walking in a crowded street or driving is an open task since the environment is changing. If environment makes the predictability of any closed task difficult, feedback mode shall have to be operated. Systems are dynamic and can organise themselves. Accordingly, development is not a rigid sequence; rather, the development offers the best solution by virtue of its flexibility, to a functional demand. 

Gibson added knowledge of performance (KP) and the results (KR) as the feedback modes. Detection of error during performance is important. [Cerebellum acts as a comparator, normally.] In neurological conditions especially affecting perception and or cognition, error should not be there. [Tasks be simple]. ADL items may have been erased from memory. They need to be learnt as the new tasks, which is possible by plasticity. Most of the modern techniques are based on theories of Bernstein and of Gibson. Dick et al found that the Alzheimer’s patients performed better on the task when learning occurred under constant training as opposed to variable. Also, it was found that gross motor memory in Alzheimer’s patients was the same as that of healthy adults when learning occurs under constant practice. Principle is summarised concisely that ‘Skill motor training stimulates synaptic reorganization in the motor cortex, strength training modifies intraspinal circuits, and endurance training promotes angiogenesis’ 

Hirsch and Fairly summarized some noteworthy preliminary studies pointing that continuous, deficit targeted, intensive exercise training may confer neuro-protection and thereby, slow, stop or reverse the progression of the disease or promote neuro-restoration through adaptation of compromised signaling pathways. While much work remains and these preliminary results await replication in larger prospective human trials, we believe a major challenge in the field of non-pharmacological, rehabilitative intervention for PD will be the extent to which healthcare providers are able to translate the science of exercise and PD to the level of the community.

Hand function in cerebellar lesions exhibits intention tremors and since isometric contractions are more affected, grip/ pinch strength are reduced. Lateral pinch is present. Perceptual deficit would deteriorate quality of hand function even if voluntary control is isolated. In apraxia, purposeful activities like hand writing are affected. An athetoid hand is unpredictable in view of fluctuating tone and it is paretic. In grip/ pinch, ‘tremors at rest’ of Parkinson’s disease get abolished but again it is a paretic hand. 

For a skilled worker, hand disturbances may pose a problem early, in maintaining needed level of accuracy. Examples are a painter, musical instrument player, surgeon or a draftsman. One may not prefer a haircut from a barber with a scissor or a blade in a shaking hand. A stage comes that even a glass in hand cannot be held stable which is disabling for a housewife or any patient, equally. If hand tremors increase, we find fixing thumb in position of opposition, and a dynamic hand splint for fingers, is useful. Wrist may be fixed in position of optimum function, as necessary. Hand function must be promoted at any cost. It must be ensured that the involuntary movements do not shift proximally while distally stabilized, mechanically. Athetosis shift in other basal ganglia lesions is common.

Akinesia can be treated by free rhythmic movements, segmentally. Use of pulleys is in order; skates or any wheeled toy could be used on a plane surface and by adjusting inclination, assistive or mild resistive active movements to a limb could be imparted. Repetition being the password, activity should be given at no or low resistance. Cyclic activities are useful. A static bicycle for lower limbs and one with hand-cranking device for upper limbs is found accessible device.

In PNF approach, Rhythmic Initiation is a technique, recommended. As movements improve, a specific technique, Fast Reversal of Antagonists is advocated. It uses agonist a well as antagonistic patterns alternately. Choice of pattern may be decided as per the rigidity, set in. Speed of movement should be adjusted as per performance of a patient as long as monosynaptic stretch reflex is not provoked which is achieved in Slow Reversal of Antagonist.  Here lies the skill of a therapist. Slow or the Fast Reversal techniques, both are on conscious feedback loop hence conducive for motor control learning. Again, various PNF patterns have different item difficulty. Distal tremors may be ignored and proximal rigidity should be attended first. Due importance be given to regain the rotatory movements at neck, shoulder, trunk and the hip. One of the reasons of short step in gait is deficit in hip rotation at the lower limb in stance phase, other than difficulty in hip-flexion and knee-extension of the limb, in swing phase. There is difficulty in initiating swing phase due to rigidity. In fact, gait as a movement programme is mediated at extra-pyramidal system though a swing phase generator is operational at spinal level. Deficient movement components should be improved individually and later on in combination, separately. Advantage of PNF is that it exercises the whole limb and a therapist could recruit individual movement components serially, paying attention to their capability and facilitating them. Further, by reinforcement reciprocal patterns other segments like trunk or limb also could be included in the treatment. There is a specific demand on skill of serial changing nature and hence I consider PNF as a task specific neuro-physiological approach.     

We have used Yoga approach in neuro-PT since 1970. A pioneering Theme of Yogasanas for neuromotor control testing and therapy, was forwarded based on the vertical progression towards standing and horizontal progression towards asymmetrical, anti-synergic, isolated voluntary control. Though many Aasanas have an ontogenic developmental basis, yet, motor learning is used to better the quality of performance of Aasanas.Our experience favours Yoga programme as the best form for postural stability. Instability and ataxia, point towards cerebellar dysfunction, in favour of multiple system atrophy. In such cases, rather than rigidity, dystonia and dyskinesis are the disturbing signs. Therefore the treatment must be planned as per the presenting problem. Rhythmic stabilization helps in maintaining isometric contractions in opposing patterns alternately, voluntarily which does not use co-contraction mechanism. Co-contraction is an automatic mechanism involving recruitment of antagonist flexors force, by auto-inhibition of part extensor excitation esp. in postural activity like weight bearing against gravity. The learnt rhythmic stabilisation has to be converted in co-contraction by the body system or used as a new learnt postural programme which is stored at the cerebellum itself.

Bhujangaasana (Cobra pose) loads upper limbs, axially; Bhudharaasana loads all 4 limbs but ULs in vertical and the lower limbs in semivertical position. Veeraasana is ½ Kneel-sitting progressing to ½ Kneel-standing an asymmetrical pose, preparatory to standing. ½ Bhudharaasana is Eka-paada-prasaranaasana, flexing one lower limb and loading it to share body weight in semiflexed position. Soorya namaskaara series is ideal for regaining postural stability, ending in standing posture. It is operative in A-P plane. We add Konaasana in standing if  permissible for lateral spinal movements otherwise it could be performed in sitting. Ardha-Matsyendrasana in sitting is appropriate for control over spinal rotation. Those Aasanas call for equilibrium reactions;  labyrinthine and optical righting reactions form a built-in component of them, stimulating the semicircular canals for balance.

Each Aasana final pose be held for 5 to 15 seconds, minimally and cumulative period of serial performances be at least 3 minutes. This is essential in the aged population with risk factors for cardio-vascular disease. Thus 8 to 10 repetitions are practiced per Aasana. Body weight is being bourn by limbs as a moderate to heavy activity hence at no time breath be held during active performance so that there is no scope for Valsalva maneuver and autonomic nervous system will not be challenged, unduly. Intermittent rest-period could be in any sitting pose, permissible. It should allow recovery time for rise in pulse rate which should settle within 3 minutes normally if heart is efficient otherwise it may be extended by a minute or two. Resting as well as peak activity PR and BP should be recorded and kept below target heart rate to ensure safety.

Activities of daily living must be practiced and maintained to ensure quality of life. Socialisation must be maintained and no stigma of disability be allowed to set in. Slowly progressive nature of disease must be explained to the patient-family. Carers must be well informed of the disability as well as functional ability enhanced by medication, physical activity, aids and environmental modifications as the patient becomes partially dependent. There is need to impart them education in handling and the caring skills with margin of safety without curtailing patient’s activity regime and exercise programme. Plasticity of nervous system is an asset to be used unless dementia intervenes drastically.

I recall two middle aged female patients known to me, affected by PD who reported for treatment at AIIPMR Mumbai, in late 1970s while they were ambulant by neurological gait, independently with sticks to restore loss of balance. Both were agreeable to undergo Yoga programme along with Physiotherapy and within 8 weeks could discard sticks (though for safety on roads they were encouraged to use sticks). They improved in ADL and were satisfied. There tendency for remaining isolated got reversed as reported by family members. Both the patient-family and the therapists were happy with the improvement. They showed good compliance to learnt programme at home for over 6 months. Within a period of 3 years or so, they deteriorated physically as well as in cognitive functions became much more dependent on carers and succumbed to death, with disease progressive. There is no intention to give a negative message but to underline the fact that the disease is progressive slowly but certainly. About one-third cases of PD progress to Alzheimer’s disease a disabling terminal condition. The role of carers becomes important.

However, the course of disease is over 10 years and more of this period must be used beneficially so that a patient leads life with minimum effect of disability. Various treatment regimes tried give positive results though at minimal clinical improvement level as seen from the following reference. I have included the clinical parameters other than just the statistical proof so that a treating therapist gets some guidelines for his own interventions being employed. Tomilson et al (2001) identified 33 trials with 1518 participants. Compared with no-intervention, physiotherapy significantly improved the gait outcomes of velocity (mean difference 0.05 m/s,), two- or six-minute walk test (16.40 m, CI: 1.90 to 30.90, P = 0.03) and step length (0.03 m, CI: 0 to 0.06, P = 0.04); functional mobility and balance outcomes of Timed Up & Go test (-0.61 s, CI: -1.06 to -0.17, P = 0.006), Functional Reach Test (2.16 cm, CI: 0.89 to 3.43, P = 0.0008) and Berg Balance Scale (3.36 points, CI: 1.91 to 4.81, P < 0.00001); and clinician-rated disability using the Unified Parkinson’s Disease Rating Scale (UPDRS) (total: -4.46 points, CI -7.16 to -1.75, P = 0.001; activities of daily living: -1.36, CI -2.41 to -0.30, P = 0.01; and motor: -4.09, CI: -5.59 to -2.59, P < 0.00001). Most of the observed differences between the treatments were small. However, for some outcomes (e.g. velocity, Berg Balance Scale and UPDRS), the differences observed were at, or approaching, what are considered minimally clinical important changes.

They further noted that however, there was no evidence of differences in treatment effect between the different types of physiotherapy interventions being used, though this was based on indirect comparisons. There is a need to develop a consensus menu of 'best-practice' physiotherapy, and to perform large well-designed randomised controlled trials to demonstrate the longer-term efficacy and cost-effectiveness of 'best practice' physiotherapy in PD. Their final observation is telling that there was no superior method than other and it supports our stand that the choice of the technique must be as per presenting problem. Perceptual motor skills must be introduced for hand function as specific tasks. For improving gait Body weight support can be used beneficially as necessary.

As per Global Burden of Disease study by WHO, 2012 report, loss of disability adjusted life years (DALYs) by stroke was 3.46% while that by Alzheimer’s disease and other dementias was 6.29%. This shows total physical, medical and social caring and financial dependency on the family and the carers as well as the system as such for last years of life, in such diseases. Expenditure on health by private sector was 67% in 2009, in India while out of pocket expenditure was 74%. If the indirect cost of treatment due to loss of productive time of family members is considered, there is substantial expenditure involved in caring for neurological patients. Private prepaid plans as part of private health expenditure in 2009 were meager 2.3%. Hospital beds per 10000 population were just 9, in 2005. India is grouped in low-income SEAR-D having high adult mortality, by WHO 2006. Hospitals are reluctant to admit chronic patients and as the vital parameters stabilise after an acute episode, a patient is convinced for discharge. Home treatment is costly and OPD treatment cannot be availed due to non-accessibility and non-affordability with a result that mostly a neurological patient like PD is confined to home without treatment. Of the total mentally ill older adults, in India, about 50% (8.56 million) might be seeking professional help and, of these, 8.5% (.72 million) of patients may need hospitalization. Hence, District Mental Health Programme (DMHP) in selected districts of each State of the country has been launched. This author observes that this is parallel with District Rehabilitation Centres (DRC) Scheme, running in over 100 districts. Decentralisation and de-professionalisation are the central theme to CBR.  I strongly put up that the DRC team having PTs/OTs should be trained in mental health beneficially, to reduce duplication of infrastructure expenditure.

As such the aged population suffers from elderly abuse due to neglect, financial and psychological abuse. Government of India had to incorporate ‘The Maintenance and Welfare of Parents and Senior Citizen Act, 2007’ in spite of joint family system we boast of. Then what to surmise on neurologically disabled elderly patients? So it is utmost essential to recognize the socio-medical problem where physical as well as cognitive disabilities go hand in hand. It is necessary to educate patient-family and develop cost-effective preventive, restorative, rehabilitative-care strategies in PD and diseases alike and their effective transfer to carers of various backgrounds considering the 75% rural aged disabled. Physiotherapy should have vaster outreach through such technology transfer. Is the field ready for facing such a national challenge?                               

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