Parkinson's Diseases -Effectiveness of Regular Exercise& Physiotherapy to Improve Quality of life-Dr. Ashutosh Sharma,PT
Physical therapy in Parkinson’s disease treatment
Physiotherapists are members within a multi professional team, which has the purpose of maximizing functions and abilities and minimizing secondary complications of several diseases.
They use movement rehabilitation within a context of education and support for the person as a whole. In patients with Parkinson’s disease, physical therapy focuses on many functions such as transfer, posture, balance improvement and fall prevention, gait, upper limb functions, and physical capacity (including cardiorespiratory capacity) essential to carry out activities of daily life. All of these goals, worked together with cueing strategies, cognitive movement and exercises, increased independence, and safety, as a consequence, improve quality of life.
Some evidence presented in the literature supported that therapeutic exercises applied in individuals with Parkinson’s disease were effective in improving both the motor and nonmotor impairments.This improvement may be linked to a number of plasticity-related physiological events including synaptogenesis, angiogenesis, and neurogenesis. This process can be mediated by use-dependent expression of endogenous neurotrophic factors. In an unedited systematic review and meta-analysis, Hirsch and his coworkers show aggregated evidence that physical exercise training increases brain-derived neurotrophic factor (BDNF) blood levels in individuals with Parkinson’s disease. This BDNF increase results in concomitant reduction in motor signs and symptoms, measured by UPDRS, confirming possible effects on dopaminergic pathways.
Together with neuroplasticity, there is some evidence pointing to the participation of motor modules (coordinated patterns of muscle activity that combine to produce functional motor behaviors) like a physiological theory for good results of physical therapy in Parkinson’s disease. For this purpose, it is proposed to consider five neuromechanical principles: motor abundance, which means that for any given task, many equivalent motor solutions are possible; motor structure, which means that motor modules reflect biomechanical task relevance; motor variability, which means that variations on motor modules are higher as much as the motor output is lower; individuality, which means that different motor repertory must be considered among different individuals; and multifunctionality, which means that muscle activity can generate a large number of different actions. It is important to emphasize that in Parkinson’s disease the basal ganglia dysfunction supposedly leads to inappropriate selection of motor modules.
It is still important to remember that motor rehabilitation is a motor relearning practice and training where it is essential to reacquire motor skills. Although individuals with Parkinson’s disease show preserved motor learning abilities, the basal ganglia dysfunction may impair the consolidation of them. Therefore, the basic rules of neural plasticity practice must be used to be successful in the rehabilitation process. It includes intensity, repetition, specificity, difficulty, and complexity of practice.
Several rehabilitative approaches have been proposed in Parkinson’s disease.
4.1.1. Resistance training and muscle strength
In the last two decades, exercise, such as resistance training, has shown to be beneficial for the improvement of both motor and nonmotor signs and symptoms. It increases low strength determined by hypokinesia and disuse, besides playing a neuroprotective effect in individuals with Parkinson’s disease. Its effect is probably determined by an increase of mitochondrial respiration and of neuroplasticity mechanisms, improving the recruitment of motor unit and generating selective activation of the muscles.
However, there is no consensus about the parameters for resistance training prescription for individuals who have Parkinson’s disease. In a systematic review and meta-analysis, Saltychev and his coworkers.concluded that there is no evidence on the superiority of progressive resistance training compared with other treatments to support the use of this approach in rehabilitation procedures.
On the contrary, it is possible to find successful directions to use this therapeutic strategy in rehabilitation of individuals with Parkinson’s disease from other systematic reviews, meta-analysis, and clinical research. Studies shows that low (3times per week over 12 weeks) to moderate (3-5 times per week over 8–10 weeks) intensity resistance training appears to be effective in people with early, mild-to-moderate Parkinson’s disease. They still show that this specific approach resulted in gaining muscle strength, balance, Parkinson’s motor symptoms, and quality of life, with low or no improvement in gait performance, freezing phenomenon, and the number of falls. The load of the exercises can be chosen using the test of maximal strength (1-RM). The number of sets may vary between 2 and 3 during initial periods. The retest of 1-RM can provide additional information to adjust the load and sets along the rehabilitation period. The resting time between the sets can be controlled by cardiovascular parameters and can vary from 30 seconds up to 3 or 4 minute.
There are numerous ways to work with resistance training, and it is up to the physiotherapists to choose the most appropriate one for the individual under their care. In resistance training, the following examples of exercises can be used: bench press, lat pulldown, military press, seated row, leg 45o, barbell squat, leg curl, leg extension, calf raises, lower abdominal exercises, and manual or external (theraband, barbell, ankle-weight, and pulley system) resistance in active movement. Treadmill and bicycle intervention can be used when performing against resistance. resistance training was an effective intervention in the reduction of anxiety symptoms and improved the quality of life in this population.
4.1.2. Transcutaneous electrical stimulation to control resting tremor
Even if the treatment of Parkinson’s disease tremor focuses on medication, and there is indication to deep brain stimulation for those patients with tremor recalcitrant using oral medication, electrotherapy has been shown to be beneficial to control this special cardinal sign.
Few studies have been performed to provide further evidence on the effects of electrotherapy on Parkinson’s tremor reduction. The theory supporting the use of this strategy is based on evidence revealing that propriospinal neurons in the C3–4 spinal cord mediate voluntary commands from the motor cortex (in Parkinson’s disease, these commands are oscillating and give rise to resting tremor) and project directly to forelimb motor neurons. This proposal assumes the importance of propriospinal neurons to interfere in tremor signal transmission, especially because there are a rich variety of afferents, including cutaneous afferents
Researchers hypothesize that cutaneous afferents evoked by surface stimulation could produce an inhibitory effect on propriospinal neurons, which in turn could suppress tremor signals passing through the propriospinal neurons.
Additionally, evidence shows benefits of electrical
stimulation, especially when applied to the superficial cutaneous radial
nerve area, in reduction refractory resting tremor. This effect is
possibly mediated by cutaneous reflex via premotor neuron interneurons,
through a disynaptic inhibitory postsynaptic potential. Some initial
research was performed to confirm this theory using transcutaneous
electrical nerve stimulation (TENS), with good results.The position of the electrodes can be verified in below figure.
Figure 1.
Use of transcutaneous electrical nerve stimulation to reduce resting tremor in Parkinson’s disease. The figure brings cutaneous superficial radial nerve area and electrodes position for transcutaneous electrical nerve stimulation (TENS). Source: Modified from Gray [56]. Picture is public domain.
The parameters used for TENS stimulation were 200 μs pulse width at 250 Hz pulse frequency. The pulse amplitude of stimuli must be adjusted during the stimulation period. First, it is necessary to discover the radiating threshold of the patient. It occurs when the patient refers to a radiating sensation, such as a paresthesia, running from the dorsal skin to the fingers. This radiating threshold has been used as a sensory marker because it indicates that the superficial radial nerve is actually activated by electrical stimulation. After detecting the radiating threshold, the intensity of electrical stimulation must be adjusted to 1.5–1.75 times radiating threshold to produce better effects on tremor control.
Nowadays, researchers have been studying a way to detect the tremors and control them simultaneously and automatically by electrostimulation. They already developed and tested a closed-loop system for tremor suppression by transcutaneous electrical nerve stimulation (TENS) using EMGs of the forearm muscles. Through this record, when a tremor is detected, a command signal triggers a stimulator to output TENS pulses to a pair of surface electrodes positioned just as described in above figure. The preliminary results showed that a closed-loop system can detect tremor properly and suppress significantly the tremor, by electrical stimulation of cutaneous afferents, in Parkinson’s disease patients. Within this new concept, a tremor’s glove was developed reaching also good result.
4.1.3. Aerobic training: treadmill, cycling, free walking, dance, and tai chi
It’s known that aerobic exercises can reduce inflammation, suppress oxidative stress, and stabilize calcium homeostasis in the brain. So, it has been prescribed as an important activity for the elderly. The form of aerobic exercise used may be adapted to the capability of the individual. In individuals with Parkinson’s disease, these exercises show important functions, once they can trigger plasticity-related changes, including synaptogenesis, enhanced glucose utilization, and neurogenesis.
In general, aerobic training has been reported to improve both motor and nonmotor signs and symptoms of Parkinson’s disease. The motor effects are extensively known and have been studied the most so far, showing the most unequivocal benefits on health across the life span. Furthermore, the neural mechanisms involving dopaminergic pathways are studied and suggest a significant preservation of nigrostriatal neuronal connections as well as striatal dopamine levels in experimental models. As a result, exercise-dependent plasticity following aerobic exercises acts on the brain in a similar manner as dopaminergic-derived treatments, using the same pathways to produce symptomatic relie.
In nonmotor signs and symptoms, aerobic training promotes positive and significant effects on global cognitive function, processing speed, sustained attention and mental flexibility, memory, and mood disorder aspects (anxiety and depression) in patients who are considered in a moderate stage of Parkinson’s disease.. In sleep disorder, present in Parkinson’s disease, aerobic exercise has been shown to have small-to-moderate effects. The mechanism involved in these effects evolved increased dopaminergic signaling and a wide variety of effects on nondopaminergic neurotransmitter systems, including serotonergic, noradrenergic, and GABAergic systems, which is relevant for depression, anxiety, and sleep.
The most common and studied form of aerobic training is
using a treadmill. In some systematic reviews, the majority of articles
considered in analyses use treadmills for aerobic training. This
approach can be used with or without a body-weight-support system,
depending on the motor difficulties of the individual with Parkinson’s
disease. It may be related with improvement in motor signs like motor
action, balance, and gait, although the evidence is not so strong.
In the same way, free walking and Nordic walking (a total
body version of walking performed with specially designed walking poles
similar to ski poles) also have good effects on motor and nonmotor
domains of Parkinson’s disease and must be stimulated and used in
physical therapy practice in rehabilitation of individuals with
Parkinson’s disease .
Similar to the aerobic training used on the treadmill,
moderate intensity of interval training for cycling has shown several
beneficial effects on the DA-dependent motor and nonmotor signs that
compromise Parkinson’s disease patients. Researchers have reported
improvement on bimanual motor control, automatic interlimb coordination,
executive functions, and neurological (UPDRS) symptoms .
An interval protocol template that can be used can be the
following: from 8 to 12 weeks of training, 3 times per week, 1-hour
session training with 10 minutes of warm-up, 40 minutes of aerobic
training, and 10 minutes of cooldown). During the 40 minutes of aerobic
training, the patient can perform 8 sets of 3 minutes of cycling or
treadmill at 60–80 rpms and 2 minutes of less than 60 rpms. The heart
rate also can be used as a parameter to improve effort during the
training period. Hence, the physiotherapist may adjust the resistance to
ensure the patient is cycling at 60–75% of his/her maximal heart rate.
This effort can increase gradually during the training period .
A guideline with some exercise modes to be used in Parkinson’s disease
was provided by Meng and coworkers in a systematic review and
meta-analysis .
Other forms of aerobic exercises have been stimulated in the rehabilitation process in Parkinson’s disease. Several data have shown that dance can provide increased activation of the reward system, determining better mood aspects in people. In patients with Parkinson’s disease, practicing dance has induced better responses and a substantial relevant improvement in motor symptoms (such as static and dynamic balance, freezing phenomenon, and gait) and functional mobility. This improvement determines also a better quality of life in performers. It probably occurs because rhythmic stimulation leads to time-perception compensation due to the synchronization of movement with rhythm.
To get these effects, a dance program must include visual
and auditory cues, rhythm tasks, and recreational activities that
motivate socialization. Another important aspect is to reach the ideal
heart rate during practice, just as discussed previously in the aerobic
training protocol .
Oriental martial arts, such as tai chi, have been successfully used in treatment of individuals with Parkinson’s disease. Tai chi combines deep breathing and slow movements and studies have provided moderate evidence that tai chi improves balance and functional mobility, reducing the number of falls, but with no significant effect in gait velocity, step length, and gait endurance improvement. A systematic review and meta-analysis showed that tai chi, plus medication, showed greater gains than medication alone or another therapy plus medication in motor function and balance. Presumably, these gains were due to the development of new motor programs, which allow faster reactions responding to postural challenge promoting better behavioral recovery through new synaptic connections.It is necessary to know and practice this technique before using it on patients.
4.1.4. Multimodal exercise program
The aim of the multimodal exercise program is to develop the patients’ functional capacity, cognitive functions, posture, and locomotion. It’s comprised of a variety of activities that simultaneously focus on the components of functional capacity, such as muscular resistance, motor coordination, and balance. It’s a 6-month program, performed 3 times per week, 1 hour per session. Each session consists of five parts (warm-up, pre-exercise stretching, the exercise session, the cooldown, and postexercise stretching). The program is divided into six phases with different uses of coordination, muscular resistance, and balance strategies. A description of each phase can be seen in below table:
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