Movement Disorders in People With Parkinson Disease: A Model for Physical Therapy

The effect of physical therapy on balance of patients with Parkinsonʼs disease

Physical therapy can improve performance of balance tests in patients with Parkinson's disease. Parkinson's disease is a chronic progressive neurological disturbance with significant effect on movements, cognitive functions, autonomous systems and psychosocial activities. The effects of physical therapy are rarely reported and not sufficiently studied. This prospective study comprised 40 persons with stage III Parkinson's disease, according to aged over 50 years and 20 healthy controls of the same age. Patients were medically stable and had no other neurological deficits, postural hypotensia, visual disturbances or musculo-skeletal deficits. Balance tests before and after physical therapy were analysed according to. Balance tests in patients with Parkinson's disease resulted in significant differences of values for tandem stance, one leg stance, step test and external perturbation when compared to the controls, and between groups with and without falling tendency. Tandem stance, one leg stance, step test and external perturbation can be used for differentiation between groups with and without a tendency to fall. Physical therapy resulted in significant improvement of these tests in both the groups analysed. Systematic application of physical therapy, as part of team treatment, improves the balance of patients with Parkinson's disease.

Huntington's disease: present treatments and future therapeutic modalities

Huntington's disease (HD) is a devastating neuropsychiatric disorder for which therapeutic interventions have been rather fruitless to date, except in a slight symptomatic relief. Even the discovery of the gene related to HD in 1993 has not effectively advanced treatments. This article is essentially a review of available double-blind, placebo-controlled trials of therapy for this condition which also includes relevant open label trials. Unfortunately, HD research has tended to concentrate on the motor aspects of the disorder, whereas the major problems are behavioural (e.g. dementia, depression, psychosis), and the chorea is often least relevant in terms of management. We conclude that there is definitely poor evidence in management of HD. The analysis of the 24 best studies fails to result in a treatment recommendation of clinical relevance. Based on data of open-label studies, or even case reports, we recommend riluzole, olanzapine and amantadine for the treatment of the movement disorders associated with HD, selective serotonin reuptake inhibitors and mirtazapine for the treatment of depression, and atypical antipsychotic drugs for HD psychosis and behavioural problems. Moreover, adjuvant psychotherapy, physiotherapy and speech therapy should be applied to supply the optimal management. Finally, some cellular mechanisms are discussed in this paper because they are essential for future neuroprotective modalities, such as minocycline, unsaturated fatty acids or riluzole.

Real-time measurement of frozen gait in patient with parkinsonism using a sensor-controlled walker

Patients with Parkinson's disease develop gait disturbances. Although the use of walkers is very effective for maintaining locomotive ability, patients who have symptoms such as frozen gait (FG) and festinating gait may fall even with a walker equipped with a brake as they cannot use the brake well in an emergency and fail to follow the accelerating walker. None of the studies on walking aids to date have addressed real-time detection of FG or the use of this information for the control of the walking aid, monitoring of the state of improvement in the ambulatory function, or evaluation of the effect of the use of a walker. In this study, we evaluated whether the state called FG, a characteristic symptom of Parkinson's disease, can be detected by the use of a sensor-controlled walker with heel-to-toe pressure sensors. The following two measurements were carried out in one male healthy and a one male patient with stage 3 Parkinson's disease by the Hoehn-Yahr scale showing mild muscle rigidity, hypokinesia, and FG. In the healthy subject, the heel-to-toe pressure showed smooth heel-to-toe shifts during the standing phase. In the patient with Parkinson's disease, the heel-to-toe response time was about 2.4 times longer than in the healthy subject at the beginning of walking, and FG could be recorded as the difficulty in lifting the foot by the toes. Also, when FG was observed during walking, the pressure waves recorded by the same sensors showed two peaks occurring at short interval, indicating double landings.

A walking support/evaluation machine for patients with parkinsonism

Various walk supporting systems have been devised and developed. However, they have not been designed for supporting or evaluating the gait of parkinsonian patients, and not much consideration has been given to gait disturbances of parkinsonian patients. In this study: (a) We prepared a tentative model of walk supporting and monitoring system in consideration of typical symptoms of parkinsonism. (b) We conducted gait rehabilitation in a parkinsonian patient using the walk supporting and monitoring system and confirmed (i) the occurrence of frozen gait during walking, (ii) brachybasia, (iii) the absence of anterior tilting of the posture, pulsion symptom, and festination, and (iv) occurrence of hesitation to start walking. Therefore, typical symptoms of parkinsonism can be detected by the use of this system. (c) The medical staff can evaluate the state of recovery of patients on the basis of the data obtained from this system and use them for purposes such as guidance of rehabilitation.

An education programme for individuals with Parkinson's disease

An education programme for individuals with Parkinson's disease. People with Parkinson's disease (PD) have to face a lot of ongoing sickness - depending on limitations in daily life and society. Ability for optimal living demands knowledge about the sickness, medications, side-effects and knowledge about the best way to go on living with PD. In this study, 43 persons with PD participated in an outpatient programme based on the structure of connection model. The programme consisted of two weekly 2-h sessions for 5 weeks. Each session consisted of 1 h of dialogue and 1 h of physical performance. The two teachers in the programme were registered nurse and registered physiotherapist. The programme was evaluated with focus on participants' psychosocial situation, mobility and activity in daily living. Participating in the programme gave these individuals an improved psychosocial situation and improved mobility pattern. However, these improvements were not transferred to habitual daily life, which suggests that task-oriented training provides the best solution.

Fear of falling and postural control in Parkinson's disease

This study investigated the relationship between fear of falling (FOF) and qualitative and quantitative postural control in Parkinson's disease (PD). Fifty-eight nondemented PD patients were studied along with age-matched healthy controls. The degree of FOF was estimated using the Activities-specific Balance Confidence scale. Qualitative postural control was evaluated using a component of the Unified Parkinson Disease Rating Scale. Postural control was quantified, using centre of pressure measures obtained from a force plate, for eight standing balance tests of different challenges. The results showed that FOF was more evident for PD patients when compared with healthy individuals of similar age. Furthermore, FOF was significantly associated with a qualitative estimate of postural control in PD; individuals with PD who had a greater degree of posture impairment reported greater FOF. The results also showed that an estimate of FOF may help to explain quantitative postural instability in PD. FOF, when coupled with a qualitative estimate of postural control, was able to explain a greater amount of variation in quantitative balance performance for five of the eight balance tests. When considered independently, the qualitative measure of postural control, in general, could not well predict quantitative balance performance. The greater degree of FOF and its possible association with altered postural control suggests that FOF should be considered as an important, independent risk factor in the assessment and treatment of postural instability in patients with PD.

Reconstructive neurosurgery for Parkinson's disease: a systematic review and preliminary meta-analysis

This systematic review and meta-analysis aimed to identify the determinants for best practice and establish current benchmarks for recovery following reconstructive neurosurgery for people with Parkinson's disease. Eleven studies reporting results for 95 grafted patients were selected on the grounds of using optimal surgical techniques and the Core Assessment Program for Intracerebral Transplantation (CAPIT) protocol for data collection. Consistent trends demonstrating high levels of recovery were identified on most outcome measures. Determinants for best practice were identified as selecting younger patients; using low dose immunosuppression; bilateral grafting; and employing strategies to ensure the quantity and viability of the grafted cells. Secondary analysis of data demonstrated a correlation of rho=0.666 (P<0.05) between increases in striatal dopaminergic activity and UPDRS Motor (off) scores. Overall effect size 'd' was found to be 1.129 UPDRS Motor (off) condition and 0.719 for UPDRS Total (off) condition. The design of the studies and the variable standards for reporting the data precluded the use of more powerful and accurate meta-analyses. It was recommended that the creation of a collaborative database would improve the extraction of data and allow for more powerful statistical analyses for evaluating the overall harm and benefits associated with reconstructive neurosurgery.

Gait and Balance Dysfunction in Adults

Determining the precise cause of gait dysfunction in adults is often difficult because of the multifactorial nature of the disorder. Additionally, elderly patients have other comorbidities that further complicate their diagnosis. A proper history and physical examination, however, often allow the clinician to arrive at the correct diagnosis. Once a diagnosis is reached, appropriate therapeutic decisions can be made. Patients presenting with Parkinsonism need a thorough evaluation to rule out potentially reversible conditions, such as normal pressure hydrocephalus. Patients with idiopathic Parkinson's disease usually develop gait difficulty and freezing episodes late in the course of the illness. Another important cause of gait disturbance in adults is the cerebellar ataxias. Among the sporadic forms, gluten sensitivity is an important consideration. Identification of this entity is important, because the disease process can be halted with a gluten-free diet. Another group is the paraneoplastic ataxias, which can often be diagnosed in the proper clinical setting. Most of the adult-onset hereditary ataxias are autosomal dominant conditions. Except for the episodic ataxias, treatment of these conditions has been disappointing. Mixed results have been obtained with the use of amantadine, buspirone, and 5-hydroxytryptophan. Physical therapy plays an important role in the gait rehabilitation of these patients. Over the past several years, researchers have developed a greater understanding of motor control and how it relates to freezing. Clinicians can now train patients to use external cues to overcome their motor blocks. Another important advance has been the development of subthalamic nucleus deep brain stimulation in the treatment of patients with troublesome peak dose dyskinesia and other motor fluctuations. Subthalamic nucleus deep brain stimulation should be considered when best medical treatment fails. Cortical myoclonus can be treated with levetiracetam, which has US Food and Drug Administration approval as an antiepileptic agent. It has been quite effective in the treatment of myoclonus and should be considered when other medications fail.

Treatment of Parkinson's disease

Parkinson's disease is a progressive neurodegenerative disorder that demands a holistic approach to treatment. Both pharmacologic and nonpharmacologic interventions play an important role in the comprehensive management of this disorder. While levodopa remains the single most effective medication for symptomatic treatment, dopamine agonists are playing an increasingly important role. Motor complications of dopaminergic therapy are a significant issue, particularly in patients with more advanced disease who have been on levodopa for several years. All therapeutic interventions must be tailored to the individual and modified as the disease progresses, with the goal of minimizing significant functional disability as much as possible.

Dual Task Interference During Gait in People With Parkinson Disease: Effects of Motor Versus Cognitive Secondary Tasks

Background and Purpose. Exacerbation of movement disorders while doing 2 tasks (dual task performance) is a characteristic feature of Parkinson disease (PD). The aim of this investigation was to identify whether the type of secondary task (motor or cognitive) determined the severity of dual task interference. Subjects and Methods. Footstep patterns for 15 people with PD and 15 comparison subjects without PD were compared when they walked: (1) at a self-selected speed, (2) while simultaneously performing a motor task (coin transference), and (3) while simultaneously performing a cognitive task (digit subtraction). Gait speed, stride length, cadence, and the percentage of the gait cycle in double-limb stance (DS) were examined with a computerized stride analyzer. Results. When there was no second task, the mean stride length was less in the group with PD (1.29 m) than in the comparison group (1.51 m), and the mean gait speed was less in the group with PD (71.47 m/min) than in the comparison group (87.29 m/min). The mean cadence was less in the group with PD (110.79 steps/min) than in the comparison group (115.81 steps/min). The percentage of the gait cycle in DS was greater in the group with PD (33.38%) than in the comparison group (31.21%). Both groups reduced their stride length and speed when they had to change from unitask performance to dual task performance and DS increased. For the group with PD, cadence also decreased. For both groups, the type of secondary task had a negligible effect on the performance decrement. Discussion and Conclusion. Although the performance of simultaneous motor or cognitive tasks compromised gait in people with PD, the type of secondary task was not a major determinant of the severity of dual task interference.

Is the functional reach test useful for identifying falls risk among individuals with Parkinson's disease?

OBJECTIVE

To evaluate the effectiveness and validity of the Functional Reach Test (FRT) as a screening tool to identify fallers (persons at risk for falls) among subjects with Parkinson's disease (PD) and control subjects.

DESIGN

A case-comparison design with a consecutive sample. Subjects performed 3 consecutive functional reach trials.

SETTING

Motor behavior laboratory in a university setting.

PARTICIPANTS

Fifty-eight adults (43 subjects with PD, 15 control subjects). Controls were recruited from a Florida hospital and the local community.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A falls history was recorded, a mean FRT score attained, and FRT scores were categorized as less than 25.4 cm, the criterion for falls risk, or > or =25.4 cm.

RESULTS

Mean FRT scores differentiated subjects with PD and a known history of falls from subjects with PD and no history of falls and from control subjects (P <.001). Tests of validity for the FRT as a screening tool indicated sensitivity as 30%, specificity as 92%, positive predictive value as 90%, and negative predictive value as 36%.

CONCLUSIONS

The FRT, using a reach less than 25.4 cm as a criterion for falls risk, is not a sensitive instrument for identifying individuals with PD at risk. However, the percentage of those persons identified as at risk by the FRT are highly likely at risk, and they should be referred for falls risk intervention. Because the FRT does not identify every person at risk, using a test battery addressing other factors contributing to falls risk may increase the sensitivity of a clinician's assessment to identify persons with PD at risk for falls.

Long-term Medical Treatment for Parkinson's Disease

The authors of this paper view Parkinson's disease (PD) as a clinically defined progressive syndrome of resting limb tremor, bradykinesia, muscle rigidity, and a shuffling unsteady gait that responds well to dopaminergic medications. Parkinson's disease is a not a single entity, but rather a syndrome with diverse causes, with both genetic and environmental risk factors. The clinician's concern is to rule out other entities, especially those having another specific treatment, and to give PD patients the best short- and long-term benefit, with the least possible unwanted side effects.

Spinal movement and performance of a standing reach task in participants with and without Parkinson disease

BACKGROUND AND PURPOSE

Evidence suggests that individuals with early and mid-stage Parkinson disease (PD) have diminished range of motion (ROM). Spinal ROM influences the ability to function. In this investigation, the authors examined available spinal ROM, segmental excursions (the ROM used) during reaching, and their relationships in community-dwelling adults with and without PD.

SUBJECTS

The subjects were 16 volunteers with PD (modified Hoehn and Yahr stages 1.5-3) and 32 participants without PD who were matched for age, body mass index, and sex.

METHODS

Range of motion of the extremities was measured using a goniometer, and ROM of the spine was measured using the functional axial rotation (FAR) test, a measure of unrestricted cervico-thoracic-lumbar rotation in the seated position. Motion during reaching was determined using 3-dimensional motion analysis. Group differences were determined using multivariable analysis of variance followed by analysis of variance. Contributions to total reaching distance of segmental excursions (eg, thoracic rotation, thoracic lateral flexion) were determined using forward stepwise regression.

RESULTS

Subjects with PD as compared with subjects without PD had less ROM (FAR of 98.2 degrees versus 110.3 degrees, shoulder flexion of 151.9 degrees versus 160.1 degrees) and less forward reaching (29.5 cm versus 34.0 cm). Lateral trunk flexion and total rotation relative to the ground contributed to reaching, with the regression model explaining 36% of the variance.

DISCUSSION AND CONCLUSION

These results contribute to the growing body of evidence demonstrating that spinal ROM is impaired early in PD.

The biomechanics and motor control of gait in Parkinson disease

Parkinson disease is a progressive neurological condition characterised by hypokinesia (reduced movement), akinesia (absent movement), tremor, rigidity and postural instability. These movement disorders are associated with a slow short-stepped, shuffling gait pattern. Analysis of the biomechanics of gait in response to medication, visual cues, attentional strategies and neurosurgery provides insight into the nature of the motor control deficit in Parkinson disease and the efficacy of current therapeutic interventions. In this article we supplement a critical evaluation of the Parkinson disease gait literature with two case examples. The first case describes the kinematic gait response of an individual with Parkinson disease to visual cues in the "off" phase of the levodopa medication cycle. The second case investigates the biomechanics and motor control of turning during walking in a patient with Parkinson disease compared with elderly and young control subjects. The results are interpreted in light of the need for gait analysis to investigate complex functional walking tasks rather than confining assessment to straight line walking, which has been the trend to date.

Reliability of measurements obtained with the Timed "Up & Go" test in people with Parkinson disease

BACKGROUND AND PURPOSE

The Timed "Up & Go" Test (TUG) is used to measure the ability of patients to perform sequential locomotor tasks that incorporate walking and turning. This study investigated the retest reliability, interrater reliability, and sensitivity of scores obtained with the TUG in detecting changes in mobility in subjects with idiopathic Parkinson disease (PD).

SUBJECTS

The performance of 12 people with PD was compared with that of 12 age-matched comparison subjects without PD.

METHODS

The subjects with PD completed 5 trials of the TUG after withdrawal of levodopa for 12 hours ("off" phase of the medication cycle) as well as an additional 5 trials 1 hour after levodopa was administered ("on" phase of the medication cycle). They were scored on the Modified Webster Scale at both sessions. The comparison subjects also performed 5 TUG trials. All trials were videotaped and timed by 2 experienced raters. The videotape was later rated by 3 experienced clinicians and 3 inexperienced clinicians.

RESULTS

For the subjects with PD, within-session performance was highly consistent, with correlations (r) ranging from.80 to.98 for the "off" phase and from.73 to.99 for the "on" phase. The performance of the comparison subjects across the 5 trials was also highly consistent (r=.90-.97). Comparisons showed differences between trials 1 and 2 on the TUG for both groups. Removal of data for trial 1 (the practice trial) further enhanced retest reliability. There was close agreement in TUG scores among raters despite different levels of experience (intraclass correlation coefficient [3,1]=.87-.99). Mean TUG scores were different between the "on" and "off" phases of the levodopa cycle and between subjects with PD and comparison subjects during the "on" phase.

CONCLUSION AND DISCUSSION

Retest reliability and interrater reliability of the TUG measurements were high, and the measurements reflected changes in performance according to levodopa use. The TUG can also be used to detect differences in performance between people with PD and elderly people without PD.