Five facts about … physiotherapy intervention for Parkinson’s disease
To coincide with World Parkinson’s Day on 11 April, Colleen Canning, Natalie Allen, Sandra Brauer, Robyn Lamont and Serene Paul present five evidence-based practice points for physiotherapists working with people with Parkinson’s disease (PD).
1. High-intensity aerobic exercise may provide disease-modifying effects in people with early PD
People with early PD benefit from regular, high-intensity aerobic exercise to improve their fitness and potentially optimise brain health.
Though further research is required, increased neurotrophic factors, improved angiogenesis, reduced inflammation, immune factors and improved mitochondrial function are all potential mechanisms contributing to the exerciserelated improvements in brain health in us all. People with early PD also benefit from increased dopamine release in the caudate nucleus and improved activation of the ventral striatum (Sacheli 2019).
High-intensity treadmill training at 80–85 per cent of maximum heart rate (MHR) (30 minutes, three times a week for six months), slowed motor symptom progression more than a moderate intensity (60–65 per cent MHR target) training program, or usual care in people with early PD (Shenkman 2018). Similar results were achieved in another large randomised controlled trial using home-based stationary cycling at the same frequency and duration, and at a target intensity of up to 80 per cent heart rate reserve (HRR) (van der Kolk 2019).
Physiotherapy intervention for people with early PD should include training and coaching of high-intensity aerobic exercise using a safe exercise method with the aim of reducing the speed of symptom decline. Further research is required before recommendations can be made regarding high-intensity training in people with more advanced disease.
2. Balance training in people with PD should be complex and challenging for optimal effects
Balance retraining is effective in people with mild to moderate PD with optimal effects demonstrated from training that is supervised, highly challenging, delivered frequently and long term. Research suggests that programs of highly challenging balance training delivered two to three times a week for 10 weeks can result in improvements in balance (Sparrow 2016, Conradsson 2017), but without maintenance these gains may be lost within six months (Wallen 2018).
A challenge for physiotherapists is how to provide high-frequency, highly challenging balance training over the long term in a way that is safe, affordable and sustainable for the client. Tai chi is a community-based exercise option that delivers benefits for balance in people with PD, though optimal dosage is yet to be explored (Song 2017).
Highly challenging exercise regimes are multimodal, including the addition of dual task training and environmental challenges often with the goal of adding a more ‘real life’ element to training. With increasing capacity and availability, virtual reality (VR) training is receiving more interest as a modality to further improve balance (Wang 2019). The research suggests that VR may be a valuable adjunct to conventional therapy, but should not be considered a replacement.
3. Physiotherapy for freezing of gait in PD should be informed by assessment of multiple factors
Physiotherapy intervention for freezing of gait (FOG) should consider recent information confirming that FOG can be triggered by motor, cognitive or emotional challenges alone or in combination (Ehgoetz Martens 2018). European guidelines (Keus 2014) report strong evidence for cueing—typically visual (eg, stepping over strips of tape on the floor) or auditory (eg, using a metronome at frequencies around 10 per cent below baseline preferred walking cadence).
Recent randomised controlled trials suggest that dance (Volpe 2013) and cueing, combined with movement strategies (Fietzek 2014), are effective in reducing FOG. Action observation of movement strategies plus physical practice may be more effective than movement strategies alone in reducing FOG (Pelosin 2010, 2018).
Physiotherapy assessment of FOG should include the New Freezing of Gait Questionnaire (Nieuwboer 2009), the Characterizing Freezing of Gait Questionnaire (Ehgoetz Martens 2018) and observation during FOG-triggering conditions (eg, Ziegler 2014) to identify FOG severity, frequency and duration;
impact of FOG on daily life; and personspecific FOG-triggers during ‘on’ and/or ‘off’ periods.
The choice of intervention should be guided by FOG assessment results, disease severity, fall history, PD-medication regime, cognitive and emotional status and patient and partner preference. The most effective dose is unknown, but needs to be intensive enough to consolidate learning, and regular follow up is recommended.
4. Falls can be prevented with appropriately prescribed exercise in people with mild to moderate PD
Physiotherapy aimed at preventing falls in people with PD should consider the individual’s risk of falls and their fall risk factors. A systematic review showed that exercise reduces the frequency of falls in PD by 60 per cent (Shen 2016). However, detailed investigation of randomised controlled trials indicates that when exercise is semi-supervised (as in clinical practice), falls are reduced in people with milder disease (ie, low to moderate fall risk), but are increased in those with more advanced disease (ie, high fall risk) (Chivers-Seymour 2019, Canning 2015).
It is recommended that physiotherapists use the three-step clinical prediction tool (Paul 2013) to quickly and accurately predict an individual’s probability of falling in the next six months as low (17 per cent), moderate (51 per cent) or high (85 per cent). People with a low to moderate risk are suitable for group or semi-supervised physiotherapy that targets their remediable fall risk factors (eg, balance, leg muscle strength, freezing of gait) commencing as soon as possible after diagnosis.
Evidence is scant regarding intervention for people with high fall risk. However, a carefully monitored multidisciplinary approach, including medical review and higher levels of exercise supervision, along with environmental and behavioural modifications, is suggested.
5. Upper limb function can be improved with appropriately prescribed exercise in people with PD
Upper limb difficulties are commonly reported by people with PD but only recently have interventions to address these been the focus of research.
Recent trials have shown improvements in handwriting (Nackaerts 2016) and dexterity (Vanbellingen 2017) following 4–6 weeks of intensive training in people with PD (30 minutes, four to five days per week). There is a clear task-specific training effect of upper limb interventions in people with PD (Fernandez-Gonzalez 2019, Nackaerts 2016, Vanbellingen 2017). However, speedaccuracy trade-offs are also apparent (Allen 2017, Nackaerts 2015).
Physiotherapy to improve upper limb function in people with PD should consider the individual’s activity limitations and goals, and prescribe exercise of sufficient intensity, as lower dose exercise appears to have less benefit (Allen 2017, Fernandez-Gonzalez 2019). Importantly, physiotherapists should pay attention to the speed and accuracy requirements of each prescribed exercise and balance these factors when prescribing upper limb exercise to address the individual’s functional limitations. Upper limb training for people with PD may be effectively carried out at home with minimal supervision using basic equipment or incorporating technology such as exergames (Allen 2017, Fernandez-Gonzalez 2019).
Email inmotion@australian. physio for references.
About the authors
Colleen Canning, APAM, is Emeritus Professor of physiotherapy at the University of Sydney. Her research investigates the contribution of motor and cognitive impairments to disability and falls in Parkinson’s disease; as well as the effectiveness of interventions designed to reduce disability and falls.
Dr Natalie Allen, APAM, is a senior lecturer in neurological physiotherapy at the University of Sydney. Her research focuses on helping people with Parkinson’s disease to live well by improving mobility and managing pain.
Sandra Brauer is a physiotherapist and head of the School of Health and Rehabilitation Sciences at the University of Queensland. Sandra conducts research to better understand the underlying motor control mechanisms contributing to altered postural control, particularly in populations with neurological disorders such as stroke and Parkinson’s disease.
Robyn Lamont, APAM, is a research fellow and clinical educator in the School of Health and Rehabilitation Sciences at the University of Queensland. Her research areas of interest relate to optimising physical assessment and physiotherapy management of gait and community ambulation in Parkinson’s disease.
Serene Paul is a lecturer in neurological physiotherapy at the University of Sydney. Her research interest is in improving physical function and increasing access to sustainable interventions for people with Parkinson’s disease.
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