Friday, October 7, 2016

Physical Therapy for PD

Exercise should be part of the daily routine of a patient with Parkinson’s disease (PD). Exercise and regular activity improve mobility, dexterity, and balance, and may even slow the progression of PD. Exercise, especially outdoors, also helps to alleviate depression, which is a common accompaniment of parkinsonism. Finally, there is a growing belief in the medical community that regular exercise improves or preserves cognitive function. For most PD patients, it is not necessary to consult with their primary care provider (PCP) before starting a low-impact exercise regimen, such as taking a daily walk for 30 minutes. However, for a PD patient with heart or pulmonary disease, in particular, it is important for the PCP to determine what exercise can be done safely.

For a more focused program, patients may want to consult with a physical therapist on specific exercises that can be done to keep muscles, joints, and limbs in an optimal state. Neurologic Clinical Specialists (NCS) are physical therapists who specialize in movement disorders, such as PD. However, a patient should not delay starting a program in order to meet with an NCS, as all physical therapists are trained movement professionals and will be able to assist in creating an exercise plan.

A physical therapy (PT) program ideally should focus on improving posture and balance and on maintaining dexterity and functional ability in the limbs. Such programs can be tailored to emphasize exercises that may reduce the risks of falling. It is common for patients with PD to have disturbances of gait, and certain exercises can help to maintain good strides, improve arm swing, and counter freezing episodes.

PD motor symptoms are usually asymmetric, affecting one side of the body more than the other. Some patients with PD show a reticence to use their affected side. Seeking to hide their tremor, they will attempt to stay the tremor by clasping hands or sitting on the tremulous hand. Others, knowing that one hand is slower and clumsier, will favor the “better” hand for most activities. Patients with PD who have predominantly lower limb symptoms often reduce the amount of walking they do, or rely increasingly on a cane or walker. If an assistive device is necessary to protect the patient from repeated falls, it should be employed —however, the danger in neglecting an affected limb is that the less the limb is used, the less usable it becomes. Patients must actively strive to do more with affected limbs. “Forced” use of an affected limb leads to neural adaptation. In other words, the limb becomes more responsive because the neural pathways that control it are activated more fully. Neural adaptation has been shown to occur in patients who have undergone forced use rehabilitative strategies after a stroke.

In the daily routine of a patient with PD, time should be spent on improving range of motion, task performance, and coordination, particularly of the more symptomatic limb. For the hands, practice precise repetitive movements: drumming or tapping the fingers, turning the palm up and down, throwing, catching, and squeezing a ball, putting small objects in small containers, using a finger to quickly touch mobile and stationary objects, and so on. Exercises to practice with the legs include: marching and stepping in place while occasionally changing directions, and toe tapping. When walking, keep the head up, the shoulders back, and swing the arms purposefully. The point is to challenge the limbs to be as active as possible.

After a PT program has been outlined and followed for a while, periodic re-evaluation by the physical therapist will help to confirm that the program is providing some benefit. PD is a disease that tends to worsen over time, and exercise programs may need to be adjusted with disease progression.

Keeping the mind limber is also important. Learning-based exercises can help maintain multi-tasking capabilities, which may —in turn— have a positive effect on work and inter-personal interactions. Solving puzzles, playing board games, and exploring new hobbies are all things that PD patients can do to challenge the mind and keep it nimble. Other activities like dance, tai chi, and yoga are especially beneficial, pairing relatively low-impact movement with learning, memory, and repetition. In addition, these activities provide pleasure and increase opportunities to socialize. Physical therapy offers the opportunity to collaborate with a movement professional to create a regimen that is unique to the patient, and will help the patient keep the body and mind durable, flexible, and resilient.