MARCH, 1971 An Approach to Physiotherapy for the Patient with Parkinson's Disease. S. H . IR W IN -C A R R U T H E R S , M .S.A.S.P., D ip. Onderwys (Pretoria) Lecturer in Physiotherapy, University o f Stellenbosch. The problem o f how to approach treatm ent o f the patient with P arkinson’s disease has been one which has taxed physiotherapists for m any years. If anything, we are faced by even larger num bers o f these patients now than we were in the past. I t may be th at the cohort group theory 1 accounts fo r this, and th a t a few generations hence Parkinson’s disease will be to future physiotherapists w hat tabes dorsalis is to present-day w orkers — interesting academically but seldom encountered in clinical practice. A t present, however, the patient w ith P arkinson’s disease is a constantly present challenge to our resources as physiotherapists, and although few physicians w ould fail to refer these patients for physio­ therapy, relatively few articles on the physiotherapy treatm ent of this disease have appeared in the literature. T hose which have been published have, for the m ain part, been based upon modifications o f proprioceptive neurom uscular facilitation techniques2’3' 1 o r on m ore traditional exercise regimes5' 6-7 and are w orth studying. T he treatm ent o f Parkinson’s disease would, however, appear to go further th an this, and many therapists are increasingly incorporating other neuro- physiologically based approaches, as well as selected aspects of more traditional exercises in their treatm ent programmes. With the advent o f L -dopa, results have been accelerated — and it is tem pting to postulate th a t the drug alone may be responsible for the patient’s im provem ent. Physicians at this hospital have, however, been adam ant on the im portance of physiotherapy and have n o t been in favour o f clinical trials which, whilst proving the issue one way o r another, might deprive certain patients o f essential therapy. It does seem th at physiotherapy has an im portant p art to play in the rehabilitation o f patients on L -dopa. L -dopa has greatly increased the functional potential o f the Parkinson’s patient, but is no t the to tal answer to the problem . In m any cases, dosage is limited by the developm ent o f side effects and physiotherapy has to assume a greater load in the further functional im provem ent o f the patient. It has also been noted in the present trials th a t one or tw o patients whose general condition did not allow full active participation in the physical therapy program m e showed correspondingly less response to L -dopa therapy. This is merely an observation, and many factors may have been involved, but it is suggestive. TH E P R O B L E M S It is not proposed to go into all the finer aspects o f the clinical picture o f the patient with P arkinson’s disease. The basic problems are threefold — rigidity, akinesia and trem or. Rigidity The rigidity appears related to a hyperactivity o f the system. It has been suggested8 th at dam age (but n o t total destruction) o f cells in the substantia nigra leads to release of its inhibitory control o f the pallidum , so th at the later structure rem its facilitatory impulses to the reticular form a­ tion. T he rigidity m ay be either plastic o r cog-wheel in nature, and affects all muscle groups (as opposed to the selective hypertonus of spasticity). T he patient does, however, tend to develop a generally flexed attitude in the later stages of the disease, flexion contractures som etimes even extending to the hands and feet. This could possibly be due to a u to ­ facilitation o f the flexors as a result of secondary stretch caused by the sustained hypertonus. T he extensors, on the other hand, would tend to be inhibited. Functionally, the rigidity augm ents the akinesia in Preventing movement. T he patient cannot initiate movement, and movement through range is slowed an d limited by Page 5 hypertonus in the antagonists. T h e effort o f movem ent may increase the hypertonus, so that reversal o f the movem ent and reciprocal m otion becomes alm ost impossible. Rigidity o f tongue an d jaw muscles retards speech chewing and swallowing — causing difficulties w ith feeding and sometimes being severe enough to cause drooling. Rigidity is h ard to dem onstrate in the facial muscles — an d the mask-like appearance o f the face m ay be m ore a result of akinesia. Akinesia T he akinesia (or bradykinesia) is thought n o t to be due to the rigidity, but to be a separate entity — there being no constant relationship between the two either in sym ptom s o r in response to treatm ent. Besides the difficulty in initiating m ovem ents an d the lack o f facial expression described above, the effects o f akinesia m ay also be seen in the loss o f a u to ­ m atic m ovem ents, such as spontaneous gestures, arm -swing when walking, or adaptations o f other body-segments to movem ents o f the limbs or head — although the patient may be able to perform these movem ents to com m and. H ere we have a paradox — whilst autom atic movements (which are presum ably on a “ less conscious” level) are lost — the p atient who is unable* to walk m ay be able to dance, and the patient who has difficulty w ith speech may be able to sing clearly. Obviously further explanation is needed on this point. A kinesia m ay also suddenly diminish in moments o f stress. T he akinesia and rigidity as outlined above further affect the p atien t’s balance an d protective mechanisms allowing him to com pensate only inadequately for changes in posture, limiting the weight-transference necessary for norm al w alking and preventing norm al balance an d equilibrium reactions of the tru n k an d limbs. T he typical gait o f the P arkinson’s patient is so well know n as to need no further description. Tremor In contrast to the akinesia, the trem or does appear to be related to the hypertonus8, 8 although n o t completely dependent u pon it. It cannot be thought o f as a true “resting” trem or, since it is superimposed upon sustained muscular hypertonus (i.e. sustained postural activity). F urtherm ore, when hypertonus is sufficiently decreased to allow movement, the trem or frequently disappears. Whilst trem or rem ains the sym ptom least affected by b o th L -dopa an d physio­ therapy (and stereotaxic surgery shows varying results) this tendency o f the trem or to disappear once purposeful activity has been facilitated generally m akes it less of a functional problem than might be supposed. T H E A P P R O A C H T O T R EA TM EN T O u r approach to therapy has been to attem pt to diminish rigidity by decreasing y activity an d by encouraging co­ ordination o f antagonists and also to overcome the akinesia by initiating and facilitating movem ent. In this way we hope (i) to assist the vital functions o f respiration, feeding and speech (ii) to re-establish rhythm ical co-ordinated movem ent o f tru n k and limbs (iii) to facilitate effective postural and protective responses (iv) to establish a n effective an d m ore norm al p attern o f locom otion as applied to m ovem ent a t all stages o f the; developm ental sequence as well as to the walking pattern as such. (v) to facilitate the re-acceptance o f the patient into norm al society. T hroughout treatm ent we have placed m uch emphasis on rhythm no t only in basic lim b an d trunk movem ents, but also in changes o f position an d functional activities. In som e cases we have been limited by the general condition o f our patients o r by the presence o f jo in t contractures. In these cases the necessary precautions were taken an d /o r additional procedures (such as passive stretching o f joints) were undertaken. The majority o f patients were, however, able to carry out the type o f program m e outlined below. P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page. 6 P H Y S I O T H E R A P Y MARCH, 1971 Patients were treated both individually an d in a class. Individual treatm ent was given with the above aims in view and was directed at intensive rehabilitation o f the patient whilst he was hospitalized for stabilization o f his L-dopa treatm ent. Class treatm ent was instituted a t the same stage, both fo r social and psychological encouragem ent o f the patients, but also, more specifically, to teach the patients exercises which they could perform routinely at hom e. It is en­ visaged th a t some patients m ay require further periods o f in­ tensive individual treatm ent at some time in the future, perhaps when adjustm ents o f their dosage o f L-dopa are necessary, b u t th at the majority will carry ou t a simple m ain­ tenance exercise regime themselves. These patients return every fortnight for a check-up at the clinic, and it was also en­ visaged th a t they should take p a rt in a class at each visit, which would afford the physiotherapist the opportunity o f not only checking the perform ance o f the exercises, but also o f picking out any patient in need o f further individual attention. U nfortunately it has not been possible to institute this yet. INDIVIDUAL TREATMENT Very few of our patients have been given any form o f cold o r heat in an attem pt to reduce rigidity prior to exercise sessions, perhaps because we have become aw are o f the possibility o f increased y activity after a latent period, but also because it was felt that the use o f ice-packs o r towels over an extensive enough 'a re a to have much effect was neither justified n o r expedient, especially in patients in the older age groups. We do not have a hydrotherapy bath. 1. Mat work T reatm ent generally began on the m at — the plinth-work later giving the patient a chance to rest before the more strenuous w alking exercises. All m atw ork was done first passively until the rigidity was diminished and rhythmical movement was established. T he patient was then encouraged to participate actively, with maximum facilitation and minim um effort so th at rhythm and speed o f movement were maintained an d tone was not increased. In contrast to other authors, who have advocated m ovem ent in one direction only initially, we have used reversal patterns from the beginning. R esistance was only introduced when the m ovement p attern was felt to be completely “ free” , and was never progressed to maximal resistance. I t was felt th at this “ sub-m axim al” resistance was less likely to increase activity. H ead and neck ro tatio n often preceded rolling, in accord­ ance with the norm al developmental sequence where head control precedes tru n k and limb movem ents and also to utilize the righting reactions. Thereafter, however, rolling was initiated from the shoulder girdle (and the arm ) or the pelvis (and the leg) in deference to the p atient’s age and possible arthritic changes in the neck. Quick stretch was used at shoulder-girdle and pelvis to initiate the movement, and emphasis was placed upon ro tatio n between shoulder-girdle and pelvis. M ovem ent o f the upper arm and leg during rolling was encouraged. In a similar m anner the patient was taken through the stages o f rolling to side-lying (elbow-support) or to prone on elbows, o f rolling to side-sitting, and o f side-sitting to kneeling. A gain rhythm ical reversals o f all movements were done from the beginning, and initial facilitation was followed by only sub-maxim al resistance. N eck patterns were often done in the prone-on-elbows position, in order to increase stretch and resistance to the neck extensors. T he patterns used were, however, the phasic patterns o f K n o tt and Voss.10 I t was felt th at the neck co-contraction p attern 11 might fu rther increase the hypertonus. In kneeling, slow rocking (weight transference forwards and backw ards) is carried out rhythm ically for a m ultiple purpose. Firstly, by acceleration an d deceleration o f the head it is hoped to increase m obility via stim ulation o f the semi-circular canals.11’12 In this case proxim al m obility will be affected, although as the m ovem ent is no t in the horizontal plane (in relation to the horizontal semi-circular canal) ro tatio n will be little affected. Secondly, in the kneeling position, stim ulation o f the carotid sinus m ay result in reduction of rigidity. Thirdly the joint-com pression also tends to reduce hypertonus and lastly, and more obviously, this type of proxim al m obility (distal segment fixed) is a prerequisite for the weight transference required for the m ore skilled action o f crawling. Weight transference laterally is also used both as preparation for crawling and in order to facilitate sideways balance reactions. It will have been noted that throughout the m atw ork the emphasis has been on movement and th a t static “ holding” positions have been avoided. We have, in fact, avoided stabilization techniques almost entirely in view o f their tendency no t only to further increase hypertonus bu t also to cause co-contraction o f antagonists. I t has been felt by several workers that such an isometric contraction o f antagonistic muscle groups m ay be behind the akinesia o f P arkinson’s disease, causing the patient to “ freeze” in one position despite all attem pts to move. R eciprocal crawling patterns and further progression in m at activities are continued according to the p atient’s ability. A lm ost all our patients, even the m ost severely involved, have been able to follow this type o f programme. A balance plank has sometimes been found useful for “ rocking” techniques in severely handicapped patients. 2. Limb movements T o allow the patient to rest, any passive stretching neces­ sary was then done with the patient com fortably supported on a plinth, p rio r to using the “rh y th m ” technique to facili­ tate limb movements in functional patterns. Scapular patterns were done first, followed by arm and leg patterns. T he proprioceptive neurom uscular facilitation patterns were used, a t first passively an d again using reversal patterns from th e beginning. As rigidity was reduced, active partici­ p ation was encouraged by the use o f quick stretch and progressed until the p attern could be perform ed easily against sub-maxim al resistance. Bilateral reciprocal (sym­ metrical) patterns were then used. The exact variation of pattern used was governed both by the patients ability and the functional significance o f the pattern, for instance in the legs flexion-adduction-external ro tatio n with knee flexion was reversed to extension-abduction-internal ro tatio n with knee extension. In this way the w alking p attern was facilitated w ithout overtaxing the p atient’s abdom inal muscles. In the arm s, flexion-adduction-lateral ro tatio n was combined with elbow flexion (for feeding), and extension-abduction- internal ro tatio n with elbow extension (for support). The bilateral asymmetrical “ lifting” p attern was also used to encourage tru n k ro tatio n with extension. Functional hand movements, where again the use of rhythm was accentuated, were practised in the class and were not, as a general rule, included in the individual treatm ent. 3. Standing and walking O f all the areas o f treatm ent in P arkinson’s disease, the overlapping influence o f various w orkers can best be seen in the re-education of standing balance and walking. It is even difficult to sort out where one idea o r technique ends and another begins — and this is how it should be. Ideas from R ood, the B obaths, K n o tt and Voss, Temple Fay and “ traditional” regimes can all be com bined to the p atient’s advantage. R o tatio n in a swivel chair fo r stim ulation o f the horizontal semi-circular canals has been found o f great help in facili­ tating rotational tru n k m obility p rio r to walking. We have used forw ards an d backw ards rocking, o f increasing am pli­ tude, in order to facilitate standing up — as advocated by so m any other workers — but have avoided pressure on the back o f the head as the patient stands up, finding th at this tends to cause them to throw their weight backw ards and lose their balance. Instead we have tried dow nwards pressure on the head once the upright position is obtained. Besides being a n excellent postural stim ulus, the jo in t compression does appear to release hypertonus, especially in the neck R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) MARCH, 1971 p h y s i o t h e r a p y Page 7 flexors where it is often increased by the patients effort to get his body weight forwards an d up. R hythm ical lateral weight transference is followed, by facilitation o f lateral balance reactions. T his swinging from foot to foot may also facilitate the tonic lum bar reflex an d so aid in the preparation for a reciprocal walking pattern. Again, no stabilization techniques are used. A ntero­ posterior weight transference in standing and then in walk- standing is thought to stim ulate the Paccinian receptors and so facilitate pick-up, and is therefore progressed immediately to walking facilitated from the hips. In this way it is found that the therapist can control the length o f the stride as well as the rhythm and speed. Later, facilitation via the shoulder- girdle starts to bring in reciprocal arm movements. Later still these arm m ovem ents are facilitated by the use o f canes —■ the patient holding one end o f each and the therapist (behind him ) the other, initiating the arm movements reciprocally with the leg movements. C hanting o r singing often helps the patient to m aintain the rhythm . T he use o f blocks or other obstacles to regulate the length o f the step and to teach the patient to lift his feet up, as well as the practising o f stopping, starting, changes o f direction, steps, etc. are well know n to all therapists and need no description; we have certainly not found any reason to change these time-proven techniques. 4. Vital functions A lthough this aspect o f the individual treatm ent is being described last, it has in practice been incorporated into the treatment at various stages — particularly when the patient needed rest from m ore strenuous activities. We do, however, feel that we could have done m ore in this field than we have done. We have used breathing exercises, utilizing quick stretch a t the end o f expiration, to increase vital capacity and thoracic mobility, b u t have not tried R o o d ’s method, which might well better encourage reciprocal action between the diaphragm an d the abdom inal muscles. We have also used vinegar (or where necessary am m onia) to activate a protective facial response in cases o f severely mask-like face. In milder cases we have used brisk rubbing w ith ice and quick stretch to activate the facial muscles. One o f the privileges o f treating patients on L -dopa has been to see those facial movem ents obtained during treatm ent carried over to autom atic facial expressions during daily activities; previously one o f the m ost difficult things to achieve. Looking back, we feel th at we should have done m ore for sucking, swallowing, tongue, movem ents and speech — our only excuse being th a t we were overwhelmed by the sudden invasion o f alm ost 20 P arkinson’s patients a t the beginning of the year! A nother problem which affects some patients — due to the use o f drugs which are parasym patholytic agents — is difficulty in voiding, both in initiating voiding and in a high residual. A lthough our patients on L -dopa have ceased their previous medications, one o r tw o still experienced this problem and it is possible th a t we could have helped here also. CLASS TREA TM EN T As mentioned before, the class treatm ent was aim ed (on the physical side) at teaching patients exercises fo r prolonged home use. These had, therefore, to be simple, bu t included easy m at (or floor) activities such as rolling, bridging and back extension as well as other exercises. T he back extension exercise (in supine) was one o f the few occasions on which an isometric contraction was called fo r — in an attem pt to increase y in back extensor muscles stretched an d weakened by the habitually flexed posture. Exercises fo r shoulder girdle and thoracic mobility, pendular arm exercises (some­ times holding a moderately light object to increase m om en­ tum) and trunk ro tatio n (sometimes combined with flexion and extension) were taught in sitting, as well as rhythmical, functional hand movements such as tearing or folding paper, aealing cards, “ counting” m oney and rolling squeezing silicone putty. Exercises in standing were, included as the patients progressed, a c cen tu atin g . large tru n k movements (especially ro tato ry stretching movements), “ m arking tim e” and m arching. G eneral agility, exercises such as bicycling or jogging became possible for m ost patients. . Since the scheme o f hom e exercises was, o f necessity, rath er long, th e patients were instructed and corrected intensively whilst in hospital. We found th at many patients would, o f their own accord, practice their class exercises alone in the w ard and it was these patients who m ade the best progress. ' ; ; _ • In addition to a scheme o f exercises, patients were given general advice such as rocking to stand up, doing exercises after a w arm o r cool bath, practising facial m o v em en ts’in fro n t o f a m irror and; above all, rem aining active at all costs. Several returned to their form er occupations. SU M M A RY A n approach to physiotherapy as used fo r patients with Parkinson’s disease being treated with L -dopa at the K arl Bremer H ospital, Cape Province, has been outlined. T h e aim was to show how neurophysiologically based techniques could be combined w ith m ore traditional m ethods in the overall treatm ent program m e. I t is felt th at the program m e as outlined could be further im proved upo n and th a t the advent o f L -dopa has, far from limiting the role o f physio^ therapy in the treatm ent o f P ark in so n ’s disease, greatly increased its possibilities. A C K N O W L E D G E M E N T S T hanks are due to D r. A. van W ieringen, fo r his referral o f the patients, to the staff o f the Physiotherapy D epartm ent at K arl Bremer H ospital fo r allowing the students to treat these patients, and to the students fo r their enthusiasm in carrying out th e treatm ent program m es. R E F E R E N C E S 1. Poskanzer and Schwab, in: G illingham , F . J.,. and D onaldson, I. M. L. (Eds.), Proc. Third Symposium on Parkinson’s Disease, Edinburgh, Livingstone and Co., 1969. 2. K n o tt, M. R ep o rt o f a Case o f Parkonsonism treated with Proprioceptive F acilitation Technics, Phys. Ther. R ev. 37, 4, A pril, 1957. 3. Alexander, B. Parkinson’s Disease: R ecent Trends in Physiotherapy. Aust. J. Physio ther., 16, 2, June, 1970. 4. Voss, D . E. Proprioceptive N eurom uscular Facilitation, in: A n E xploratory and A nalytical Survey ofT herapeutic Exercise, A m . J. Phys. M ed., 46, 1, Feb., 1967. 5. Stevens, I. H . K ., and R oche, G . D . M anagem ent o f Parkinson’s Disease, Ann. Phys. M ed. 1, 8, Oct., 1953. 6. M urray, W. Parkinson’s Disease, Aspects o f Functional Training, Phys. Ther. Rev., 36, 9, Sept., 1956. 7. Bilowit, D . S. Establishing Physical Objectives in the R ehabilitation o f Patients w ith P arkinson’s Disease, Phys. Ther. R ev., 36, 3, M arch, 1956. 8. Spiegel, E. A. Problem s in P arkinson R esearch regarding the M echanisms o f R igor, A kinesia and T rem or, C hap. 19 in: Sym posium on Parkinson’s Disease, ed. Barbeau et al, New Y ork and L ondon, G rune and S tratton, 1965. 9. C ooper, I. S. R elationship o f Cerebellar Intention T rem or to R esting T rem or o f P arkinson’s J. A m . Ger. Soc., 14, 3, M arch, 1966. 10. K n o tt, M ., and Voss, D . Proprioceptive Neuromuscular Facilitation, New Y ork, H arper-R ow , Publ. 1966. 11. Stockmeyer, S. A. A n Interpretation o f the A pproach o f R o o d to the T reatm ent o f N eurom uscular D ys­ function, in: A n Exploratory and A nalytical Survey o f Therapeutic Exercise, A m . J. Phys. M ed., 46, 1, Feb.. 1967. 12. R ood, M. S. U npublished notes, S.A.S.P. P ost-graduate course, Johannesburg, July-August, 1969. 13. Stem , P. H ., M cDowell, F ., Miller, J. M ., and R obinson, M. Levadopa and Physical T herapy in T reatm ent o f Patients with Parkinson’s Disease. Arch. Phys. M ed. and Rehab., 51, 5, M ay, 1970. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )