Patients diagnosed with Parkinson's disease, a chronic illness with known progressive qualities, are left with an unknown sense of the future and limited control over the course of the disease. But with proper education, management strategies and physical therapy interventions, patients can influence how they adapt to the disease and learn to maintain function.

"Reducing falls and maintaining independence are major concerns in the safe management of patients with Parkinson's disease. Physical therapy is often prescribed to mitigate motor signs, decrease fall risk and increase physical activity," explained Joy Caguimbaga, PT, DPT, physical therapist and research associate, department of PT and rehabilitation science, University of California San Francisco Medical Center.

Parkinson's disease (PD) is a brain disorder that occurs when certain neurons in the brain die or become impaired, according to The National Parkinson Foundation. These cells normally produce dopamine which is a vital chemical that allows smooth, coordinated function of the body's muscles and movement.

The loss of dopamine production in the brain causes the primary symptoms of PD including tremors, slowness of movement, rigidity and difficulty with balance. Other signs of PD may include small, cramped handwriting, stiff facial expression, muffled speech, joint pain and depression.

At the UCSF Physical Therapy Health and Wellness Center in San Francisco, individuals with PD are evaluated by a physical therapist to identify limitations and problems and recommend interventions. Along with Dr. Caguimbaga, Nancy Nies Byl, PT, MPH, PhD, FAPTA, professor emeritus, UCSF and San Francisco State University, treats patients and conducts research using an antigravity treadmill with patients with PD.

Nancy Nies Byl, PT, MPH, PhD, FAPTA, works on dual-task training with a patient with Parkinson's disease at UCSF Physical Therapy Health and Wellness Center in San Francisco.

The Rehab Component

The exercise program at UCSF emphasizes integrative flexibility, strengthening, balance, mobility, aerobic, rhythmic activities and learning based multitask training. Cognitive problem solving and motor and memory training are performed during aerobic and moderate exercise. Ideally, patients are encouraged to sign up for training sessions twice a week for eight weeks. In this setting, patients must pay out of pocket for physical therapy.

"As the disease progresses in severity, it becomes more difficult for patients to exercise intensively and gait may become more unstable," Dr. Byl shared. "Postural righting reactions become more compromised, for example, poor postural alignment, kyphosis and an anterior bias of the center of support. In addition, poor foot clearance, due to excessive inversion and plantar flexion, shuffling and freezing can further increase the risk of falling."

The program includes supervised PT and aerobic training on a bodyweight supported treadmill system with computer assisted memory training while walking or cycling. Before beginning the program, baseline performance measurements are taken for walking speed, endurance, balance, functional independence and depression.

According to Dr. Caguimbaga, clinical trials confirm the effectiveness of medications in managing the signs and symptoms of PD but drug therapy cannot predictably modify disease progression. Oral medications such as include MAO-B inhibitors, dopamine agonists and Levodopa are the current mainstay treatment for patients with PD.

At UCSF's Center for Parkinson's disease, exercise is considered a necessary component of the comprehensive management of patients with PD. Along with maintaining physical endurance and strength, there is increasing interest in learning-based aerobic exercises to retain healthy function of an aging nervous system.

"When patients can achieve the rapid reciprocal movements needed for jogging and skipping, they can overcome the restrictions imposed by rigidity, shuffling and freezing," Dr. Caguimbaga shared. "The ability to exercise aerobically can contribute to a positive sense of well-being, increased confidence and decreased depression."

Dr. Caguimbaga suggests that patients with PD receive periodic PT evaluations to match patient and family objectives with therapy recommendations. The physical exercise program must also match the patient's current physical abilities.

According to Dr. Byl, the exercise program at UCSF complements medical and surgical management strategies provided by faculty in the departments of neurology, neurosurgery, urology and psychiatry. Regardless of age, each patient with PD must obtain a clearance from a physician to exercise aerobically. Patients are encouraged to exercise daily and to exercise at an aerobic level at least four times per week.

Patients are also instructed in a home exercise program to reinforce the supervised exercise training program. "Each patient is educated about the benefits of healthy aging including adequate hydration, diet, exercise and learning-based activities," Dr. Byl relayed.

Patients with Parkinson's disease may reap benefits from performing aerobic mobility training on an air supported bodyweight treadmill system.

Aerobic Mobility Training

Many of the patients with PD in the UCSF program perform aerobic mobility training on an air supported bodyweight treadmill system. Contrary to medications, there are minimal side effects of moderate to aerobic exercise on an air supported bodyweight treadmill, shared Dr. Caguimbaga.

"Some patients with significant movement disorders have difficulty exercising intensely to achieve aerobic levels of exercise," she shared. "Thus, the treadmill systems can create a safe environment for intense exercise."

After warming up overground, patients perform flexibility, strengthening, high stepping and balance exercises on a bodyweight supported treadmill with the belt still and the patient unweighted at 10 to 20 percent.

"The bodyweight supported treadmill we use allows comfortable unweighting with air to decrease the ground reaction forces while providing stability and safety," Dr. Byl relayed.

In this unit, the patient's arms are free and an air bag protects the patient from falling. The patient is zipped into an airtight bag and is weighed as air is pumped into the bag. To begin the workout, the amount of air needed to unweight the patient is programmed at the desired level. The air is proportional to the patient's calibrated body weight.

"In addition to safety, unweighting provides an opportunity for patients to challenge righting responses and retrain motor programs to walk briskly or even jog," Dr. Caguimbaga said.

The amount of unweighting is determined by patient strength, flexibility, motor ability and postural alignment. "Evidence indicates it is necessary to exercise at a higher speed or for a longer period of time to achieve aerobic levels of exercise when a patient is unweighted," Dr. Byl explained.

While exercising aerobically, the patient performs multiple tasks including problem solving, talking, spelling, ball throwing and catching and brain games. Often two patients work together to increase social interactions.

The air supported bodyweight treadmill system has significant assets over harness-based unweighting systems for patients with orthopedic and neurological problems. The air supported treadmill is more comfortable than a harness based system if unweighting is beyond 20 percent. The lifting force is distributed over the entire surface of the specialized shorts worn to use the device, rather than concentrated on the trunk and thighs as is common in a harnessed based system.

Unweighting with an air supported bodyweight treadmill system can range from 10 to 80 percent (adjustable in 1 percent increments). Unlike in a harness system, the patient's arms are free to move, facilitating reciprocal movements with the legs as well as performance of fine motor skills.

Exercising on a bodyweight supported treadmill system is not the appropriate modality for all PD patients, according to Dr. Caguimbaga. Patients with mild PD may benefit from aerobic exercise on a bicycle or elliptical machine as long as they are able to get on and off safely and are able to move quickly.

PTs need to consider the technological limitations to air supported unweighting on a treadmill. Accessing this type of treadmill requires the patient to step up and over the bag onto the treadmill.

"The pressure of the airbag may increase symptoms of urinary urgency or incontinence, especially with unweighting 40 percent or more," Dr. Caguimbaga explained. These challenges can be addressed using harness systems to assist patients on to the treadmill. In addition, patients are encouraged to go to the bathroom prior to beginning training. It is possible that the controlled pressure could also be therapeutic, progressively decreasing urinary urgency.

Dr. Byl encourages PTs to consider all possible resources to enable safe aerobic training for patients with neurological conditions. In the gym, at a senior center or at home, these activities include biking, walking and swimming. As science, technology and bioengineering advance, unweighting opportunities are expanding from harness and air supported treadmill systems to the integration of robots and computer assisted exoskeletons.

In these devices, patients can safely practice balance activities statically and dynamically with and without walking. "When a patient feels safe, there are increased opportunities to facilitate normal postural reactions, improved motor control as well as decreased dyskinesia, shuffling, bradykinesia and freezing," Dr. Byl said.

A patient at UCSF Physical Therapy Health and Wellness Center in San Francisco uses an air supported bodyweight treadmill system with computer assisted memory training as part of his walking program for Parkinson's disease.

Patient Case

The PTs at UCSF recently worked with a 71-year-old female who was diagnosed with PD 18 years ago. The patient, Kay Taylor*, is taking Mirapex, Sinemet and Levodopa. Taylor's major complaints included a tremor of the right hand, dragging of the right foot and falls once every two months. She participated in UCSF's 8-week exercise program and continues home exercise including 2.5-mile walks three times a week and gym workouts twice a week.

The PTs aimed to improve Taylor's mobility and balance through dual task aerobic exercise. Taylor's baseline measurements before exercise included the 10-meter walk, 6-minute walk, timed get up and go, five times sit to stand, depression and functional independence.

Taylor warmed up with overground flexibility and balance exercises before beginning to jog on the air supported bodyweight treadmill. On the treadmill, she performed deep knee bends, lunges, toe rises and heel cord stretches before beginning walking, skipping and then jogging. During the aerobic training, she was unweighted to 50 or 60 percent of her body weight.

Aerobic exercise was paired with cognitive stimulation, talking, spelling, defining words and ball throwing and catching. "We emphasize having fun while safely participating in dual task activities during aerobic exercise," Dr. Byl explained.

Taylor was part of a research study evaluating the feasibility and safety of carrying out dual task, balance and memory training under aerobic and moderate exercise conditions. Taylor made clinically significant gains in balance, depression and functional independence and increased walking speed and endurance. She has not had any falls in a year and is now participating in the one-year follow up.

A randomized clinical trial is underway at UCSF to determine the effect of the different components of the aggressive exercise program. Clients are assigned to one of four groups: aerobic exercise alone, aerobic exercise with dual task training, aerobic exercise, dual task training and balance exercises or aerobic exercise with dual task practice, balance training and memory training. The supervised intervention is supplemented by a home exercise program.

According to Dr. Byl, therapists who work with patients with PD must keep abreast of research as well as devices and community programs that can help patients maintain function. The fear of falling can limit participation in home exercises and community activities. PTs must consider ways to protect patients during exercise and functional activities. Walking sticks, for instance, can enhance sensory feedback as well as inform others to be careful of the patient's abilities in the community.

Dr. Byl stresses the importance of regular exercise to maintain independence in daily living and community activities. She suggests incorporating rotational, transitional, and brisk walking-stopping movements as well as strengthening, balance and aerobic activities into daily life. Finally, she encourages all individuals with PD to learn something new each and every day.

* Name has been changed to protect the patient's privacy.

References

Please see complete list of sources at: www.advanceweb.com/pt

Rebecca Mayer is senior regional editor of ADVANCE and can be reached at rmayer@advanceweb.com