As more is discovered about Parkinson's disease (PD), physical therapists have become increasingly involved in trying to help sufferers of the disease to maximize function. Pharmacological interventions and neurological studies have helped make living a little easier for patients with Parkinson's, but a full return to function is still a goal on the distant horizon. Therapists have been trying to contribute to improvements for people who have this degenerative disease.

Audio Visual

In recent years, the use of auditory and visual stimulation has become the subject of much research in the PD arena. Margaret Schenkman, PhD, PT, has been studying Parkinson's treatment options for nearly 20 years.

"There is some nice work that shows auditory stimulus can be helpful getting people moving more efficiently," she said. "We use a CD using music at different tempos, from slow to fast, with a metronome marking the beat. In our flexibility function program, we find that using that music with the beat is really helpful to get participants moving more smoothly and faster."

Dr. Schenkman, professor of physical medicine and rehabilitation and director of physical therapy program at University of Colorado at Denver and Health Sciences Center (USDHSC) admits, however, that there is little known about the carryover of auditory stimulus in daily living. As an adjunct to physical therapy, Dr. Schenkman has found a benefit to using the auditory stimulus, but in ADLs, it is not known whether the auditory stimulus is of any help.

Jon Ruttenberg, PT, a small private practice owner who sees mostly outpatient orthopedic patients and some neurological patients, has also used auditory stimulation in practice with individuals with Parkinson's. Anecdotally, Ruttenberg said he has had some success with carryover of the auditory stimulus in his patients with PD.

"I recorded a metronome at 60 beats per minute," said Ruttenberg. "I've found in my clinical experience that velocity, gait speed, stride length and direction all really straighten out nicely. I've also found that, depending on how long you work with the patient, it has very good carryover."

Ruttenberg explained he videotaped a patient before and after working with the auditory stimulus. "The patient's stride length evened out. His velocity slowed down to a reasonable pace. Sixty beats was actually a little slow for walking, but it worked very well for him because it would give him that attention and he would take a step at each beat. Also, when he froze, if I put that on, he could synch up to it and unfreeze," explained Ruttenberg.

Ruttenberg has also found some success in using visual stimulation for treatment of individuals with PD. Through research he discovered that placing canes along the floor at equal intervals or even just pieces of tape on the floor helped to "straighten out a festinating gait."

This approach is used to help with "freezing" in a person with Parkinson's. The visual stimulation has been found to help with smoother and more consistent movement in individuals with the disease.

Research

"The effects of PD are on much more than gait," said Dr. Schenkman. "The disease has an effect on one's ability to do almost every aspect of daily life from getting out of bed, to getting up from a chair, to being able to work in the home environment."

Part of the effort to counteract these effects, or at least delay them, is the incorporation of an exercise regimen into the day-to-day self-care of the individual with Parkinson's. Dr. Schenkman is currently leading an NIH-funded study comparing three approaches to exercise in individuals with Parkinson's.

"Most of the studies today have been small, asking relatively targeted questions. What we really need to do now, because there is a large enough body of evidence that suggests exercise is important, is determine what is the best type of exercise," explained Dr. Schenkman. "Our current work is focused on comparing a very specific, PD-targeted program based on our earlier work with flexibility, combined with a program of balance and functional training."

The three approaches to exercise include aerobic conditioning, standard care exercises based on the home exercise programs of the American Parkinson's Disease Foundation, and a flexibility for balance and functional-training program based on Dr. Schenkman's earlier work.

"The idea of the exercise program is to have an impact on overall daily functional activity. In our outcome measures, we're not looking simply at gait but also at a broad range of functional performance. I think if we only [consider] gait, and patients can walk better but they can't function better in daily life, then we're only solving half the problem," she said.

According to Dr. Schenkman, neurologists often recommend to people with Parkinson's doing the home exercise programs, which Dr. Schenkman agrees are excellent exercises.

"The question is, is that enough, or do [the people with PD] need one-on-one help. What we're looking at is not just how they do after training—our training is four months because for aerobic conditioning you need 16 weeks of training—but it's important to know how they'll do a year later."

Dr. Schenkman explained the concern is over whether patients will be able to continue the exercises on their own. "We're looking not just at the short term benefits of the program, but also at the ability of people to stay on the program and exercise and continue to do well despite the degenerative nature of the disease," she said.

The flexibility program Dr. Schenkman developed, which was published in 1997, seems to have improved people's balance.

"Combining it with the home functional and balance training really seems to augment the program substantially," she said. "We have people who completed the program a year ago and are now just graduating from the year follow-up, who still seem to be doing quite well. These are individual reports, so we're not yet sure of the overall benefits statistically, but certainly for some individuals, that program seems to be quite helpful."

On the Horizon

A popular buzzword in the PD community today is neuroprotection. Although there are many pharmacological interventions being tested right now, exercise is also being studied as a possible neuroprotective agent.

"I think the work on the horizon that will probably be most influential, if it can get off the ground, will be that of neuroprotection," said Dr. Schenkman. "If exercise truly turns out to be neuroprotective, that is a tremendously important statement, and if we can figure out what aspect of the exercise is necessary, it would be very important. It would change the whole medical management of people with this disorder. The problem is that, technically, it is hard to study."

Researchers at the University of Pittsburgh, however, are trying to find out if this link is, in fact, viable. Currently the project, headed by Michael J. Zigmond, PhD, is looking at the effects of forced execution of a motor act in neuroprotection and the effects of exercise on the loss of central dopamine (DA) neurons.

Resources

Fisher, B., & Yip, J. (2005). Physical Therapy For Individuals With Parkinson's Disease: A Paradigm Shift. Accessed at http://www.parkinson.org/site/pp.aspx?c=9dJFJLPwB&b=667077&printmode=1

National Institute of Neurological Disorders and Stroke. University of Pittsburgh Research. Accessed at http://www.ninds.nih.gov/funding/research/parkinsonsweb/udall_centers/pittsburgh.htm

Stefanie Carter is on staff at ADVANCE and can be reached at scarter@merion.com

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