Physical Therapists’ Impact on Parkinson’s Disease Detection and Treatment

By Kalynne Ballares, PT, NCS

Physical Therapist

Physical therapists, how many of you have experienced this Parkinson’s disease scenario during your average treatments? It’s a typical day in the field with a new referral for “gait abnormality” and “frequent falls.” You arrive for the evaluation and ask for the patient’s signature when you request informed consent. To your surprise, not only is it illegible, but it’s too small for the patient to even recognize their own signature. They joke that they “should have been a doctor!”

Upon further observation, during their history and interview, a resting hand tremor becomes apparent in the same hand they used to sign their name. After your evaluation is complete, you begin by recommending physical therapy three times per week and additionally recommend a referral back to the doctor. Six weeks later, suspicions are confirmed by a neurologist…Parkinson’s disease (PD) is his new diagnosis.

THE PROBLEM WITH DIAGNOSING PARKINSON’S DISEASE

PD is a progressive, neurodegenerative movement disorder that will affect nearly one million people in the US by 2020. Up to 60,000 Americans are diagnosed with PD each year per the Parkinson’s Foundation. It is considered a movement disorder from its cardinal motor symptoms that can present at early onset of the disease. PD has motor and non-motor signs and symptoms as part of its clinical presentation. PD signs and symptoms vary widely from person to person, and the disease rate of progression also may vary widely from person to person. Early symptoms of the disease include a tremor, small handwriting, constipation, loss of smell, and difficulty walking. Other specific motor symptoms (this following list in not inclusive) include: stiffness, rigidity, hypophonia, postural instability, festinating gait, akinesia “freezing,” drooling, stooped posture, dual-task interference, and balance impairments.

This variation in presentation and initial gradual progression of symptoms can make it difficult for a diagnosis. That’s even if the patient even recognizes that it is a sign or symptom of a more serious problem.

PARKINSON’S DISEASE DETECTION: HOW TO EVOLVE FROM NOVICE TO EXPERT

This leads us into one of our most important roles as skilled clinicians. We cannot take for granted our training of skilled observation and assessment.

Often our PT referrals are for “falls.” By simply asking a patient, “Please, show me how well you walk,” we detect postural instability when they first rise to stand up, very slow walking speed, absent arm swing, shuffled steps, and/or “freezing” when the patient attempts to walk over a threshold. Often, the patient and family are unaware these could be symptoms of a more serious condition: “He’s always been this slow!” Anecdotally, patients and family members tell me it was an average of one to two years before diagnosis and/or meeting with a neurologist. The median time for motor symptom onset to primary care physician diagnosis of PD was 11 months. There’s a greater delay in diagnosis in men than women, and if initial symptoms are gait dysfunction before tremor.

Per American Parkinson’s Disease Association, 80 percent of people with PD present with a tremor. Again, this information illustrates that not everyone with Parkinson’s disease has a symptom of tremor. We synthesize our evidence gathered and formulate our hypotheses. As the “movement” experts, we know how varied the clinical presentation for people with PD can be. So our roles are further defined for us as detectives to determine cause for gait dysfunction and falls.

Early detection and accurate diagnosis is the first step toward optimal medical management of PD.

SIGNS & SYMPTOMS BENEFITTING FROM PHYSICAL THERAPY INTERVENTIONS

Another key role for physical therapists includes delivery of evidence-based interventions that address signs and symptoms of PD. The implications of impaired motor learning contributing to symptoms and degradation of gait and postural instability. As physical therapists, we teach new feedforward strategies to manage symptoms interfering with function. These strategies include considerations to impaired motor learning specific for patients with PD, learning may be at a slower rate and will require HIGH repetition of practice for optimal success.

The following interventions have been found to slow disease progression, minimize disability and improve quality of life.

• Reduced economy of movement, aerobic deconditioning, fatigue:
  Inefficient movement patterns and secondary deconditioning can be a vicious cycle for those living with Parkinson’s. No one mode for aerobic conditioning has been found to be superior over another. What’s important is to consider the patient’s preference for exercise as this lends to a lifestyle commitment with exercise in it. Evidence supports treadmill training overground walking and cycling. Other forms of exercise used for aerobic conditioning are boxing and dancing. Recommended dosage is 30 minutes of moderate to vigorous-intensity aerobic exercise five times per week for 150 minutes every week.
• Bradykinesia, hypokinesia:
  Impaired sensory feedback systems may affect quality of movement and warrant reliance on external cues and attentional strategies. People with PD have been found to lack full appreciation of proprioceptive input. They may also have inappropriate responses to that feedback. Many physical therapists are certified specifically for evidence-based interventions such as LSVT “Big” or Parkinson Wellness Recovery (PWR!) that target recalibration of a sensory mismatch typical for people with Parkinson’s. The use of these strategies helps the person with PD manage slow speeds and shuffled walking. Feedback from the therapist, use of mirrors, and patient/caregiver training are extremely useful to help with overall safety and functioning in their home and community.
• Akinesia “freezing”:
  Freezing is an impairment that is not fully understood, but together with physical therapy, concrete strategies can be developed to find what works best to help the person “unfreeze.” Strategies supported by evidence include the use of auditory and visual cues. Visually, taping on floor for targets placed in typical places where freezing occurs is an example. To use auditory cues, one can make use of a metronome. Task specific training, again in circumstances where freezing occurs, has been supported by evidence. This includes use of a metronome with the task, music, visual imagery, rocking or weight shifting to “un-freeze,” dual-task training, multidirectional training, and mass practice of these strategies…repetition, repetition, repetition.
• Stiffness and rigidity:
  Hallmark signs and symptoms of PD are stiffness and rigidity. This lends to adaptive shortening of key two joint muscles, loss of axial rotation and spinal extension, and pain. As a result, this leads to a classic postural presentation with a forward head, rounded shoulders, thoracic kyphosis, and crouched posture in standing. Evidence supports stretching on a routine basis, specifically three times per week. Of importance are the hamstrings, quadriceps, gastrocnemius and pectoralis muscle groups.
• Weakness:
  Strength deficits are often a result from many causes including deconditioning, an altered central drive to the muscles for force production, and aging. Weakness lends to a functional decline, balance impairments and greater fall risk. Evidence supports strengthening of lower extremity and postural extensor muscles two-to-three times per week, one-to-three of each for eight-to-12 repetitions maximum.
• Impaired balance:
  Impaired balance and frequent falls are often reasons for a physical therapy referral. There’s a study reporting the incidence of falls and recurrent falls in people with PD: Many people with PD fall and will continue to fall. Once again, the mismatch in sensory perceptions and inappropriate responses to that feedback lend to impaired balance. With impaired motor learning, it is suggested that people with PD have challenges with switching between motor sets and flexibility of those motor sets are very difficult.  Meaning, adaptability is difficult. This may explain why new situations that require different balance strategies prove to be a difficult task. From the 2017 NICE CPG for People with Parkinson’s Disease in Adults, “consider” the Alexander Technique for people who experience balance or motor function problems. Other evidence supports balance training: feedforward and reactive balance training, planned and unplanned reaction balance training. Strength training also improves balance in people with PD. Tai chi and other balance activities that target weight shifting in multiple directions, movement strategy training and dance (tango and waltz) have also been supported by evidence. Physical therapy dosage recommendations vary from different sources. We do know that timing matters, meaning EARLY intervention is recommended. Mass practice, meaning HIGH REPETION of practice, is supported for successful motor learning. Furthermore, what is repeated matters. Meaning, the activities should be challenging, should be “layered,” functional, task-specific and working towards that person’s goals. If it’s too easy, then we might be “under-dosing” in our prescriptive interventions. Lastly, we promote a commitment to life-long physical activity. Finding exercise and activities that are meaningful and fun for the person with PD is how we facilitate this commitment.
• Dual task interference:
  Multiple systems are responsible for our ability to dual-task with walking. Specific to dual-task with walking in people with Parkinson’s disease, it’s reported within three years of diagnosis over 85 percent of people with clinically probable PD develop gait problems. Motor contributions of impaired motor learning with progressive loss of automaticity and cognitive contributions of impaired executive functioning, set-shifting, and attention have been suggested for dual-task interference with walking. Evidence supports external cueing, cognitive attentional strategies, and dual-task gait training. Once again, evidence suggests there may be improvement in dual-task performance with gait due to improvements in gait automaticity. Dosage varies among dual-task interventions studied, but again we lean on our understanding from motor learning literature for recommendations.

WHAT PHYSICAL THERAPISTS DO BEST

Many people with PD have difficulties with functional tasks and activities of daily living. It is suggested that motor performance that requires integration of multiple components is often impaired with implicit motor learning. Physical therapists are experts in motor learning and its framework. Its principles are a central theme to any physical therapy plan of care.

In the early phases of PD, we should be practicing at a high rate of repetition, focusing on relevant task-specific skills (walking, turning, sit-to-stand transfers and bed mobility), allowing for errors and self-correction, training for dual-task function, and concentrating on strengthening. We should be training reactive, planned and un-planned responses for balance to improve balance and safety with function. Unfortunately, as the disease progresses, we are the ones who pick up on subtle changes with structures and function affecting functional mobility.

With our knowledge that the signs, symptoms, and rate of progression vary widely, we can be immediate with making appropriate changes in our treatment plans. Refer back to other specialty team members when warranted. Our skillset gives us the advantage to be key communicators among the healthcare team and also signifies how vital our role is in providing optimal care.

FUTURE DIRECTIONS FOR PHYSICAL THERAPY AND PARKINSON’S

Part of our professional obligations is a commitment to lifelong learning, the effort to always strive to be experts in our field, and a social responsibility. Knowing that evidence supports early detection, early medical management, and comprehensive management with specialty care teams, we still will get referrals for patients who are in the moderate to late stages of Parkinson’s disease. Patients and their families rely on us to be their guidance in navigating this disease process. It is our privilege and responsibility to them. We are charged with the task to support our communities by educating our referring providers, participating in local support groups to educate members, teaching self-advocacy and empowerment, and promoting a lifestyle with long term exercise by partnering with community fitness centers.

Let’s go back to the patient from the beginning of this article. They have been in skilled… they have been in skilled PT for seven months and are about to discharge. They have now added a movement disorder neurology specialist to their medical care team.  They have joined the local support group. Additionally, they are now participating in a community fitness program with boxing. The patient and the family are much happier. The patient is functionally more independent in the home and community participation and has an improved quality of life since participating in physical therapy.