REHABILITATION OF PARKINSONIAN PATIENTS. M. Gabriella Ceravolo, Lucia Paoloni, Leandro Provinciali

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1 REHABILITATION OF PARKINSONIAN PATIENTS M. Gabriella Ceravolo, Lucia Paoloni, Leandro Provinciali Neurorehabilitation Clinic, Department of Nervous and Motor Diseases, University of Ancona, Italy Reprint requests to: Dr M. Gabriella Ceravolo, Dipartimento di Scienze Neurologiche e Motorie, Università di Ancona, Via Conca 1 Osp. Torrette 60020, Ancona, Italy. l.provinciali@popcsi.unian.it Many environmental and occupational chemicals are known to affect the central and/or peripheral nervous system, causing changes that may result in neurological and psychiatric disorders. Because of the limited accessibility of the mammalian nervous tissue, new strategies are being developed to identify biochemical parameters of neuronal cell function, which can be measured in easily obtained tissues, such as blood cells, as potential markers of the chemically-induced alterations occurring in the nervous system. This review includes a comparative analysis of the effects of mercurials on calcium signalling in the neuroadrenergic PC12 cells and rat splenic T lymphocytes in an attempt to characterize this second messenger system as a potential indicator of subclinical toxicity. The suitability of neurotransmitter receptors in blood cells, such as the sigma binding sites, as biological markers of psychiatric disorders is also discussed. KEY WORDS: Disability, guidelines, Parkinson s disease, rehabilitation. FUNCT NEUROL 2001;16: INTRODUCTION The challenge in Parkinson s disease (PD) is to control the dynamic balance between the rate of neuronal death, the worsening of clinical features and the rapidly fluctuating response to pharmacological treatment. Over the last 20 years, many attempts have been made to demonstrate the efficiency of a broad spectrum of non-pharmacological approaches to the management of PD-related disability. Recent proposals from different groups stress the need for a comprehensive medical and non-medical management of PD patients that slows the disease progression, delaying the onset of dependence and reducing the burden of care. In 1993, Homberg (1) defined the goals of physical therapy as being the prevention of tertiary damage (i.e. sequelae of immobilisation) and the improvement of voluntary movements, of quality of life and of social activities. More recently, Olanow and Koller (2) have identified four domains of non-pharmacological management of PD Education, Nutrition, Support and Exercise designed to help patients cope with their disability. The PILS rehabilitation project, mean- FUNCTIONAL NEUROLOGY (16)

2 M.G. Ceravolo et al. while, establishes four target areas: Prevention, Independence, Lifestyle and Social Resources (3). Both Olanow and Koller (2) and the PILS project point to a global pragmatic approach to PD. Alternatively, the so-called eclectic approach can be considered. This does not include stereotypic techniques, but instead tailors procedures to the single patient s needs and expectations (4). U n f o r t u n a t e l y, most PD rehabilitation trials giving positive results are handicapped by poor methodological quality; this makes it difficult to compile systematic reviews providing conclusive evidence of the efficacy of any given protocol (5). We attempted an analysis of available studies in order to extrapolate the following recommendations, labelled according to evidence-based medicine suggestions (6) and classified as falling within either the pragmatic or the eclectic approach. GUIDELINES TO PREVENT DISABILITY ONSET AND PROGRESSION IN PD. A) The global pragmatic approach 1 st domain: education. G reater knowledge of the disease can help to reduce alarm and anxiety, improving the ability to cope with emerging disability. This may be assumed to be a Grade B recommendation, supported by a 2b level of evidence (6). At least two randomised controlled trials ( R C Ts) show how an education programme ( P R O PATH) is effective in: improving patients perception of their health, in providing information and support and in promoting patients cooperation with the physician in order to achieve the best medical treatment (7,8). The 12-month follow up confirms the role of P R O PATH in helping patients deal with the psychological aspects of PD, but fails to demonstrate any effect on resource utilisation: in other words, it shows how education changes the attitude of patients towards disability, but does not decrease their needs. 2 nd domain: exercise promotion. E x e rcise training increases exercise tolerance and limits disability. This is a Grade B recommendation, supported by both RCT and case-control studies. An 8-month home exercise regimen for PD patients proved effective in promoting self-care in activities of daily living (ADL) (9). Participation in a 12-month aerobic exercise programme has been shown to improve fitness and increase habitual activity level (10). Both trials were conducted on ambulatory (i.e. Hoehn & Yahr stage III) subjects. A more recent report (11) showed the efficacy of a 5-week exercise training programme, including pulmonary rehabilitation techniques and unsupported upper extremity exercises, on both pulmonary function parameters and exercise tolerance. 3 rd domain: support. G roup therapy should be considered as a means of improving social contacts, motivation and quality of life. The above is a Grade B recommendation. Two RCTs, conducted 10 years apart, highlighted the effectiveness of a group approach in improving motor symptoms and quality of life in PD patients (12,13). The techniques applied were different, the former trial involving occupational therapy, and the latter using an interdisciplinary treatment including physical exercises, leisure activities, handicrafts and art thera p y. Long-lasting benefits are described only by Gauthier et al. (12). A subgroup analysis, taking into account the highest efficacy of group therapy on depressed subjects, stresses the hypothesis that such an approach promotes social interaction, in particular, and that it in- 158 FUNCTIONAL NEUROLOGY (16)2 2001

3 Rehabilitation of Parkinsonian patients creases perception of wellbeing rather than improving motor function (13). 4 th domain: nutrition. PD patients should undergo regular scre e n i n g of swallowing abnormalities, from Hoehn & Yahr stage II on, in order to assess dysphagia, detect silent aspiration and establish the pos - sible need for re f e rral for speech therapy. The above is a Grade B recommendation. Complaints of dysphagia (food, liquids and tablets) are significantly higher in PD patients compared with age-matched controls (14,15), abnormal swallowing being prevalent in about 30% of cases. The decline in swallowing speed worsens as the Hoehn & Yahr score increases. Dietary advice can be given and airway protection techniques taught to those requiring them in order to prevent aspiration (2). Changes in the timing of antiparkinsonian medication may improve dysphagia (16). B) The eclectic approach 1. HOW to cope with speech problems. Oral communication may be improved through intensive voice rehabilitation programmes. The above is a Grade C recommendation. Long-term benefits lasting 1 year after treatment completion, may be achieved using speech therapy based on intensive voice and respiration training (17). A one-month treatment (with a 4-session-per-week schedule) has a positive impact on vocal intensity, and hence, on communication skills, thereby improving the psychosocial wellbeing of PD pat i e n t s. 2. HOW to cope with the risk of falls. Teaching conscious strategies for overc o m i n g obstacles to movement is an effective treatment for managing the problem of falling. The above is a Grade C recommendation. According to Koller et al. (18), 10% of PD patients fall more than once a week. Furthermore, they are five times more likely to suffer fall-related fractures (19) and nine times more likely to fracture their hips than healthy older adults (20). Occupational therapy is aimed particularly at teaching patients how to manage developing disability and should be considered for PD patients experiencing falls. H o w e v e r, among the many trials addressing the efficacy of occupational therapy in advanced PD only a few address the problem of controlling the risk of falls. Yekutiel (21) has described the benefits of a tailored approach whose aim is to teach conscious strategies to overcome the problem in which the time and location of falls are recorded using plans of patients apartments. 3. HOW to cope with freezing. F reezing can be reduced by the use of visual/ a u d i t o ry cues. The above is a Grade B recommendation. Gait deficits are the most characteristic and most functionally disabling signs of PD. They are often resistant to pharmacological treatment despite the general effectiveness of dopaminergic drug therapy. A growing number of studies point to the usefulness of an educational approach. This kind of approach aims to overcome the defective automatic planning of movement, typically seen in PD patients, by means of taught conscious strategies designed to render motor plan rules explicit. The use of rhythmic auditory cues may improve gait velocity, cadence and stride length after a few weeks training (22), but there is no carry over when cues are removed. Freezing can be helped by techniques that involve the use of sensory or mental imagery. Thus, a patient with start hesitation may be taught to circumvent this inhibition using strategies such as: taking steps towards a target on the ground, stepping over a cane, taking the first step with a long-striding military FUNCTIONAL NEUROLOGY (16)

4 M.G. Ceravolo et al. gait (18), and using an inverted walking stick ( 2 3 ). PD patients experience many other problems besides the three reported above. In part i c u l a r, pain arising from stiffness, muscle spasms and bradykinesia are all causes of disability that contribute to poor quality of life. H o w e v e r, few clinical trials have selectively addressed the need to search for a solution to these problems and, of those that have have, none has produced any conclusive evidence on the efficacy of a given approach. Recent reports by Deane et al. (5,24,25) highlight the lack of evidence-based strategies aimed at reducing PD-related disability using either physical or occupational or even speech therapy. FUTURE PERSPECTIVES: THE THEO- RETICAL/SCIENTIFIC BASIS OF SINGLE S T R AT E G I E S There is a growing need to scrutinise PD rehabilitation approaches according to the evidence-based treatment and outcome eff i c a c y parameters that are applied to other means of therapy. Research on the pathophysiology of motor dysfunction in PD is being carried out in order to provide a solid theoretical background in support of rehabilitation approaches. Recent guidelines (26) summarise as follows current knowledge of basal ganglia functional deficits: 1. Normal movement is possible in PD, all that is required is activation; 2. Movement sequences should be broken down into smaller components; 3. Attention processes should be used to think each movement component through consciously; 4. Cues should be used to initiate and maintain movements; 5. Simultaneous tasks should be avoided. CONCLUDING REMARKS Over the last ten years there has been a significant shift of attention towards the appropriateness of the non-pharmacological management of PD patients, although much work is still to be done. Recommendations on how to provide reliable treatment protocols should be mutated from evidence-based medicine. The following guidelines, produced by the Cochrane reviewers (5), could be useful for those wishing to undertake a rehabilitation efficacy trial in PD: Firm diagnostic criteria should be used. Inclusion and exclusion criteria should be clear and trials should aim to enrol uniform cohorts of PD patients. Investigators should clarify at what stage of the disease rehabilitation treatment is being evaluated. Trials must have sufficient numbers of patients to avoid false negative conclusions. Trials must include an adequate placebo control group and a clear description of the therapeutic intervention. The patients should be followed up for at least 6 months after treatment to assess the duration of any benefit derived from the intervention. Regardless of the assessment scale used, trials should report whether scores of impairment and disability refer to the on or off phase. Suitable outcome measures should be chosen so that the efficacy and effectiveness of rehabilitation can be assessed and an economic analysis can be performed. Outcomes which have meaning to patients should be used wherever possible since they need to know the value of their treatment in practical terms. The data must be analysed on an intention-totreat basis and the change in an outcome measure must be compared statistically across the two therapy groups. 160 FUNCTIONAL NEUROLOGY (16)2 2001

5 Rehabilitation of Parkinsonian patients REFERENCES 11. Homberg V. Motor training in the therapy of Parkinson s disease. Neurology 1993;43 (Suppl 6): Olanow CW, Koller WC. An algorithm (decision tree) for the management of Parkinson s disease: Treatment guidelines. Neurology 1998;50(Suppl 3):S Ward CD. Rehabilitation in Parkinson s disease and Parkinsonism. In: Meara J, Koller WC eds Parkinson s Disease and Parkinsonism in the Elderly. Cambridge University Press 2000;10: Chatterton H, Lovgreen B. Rehabilitation, physiotherapy and elderly patients with P a r k i n s o n s disease. In: Meara J, Koller WC eds Parkinson s Disease and Parkinsonism in the Elderly. Cambridge University Press 2000;12: Deane KHO, Ellis-Hill C, Clarke CE, Playford ED, Ben-Shlomo Y. Cochrane systematic reviews of physiotherapy for Parkinson s disease. Mov Dis 2000:P 829 (abstract) 16. Yusuf S, Caims JA, Camm AJ, Fallen EL, Gersh BJ. Evidence-Based Cardiology. London; BMJ Publishing Group Montgomery EB, Lieberman A, Singh G, Fries JF and the remaining members of the PROPATH Advisory Board. Patient education and health promotion can be effective in Parkinson s disease: a randomised controlled trial. Am J Med 1994;97: Mercer BS. A randomised study of the efficacy of PROPATH program for patients with Parkinson disease. Arch Neurol 1996; 53: Hurwitz A. The benefit of a home exercise regimen for ambulatory Parkinson s disease patients. J Neurosci Nurs 1989; 21 (Suppl 3): Bridgewater KJ, Sharpe M. Aerobic exercise and early Parkinson s disease. J Neurological Rehabilitation 1996;10: Koseoglu F, Inan L, Ozel S et al. The effects of a pulmonary rehabilitation program on pulmonary function tests and exercise tolerance in patients with Parkinson s disease. Funct Neurol 1997;12: Gauthier L, Dalziel S, Gauthier S. The benefits of group occupational therapy for patients with Parkinson s disease. Am J Occ Ther 1987;41(Suppl 6): Fiorani, C, Mari F, Bartolini M, Ceravolo MG, Provinciali L. Occupational therapy increases ADL score and quality of life in Parkinson s disease. Mov Dis 1997;12:135 (abstract) 14. Clarke CE, Gullaksen E, Macdonald S, Lowe F. Referral criteria for speech and language therapy assessment of dysphagia caused by idiopathic Parkinson s disease Acta Neurol Scand 1998;97: Mari F, Matei M, Bartolini M, Montesi A, Ceravolo MG, Provinciali L. Poor predictive value of clinical measures of dysphagia versus aspiration risk in Parkinsonian patients. Mov Dis 1997;12:135 (abstract) 16. Fonda D, Schwarz J. Parkinsonian medication one hour before meal improves symptomatic swallowing: a case study. Dysphagia 1995;10: Ramig LO, Countryman S, O Brien C, Hoehn M, Thompson L. Intensive speech treatment for patients with Parkinson s disease: short- and long-term comparison of two techniques. Neurology 1996;47: Koller WC, Glatt S, Vetere-Overfield B, Hassanein R. Falls and Parkinson s disease. Clin Neuropharmacol 1989;12 (Suppl. 2): Johnell O, Melton LJ, Atkinson EJ, O Fallon WM, Kurland LT. Fracture risk in patients with Parkinsonism: a population based study in Olmsted County, MN. Age Ageing 1992;21: Grisso JA, Kelsey JL, Strom BL et al. Risk factors for falls as a cause of hip fractures FUNCTIONAL NEUROLOGY (16)

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