Physiotherapy is essential for patients suffering from Parkinson’s disease to maintain their independence for a long time. Depending on how advanced Parkinson’s disease is, physiotherapy in functional training targets those activities where the patient feels the greatest restrictions in everyday life. Parkinson’s disease (PD) is defined as a condition in which a patient displays four major symptoms.
These are lack of movement (brady- or akinesia), increased muscle tension leading to stiff, cog-like movements (rigor), a resting tremor (tremor) and unstable posture (postural instability). These symptoms have far-reaching consequences for the Parkinson’s patient, which are addressed by physiotherapy. Bradykinesis has the consequence for the patient suffering from Parkinson’s disease that movements are only slowed down.
In most cases, the lack of movement starts in the upper extremities and makes it difficult for the patient to perform actions that require fine motor skills, such as closing shirt buttons. If the lower extremities are also affected later in patients with Parkinson’s disease, the patient typically takes very small steps when walking. In addition, many Parkinson’s patients find it difficult to start and stop walking, i.e. to start a movement and stop it again later.
Gait training is therefore an important part of physiotherapy. The facial muscles can also be affected, so that only very little facial expression is visible. Often this circumstance leads to misunderstandings in the communication with fellow men, because emotions are only weakened or not represented at all in facial expressions.
The contents of physiotherapy therefore aim to improve intra- and intermuscular coordination in patients with Parkinson’s disease. In patients with Parkinson’s disease, the muscles are permanently tense and therefore stiff, which causes rigor. When the joints of patients with Parkinson’s disease are moved by the physiotherapist in physiotherapy, it feels as if there are gears in the patient’s joints over which they are moved.
This cog-like movement is caused by the fact that not only the playing muscle is very tense, but also its opponent. For the mobility of a joint there is always at least one muscle that moves in one direction and one that moves in the opposite direction. Normally, the muscle tension is regulated in such a way that, for example, the extensor muscle reduces the tension slowly and in a controlled manner while the flexor muscle flexes the joint.
In patients with Parkinson’s disease, this muscle regulation functions poorly. This must be restored during the respective physiotherapy sessions. Tremor (rest tremor) can usually be observed at rest in patients with PD.
With targeted movements, it usually subsides gradually, and with mental stress, it increases even when the patient is forced to make rapid targeted movements. The rest tremor has a slow frequency of about 4-5 Hz, which is why it is also called “pill twisting syndrome”. Postural instability in patients suffering from Parkinson’s disease develops from the lack of movement, as the muscles cannot react quickly enough to external stimuli.
Patients with Parkinson’s disease therefore find it difficult to react appropriately to a stumble while walking or an unintentional push from outside. Looking at the posture of a Parkinson’s disease patient, it can be seen that he usually stands with his upper body bent forward and his head resting on the back of his neck to compensate. The content of physiotherapy should therefore also include balance training.
In addition to the four main symptoms, patients suffering from Parkinson’s disease often have pain in the shoulder and neck area due to the unstable posture and stiffness of the muscles. The lack of movement can lead to a reduced general level of activity, which in turn can lead to depressive phases and a reduction in memory performance in some patients with Parkinson’s disease. This is because the body is smart and saves resources, and what is not used is reduced.
Exercise requires brain power, and if there is a lack of exercise, the brain is also put on the back burner. Among other things, less “happiness hormones” such as serotonin and the already misproduced dopamine are then produced, which can be reflected in the mood. In order to keep this in check, the physiotherapist creates a specially designed physiotherapy.The symptoms described are caused by the regression of the so-called corpus striatum in the basal ganglia of the brain, which normally regulates dopamine production.
Dopamine is a messenger substance and is needed to trigger movement impulses. If this messenger substance is missing, the movement impulse is missing. Against this background it is easy to understand why Parkinson’s disease leads to a lack of movement; there are simply too few impulses reaching the muscles.
Although this change in the brain can be easily compensated for by medication, it cannot be prevented or even reversed. In physiotherapy, of course, the cause cannot be eliminated in Parkinson’s disease patients, but the consequences of the disturbed regulation can be influenced in order to alleviate the course of the disease and slow its deterioration. To do this, the physiotherapist must conduct a detailed examination with the patient to find out which symptoms are particularly pronounced and in which activities of his daily life he is particularly restricted by the symptoms.
This results in the physiotherapeutic working diagnosis during physiotherapy. In most cases, the aim of physiotherapy is to improve gait, make patients suffering from Parkinson’s disease more confident and thus prevent falls. In addition, the maintenance of fine motor skills is often the main focus.
Here, the physiotherapist and occupational therapist should work closely together. Both therapeutic goals require regulation of muscle tension and demand movement. In order to regulate muscle tension, the patient suffering from Parkinson’s disease can carry out specific movements in physiotherapy with the assistance of the physiotherapist and learn a daily self-exercise program.
Because patients with PD typically tend to take short, quick steps while leaning far forward, there is an increased risk of falling. This is because this posture shifts the body’s center of gravity to the front and is located outside the patient’s own body. Such a gait pattern increases the risk of falls and subsequent injuries, which in turn can restrict independence and accelerate the progression of the disease.
It is therefore important that the physiotherapist with PD works on his gait pattern during physiotherapy. Factors to be considered here are adequate straightening and large, safe steps. If one straightens up, the body’s center of gravity shifts back towards the middle of the body.
Therefore, the risk of falling is reduced by walking upright and taking large steps. In order to counteract this, patients with Parkinson’s disease must practice large movements during physiotherapy and repeat the exercises regularly. A study by Farley & Koshland in 2005 investigated the so-called BIG method (big= large), in which certain movements are repeated frequently on a large scale, and concluded that patients with Parkinson’s disease who were treated with the BIG method improved their walking speed by increasing their stride length, and the accuracy of their arms was improved even over longer distances.
In order to improve posture in patients with Parkinson’s disease, they must learn to feel their body’s center. To do this, he will learn, with the help of the physiotherapist, various exercises during physiotherapy for pelvic control and mobility, as well as for straightening up. It is also interesting to note that studies on whole-body vibration indicate that training with vibration plates can contribute to better body stabilization.
The balance sensors in the musculature are activated and cause the brain to release messenger substances, so-called neurotransmitters, which are otherwise only produced in small quantities in patients suffering from Parkinson’s disease. Many physiotherapists use such an aid in the respective sessions of physiotherapy. If the Parkinson’s disease (PD) patient has difficulties with certain activities and movements in everyday life, “Proprioceptive Neuromuscular Facilitation” (PNF) is a very suitable treatment method in physiotherapy.
Muscle functions are stimulated (facilitated) by specific stimuli of the neuromuscular system. By means of active-assistive movements a regulation of muscle tension as well as an improvement of coordination and muscle strength during physiotherapy can be achieved. In PNF there are different movement patterns that correspond or resemble movements from everyday life and are selected by the physiotherapist according to the objective.For example, if the patient suffering from Parkinson’s disease finds it difficult to take a cup from the cupboard above the sink, the physiotherapist first analyzes how the patient performs the movement and which component is causing him difficulties.
This is because an apparently simple overhead movement has many different individual movement components where there could be a restriction of movement or too little strength. This must be taken into account during physiotherapy. In addition, a movement process requires that the joints can move freely.
Due to the high muscle tension, problems can occur here. In this case, the physiotherapist can also work manually in physiotherapy on the muscles, the connective tissue or on the joint itself in patients with Parkinson’s disease and reduce excessive tension or release blockages. The forward bent posture in patients with Parkinson’s disease causes muscle shortening in the entire frontal trunk wall.
Muscles remain supple through movement and become stiff through immobilization. Again, the patient suffering from Parkinson’s disease must work on his or her uprightness in the physiotherapy sessions to prevent him or her from remaining in the forward-bent position. In addition, the physiotherapist can perform stretching exercises and movements to counteract muscle shortening in patients with Parkinson’s disease.
Special attention should be paid here during physiotherapy to the hip flexor and chest muscles. For patients suffering from Parkinson’s disease, movement is essential! Regular exercise, both during physiotherapy and alone, can prevent the vicious circle of muscle shortening, joint stiffness and pain, and independence is maintained.
It is well known that exercise lifts the mood and prevents depression and a loss of memory. A study by Hackney & Earhart from 2010 recommends that people affected should go dancing regularly. Music while dancing makes it easier for patients suffering from Parkinson’s disease to find a beat, which is also important when walking, and the dance partner can guide (facilitate) the movements through good leadership. In addition, the social aspect of dancing in groups should not be neglected, as social isolation leads to a negative reinforcement of the symptoms, and the promotion of social contacts helps the patient to maintain self-confidence and confidence in his or her abilities.
