Therapy & Practice

Training in neurology

and geriatrics

Using various neurological and geriatric clinical pictures, we want to show how effective training can be designed. In this instalment we will deal with Parkinson’s disease (idiopathic Parkinson’s disease), a very common neurological clinical picture worldwide. Neurological diseases are now the most common causes of disability.

Click here for part 1 of the series (stroke)

Text: Sabine und Hans Lamprecht

Parkinson’s disease is the disease that is increasing most in the population, more so than Alzheimer’s dementia and others. From 1990 to 2015, the prevalence and thus the number of people with Parkinson’s disease more than doubled. [3] The number of people with Parkinson’s disease will also increase from 6.9 million to 14.6 million between 2015 and 2040. [2]

James Parkinson, the first person to describe Parkinson’s patients, described in his essay “An Essay on the Shaking Palsy” in 1817 that patients had involuntary, trembling movements combined with reduced muscle strength. [5]

The prevalence of Parkinson’s disease is strongly age-related. Most patients fall ill between the ages of 58 and 62. The prevalence among over 65-year-olds is 1,800/100,000 persons with an increase of 0.6% per year up to a prevalence of 2,600/100,000 among persons between 85 and 89 years of age. There are no gender-specific deviations. [1]

Parkinson’s disease therapy must be interdisciplinary

The clinical picture has very different symptoms and courses. Drug therapy is fundamental; an interdisciplinary approach is essential. This includes activating physiotherapy and occupational therapy, specialised speech and swallowing therapy and much more. Physiotherapy with emphasis on gait training, balance exercises, strength and stretching exercises as well as fall prevention receives the highest recommendation level in the guidelines of the German Neurological Society and in the European physiotherapy guidelines. People with Parkinson’s disease need a specific approach to physiotherapy and occupational therapy, which should be based on evidence-based knowledge, independent of concepts. The above-mentioned guidelines help us to do this.

Development and therapy in phases

The symptoms of Parkinson’s disease are caused by a disturbance in the extrapyramidal system and the basal ganglia. Dopaminergic cells die in the substantia nigra, resulting in a lack of dopamine and an excess of acetylcholine in the striatum. Hypokinesia, bradykinesia and akinesia are the main symptoms of Parkinson’s disease. Cardinal symptoms are rigor, tremor and the disruption of postural control.
Therapy and training should take place in the on-phase [4] and be adapted to the stages of the disease. Non-medical therapy – physiotherapy, occupational therapy, speech therapy – should focus on the symptoms that cannot be influenced by medication or DBS (deep brain stimulation) or cannot be influenced sufficiently. These symptoms are speech disorders, balance disorders, and complex gait and posture disorders.

In the early phase (Hoehn & Yahr 1 to 2) the patient has only minor disabilities and the therapy focus should be in the area of avoiding inactivity and lack of movement, avoiding fear of movement and falling, and improving or maintaining physical performance (condition, muscle strength, voice volume, dexterity). A high-intensity treadmill training with a load of about 80% of the maximum heart rate has shown that the ability to walk, measured in the UPDRS (Unified Parkinson’s Disease Rating Scale) motor evaluation, could be stabilised within 6 months. [7]

In the middle phase (H & Y 3 to 4) patients increasingly notice disabilities and balance pro­blems. Walking is affected and the risk of falling increases. In this phase, the therapy focus is on maintaining and improving everyday activities. Furthermore, the improvement of posture and fine motor skills is important. Speaking and swallowing should be treated by speech therapy, and walking and balance, especially reactive balance, must be trained intensively.

In the late phase (H & Y 5), patients are in­creasingly dependent on outside help, mobility is more and more restricted and patients are de­pendent on a wheelchair or bedridden. [6] The focus of therapy is now concentrated on training transfers; fall and injury prophylaxis are becoming more and more important, and communication possibilities must also be practised. Important aspects are of course also the avoidance of aspiration and contractures, the prevention of bed sores and, if necessary, palliative measures.

Gait training for Parkinson’s disease patients

Gait training with a treadmill for Parkinson’s patients is indispensable to train gait speed and dual tasking. Gait endurance can also be ideally trained by using a treadmill. With the gait trainer lyra from THERA-Trainer, walking speed, stride length, balance and dual task as well as endurance can be trained. When it comes to walking speed, it is important that you can reach speeds of over 3.0 km/h in the gait trainer. Of course this has to be adapted individually. However, only by demanding higher speeds can you achieve a targeted speed training with an improvement in walking speed.

If you want to train more endurance, you should also walk as fast as possible, but the focus is on gait endurance. Here, interval training has proven to be very effective, where you take short breaks and then continue. The patients take a break in the lyra by simply placing a stool in the device to allow them to sit. During balance training it is essential that patients do not hold on to anything – not even to the training device itself. TheraBands, which the patient can hold on to, help in this process.

These make it possible for the patient not to hold on permanently while walking. Now dual-task training can be done as an improvement by asking the patient to find things in the room, to calculate, to count backwards or to report fluently about events.

Regular standing and movement training

With a movement exerciser, training should be done with little resistance and the highest number of revolutions. It is important here to do regular training, preferably three times a day at least three times a week.

With a movement exerciser, training should be done with little resistance and the highest number of revolutions. It is important here to do regular training, preferably three times a day at least three times a week.

In the standing frame balo, even severely affected patients can practise reactive balance and lunges in secured positions. In addition, postural difficulties can be specifically trained or the muscles can be stretched as actively as possible in the balo in a secure position. When stretching, it is important that the patients stretch as much as possible, for example the pectoralis and the entire flexor chain of the upper extremity and hands, similar to the BIG exercises. Likewise, ischiocrural or calf muscles can be actively stretched in the balo. The shifting can be used, for example, to stretch the calf even more intensively in a step position or the hip flexors of the other leg. Active stretching in severely affected patients is very possible in the balo. In addition, swallowing or speech therapy can also be done in the standing trainer, as the upright body position supports this. Of course, for severely affected Parkinson’s patients, as for other severely affected patients, standing is an essential therapy approach that should be carried out daily and in which many prophylactic measures are cumulative. The same applies here: daily standing of one hour is recommended.

Gait, movement and standing frames such as lyra, tigo and balo can be used individually, specifically and sensibly for Parkinson’s disease patients, depending on the phase of the disease.

  

At a glance – Summarised

  1. The number of people suffering from
    Parkinson’s disease is currently in­crea­sing and will continue to do so
    in the coming years. In spite of diffe­rent symptoms and courses, the DGN guideline always recommends gait training, balance, strength and stretching exercises as well as fall prevention.
  2. The training should be adapted to the stages of the disease and should sensibly take place with the support of therapy equipment such as gait, balance and movement exercisers.
  3. Both gait and movement training should take place at the highest possible step frequency or number of revolutions.
     

Literature

[1] de Rijk MC, Launer LJ, Berger K, Breteler MM, Dartigues JF, Baldereschi M et al. (2000). Prevalence of Parkinson’s disease in Europe. A collaborative study of population-based cohorts. Neurologic Diseases in the Elderly Research Group. In: Neurology 54 (11 Suppl 5), S21-3.

[2] Dorsey ER, Bloem BR (2018). The Parkinson Pandemic – A Call to Action. In: JAMA neurology 75 (1).

[3] Feigin VL, Abajobir AA, Abate KH, Abd-Allah F, Abdulle AM, Abera SF et al. (2017). Global, regional, and national burden of neurological disorders during 1990-2015. A systematic analysis for the Global Burden of Disease Study 2015. In: The Lancet Neurology 16 (11), S. 877-897.

[4] Frank MJ, Seeberger LC, O'Reilly RC (2004). By carrot or by stick. Cognitive reinforcement learning in parkinsonism. In: Science (New York, N.Y.) 306 (5703), S. 1940-1943.

[5] Parkinson J (2009). Eine Abhandlung über die Schüttellähmung. Zweisprachige Ausgabe: Englisch/Deutsch. Hg. v. Jürgen Flügge. Norderstedt: Books on Demand.

[6] Sato K, Hatano T, Yamashiro K, Kagohashi M, Nishioka K, Izawa N et al. (2006). Prognosis of Parkinson’s disease. Time to stage III, IV, V, and to motor fluctuations. In: Movement disorders: official journal of the Movement Disorder Society 21 (9), S. 1384-1395.

[7] Schenkman M, Moore CG, Kohrt WM, Hall DA, Delitto A, Comella CL et al. (2018). Effect of High-Intensity Treadmill Exercise on Motor Symptoms in Patients With De Novo Parkinson Disease. A Phase 2 Randomized Clinical Trial. In: JAMA neurology 75 (2), S. 219-226.

Authors


Sabine Lamprecht completed her physiotherapy exam in Berlin in 1982. Since then, she has completed various further training programmes. In 2006 she obtained her Master of Science degree in Neurorehabilitation at Danube University Krems, Austria.

From 1983 she worked as lead physiotherapist at Neurologische Klinik Christophsbad where she helped to set up the Physiotherapy Department.

 


Hans Lamprecht has also been working as a physiotherapist since 1982. He founded the Kirchheim regional group in the Baden-Württemberg Association of Physiotherapists.

In 1987, Sabine and Hans Lamprecht opened their own practice together.