(WHOQOL-BREF); and the Short Form Health Survey (SF-36) and its abbreviated version, the 12-Item Short Form Health Survey (SF- 12). Both the PDQ-39 and the WHOQOL-BREF have good evidence for measuring performance in participation when used in individuals with PD. They are paper-and-pencil questionnaires and require 30 to 60 minutes to administer. The SF-36 and SF-12 are popular quality of life measures that have been used extensively in research trials, but their validity has been questioned for use with individuals who have neurologic diseases. One study found that four of the eight
scales, as well as the summary scales, did not validly measure the intended constructs in individuals with PD (Hagell et al., 2008). With changes in insurance coverage, it will be necessary for clinicians to use measures of participation because many insurers now require therapists to demonstrate that therapy is affecting participation. These measures can be time-consuming to administer but will be worth the time spent for individuals undergoing long-term therapy because they will lead to better tracking of return to participation-level activities and may improve reimbursement.
MANAGING THE CLIENT WITH PARKINSON’S DISEASE
● Use of meaningful, functional activities. ● Exercises designed to specifically address individual impairments. Cramer and colleagues (2011) reviewed numerous studies across multiple populations. Their review found that the studies demonstrated that neuroplasticity relies on repetition. For example, constraint-induced therapy in stroke relies on requiring the individual to use the impaired extremity over and over in functional activities in order to regain use of the extremity. Studies have also demonstrated that for individuals with PD, treadmill training is superior to therapist-assisted over-ground walking. This is thought to be because of the increased number of repetitions of stepping that occur with the treadmill versus over-ground walking (Herman et al., 2009). The use of cueing has been found to change the speed and amplitude of movement in individuals with PD (Ghai et al., 2018). Both auditory and visual cues have been shown to influence movement. Auditory cueing, such as saying “big step” or having the individual walk to the beat of a metronome or song, improves gait by increasing stride length and gait velocity (Ghai et al., 2018). It can also be used to improve micrographia. In a classic study by Oliveira and colleagues (1997), subjects were verbally reminded to write “big” throughout the writing task. Not only did cueing resolve the micrographia, but also the effect lingered when participants were tested a short time later. Studies are also examining how cues are given and their influence on movement. One study has shown that a self-given auditory cue is more effective than an externally given cue for a reaching task (Maitra, 2007). Subjects with PD were asked to reach for a bottle and put it in a cabinet. They performed the task under four conditions: ● No cue was given (no cue). ● The subject verbally cued himself or herself (self-cue). ● The researcher verbally cued the subject (external cue). ● The subject silently imagined cueing himself or herself (silent cue). The self-cue produced faster and smoother movements than the movements under any of the other three conditions (Maitra, 2007). People with PD may have freezing of gait when walking through doorways or transitioning across floor surfaces (e.g., going from hardwood to carpeting). There is evidence that physical therapy interventions focused on freezing provide short-term benefits (Cosentino et al., 2020). People with PD may benefit from visual cues such as taped lines on the floor. The lines should be perpendicular to the walking path, and the distance between the lines should be the length of a normal stride. The difficulty is that stride length varies based on height and gender, so a generic set of lines on the floor will not work for all clients. However, this strategy may be beneficial in the individual’s home if there is a particular area that seems to initiate a freezing episode. Another problem with this method is that it encourages the participant to look at the floor while walking, which is not a desired pattern. The therapist should encourage the individual with PD not to look at the floor and place the lines far enough beyond the doorway to allow the individual to see them without looking down.
Neuroplasticity (referred to as brain plasticity, cortical plasticity, or cortical remapping) refers to changes that occur in the organization of the brain as a result of experience. In neurodegenerative diseases, the brain constantly has to reorganize because of the loss of neurons. Effective treatment for neurodegenerative diseases is based on an understanding of neuroplasticity and how to guide interventions that will promote positive plasticity and avoid negative plasticity. Animal studies have demonstrated that exercise immediately after lesioning is neuroprotective, protecting neurons from injury or degeneration (Tajiri et al., 2010; Tuon et al., 2012). Additionally, studies in animals show that treadmill training ameliorates motor symptoms and neurochemical deficits within the striatum (Gorton et al., 2010). Although these studies are useful, it is important to note that the animal model of PD is not equivalent to the human condition. In the animal model, a neurotoxin is injected into the brain to damage the dopaminergic neurons in the nigral striatum, but this toxin does not continue to cause damage, whereas in PD the damage is ongoing. Additionally, in animal studies, researchers can incorporate exercise at the time of the lesion, whereas in humans, diagnosis is typically not made until more than 50% of the nigral striatal cells are already gone, generally at least 2 to 3 years after the first symptoms were noted. Efforts to extend the findings from animal studies to humans have been encouraging. After demonstrating that there are improvements in activity and in body structure and function, it is necessary to determine whether these changes are because of neuroplastic changes in brain structure and function. A systematic review of the literature showed low-grade studies only in this area, but they indicate that brain structure and function can be positively impacted by exercise in individuals with PD (Johansson et al., 2020). In two studies by Fisher and colleagues (2008, 2013), treadmill training in individuals identified as being in Hoehn and Yahr stages 1 to 2 improved function and led to neuroplastic changes. Treadmill walking improved corticomotor excitability and improved dopaminergic signaling. Demonstrating these changes in brain function indicates that the pattern of activity in the brain was different after the use of treadmill training. Therefore, the treatment led not only to changes in body functions, such as cardiovascular endurance and strength, but also changed the way the brain functioned. This and similar studies provide evidence that physical therapy interventions are not just bringing about changes in limb function but are also leading to actual neuroplastic changes in the central nervous system. Despite these encouraging findings, to date no study has demonstrated the capability of exercise to alter the course of PD in humans. It is important to note that the type, duration, and intensity of exercise are all factors that determine whether an exercise will lead to improvements in ability to engage in daily activities and promote general health and fitness. Therapists need to design therapy pro- grams that lead not only to functional changes and improved fitness but to positive neuroplasticity as well. There is strong evidence on which to base treatment programming for individuals with PD. Key components to successful therapy programs for individuals with PD include: ● Repetition. ● Cueing.
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