Some individuals respond well to following another person and imitating the walking speed and stride length. Micrographia responds well to visual cues such as dots on the page to indicate the desired writing size, with some carryover of the results for a short time after the visual cue is removed (Oliveira et al., 1997). Based on these studies, using visual and auditory cueing can improve movement size and functional activities in individuals with PD. These improvements will not carry over, and the need to engage in cueing purposefully means that the person will not be able to engage in other tasks, such as talking or carrying an object, while walking. The use of cueing requires the individual to focus on each step explicitly while walking. Although this treatment technique is helpful, it is compensatory and so should be used only when other treatments to rehabilitate have not adequately improved safety and function. Any treatment program should address specific functional deficits through training in a task-specific manner. Motor learning theory teaches that individuals have to practice the specific task that they want to improve. Therefore. if balance is the underlying impairment leading to a deficit in gait, therapy should address balance impairment and then incorporate the improved balance into walking activity by having the individual practice walking. Extensive repetition remains a key factor, so the functional task should be practiced at every session. Every treatment plan should incorporate elements designed to address both underlying impairments and specific functional activities. al., 2007). Therefore, these muscle groups are particularly prone to contracture if a flexibility program is not initiated early in the disease progression. One way to stretch the trunk flexors without risk of falling is to lie prone on elbows. Leg cramping and pain are frequent complaints of individuals with PD. Although no research to date has studied this intervention, clinicians typically use flexibility programs to address these complaints and report good clinical success in those individuals who are compliant with daily stretching. For example, thigh pain can be improved with hamstring stretches. One suggestion is to teach individuals with PD to do hamstring stretches three times per day until the pain is gone and then maintain flexibility with stretches one to two times per day. Motor planning and interlimb coordination There are often deficits in coordination during reach and grasp tasks in people with PD. There is also evidence from several of the items on the UPDRS of deficits in performing reciprocal movements. One way to improve a client’s performance of reciprocal movements is to have the client practice reciprocal movements whenever doing exercise or ROM, always using a right, left, right, left pattern of movement rather than doing 10 repetitions on one side and then 10 on the other side. Any coordination deficits can be addressed with appropriate coordination exercises and activities such as practicing alternating finger-to-finger motions, rapid target tapping with the fingers or feet, or use of the Four Square Step Test for dynamic coordination. Anecdotal evidence supports the use of these exercises and activities; however, evidence-based research Although gross impairments in strength are not common in early or even middle stages of PD, strength training is indicated (Corcos et al., 2013). Strengthening that does not address muscle groups associated with the functional activity will not improve function or participation. However, strength training that is combined with functional training can improve treatment efficacy. One study has demonstrated that individuals with PD can perform an eccentric resistance training program safely and as a result experience improvements in gait speed and TUG scores. The control group, which performed stretching and treadmill walking only, also improved in gait speed and the TUG Test but did not exhibit as much improvement as the group that is lacking. Strength
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. Laser lights attached to a walking device or glasses worn by the individual are used to provide a visual cue that moves with the individual; however, studies have not demonstrated that there is any long-term carryover from these techniques. Moving targets trigger a faster movement than stationary targets, and thus may be a better cue to use for walking (Majsak et al., 2008). Bodily functions Among individuals with PD, typical impairments in bodily functions include orthostatic hypotension, deficits in flexibility and ROM, motor planning, interlimb and intralimb coordination, and strength. In order to improve function, physical therapy must address underlying impairments. Interventions to manage impairments can often be implemented using simple exercise programs performed as part of a home exercise program. Orthostatic hypotension is a significant safety issue because episodes of hypotension can lead to falls. Optimal management is multifactorial and includes both education and exercise. The individual should be educated to make slow position changes and to perform ankle pumps and lower extremity isometric movements before standing. These actions increase lower extremity blood flow and lessens the chance of a hypotensive episode. Additionally, the individual is instructed to pause after standing to allow blood pressure to adapt and, when possible, to have something solid to grab onto such as a chair or couch if Individuals with PD have primary deficits in rotation in all joints, so exercise incorporates rotation of the trunk and limbs whenever appropriate. One such exercise is performing shoulder elevation in a diagonal pattern, with external rotation occurring on the upward movement and internal rotation occurring on the downward movement. Rotation can be incorporated into standing and balancing activities by incorporating a step forward on a diagonal rather than straight ahead and then performing an upper extremity reach with the contralateral arm in order to induce trunk rotation. Both aging and PD lead to a loss of range of motion into extension throughout the body. Stretching is initiated early in the disease and should become part of the daily routine. A focus on shoulder external rotation and abduction, hip flexion with knee extension, hip extension, and trunk extension is recommended because these motions are particularly difficult to perform, and individuals with PD are prone to contractures in the flexor muscles opposing these motions. A recent study demonstrated that a flexibility program can improve function, as measured by the Continuous Scale – Physical Functional Performance (Schenkman et al., 2012). he or she should become faint. Range of motion/stretching Evidence suggests that hypertonicity in the trunk musculature in individuals with PD is not responsive to levodopa (Wright et
EliteLearning.com/Physical-Therapy
Page 116
Powered by FlippingBook