The document summarizes recent advances in the management of Parkinson's disease. It discusses pathophysiology, signs and symptoms, recent research on interventions such as neuroprosthesis for tremor, action observation to reduce bradykinesia, audio biofeedback training for posture and balance, Irish set dancing vs exercises, intensive rehabilitation treatment, augmented visual feedback, robot-assisted gait training, virtual games and different types of physical exercise. The studies presented are randomized controlled trials and systematic reviews that evaluate the efficacy of these interventions for symptoms of Parkinson's disease.

1. RECENT ADVANCES IN THE
MANAGEMENT OF
PARKINSON’S DISEASE
Rajin Tandan
MPT- nEuro
12/8/2013
1

2. Definition:
2

Parkinsons disease is a chronic, progressive disease
of the nervous system characterised by cardinal
features of rigidity, bradykinesia, tremor, and
postural instability.
- Physical rehab 5th edition by susan B,
o’sullivan.
12/8/2013

3. Etiology:
3



The term PD is used to refer to a group of disorders
that produce the abnormalities of BASAL
GANGLIA function.
Idiopathic parkinsonism most common form.
Secondary parkinsonism caused by virus, toxins,
drugs, tumors.
- Physical
o’sullivan.
rehab 5th edition by susan B,
12/8/2013

4. Pathophysiology:


Caudate and lentiform nucleus (collectively termed the
striatum ) plus the Subthalamic nucleus and the
substantia nigra(pc).

4
The basal ganglia (BG) are a collection of
interconnected gray matter nuclear masses deep within
the brain.
Degeneration of dopaminergic neurons that produce
dopamine and cell bodies in SNpc.
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5. 
Loss of dopamine results in :


5
An overactive indirect pathway that is thought to
underlie akinesia and rigidity.
An underactive direct pathway is thought to be
responsible for bradykinesia.
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6. Signs and symptoms:









Rigidity – cogwheel, leadpipe
Bradykinesia
Tremor
Postural instability (posture and balance)
Motor planning- when, where, how
Gait – festinating gait
Speech, voice, swallowing disorders
Autonomic nervous system
Cardiopulmonary function
- Physical rehab 5th edition by susan B, o’sullivan.
6
12/8/2013

7. Recent advances
7
12/8/2013

8. Search criteria:

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





8
Journal of APTA
Australian journal of physiotherapy
Journal of Parkinsonism and related disorders
Journal of movement disorders
Journal of neuro rehabilitation and neural repair
Journal of physical medicine and rehabilitation
Journal of neurological sciences
Journal of brain research
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9. 

Full text articles

Systematic reviews, RCTs and Experimental
comparative studies, pilot study.

9
Year: 2009-2013
Level of Evidence: Sacketts, NHMRC, Pedro.
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10. NHMRC 2009
10
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11. Sacckets:
11










1A = Systematic Review of Randomized Controlled
Trials (RCTs)
1B = RCTs with Narrow Confidence Interval
1C = All or None Case Series
2A = Systematic Review Cohort Studies
2B = Cohort Study/Low Quality RCT
2C = Outcomes Research
3A = Systematic Review of Case-Controlled Studies
3B = Case-controlled Study
4 = Case Series, Poor Cohort Case Controlled
5 = Expert Opinion
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12. Interventions:
12









Neuroprosthesis
Action observations
Audio-Biofeedback training
Irish set dancing
Intensive Rehabilitation Treatment
Augmented visual feedback
Robot-assisted gait training
Virtual games
Physical Exercise
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13. Tremor
13
A neuroprosthesis for tremor management
through the control of muscle co-contraction

Authors: Juan Alvaro Gallego, et.al

Published year: 2013

Journal: Journal of NeuroEngineering and
Rehabilitation
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14. 14

Objective: Pathological tremor is the most prevalent
movement disorder, which makes tremor a major
cause of loss of quality of life. Therefore, novel
forms for tremor management are required.

Research design: Pre-post experimental design.
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15. 15

Method: A neuroprosthesis that regulated the level of
muscle co-contraction by injecting the current at a
pair of antagonists through transcutaneous
neurostimulation was used.
6 patients suffering from parkinsonian or essential
tremor of different severity were taken, and the effect
of the neuroprosthesis during standard tasks was
evaluated.
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16. 16
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17. 17

Results: The neuroprosthesis attained significant
attenuation of tremor and reduced its amplitude.
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18. 18

Conclusions: This study sets the basis for the
validation of the neuroprosthesis as an alternative,
non-invasive means for tremor management.

LOE: 3b (NHMRC)
12/8/2013

19. Bradykinesia:
19
Reduction of Bradykinesia of Finger
Movements by a Single Session of Action
Observation in Parkinson disease

Authors: Marco Bove, et.al.

Year: 2013

Journal: Neurorehabilitation and Neural Repair
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20. 20

Objective: To understand the effects of action observation on
the spontaneous rate of finger movements in patients with
Parkinson disease.

Methods: 38 pts with PD and 14 healthy controls, were
randomly divided into 2 groups.
All participants performed a finger sequence at
their spontaneous pace at different intervals.
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21. 21
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22. 22

Results: Both VIDEO and ACOUSTIC training
increased the spontaneous rate in all participants.

Conclusions: The findings suggest that the
dopaminergic state contributes to the effects of action
observation, and the training may be a promising
approach in the rehabilitation of bradykinesia in PD.

LOE:1b (Sacckets)
12/8/2013

23. Posture and Balance:
23
Audio-Biofeedback training for posture and
balance in Patients with Parkinson’s disease

Authors: Anat Mirelman, et.al.

Journal: Journal of neuroengineering
and rehabilitation

Published year: 2011
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24. 24

Objective: To test the feasibility and effects of
Audio-Biofeedback training modality
in patients with PD.
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25. 25

Method: Seven patients with PD were included in a
study,that comprised of a six weeks intervention
program.
The training was individualized to each
patient’s needs and was delivered using an audiobiofeedback (ABF) system with headphones.
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26. The device is worn on the patient’s lower back and is attached to headphones
by which he hears the auditory feedback.
26
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27. 27

Results: The ABF system was well accepted by all
participants, with high satisfaction with the
training. A significant improvement of balance,
was observed.
In addition, the training appeared to
have a positive influence on psychosocial aspects
of the disease and the level of depression.

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28. 28

Conclusion: Audio-biofeedback training for
patients with PD is feasible and is associated with
improvements of balance and several psychosocial
aspects.

LOE: 4 ( Pedro)
12/8/2013

29. 29
A comparison of Irish set dancing and exercises
for people with Parkinson’s disease: A phase II
feasibility study

Authors: Daniele Volpe, et.al.

Journal: BMC Geriatrics

Published year: 2013
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30. 30

Objective: The objective of this study was to
evaluate the feasibility of Irish set dancing
compared with routine physiotherapy for people
with mild to moderately severe PD.
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31. 31

Method: Twenty-four people with idiopathic PD
receive standard physiotherapy exercises or Irish set
dancing classes once per week plus a weekly home
program for 6 months (12 in each group).

Results: Both the Irish set dancing and physiotherapy
exercise program were shown to be feasible and safe.
Compliance and adherence to both the exercise and
dance programs were very high.
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32. 32

Conclusion: A larger multi-centre trial is now
warranted to establish whether Irish set dancing is
more effective than routine physiotherapy for
enhancing mobility, balance and quality of life in
people living with idiopathic PD.

LOE: 2 ( Pedro)
12/8/2013

33. 33
Short- and Long-Term Efficacy of Intensive
Rehabilitation Treatment on Balance and Gait in
Parkinsonian Patients



Authos: Giuseppe Frazzitta, et.al.
Journal: Hindawi Publishing Corporation Parkinson’s
Disease
Year: 2013
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34. 34

Objective: The aim of this study was to investigate
whether a 4-week inpatient multidisciplinary
intensive rehabilitation treatment (MIRT) is effective
in improving balance and gait and whether
improvements persist at a one-year follow up.
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35. 35

Method: 20 PD inpatients, were taken for the
study. Patients were evaluated at admission, at
the end of the 4-week treatment, and at a 1-yr
follow up.
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36. 36

Outcomes:

UPDRS
Berg Balance Scale
six-minute walking test
Timed Up and Go Test
Comfortable-Fast gait speeds.




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37. 37

Results: MIRT was effective in improving balance
and gait and that the improvement in gait
performances was partially maintained after 1 year
also.

LOE: 3a ( Pedro)
12/8/2013

38. 38
The effects of augmented visual feedback
during balance training in Parkinson’s
disease

Authors: Maarten RC van den Heuvel, et.al.

Published year: 2013

Journal: BMC Neurology
12/8/2013

39. 39

Objective: To investigate whether a training program
capitalizing on virtual-reality-based visual feedback
is more effective than an equally-dosed conventional
training in improving standing balance performance
in patients with Parkinson’s disease

Study design: randomized clinical trial
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40. 40

Methods: Patients with idiopathic Parkinson’s
disease,were participated in a five-week balance
training program
comprising ten treatment sessions of 60
minutes each.
Experimental group
Control group
balance training using
augmented visual feedback
balance training 12/8/2013

41. 41
Training sessions consist of task-specific exercises
that are organized as a series of workstations.
Assessments were done before training, at six
weeks, and at twelve weeks follow-up.
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42. 42
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43. 43

Discussion: They hypothesize that balance training
based on visual feedback will show greater
improvements on standing balance performance
than conventional balance training.

LOE: 1b (Sacckets)
12/8/2013

44. Gait:
44
Robot-assisted gait training versus equal intensity
treadmill training in patients with mild to moderate
Parkinson’s disease

Authors: Alessandro Picelli, et.al

Year: 2013

Journal: Parkinsonism and Related Disorders (Elsevier)
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45. 45

Aim: The aim of this study was to compare the
effects of robotic gait training versus equal intensity
treadmill training and conventional physiotherapy on
walking ability in patients with mild to moderate
Parkinson’s disease.
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46. 46

Methods: Sixty patients with mild to moderate
Parkinson’s disease were randomly assigned into
three groups.
All patients received twelve, 45-min treatment
sessions, three days a week, for four consecutive
weeks.
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47. 47

Robotic Gait Training group
robot- assisted gait
training.

Treadmill Training group
performed equal intensity treadmill
training without body-weight support.

Physical Therapy group
conventional gait therapy according to
the PNF concept.
- Patients were evaluated before, after and 3 months post- treatment.
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48. 48

Results: No statistically significant difference was
found on Robotic Gait Training group and the
Treadmill Training group after the treatment
evaluation.
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49. 49

Conclusions: The study support the hypothesis
that robotic gait training is not superior to
equal intensity treadmill training for
improving walking ability in patients with
mild to moderate Parkinson’s disease.

LOE: 1b (Sacckets)
12/8/2013

50. Quality of life:
50
Virtual games and quality of life in
Parkinson’s disease

Authors: Danilo Cruz

Year: 2013

Journal: Advances in Parkinson’s Disease

Research design: A randomised controlled trial
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51. 51

Objective: To evaluate the efficacy of Nintendo
Wii training in quality of life in Parkinson’s disease patients when compared to traditional
physical therapy.
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52. 52

Methods: Forty-four PD were taken. Both groups executed a
warm up session for 10 minutes.
PT group
followed a program that consisted of trunk and limb
mobilisation, balance, muscle strengthening, rhythmic
movement, postural alignment, double-task execution, bimanual
tasks, and gait training.
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53. 53
Nintendo Wii group
executed a sequence of tasks according to a
previously established protocol, with similar
training exercises.
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54. 54

Results: Subjects in the Nin- tendo Wii group showes greater
improvement. Also, significant differences were observed in
ADL, stigma, social support and communication when
comparing subjects before and after intervention in the
Nintendo Wii group.

Conclusions: Rehabilitation using Nintendo Wii may have
beneficial effects in quality of life of PD subjects, and
superior when compared to traditional PT.

LOE: 1b (Sacckets)
12/8/2013

55. 55
Randomized Clinical Trial of 3 Types of Physical
Exercise for Patients With Parkinson Disease

Author: Lisa M. Shulman

Year: 2013

Journal: JAMA Neurol.

Research design: Randomized Clinical Trial
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56. 56

Objective: To compare the efficacy of treadmill
exercises and stretching and resistance exercises in
improving gait speed, strength, and fitness for
patients with Parkinson disease.
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57. 57

Method: A total of 67 patients with PD who had
gait impairment were randomly assigned to 1 of 3
arms of the trial.

A higher-intensity treadmill exercise was
performed,

A lower-intensity treadmill exercise was
performed and
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58. 58

Stretching and resistance exercises was performed.
These all exercises were performed 3 times a week
for 3 months.
Outcome Measures :
> 6-minute walk
> peak oxygen consumption per unit time
> 1-repetition maximum strength.
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59. 59

Results All 3 types of physical exercise improved
distance on the 6-minute walk.
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60. 60

Conclusions:

The lower-intensity treadmill exercise resulted in the greatest improvement
in gait speed.

Both the higher- and lower-intensity treadmill exercises improved
cardiovascular fitness.

Stretching and resistance exercises improved muscle strength.
Hence, exercise can improve gait speed, muscle strength, and fitness for
patients with Parkinson disease.

LOE: 1b (Sacckets)
12/8/2013

61. Falls:
61
Slow Down and Concentrate: Time for a
Paradigm Shift in Fall Prevention among People
with Parkinson’s Disease?

Author: Emma L. Stack and Helen C. Roberts

Year: 2013

Journal: Hindawi Publishing Corporation
Parkinson’s Disease
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62. 62

Aims. To survey falls beyond home, identifying
challenges amenable to behavior change.

Methods: They distributed 380 questionnaires to
PwP in Southern England, asking participants to
count and describe falls beyond home in
the previous 12 months.
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63. 63

Results: Among 255 responses, 136 PwP reported
falling beyond home.They described 249 falls in detail,
commonly falling forward after tripping in streets.
Single fallers (one fall in 12 months) commonly
missed their footing, walking, or changing position and
recovered to standing alone or with unfamiliar help.
Repeat fallers (median falls, two) commonly felt
shaken or embarrassed and sought medical advice.
Very frequent fallers (falling at least monthly; median
falls beyond home, six) commonly fell backward, in
shops and after collapse but often recovered to
standing alone.
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64. 64

Conclusion: Even independently active PwP who do not
fall at home may fall beyond home, often after tripping.
Falling beyond home may result in psychological and/or
physical trauma (embarrassment if observed by strangers
and/or injury if falling backwards onto a hard surface).
Hence prevention requires vigilance and preparedness:
slowing down and concentrating on a single task might
effectively prevent falling.

LOE: 2c (Sacckets)
12/8/2013

65. Summary:
65
Tremor:

Neuroprosthesis can be
used as an
valid,alternative, noninvasive means for
tremor management.
Bradykinesia:

Dopaminergic state
contributes to the effects
of action observation,
and training by
observing action may
be a promising approach
in the rehabilitation of
bradykinesia in PD.
12/8/2013

66. 66
Posture and
balance:

Audio-biofeedback
training for patients
with PD is feasible and
is associated with
improvements of
balance and several
psychosocial aspects.
Augmented visual
feedback:

Balance training based on
visual feedback shows
greater improvements on
standing balance
performance than
conventional balance
training.
12/8/2013

67. 67
Irish set dancing:

It showes superior
results to standard
physiotherapy in
relation to freezing of
gait, balance and motor
disability.
Intensive Rehabilitation
Treatment:

MIRT was effective in
improving balance and
gait and that the
improvement in gait
performances was
partially maintained
also after 1 year.
12/8/2013

68. 68
Gait:

Robotic gait training is
not superior to equal
intensity treadmill
training for improving
walking ability in
patients with mild to
moderate Parkinson’s
disease.
12/8/2013

69. 69
Quality of life:

Rehabilitation using
Nintendo Wii may
have beneficial effects
in quality of life of PD
subjects, and superior
when compared to
traditional PT.

Physical exercise can
improve gait speed,
muscle strength, and
fitness for patients with
Parkinson disease.
12/8/2013

70. 70
Falls:


Slowing down and concentrating on a single
task might effectively prevent falling.
Using an appropriate walking aid outdoors
may afford extra postural stability and can
prevent falls.
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71. 71
Thank you!!!
12/8/2013