Physical Therapy intervention in PD :part 1.

PHYSICAL THERAPY INTERVENTION

1.MOTOR LEARNING TECHNIQUES:
Patients with PD have difficulty in performing complex tasks involving long sequential movements.So basically the movements have to be simplified for the patient's convinience . External cues or commands have to be given to the patient.A simple instruction is very beneficial because it improves patient's attention .It bypasses the internal cueing of basal ganglia which is faulty.Visual cues like floor markings , or auditory cues like short verbal instructions, tactile cues by touching or even multisensory cues (auditory&visual) are very effective. They reduce the freezing episodes.
A very important aspect is repititions.A long sequential movement is broken down and the parts is repeated frequently with proper instructions.

2:EXERCISE TRAINING:
a-Relaxation exercises:
 Relaxation is needed to reduce the tension developed in muscles due to rigidity.Gentle and slow rhythmic movements of extremities and trunk should be considered before stretching and functional training.The PNF technique of rhythmic initiation can be used. 
This begins as a passive movement and progresses to active assisted, active and finally resistive movement.This helps to overcome rigidity.
Breathing exercises like diaphragmatic breathing should be taught as breathing promotes relaxation.
Sustained steady stretching can begiven to reduce rigidity


 b-Flexibility exercises: 
Flexibility is improved by giving passive movements initially and progressing to active movements or range of motion(ROM) exercises.This helps to lengthen the short flexor muscles and strengthern the elongated extensor muscles.Hold-relax and contract-relax methods of PNF can be used.
Traditional stretching techniques with joint mobilzation can be used whie maintaining the stretch for atleast 15-30 seconds.
Passive positioning in prone lying can be given to counteract the acquired 'phantom-pillow' posture in supine.Trunk extension should be done to oppose the kyphosis and hip-knee extension should be maintained to prevent adducted and flexed posture.


 c-Strength training:
Patients demonstrate typical disuse atrophy of muscles and weakness.And this leads to stooped posture, postural instability and frequent falls.Strengthening exercises show good improvement in patients with mild to moderate PD.Strength training along with balance training is effective .It includes high intensity resistance training for lower extremities.The strength training can be timed with the L-dopa for optimum results when the drug is administered .Not much effect can be expected during the off period of the drug.Training during 1 hour after the drug is taken is helpful.


 d-Functional training:
 The exercise training should focus on functional training. This helps to make the patient become independent in his daily activities.
Specific emphasis should be laid on improving the mobilitty of axial structures like the neck , the trunk, shoulders and hips. Bed mobility should be taught,focusing on rolling, supine to sitting,etc.Segmental rolling is better than complete rolling.This can be practiced on different surfaces , progressing from firm to soft.
Using the therapy ball, the patient can be taught anterior and posterior tilts, side-to-side tilts,and pelvic clock exercises.these activities can then be progressed to a firm surface like a mat or plinth.
Sitting activities can be taught using PNF patterns UE D2F and D2E .They promote upper trunk extension
Gentle rocking movements have been proven beneficial to induce a desired movement keeping the body relaxed. eg, sit to stand.
Standing in a modified plantigrade position improves stability.
Once the patient learns how to balance while standing, then rotational movements of the trunk can be practiced.
Due to the tendency of fall in PD patients, they should be taught how to get up on their own after an episode of fall.quadruped creeping to kneeling , half kneeling and finally standing should be taught.


e.Adaptive and supportive devices:
The following devices and modifications will help the patient to regain mobility,stability and support:
-elevated head of the bed
-a rope tied to the end of the bed to pull onto while getting up
-high sitting chairs and sofas
-rocking chair
-a cane or walker (without wheels)
-reachers (to grab things)
-loose fitting clothes
-sneakers with velcro , with a raised heel .