Feature Article Review: Striding out with Parkinson's disease
Evidence-Based Physical Therapy for Gait Disorders
By Meg E. Morris, Clarissa L. Martin, Margaret L. Schenkman
Physical Therapy Vol 90 No. 2 February 2010 p 280 – 288
Although Parkinson disease (PD) is common throughout the world, the evidence for physical therapy interventions that enable long-term improvement in walking is still emerging. This article critiques the major physical therapy approaches related to gait rehabilitation in people with PD: compensatory strategies, motor skill learning, management of secondary sequelae, and education to optimize physical activity and reduce falls. The emphasis of this review is on gait specifically, although balance and falls are of direct importance to gait and are addressed in that context. Although the researchers who have provided the evidence for these approaches grounded their studies on different theoretical paradigms, each approach is argued to have a valid place in the comprehensive management of PD generally and of gait in particular. The optimal mix of interventions for each individual varies according to the stage of disease progression and the patient’s preferred form of exercise, capacity for learning, and age.
Review contributed by Mariella Graziano, Physiotherapist, BSc (Hons)
In this article, Morris and colleagues provide a concise overview of the main physical therapy approaches for gait disorders, in particular and on rehabilitation in general for Parkinson‘s disease (PD). The authors identify 3 evidence-based elements to gait rehabilitation: cognitive strategies, management of secondary sequelae as consequence of deconditioning and education to optimize physical activity and minimize falls.
The cognitive strategies approach is defined as strategy training. The theory behind this approach is to target the primary motor control deficit in the basal ganglia, brain stem and motor cortex. The authors identify two forms of training: compensatory strategies to bypass the dysfunctional basal ganglia and learning strategies. The former refers to strategies, such as cueing to compensate for gait hypokinesias by increasing step length and walking speed at a rhythm tailored to the individual patient. Other strategies include visualizing walking with longer steps or mentally rehearsing the movement before performing it. Learning strategies refers to improving functional performance through repetition and practice.
Following analyses of the present evidence, the authors recommend that when choosing the appropriate strategy, therapists should take into account the level of disease severity, age, specific needs, learning capacity and preferred form of physical activity of each individual.
The article provides a literature review from 2003 to 2009 on rehabilitation of gait disorders in PD. Six randomized controlled trials were analyzed and the authors concluded that though the studies included a comparison group, they did not compare evidence-based "best practice" interventions such as strategy training, cueing, or the management of musculoskeletal sequelae.
The clear and concise style of this article makes it a good reference for all health professionals and members of the Movement Disorders Multidisciplinary team.
About Mariella Graziano, BSc (Hons)
Mariella Graziano is a physiotherapist, active in patient associations, engaged in international multidisciplinary networks in the care of Movement disorders. She was first qualified as physiotherapist in Argentina, later emigrated to Great Britain where she retrained as a physiotherapist. She developed a special interest in Movement Disorders at the National Hospital for Nervous Diseases in London and is currently living in Luxembourg, where she runs her neuro-physiotherapy practice. She writes teaching material for people with Parkinson's and their families, lectures to physiotherapists and other health care professionals, and runs workshops for people with Parkinson's.
She is the president of the Association of Physiotherapists in Parkinson Disease Europe (APPDE) and she is currently serving her fourth term in office as a member of the board of the European Parkinson's Disease Association (EPDA). She is also vice president of Parkinson Luxembourg (Patient Association) and a member of The Movement Disorder Society Health Professionals (Non-Physicians) Special Interest Group.