Treatment of rigidity in parkinsons patients?

[vaibhav yadav]

loook my personal fav. is rocking relaxation movements+PNF..................IN rr i 'lll mostly do rockers traing either through swiss balll in quadripod or in supine PNF pattern u vl b knowing

[gcoe]

With all due respect I think we need to approach our treatment with some humility here. There is absolutely no evidence that I am aware of that we are able to reduce muscle rigidity in PD. One of the sequel of muscle rigidity is the development of muscle pain. It makes sense to me that massage and stretching may be beneficial for reducing such pain and maybe achieve some temporary reduction in muscle stiffness. However it is fanciful to think that such techniques reduce the underlying Parkinsonian rigidity.

Using sensory and cognitive cues and practicing tasks can benefit people with PD to perform these very tasks more efficiently and there is some good evidence for task practice and cue training. It is conceivable but not demonstrated that improved efficiency of movement may amount to a reduced amount of muscle stiffness. However the rigidity is a primary impairment of PD and is probably due to rampant cholinergic activity in the Basal ganglia. All the behavioural and physical techniques in the world aren’t going to change that. My guess is we need to leave that to our medical colleagues to do a better job of drug management. Influencing dopaminergic activity in the BG and improving the balance between dopaminergic and cholinergic activity is where it is at. Dopaminergic drugs demonstrably reduce rigidity – no question.

Strengthening of the trunk - why just the trunk and for what purpose? Certainly our patients have huge problems with inability to generate force and the role of weakness is way under emphasised. If they have such things as flexion dystonia and are developing kyphotic posture extensor strengthening and shoulder girdle strengthening seems a really good idea to me. But let’s not fool ourselves that we know this will help when the evidence is isn’t there yet. Weakness seems to be a big issue in the ageing adult that contributes to falls. So perhaps we should be strengthening our patients lower limbs as part of a balance improvement programme – good evidence in the normal population but not much in the PD population in terms of actually preventing or reducing the number of falls. I would think about strengthening the lower limb muscles involved in antigravity work and in the hip and ankle balance strategies.

Don’t you think it is time we based the choice of our treatments more on available evidence? And where there isn’t much evidence at least have some sound rationale for what you are doing based on science? This seems really lacking in this forum. Physios often say “well there isn’t much evidence out there and if we just based our treatments on evidence we wouldn’t do anything”. Well times have changed and for many of our more common conditions and common interventions there is now a wealth of information to inform your practice. Selecting techniques that we favour or on the basis of fanciful thinking, rather than techniques that have good evidence does our patients a great disservice and hampers the development of physiotherapy. It would be better for us to think about achieving things we can have some confidence in success and not fool ourselves into thinking we are achieving goals we probably can’t.

In PD Reducing activity limitations by task based therapies and cue training, helping our patients participate in active life, improving physical activity (it is possible aerobic activity may slow down disease progression – though yet to be demonstrated in humans), strengthening antigravity muscles for balance and posture – these are things we can most likely do.
For a recent coverage evidence for physiotherapy PD. have a look at this rather massive clinical guideline prepared by the Dutch Physiotherapy association:

KNGF. Guidelines for physical therapy in patients with Parkinson's disease (English Version). Dutch Journal of Physiotherapy. 2004;114(S3):1-90. You can a PDF for free on the web – just google it and happy reading.