Treatment of rigidity in parkinsons patients?

[Liseann]

Hey there,

This question probably has a really simple answer but im stuck on it at the moment. Im trying to find out the best way to treat rigidity in a parkinsons patient and all Im coming up with is massage and stretching exercises. Any ideas?

Its the week before my exams and i would really appreciate some help

Similar Threads:

• positioning for decerebrate and decorticate rigidity patients.
• Treatment Protocol for Patients with Hemiplegia
• Rigidity in Parkinson's
• Botox injections for Parkinsons
• Acupuncture and Parkinsons

[Dr Damien]

your best best would be to use visual and/or cognitive cues

stretching and massage will only reduce the rigidity temporarily and may require passive efforts, you need something that the patient can learn and manage on his/her own

One method is to break down the activity the patient wants to perform into simpler sequences. Then the patient uses cognitive or mental tasks to replay the motion in his mind. He can then include several rocking motions that to achieve each step of the sequence. What you need to understand his the abnormality of movement which might be unique to the patient, therefore using visual cues or auditory cues will serve as reminders for the correction of abnormal movements. After a few training sessions, you can begin to combine all the sequence of movements and may perhaps time the patient as an outcome measure. The smoother the movement, the better the control over rigidity.

These steps are to avoid the onsets of rigidity, however if rigidity occurs before a task is complete you can include the stretching, relaxation (breathing techniques) or massage, postural tone correction using key points on the axial skeleton (e.g shoulder retraction plus elevation of head) to reduce the dystonia. the key is to overcome ridity before it occurs and that takes learning on the part of the patient


An example of these techniques would be

Case study:A patient who becomes rigid when trying to get up from sitting to standing on his walker.

Breaking down the sequence of movement;
hands on arm rest (sequence one)
Foreward head and retraction of shoulder (sequence two)
getting up from chair (sequence three)
Grabbing the handles of the walker (sequence four)
taking the first few steps (sequence five)

Mental/cognitive cues/tasks;
tell the patient to replay these mentions in his mind. You may need to demonstrate these movements and he can recite them as he thinks about them.

Rocking
For every sequence he should rock back and forth to avoid the CNS the time to become rigid. this is similar to the continuous passive movements used for stroke patients to reduce spasticity except this is active not passive.

Using visual cues
you could place colored spots on objects in the room as reminder that when these actions are about to take place, a certain posture is required. e.g head elevation, a flexed head causes protraction and rigidity.

Outcome measure
decrease the time spent on each phase of the movement to mimick a more natural movement

I know this is more than a year late but it may help other physiotherapists with a similar problem in their practice.

LoL

[manimaran1406]

Dear sir,

Is there is effectiveness of trunk strengthening in PD

[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.