Maria Gabriella Ceravolo
Dept of Experimental and Clinical Medicine – Politecnica delle Marche University – ANCONA - ITALY
Parkinson's disease (PD) is the second most common neurodegenerative disorder after Alzheimer's disease occurring worldwide, and in all ethnic groups. The prevalence of PD in industrialized countries is generally estimated at 0.3% of the total population and about 1% in people over 60 years of age (Nussbaum & Ellis, 2003). The management of early PD involves the treatment of motor symptoms and, increasingly, non- motor symptoms. Current treatments provide adequate control of the cardinal motor features of the disease but do not modify its evolution towards increasing disability. Over the years, this relates to the emergence of other features—such as cognitive impairment, autonomic dysfunction, and disequilibrium—that reflect the extension of the pathological process in different central and peripheral neurological areas.
In my lecture I will address the following issues:
- Key Recommendations for rehabilitation Intervention in PD. Current recommendations are based on the Dutch guidelines , better known as the KNGF Guidelines (Keus et al., 2007, and consist of: (I) Application of cueing strategies to improve gait; (II) Application of cognitive movement strategies to improve transfers; (III) Specific exercises to improve balance; (IV) Training of joint mobility and muscle power to improve physical capacity. In addition, other general recommendations are as follows: involve the partner or caretaker; recognize on and off periods; preferentially select functional exercises; avoid dual tasking; evaluate treatment outcome every 4 weeks, to decide whether the intervention needs to be continued, adjusted, or terminated. Duration and frequency of a course of physical therapy strongly depend on the needs and potential of the patient, and on the course of the disease. For each patient treatment will focus on the main problem related to his need.
- Feasibility of technology-assisted home rehabilitation. Provided patients are given adequate instructions, they can perform the exercises on their own at home; therefore, a low treatment frequency (e.g. once a week to adjust the exercise program) is sufficient. Goals should be evaluated every four weeks and adjusted, if necessary, throughout the treatment program; information and advice should be given regularly throughout this process.
- Biological rationale and effectiveness of intensive training. There is strong evidence from the literature that goal-based and aerobic exercise might strengthen and improve motor circuitry through mechanisms that include increased synaptic strength resulting from raised dopamine and glutamate neurotransmission within the basal ganglia accompanied by increased dendritic spine formation. Exercise leads to improved brain health including increased expression of neurotrophic factors, increased blood flow, altered immune response, increased neurogenesis (especially within the hippocampus), and altered metabolism (ie, improved mitochondrial health). Such changes might lead to enhanced neuronal circuitry between the basal ganglia and its cortical and thalamic connections, which ultimately result in improved motor, non-motor, and cognitive behaviour in patients with Parkinson's disease (Petzinger et al., 2013). Both basic research and clinical studies suggest that high intensity (ie, high repetition, velocity, complexity) is a characteristic of exercise that may be important in promoting activity- dependent neuroplasticity of the injured brain, including the basal ganglia (Fisher et al., 2004), and improving motor performance (Fisher et al, 2008). This observation offers wide perspectives to the use of robot-assisted rehabilitation in the management of people with movement disorders, even in case of chronic degenerative diseases.