Geert Verheyden, Annick Van Gils, Alice Nieuwboer Rehabilitation services are typically provided by a group of health care professionals, each of whom has a different health education background. Interdisciplinary rehabilitation—the collaboration and interaction between these professionals with regard to patient care—is believed to be of benefit for the patient. This chapter will present the work of physical and occupational therapists within the rehabilitation process and discuss general therapy techniques for treating the older geriatric patient, as well as specific, evidence-based therapy techniques for people with stroke and Parkinson disease. The World Confederation for Physical Therapy (WCPT) defines physical therapy as follows1: Physical therapy provides services to individuals and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan. This includes providing services in circumstances where movement and function are threatened by ageing, injury, pain, diseases, disorders, conditions or environmental factors. Functional movement is central to what it means to be healthy. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, treatment/intervention, habilitation and rehabilitation. This encompasses physical, psychological, emotional, and social well-being. Physical therapy involves the interaction between the physical therapist, patients/clients, other health professionals, families, caregivers and communities in a process where movement potential is assessed and goals are agreed upon, using knowledge and skills unique to physical therapists. The physical therapy process entails a series of steps1: (1) assessment of the patient and evaluation of the assessment within a process of clinical reasoning; (2) diagnosis and prognosis, not in terms of the underlying health condition or disease but in terms of the mainly physical consequences of the health condition of the patient; (3) intervention and treatment; and (4) reassessment in terms of the predefined outcomes. Both physical and occupational therapists work within the framework of the International Classification of Functioning, Disability and Health. This framework is based on the biopsychosocial model and considers a person with a health condition as having problems on three different levels2: (1) the body functions and structure level, (2) activity level, and (3) participation level. Additionally, contextual factors, including environmental and personal factors, affect the relationship among the three different levels. For example, a person with stroke (health condition) can have a variety of impairments (problems in body functions and structure), such as muscle weakness, sensory deficits, cognitive problems, and emotional disorders. These impairments will result in activity limitations—difficulties an individual may have in executing activities—such as the inability to walk over uneven ground and, consequently, leave the house and use public transport. Finally, the activity limitations will result in participation restrictions, which are problems that an individual may experience in life situations, such as the inability to go out with friends to a museum, movie, or theater. Contextual factors can positively or negatively influence this interaction; for example, a restrictive environmental factor would be living on the third floor without an elevator for a hemiparetic person with stroke, whereas a stimulating personal factor would be a patient having a wide network of social support. Motor rehabilitation in the field of physical and occupational therapy is underpinned by motor learning principles because motor recovery is based on motor (re)learning. The key principles of motor learning are as follows.3 Repetition is a key aspect of motor learning. Patients should be stimulated to perform exercises in subsequent series, with adequate rest breaks. This regimen should not only be applied in the face to face therapeutic setting, but also in group sessions and self-training programs. Based on a high number of repetitions, motor skills will be (re)learned and, to continue motor learning, exercises should be made more difficult and more challenging for the patient, yet still be within her or his capabilities. An exercise that is too difficult can lead to demotivation. Performing the same exercise over and over again might also lead to reduced motivation. Thus, it is important in a therapeutic setting to incorporate a variety of similar exercises to train one specific motor skill. This is a different aspect than progression in that variation of an exercise does not mean that the difficulty of the exercise increases. Exercises performed in a therapeutic setting will lead to improvement in that specific exercise. For example, if balance has to be improved, therapy should primarily be focused on performing balance exercises. There is little to no evidence in the rehabilitation literature that exercises have what is called a carryover effect. For example, this would mean that a muscle-strengthening exercise on its own will improve walking. This implies that therapy should mainly consist of performing functional exercises to improve functional activities. Conducting exercises without a clear goal or aim are meaningless for patients and, again, can reduce motivation. Thus, therapists should incorporate specific goals for all the exercises conducted in a therapeutic session. The patient should be provided with feedback about the performance of the exercise—how the movement was conducted—and the actual result, if the goal was achieved. This is called knowledge of performance and knowledge of result, respectively. This example is presented to clarify the incorporation of these motor learning principles for an older adult who has difficulty standing up from a chair. Based on the visual movement analysis and assessment, it appears that the trunk is not moving sufficiently far forward to bring the body weight forward to transfer the body weight (center of mass) over the feet (base of support). The therapist can use a standardized measurement, which includes a sit-to-stand movement to assess the current state and subsequently to evaluate progress during and after treatment. A measurement that could be used is the five times sit-to-stand test (timed test) or, if the person is still able to walk, the timed get-up-and-go (TGUG) test. An exercise for this patient could be to perform sit-to-stand movements with a little knee-high box in front of him or her. The person should, while standing up, bring the hands in front and touch the box with the hands. Touching the box with the hands is a goal-oriented movement; the exercise is also task-specific because sit-to-stand is specifically designed for this person. It can be varied by performing the same exercise from a different chair (with and without an arm rest or back rest) or sofa, as is necessary in daily life. Progression is incorporated by moving the box further forward; this would require a greater forward leaning posture when touching the box before being able to stand up. Alternatively, the seat height could also be lowered systematically, because this would make the overall sit-to-stand more difficult. The person has to perform these sit-to-stands eight to ten times, if possible, after he or she rests for 30 to 60 seconds, with a total of three to five series conducted before variation or progression is incorporated. Finally, feedback is provided by the therapist (orally) about the performance and result. The person also receives feedback when touching the box, knowing that there was an adequate forward lean and knowing performance, and when standing up, knowing that a successful sit-to-stand was conducted and knowing the result. Veerbeek and colleagues have recently published a systematic review and meta-analysis of the evidence for physical therapy poststroke.4 This was an update of the 2004 study of Van Peppen and associates,5 which included 123 randomized controlled trials in the field of physical therapy poststroke. The updated review included 467 randomized controlled trials involving 25,373 patients. More importantly, the quality (risk of bias) of physical therapy trials improved over the last decade; the median PEDro score (http://www.pedro.org.au) improved from 5 of 10 in 2004 to 6 of 10 in 2014. Evidence-based therapy techniques will be discussed based on the recent review4 for the following domains: gait and mobility-related function and activity, arm-hand activities, and physical fitness. Only (positive or negative) results from meta-analyses or phase III randomized controlled trials will be presented. For more information, the reader is directed to Verbeek and coworkers’ report.4 Reaching activities in sitting beyond arm’s length have a significant positive effect on sitting balance. Practicing standing balance with biofeedback has a significant positive effect on postural sway. Balance training has a significant positive effect on balance and activities of daily living (ADLs). Body weight supported treadmill training demonstrates a significant positive effect on comfortable gait speed and walking distance. Electromechanical gait training leads to a significant positive effect on maximum gait speed, walking distance, peak heart rate, and ADLs. Incorporating functional electrical stimulation with electromechanical gait training has a significant positive effect on balance and walking capacity, but only in the early rehabilitation phase (<3 months poststroke). Treadmill training has a significant positive effect on maximum gait speed and step width. Walking overground (as frequently done in regular face to face physical therapy sessions) demonstrates only a significant positive effect on fear. It has a significant negative effect on aerobic capacity in people unable to walk. Circuit class training has a significant positive effect on walking distance, balance, walking capacity, and physical activity. Training of the caregiver by the physical therapist demonstrates a significant positive effect on ADLs and caregiver strain. Hydrotherapy has a significant positive effect on muscle force. Neuromuscular electrostimulation has a significant positive effect on motor function, muscle force, and muscle tone. Finally, transcutaneous electrical nerve stimulation (TENS) shows a significant positive effect on muscle force and walking capacity. Positioning of the arm shows a significant positive effect on passive range of motion for outward rotation of the shoulder. The use of inflatable splints has a significant negative effect on muscle tone in the early rehabilitation phase (<3 months poststroke). The original constraint-induced movement therapy (CIMT) concept demonstrates a significant positive effect on arm-hand activities and self-reported use and quality of the arm and hand. In the original CIMT concept, therapy is provided for 2 weeks, with the patient wearing a padded mitt over the unaffected hand for 90% of her or his waking hours to stimulate use of the affected hand. Additionally, during these 2 weeks, 6 hours of therapy is given daily. High-intensity CIMT (therapy provided from 3 to 6 hours daily) has a significant positive effect on arm-hand activities and self-reported use and quality of the arm and hand. Low-intensity CIMT (wearing the padded mitt between zero and 90% of the waking day and receiving from 0 to 3 hours of therapy daily) also has a significant positive effect on motor function, ADLs, arm-hand activities, and self-reported use and quality of the arm and hand. Robot-assisted training focusing on the shoulder and elbow demonstrates a significant positive effect on proximal motor function, muscle force, and pain. Robot-assisted training focusing on the elbow and wrist has a significant positive effect on proximal motor function and muscle force. Interestingly, a meta-analysis of trials investigating robot-assisted training focusing on the shoulder, elbow, wrist, and hand did not show any significant effect. Mental practice has a significant positive effect on arm-hand activities. Virtual reality training demonstrates a significant positive effect on ADLs, but a significant negative effect on muscle tone—the meta-analysis showed an increase in muscle tone. Neuromuscular stimulation for the flexors and extensors of the wrist and fingers has a significant positive effect on motor function and muscle force. Neuromuscular stimulation of the shoulder has a significant positive effect on a subluxation. Electromyography (EMG)–triggered neuromuscular stimulation of the extensors of the wrist and fingers demonstrates a significant positive effect on motor function, arm-hand activities, and active range of motion. The use of trunk restriction to promote upper limb movement has a significant negative effect on self-reported arm and hand use. Finally, somatosensory stimulation demonstrates a significant positive effect on somatosensory function and muscle tone. Fitness training focusing on the lower limb has a significant positive effect on muscle force, muscle tone, and spatiotemporal gait parameters. Interestingly, a meta-analysis of fitness training focusing on the upper limb did not show significant effects. Training of aerobic capacity demonstrates a significant positive effect on aerobic capacity and respiratory function. A mixed fitness approach (muscle force and aerobic training) has a significant positive effect on lower limb motor function, lower limb muscle force, comfortable and maximum gait speed, walking distance, aerobic capacity, heart rate at training, balance, physical activity, and quality of life. The review4 also reported that a statistically significant effect on outcome can be seen if an increase in therapy time of, on average 17 hours over a number of weeks, was included. The effect size ranged from 5% to 15%; with a typical measurement error for clinical outcomes of around 10%, several statistically significant results are in the measurement error interval. As a result, this was not a true reflection of change in the patient’s performance. Future research should therefore focus on combining effective therapy approaches and evaluating whether effect size improves due to the combination of approaches. Parkinson disease (PD) is a highly prevalent condition in those older than 60 years.6,7 Age-specific prevalent rates indicate that PD is present in 1% of those older than 60 years, rising to 4% in the oldest age groups.6 Although mortality is significantly increased versus age-matched controls (by ≈1.5) and disease progression varies greatly, mean disease duration is estimated to be from 6.9 to 14.3 years.8 The basal ganglia are the central nervous system structures affected by PD, so patients lose the ability to move automatically. This overarching automaticity deficit can be defined as the ability to perform a motor task while at the same time focusing on executing an additional task.9 Loss of automaticity implies that patients find it difficult to maintain movement amplitude, rhythm, balance, and postural tone without consciously attending to movement activity. As a consequence, dual task interference is exacerbated in PD, over and above that seen as a result of aging.10 Another correlate of dual task interference, constituting a particularly bothersome problem of PD, is freezing of gait (FOG). FOG is defined as a brief episodic absence or marked reduction of forward progression of the feet, despite the intention to walk.11 FOG often occurs during starting to walk, when almost reaching the intended destination, and during turning. FOG is a very disabling symptom and severely curtails functional independence.12 Other debilitating symptoms of PD include rigidity, bradykinesia, and postural instability. The varied ways in which these symptoms present themselves in different patients determines the heterogeneity of the gross motor dysfunction, gait impairment, and fine motor deficits inherent to PD.13 PD symptoms can only partially be relieved by medical treatment and, with disease progression, induce a significant loss of functional activity.14 Patients with PD have a lower level of physical activity than healthy older adults, not only resulting from motor15,16 but also from cognitive decline,17 including executive dysfunction,18 mood disturbance, depression, and fatigue.19 A sedentary lifestyle threatens overall physical capacity, exaggerates signs of frailty, and increases the risk of comorbidity.15 Secondary changes associated with PD include cardiovascular and respiratory problems but also osteoporosis in early to mid-stage disease,20 as well as contractures, bed sores, and pneumonia in later stages of the disease.21 Falls in people with PD occur frequently and recurrently22 and are particularly common with increasing disease duration, age, and cognitive impairment.23,24 The basal ganglia are also crucially involved in motor learning, particularly during the consolidation phase.25 Therefore, the most important challenge that physiotherapists face is to use the most optimal strategies to deal with PD patients’ lack of movement automaticity and inherent difficulty with motor learning retention. Physical therapy has the potential to modify the risk factors of inactivity and falling in PD.15,26 Tomlinson and colleagues27 have published a systematic review and meta-analysis based on randomized controlled trials that included 39 trials with 1827 patients. This high-quality evidence demonstrated overall efficacy of physical therapy in the short term (mean follow-up, 3 months). More specifically, significant benefits of exercise interventions were found for gait speed, 6-minute walk test, FOG score, and TGUG test. In addition, positive effects of physical therapy were demonstrated on the functional reach test, Berg balance scale, and unified Parkinson disease ratings scale (UPDRS) motor scores. Most of the observed between-group changes were small, but three outcomes (gait speed, Berg balance, and UPDRS) showed clinically meaningful improvements, approaching or beyond the minimal detectable change threshold. No effects of physical therapy were found on patient-rated quality of life or on fall frequency. This comprehensive review also did not show differential treatment effects among various types of physical therapy interventions. Current thinking about which components of a physical therapy program are most optimal for PD point to exercise on the one hand and goal-directed motor learning on the other, despite the known learning limitations.28,29 Because patients with PD are particularly sensitive to external motor drive due to their loss of automaticity, various methods of external pacing (or cueing), visual targets, and visual feedback are recommended to enhance practice and learning.28 Exercise for PD usually incorporates a mixture of repetitive practice to optimize physical activity, increase strength, and prevent secondary consequences, such as loss of flexibility and fitness. Usually, exercise is embedded in functionally relevant movements to optimize transfer to ADLs. For example, PD patients in all disease stages exhibit difficulties in rising from a chair.30 The inability to stand up from a seated position prohibits engaging in upright activities such as walking, thus reinforcing the vicious circle of physical deconditioning and functional deterioration. The sit-to-stand task involves large muscle work from the trunk and lower limbs and is therefore a valuable exercise to increase fitness, postural control, and leg muscle strength. Sit-to-stand has proved as trainable for those with PD as for age-matched controls by using repetitive muscle work and biofeedback.31 Most recent publications indicate that there is an important role for progressive resistance training in PD.32,33 These studies have shown that twice-weekly, supervised, progressive strength training continued for 2 years induce strength increases and functional improvements, overruling the deterioration predicted by disease progression. Generally, evidence is lacking about what the optimal dose and intensity of exercise intervention should be, particularly in a geriatric setting. Currently, clinical advice on exercise is guided by age, health status, disease stage, and general World Health Organization’s guidelines for exercise.34 As was demonstrated by the progressive resistance training studies,32,33 it is as important in PD as in other populations that the intensity of exercise be appropriately set and progressed to achieve physiologic adaptations. Furthermore, maximizing the intensity of exercise in a PD-specific way can be achieved by prompting patients to move with large amplitude and optimal speed.35 PD patients’ needs vary according to the different stages of the disease. In the early stages, interventions can still aim at motor learning, stimulating consolidation and automaticity. A review of 11 motor learning studies36 has shown that the capacity for motor learning of novel tasks remains relatively preserved in PD. This applied to well-defined discrete movements of upper and lower limbs as well as balance maneuvers, postural sequences, and obstacle stepping performed in a laboratory-based environment. Interestingly, most acquisition slopes were similar in PD to those in healthy age-matched controls, although final performance never reached healthy control levels. However, retention of learning, although sometimes preserved in PD for up to 2 months, was also impaired and appeared more dependent on the learning condition. The close relationship between practice context and retention effects emphasizes the importance of training functionally relevant tasks if the goal is to implement the learned tasks in daily life. In the later stages, and in some specific patient subgroups in which motor and cognitive deterioration is more advanced, the generalization of learning will be affected even more, and the use of compensation strategies will become more crucial. Most patients experience symptom fluctuations. Motor learning and exercise are best applied during the “on” phase of the medication cycle—when medication works best. Strategies to tackle FOG or bed transfers need to be practiced during the off phase as well, when medication is working suboptimally.
Rehabilitation
Evidence-Based Physical and Occupational Therapy Techniques for Stroke and Parkinson Disease
Introduction
Physical Therapy
General Physical Therapy Techniques
Key Principles
Intensity.
Progression.
Variation.
Task Specificity.
Goal-Oriented.
Feedback.
Incorporation of Motor Learning Principles
Evidence-Based Physical Therapy Techniques
For Stroke
Gait and Mobility-Related Function and Activity.
Arm-Hand Activities.
Physical Fitness.
For Parkinson Disease
Effects of Physical Therapy.
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