Rehabilitation of multifunctional disorders in Parkinson's disease

Parkinson's disease (PD) is a slowly progressive neurodegenerative disease that is common in middle-aged and elderly people, characterized by progressive degeneration of dopamine neurons in the substantia nigra of the midbrain and multi-system involvement. The main clinical manifestations of PD are motor symptoms such as bradykinesia, resting tremor, muscle rigidity, and posture and gait disorders, as well as non-motor symptoms such as cognitive and emotional disorders, sleep disorders, abnormal bowel movements, pain, and fatigue.

The symptoms of PD are complex and diverse, often leading to various degrees of functional impairment, seriously affecting patients' ability to carry out daily activities, resulting in a decline in quality of life and loss of work ability.

At present, drug therapy is still the main treatment for PD, while rehabilitation therapy is believed to improve the various functional disorders of PD patients, improve their ability to take care of themselves, and even delay the progression of the disease. The "Chinese Expert Consensus on Parkinson's Disease Rehabilitation" summarizes the standardized assessment and rehabilitation methods of PD functional disorders, promotes the popularization and development of PD rehabilitation, and better improves the quality of life of patients.

The motor symptoms and non-motor symptoms of PD patients cause a series of functional impairments of varying severity. Rehabilitation therapy mainly targets the functional impairments of patients, so a comprehensive assessment of the functional impairments of patients should be conducted to determine the types, severity and causes of the various functional impairments of patients, so as to formulate objective and individualized rehabilitation goals and plans, and conduct targeted and precise rehabilitation treatment. The PD rehabilitation process based on ICF classification is shown in Figure 1.

Figure 1 PD rehabilitation flow chart based on ICF classification

* Assessment of PD functional impairment

1. Assessment of Disease Severity

The Hoehn-Yahr (HY) staging scale can be used to roughly stage the severity of the disease. The scale is divided into 1 to 5 stages according to the symptoms and severity of PD patients, among which the early stage of PD refers to HY stage 1 to 2, the middle stage refers to HY stage 3 to 4, and the late stage refers to HY stage 5.

The MDS Unified Parkinson's Disease Rating Scale (MDS-UPDRS) can be used to conduct a comprehensive and detailed assessment of the severity of the disease, including four parts: non-motor symptoms of daily life, motor symptoms of daily life, motor function tests, and motor complications.

2. Assessment of motor dysfunction

Movement dysfunction can be divided into two categories: primary and secondary. Primary disorders are caused by the disease itself, while secondary disorders are usually caused by factors such as reduced activity or even immobility (mainly disuse syndrome) or side effects of PD drugs.

1. Assessment of somatic motor dysfunction

① Assessment of primary dysfunction

The corresponding items of the MDS-UPDRS Part III motor function examination subscale (MDS-UPDRSⅢ) are mainly used to assess bradykinesia, rigidity, postural balance disorders, gait abnormalities and hand function activity disorders.

The above assessment should be carried out separately during the "on" period and the "off" period.

② Assessment of secondary sexual dysfunction

Disuse muscle atrophy and weakness often occur in the core muscles of the trunk, such as the abdominal muscles and back muscles, as well as the large proximal muscles of the limbs. The muscle strength can be assessed by manual muscle testing (MMT) or quantitatively assessed by isokinetic and isometric muscle testing instruments.

Limitation of joint range of motion (ROM) can be measured visually and with a protractor;

For physical decline, 6MWT, Borg Scale 6-20 and FTSTS can be used for assessment.

2. Assessment of speech disorders

The main manifestation is hypokinetic dysarthria. It is recommended to use the modified Frenchay dysarthria assessment method (mFDA) for assessment.

3. Assessment of dysphagia and drooling

① Swallowing disorder

The oral and pharyngeal phases are mainly affected, which is manifested as slow chewing and swallowing. The water drinking test (WST) or repeated saliva swallowing test (RSST) is often used for rapid screening. For those who screen positive, a more intuitive and reliable examination should be performed using a video fluoroscopic swallowing function test (VFSS) or a fiberoptic endoscopic swallowing function test (FEES) if conditions permit.

② Drooling

The drooling severity and frequency scale (DSFS) and the SCS-PD drooling scale can be used to assess the severity of drooling.

3. Assessment of non-motor dysfunction

The PD Non-Motor Symptom Questionnaire (NMSQuest) is usually used for screening, and the PD Non-Motor Symptom Rating Scale (NMSS) is used for overall assessment. If necessary, specific rating scales can be used to further assess various functional disorders.

1. Cognitive dysfunction

The cognitive dysfunction of PD patients is mainly manifested in attention, execution, memory and visual space dysfunction. The Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) are often used for screening. The Parkinson's Disease Cognitive Outcome Scale (SCOPA-COG), Parkinson's Disease Cognitive Rating Scale (PD-CRS) and Mattis Dementia Rating Scale (MDRS) can be selected for comprehensive assessment.

2. Mood disorders

The Beck Depression Inventory (BDI), Beck Anxiety Inventory (BBAI), Hamilton Depression Rating Scale (HAMD) and Hamilton Anxiety Rating Scale (HAMA) were used to assess the severity of depression.

3. Sleep disorders

The Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Parkinson's Disease Sleep Scale (PDSS) and Rapid Eye Movement Sleep Behavior Disorder Questionnaire (RBDQ) can be selected for assessment. Polysomnography (PSG) monitoring should be performed when conditions permit.

4. Pain

The brief pain rating scale (BPI), simplified McGill pain questionnaire (SF-MPQ) and visual analogue scale (VAS) can be used for assessment.

5. Postural hypotension

The commonly used method for measuring blood pressure in the supine and standing positions is to measure blood pressure in the supine position and 1 minute, 3 minutes, and 5 minutes after standing up.

6. Bowel and bladder disorders

Catheterization and bladder ultrasound can be used to measure residual urine volume in patients with urinary retention. Urodynamic testing is recommended to clarify lower urinary tract dysfunction.

7. Fatigue

The Fatigue Severity Scale (FSS) is the preferred choice, and the Parkinson's Disease Fatigue Scale (PFS) and Multidimensional Fatigue Inventory (MFI) can also be used for assessment.

4. Assessment of daily living activities

The modified Barthel Index (MBI) is often used to assess basic activities of living (BADL) such as washing, bathing, dressing, toileting, transfers, bladder and bowel control, eating, etc.; the Functional Independence Scale (FIM) is often used to assess BADL and cognitive function; the Functional Activity Questionnaire (FAQ) is often used to assess instrumental activities of living (IADL) such as riding, shopping, cooking, housework, etc.

V. Assessment of Participation Ability and Quality of Life

The 39-item Parkinson's Disease Quality of Life Questionnaire (PDQ-39) and the Short Form Health Survey (SF-36) can be used to assess health-related quality of life.

*Rehabilitation treatment for PD

The purpose of rehabilitation therapy: On the basis of drug treatment, strengthen self-management and participation, delay disease progression to the maximum extent, improve various functional disorders, improve functional independence and overall adaptability, minimize secondary disorders and various complications, improve ADL, and ultimately improve the quality of life of PD patients.

Rehabilitation treatment should be tailored to the individual. Individualized rehabilitation goals and targeted rehabilitation treatment measures should be formulated based on the severity of the PD patient's disease and the types and degrees of various functional disorders that exist.

For early-stage patients, self-management and the promotion of an active lifestyle are the main focus. Participation in sports, such as brisk walking, Tai Chi, yoga, and dance, as well as moderate aerobic training (such as activity treadmills), resistance training, and dual-task training are encouraged to improve physical fitness, reduce daytime sitting, and delay the occurrence of activity restrictions. For mid-stage patients, active functional training is the main focus, maintaining or improving mobility and preventing falls, especially balance, gait, and upper limb functional activity training; psychological prompts, external prompts, and cognitive motor strategies can be used.

For patients in the advanced stage, the main focus is on maintaining the functions of important organs such as the heart and lungs, while avoiding complications such as pressure sores, joint contractures, and venous thrombosis. Posture changes in bed or wheelchairs are performed in a timely manner, as well as assisted active exercise training.

1. Motor Function Rehabilitation

1. Rehabilitation of body movement function

①Basic rehabilitation training methods

a Relaxation training: Deep breathing and imagination relaxation are commonly used. Rhythmic trunk rotation and massage can improve stiff muscles.

b Joint range of motion training: Perform full range of active or passive motion of the trunk and limb joints, with emphasis on stretching the flexor muscles and expanding the thorax. Be careful to avoid excessive stretching and pain.

c Muscle strength training: focus on training the core muscles and proximal muscles of the limbs. Progressive resistance training can be performed using techniques and equipment.

d Posture training: The focus is on correcting the trunk flexion posture, such as using a posture mirror to perform anti-gravity stretching training.

e Balance training: includes three levels of balance training in sitting and standing positions (level one static, level two self-dynamic and level three other-dynamic balance). The difficulty of training can be adjusted by the height of the center of gravity, the size of the support surface, and opening and closing of eyes. Training can also be carried out with the help of balance boards, balance pads and balance instruments.

fGait training: The focus is on correcting the forward leaning posture of the trunk and improving the panic gait caused by chasing the body's center of gravity. It is recommended that patients keep their heads up and chests out when walking, and touch the ground with their heels first. They can use a posture mirror to perform high-leg stepping and upper limb swinging exercises to improve the coordination of the upper and lower limbs. The difficulty of walking training can be adjusted by increasing the stride, increasing the walking speed, crossing obstacles, walking around obstacles, and changing the walking direction.

g Transfer training: including turning over and translating in bed, sitting up beside the bed, sitting up and bed-chair transfer. Late-stage patients should turn over in bed regularly and can do bed-chair position change training.

h Hand function activity training: Focus on training in reaching, grasping and manipulating objects to improve the speed, stability, coordination and accuracy of activities. For example, drinking water from cups of different sizes, shapes, weights and materials (paper cups and glasses, etc.), using various tableware and buttoning, etc.

②Specific rehabilitation training methods

Dual-task training usually involves walking while performing another motor or cognitive task, such as holding a cup full of water while walking (walking and carrying dual task), or walking while saying words that begin with the character “发” (fa) (walking and speech fluency dual task).

In the early stages of the disease, PD patients have only mild impairments in dual tasks and should be encouraged to conduct dual-task training to gradually increase the difficulty of the training and improve the ability to perform dual or several tasks simultaneously.

In the middle and late stages, dual tasking often significantly affects the quality of activities or tasks, and dual tasking should be avoided or reduced as much as possible to allow the child to focus on performing the current activity or operational task.

Motor strategies include psychological prompts, external prompts, and cognitive motor strategies. Task specificity is emphasized during training. It is best to train in situations where PD patients have limited mobility, preferably in such situations or to imitate such situations as much as possible.

The exercise strategy training method is as follows:

aPsychological prompting strategy training: requires the patient to consciously focus on the current task to improve motor performance. For example, the patient is required to learn to take big steps when walking, turn big corners when turning, and write big characters when writing.

bExternal prompt strategy training: Using external prompts such as vision, hearing, proprioception or touch can help patients start or continue exercise, which helps to improve starting difficulties and freezing gait. Auditory prompts can be rhythmic marches, metronomes or commands; visual prompts are mainly lines similar to zebra crossings, tiles on sidewalks or floor patterns; proprioception prompts are usually rhythmic vibrations of vibrating wristbands.

c Cognitive motor strategy training: also known as complex motor sequence training, refers to breaking down complex movements into multiple simple steps, allowing patients to concentrate and complete these movements step by step in order to improve the difficulty of executing complex movements, especially the ability to transfer. Targeted training is carried out through guidance and demonstration, and patients are encouraged to rehearse these steps through motor imagination and mental rehearsal before starting the movement or completing the task.

2. Speech function training

The focus is on training the respiratory system (abdominal and thoracic breathing), vocal system (vocal cords and larynx) and tuning system (lips, tongue, teeth, jaw and soft palate, etc.) for speech production, improving sound intensity, pitch and sound quality to improve speech clarity.

① Breathing training

Breathing training is used to enhance the range of motion of abdominal breathing (diaphragm) and thoracic breathing (intercostal muscles). For example, repeated deep breathing training can increase the expansion of the chest; increase the volume by increasing vital capacity; and increase the length of speech by extending the exhalation time.

②Voice training

Leeds-Schiffman Voice Therapy (LSVT) is considered to be a specific and effective voice therapy technique for PD. It improves voice intensity, pitch, and voice quality through training the control of the vocal cords and larynx and prolonging the maximum sustained phonation time of vowels.

③Tuning training

Emphasis is placed on motor training of oral and facial muscles (such as lips and tongue) and other vocal organs to improve stiffness, increase mobility, movement coordination and pronunciation clarity.

3. Swallowing function rehabilitation

The purpose is to improve the speed and coordination of swallowing muscle movements, strengthen the perception of the swallowing organs, so as to safely, fully and independently ingest sufficient nutrition and water, and improve drooling.

①Main methods

Oral phase disorders mainly involve motor function training of lips, tongue and mandible. Pharyngeal phase disorders mainly involve voice training, which strengthens vocal cord closure, prolongs exhalation time, and improves breathing control, thereby achieving supraglottic swallowing, improving coughing ability, and reducing the risk of aspiration.

② Targeted strategy

For patients with mild dysphagia who occasionally cough when drinking water, it is recommended to use thickeners and other methods to change the properties of food, choose semi-fluid food with uniform texture that is not easy to cause aspiration, or reduce the amount of food eaten at one mouthful; for patients who chew for too long and/or leave food in the mouth without swallowing or swallowing slowly, prompt them to swallow consciously according to the steps, and make appropriate compensation by swallowing repeatedly with continuous efforts or retracting the lower jaw when trying to swallow (nodding swallowing), increase the swallowing force, and reduce the food residue in the pharynx.

Patients with obvious drooling should be reminded to fully close their lips and increase the frequency of swallowing saliva. Severe drooling can be treated with salivary gland botulinum toxin injection. For patients with severe dysphagia and obvious risk of aspiration or insufficient food intake, tube feeding should be used as early as possible. Nasogastric tube feeding can be used in the short term, and percutaneous endoscopic gastrostomy feeding is recommended for the long term.

2. Non-motor function rehabilitation

1. Cognitive rehabilitation

The purpose is to improve the individual's cognitive level, compensate for cognitive damage or develop adaptive methods to improve the ability to take care of oneself. The main methods include cognitive training, cognitive stimulation and exercise training. Cognitive training mainly conducts functional training such as attention, execution and visual space. Combining the training content with daily life and work tasks can better promote the improvement of cognitive function. Cognitive stimulation is to let patients participate in a series of group activities and discussions, which can improve patients' cognitive function and social function. Exercise training has a promoting effect on cognitive function, such as riding a bicycle, treadmill and progressive resistance training. Combining cognitive training with exercise training has a more obvious effect on improving cognitive function.

2. Emotional recovery

Commonly used cognitive behavioral therapy changes negative cognition by changing thinking/beliefs and behaviors, thereby eliminating negative emotions and behaviors. Rational emotional behavioral therapy changes irrational beliefs to achieve the effect of changing and controlling emotions and behaviors.

3. Sleep rehabilitation

Individualized treatment should be carried out according to the cause and type of sleep disorders in PD patients. Common rehabilitation methods for insomnia include stimulus control therapy and sleep restriction therapy. Stimulus control therapy focuses on improving the interaction between the sleeping environment and sleepiness, restoring the role of bed rest as a sleep-inducing signal, and making it easier for patients to fall asleep. Sleep restriction therapy aims to break bad sleeping habits, reduce non-sleep behaviors in bed, cause mild sleep deprivation, re-establish the conditioned reflex between bed and sleep, and improve sleep efficiency.

4. Pain rehabilitation

PD pain takes many forms, with skeletal muscle pain being the most common. Depression can induce and aggravate Parkinson's disease-related pain. In addition to causal treatment, physical factor therapy (such as hydrotherapy, thermotherapy), Chinese massage, and regular physical exercise can relieve pain. Analgesics can be used in combination if necessary.

5. Urinary function rehabilitation

The main rehabilitation methods for urinary incontinence include pelvic floor muscle voluntary contraction training or biofeedback training to enhance pelvic floor muscle strength and improve urine control ability; bladder expansion training to extend the interval between urination as much as possible to gradually expand the bladder capacity; when urine is retained, it is recommended to drink water at regular intervals or to use clean intermittent catheterization.

6. Rectal function rehabilitation

Mainly carry out abdominal muscle and pelvic floor muscle exercise training; develop a habit of regular bowel movements and gradually establish a defecation reflex; or induce the rectal-anal reflex through rectal stimulation to promote peristalsis of the colon, especially the descending colon.

7. Postural Hypotension Rehabilitation

It mainly involves body stress-resistant movement training, including crossing legs, squatting, bending forward, etc.; using abdominal belts and wearing compression stockings, etc.; raising the head of the bed 30°~40° when resting or sleeping, etc.

8. Fatigue recovery

Exercise, such as treadmill training, can improve fatigue, but rest does not necessarily relieve fatigue. Appropriate temperature can reduce fatigue in PD patients, but there are individual differences.

3. Other rehabilitation techniques

1. Neuromodulation therapy

Deep brain stimulation (DBS) can improve PD motor symptoms, some non-motor symptoms and motor complications. It is currently the main means of neuromodulatory treatment for PD. For specific indications and target selection, please refer to the Chinese Expert Consensus on Deep Brain Stimulation Therapy for Parkinson's Disease.

Non-invasive neuromodulation technologies mainly include repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), which can improve bradykinesia and freezing of gait, improve dyskinesia, improve speech clarity, improve cognitive disorders such as working memory and executive function, and relieve mood disorders such as depression, pain, and insomnia.

Biofeedback training, including biofeedback training of multiple physiological indicators such as electromyography, respiration, skin resistance, heart rate variability, etc., can improve muscle stiffness, insomnia, mood disorders, etc.; pelvic floor muscle biofeedback training can improve bowel and bladder disorders and sexual function.

2. Virtual Reality (VR)

Virtual reality technology can improve patients' gait, balance, mood, sleep, cognition and other functional disorders through interactive scenarios with different levels of immersion.

3. Traditional Chinese Medicine

Acupuncture, Tuina, massage and Chinese medicine treatment have good effects on various non-motor symptoms of PD.

IV. Comprehensive rehabilitation management

The purpose is to improve the patient's daily living activities and ability to participate in family and society through health education, advocating an active lifestyle, optimizing daily structure and activities, modifying the home environment and using assistive devices, and ultimately improving the patient's quality of life.

1. Health education

By providing PD patients with specific, scientific and practical health education guidance, the quality of life of PD patients can be significantly improved, enabling patients to actively cooperate with treatment with a positive and healthy attitude and reduce the occurrence of uncontrolled behaviors.

2. Promote an active lifestyle

A home training plan should be developed based on the patient's degree of functional impairment and sports preferences, so that he or she can participate in the sports he or she likes. This can significantly improve motor function and self-care ability, improve mood and sleep quality, and improve quality of life and social interaction ability.

3. Relieve tension and time pressure

Through stress management, learning relaxation techniques and principles of time management, reducing time pressure when planning and organizing activities, and guiding PD patients to carry out activities in a relaxed manner.

4. Optimize your daily activities

The activities selected should match the patient's interests and motivations and be appropriate to the patient's functional and physical fitness level. Prioritize activities and develop a structured daily or weekly activity plan that can serve as an external guide and prompt.

5. Home environment modification and use of assistive devices

The use of assistive devices, adaptive tools, and environmental modifications can compensate for patients’ cognitive and motor difficulties, reduce the number of falls, improve the quality of completing various operations and tasks, and make family life more independent and safer [73-75]. They can also reduce the burden on caregivers and make nursing work less laborious. For example, rearranging the furniture in the room to create an unobstructed walking and turning route; or raising the height of the bed/chair/sofa and raising the toilet to facilitate patient transfer.

6. Late-stage rehabilitation care

The treatment goal for patients with advanced PD is to protect the function of important organs, prevent complications and disuse syndrome, and improve the quality of life as much as possible. Exercise and movement strategies may still be effective, and exercise should be actively supported to minimize further decline in physical fitness; maintain correct body posture in bed or wheelchair, and get out of bed and sit in a wheelchair or chair as much as possible.

5. Precautions for rehabilitation of PD patients

Patients should exercise and learn new motor skills during the period of the day when they are in better condition (the "on" period); and use and practice the motor strategies and skills they have mastered to improve limited activities during times and environments with limited functions (such as the "off" period or at home), while ensuring safety.

Rehabilitation training should follow the principles of individualization and targeting, and appropriate intensity training should be given, with each training lasting 30 to 60 minutes, 1 to 2 times a day, and more than 5 times a week.

It may be normal to feel tired and sweat during exercise, but you should stop training and seek medical attention immediately if the following situations occur: nausea, chest tightness, chest pain, shortness of breath (such as more than 40 times per minute), dizziness or vertigo, tachycardia, pain, cold sweat or severe fatigue, etc.