Photo: Therapist is Stephanie Seifert, PT, DPT. Patient/volunteer is Mary Ann Brennan.
The ability to perform seemingly simple body movements can slip away as Parkinson’s disease progresses, but paradoxically, research suggests that movement itself could be a key to staving off the speed at which the disease impacts patients’ nervous systems. At Chester County Hospital, a specialized rehabilitation program is helping patients build confidence and maintain control as they cope with the disease’s symptoms.
The initiative focuses on specific movements and balance to help patients maintain their current level of activity.
“It’s not so much halting the degeneration as delaying it,” says Boris Radisic, PT, BA, site lead for Chester County Hospital’s Physical Therapy, Rehabilitation and Sports Medicine center in Kennett Square.
Mounting evidence suggests that exercise is an effective neuroprotective therapy, which aims to slow, block, or even reverse the disease’s progression by slowing the underlying loss of dopamine neurons. Chester County Hospital’s Parkinson’s disease rehabilitation program is based on a revolutionary progression of movements developed by Becky Farley, PhD, MS, PT, at Chester County Hospital that are designed to optimize mobility and the brain’s health and even encourage new learning across all levels of disease severity.
Farley’s Parkinson Wellness Recovery program, or “PWR!,” is described as “progressive aerobics and Parkinson’s disease-specific skill training” that’s performed with “large amplitude, high effort and attention to action in multiple postures.” The regimen is also evolving. More recently, components were added to specifically address cognitive and emotional symptoms of the disease.
At Chester County Hospital, the program is six to eight weeks long. Patients typically come in at least twice a week to work one-on-one with a physical therapist. From the start, Radisic says, the idea is to restore confidence in fundamental movements that the patients felt incapable of doing independently anymore—extending and raising their arms, flicking their fingers, rolling onto their stomach and supporting themselves on all fours.
The installation of a suspension system in December has enabled a new line of bodyweight-supported exercises on and off the treadmill that are intended to facilitate easier coordinated movements.
“Parkinson’s patients end up having very small movements, rotating the trunk, walking, swinging the arms,” says John C. Gose, PT, MS, OCS, director of Rehabilitation at CCH. “The idea behind the suspension system is to allow Parkinson’s patients to do large movements in a safe way.”
While the exercises are relatively new, the suspension system’s been a part of inpatient therapy dating back to the 1940s, when it was used to treat paralysis during the polio epidemic. As part of the Parkinson's program, though, it’s intended to develop not just strength and stamina but to reinforce the memory of the movements. From that recognition and the physical ability springs a new self-confidence.
“When patients feel safe and secure, they open up a bit more,” Radisic says. “Patients get better gait dynamics and mobility, and psychologically, it is very beneficial for therapy.”
Radisic cites one patient who arrived for his first session in a wheelchair. Today, he’s getting around on his own with a walking stick.
“I’ve been working with physical therapy patients for 40 years,” Radisic says. “Historically, patients sat in a chair and therapists put some weight on them, and that was it as far as rehabilitation. Now, it’s totally different. Therapists want patients to get on a mat, to roll over. All the while, they’re learning and the brain is kind of reconfiguring itself. Being positive and encouraging every step of the way really helps, too.” Much of the change that Radisic refers to has come just over the last several years. In 2016, researchers at Penn Medicine and other institutions announced an exciting discovery: They had identified a way to determine which patients with early onset Parkinson’s disease were most likely to experience tremors, and which would experience difficulty with balance and walking.
“Parkinson’s disease looks like it has slightly different flavors. That’s how I talk about it with patients,” says the study’s senior author, Alice S. Chen-Plotkin, MD, an associate professor of Neurology at the Perelman School of Medicine and senior author. “One flavor is tremor-predominant, where a hand at rest will begin to shake involuntarily. The other is postural instability and gait difficulty (PIGD), which entails balance and talking issues. Knowing which type a patient is at the onset of Parkinson’s disease is critical in tracking the disease’s rate of progression.”
It was observed decades ago that people with Parkinson’s who experienced balance and walking trouble in the beginning had a more severe progression of the disease. More recently, though, clinicians realized that as the disease progressed, those people who initially had tremors started looking, clinically, like those with PIGD, which begged the question: Could these two “flavors” be the same? Do patients with PIGD appear as having more severe cases simply because they were later in the disease’s progression?
Chen-Plotkin’s study pinned the two “flavors” to a genetic marker that effectively provides a fixed point from which that question can now be explored. An added benefit of the study is that it also opens the door to potentially providing these people with targeted treatments, a first for a neurological disease.
“With Parkinson’s, we’re looking at people and guessing what kind of disease progression they might have,” Chen-Plotkin says. “The next phase, certainly for Parkinson’s disease and I hope for all of the neurodegenerative diseases, is going to be about finding the kind of markers that are easy to measure. Then, we could pin them to specific therapies that might be more effective.”
The cusp of something meaningful
“What we have for all the neurodegenerative diseases right now is only symptom management,” Chen-Plotkin says. “We have medications that treat the symptoms that result from the death and destruction of neurons. We don’t have any medications that slow or stop the destruction itself.”
However, a recent meta-analysis supported exercise as being beneficial to physical functioning, strength, balance, gait speed, and health-related quality of life for Parkinson’s patients. And a large study that followed 438 Parkinson’s patients found after four years that mortality was lower for the patients who exercised regularly, even for those who couldn’t walk independently.
“There’s no question in my mind that Parkinson’s patients benefit from physical therapy,” Chen-Plotkin says. “I think that what it does is, while you’re losing some systems, you’re shoring up others.”
The findings, Chen-Plotkin says, “open up the possibility of achieving a hallmark of precision medicine: targeted therapies for different ‘versions’ of what was once thought to be a single disease.”