Directing Rehabilitation Approaches

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Therapists may choose from a variety of treatment approaches and strategy. These include treatments that target problems at the impairment or functional level, and interventions that aim to restore to a previous level of functioning or compensate for loss of previous healthy functioning. Although the literature on rehabilitation with patients with PD is not yet adequate to establish comprehensive evidenced-based guidelines, the growing body of evidence supports the efficacy of rehabilitation and suggests approaches that rehabilitation teams may use in patients with idiopathic PD and APDs. Consistent themes that arise from the research in idiopathic PD include improvements in walking ability and ADL status following rehabilitation targeting these functional areas. Task-specific training at the functional level appears to be a critical ingredient. Studies of other neurologic disorders support the notion that performance of tasks improves in relation to direct task practice (16,17). Furthermore, Lin and colleagues suggest the adult neurological population is more likely to put effort into purposeful everyday tasks, as opposed to tasks perceived as nonpurposeful or less meaningful (18).

The lack of effect of rehabilitation at the impairment level in patients with PD suggests that rehabilitation programs aimed at reducing rigidity, tremor, and other PD impairments are less likely to lead to changes in functional status. However, indirect impairments such as flexibility, range of motion, strength and cardiorespiratory status may benefit. Interventions targeting these indirect impairments yield improvements in function and quality of life.

The choice of restorative vs compensatory strategies can vary among individuals, for different treatment goals and at different times in the progression of the disease. The success of restorative approaches is in part linked to improvement at the indirect impairment level. For example, as axial mobility of the spine improves with treatment aimed at increasing range of motion, the patient's ability to get out of bed in a way that resembles premorbid performance of the task also improves. If underlying impairments do not improve significantly enough to allow successful use of previous movement patterns in the functional task, a compensatory approach may be required to improve function. For example, if axial mobility remains limited, a new strategy relying less on spinal mobility may be introduced to compensate for a loss of mobility. In this case, successful completion of the task can still occur by adopting this new strategy. In idiopathic PD, a combination of restorative and compensatory strategies is often implemented to improve function and quality of life. In early PD, when medications are most effective in treating direct impairments and indirect impairments are most amenable to change with rehabilitation, a restorative approach is often successful. As the disease progresses, fewer changes at the impairment level are expected and a greater emphasis on compensatory strategies to improve function should be adopted. In APDs, the impact of intervention on impairments is usually less than that expected in idiopathic PD. The effect of medication on the reduction in direct impairments, such as rigidity, and indirect impairments, such as spinal mobility, are often less than what is expected in idiopathic PD. In order to improve function in those with APDs, a compensatory approach at the functional level is usually necessary. For example, if a patient with an APD is having difficulty rising from a chair, adopting a strategy using momentum or counting may improve ability to perform the task. In addition, changing the environmental conditions such as raising the height of the chair or using a chair with arm rests is often a successful compensatory strategy.

In summary, indirect impairments have the potential to be modified but greater changes would be expected to occur in the idiopathic PD population compared to the APD population. Frequent reassessment to evaluate the degree of change is necessary to help steer or adjust treatment direction. Several studies support the effectiveness of task specific practice at the functional level to yield improvements in functional status in patients with PD. A restorative approach may be successful when underlying impairments are amenable to improvement; otherwise compensatory approaches in strategy and environmental constraints may yield the greatest changes in functional status and quality of life.

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