Fig 1. Disability model with direct and indirect impairment.
tary lifestyle over time. For example, in APDs, the presence of axial rigidity often leads to indirect impairments such as loss of range of motion into spinal rotation and extension. Indirect impairments such as poor endurance may evolve because of a decline in activity level as the disease progresses. Functional limitations include limitations in performance at the level of the whole person such as walking, moving in bed, rising from a chair, and handwriting. Disability refers to limitations in performance of socially defined roles and tasks including work, travel, and other leisure or recreational activities. (See Fig. 1.)
The role of the rehabilitation team is to choose and administer the appropriate therapeutic interventions with the goal of maximizing function and minimizing disability ultimately leading to improving quality of life. In order to choose the most appropriate interventions, the level of impact must be defined. The neurologist typically intervenes with pharmacological intervention aimed at the pathology level. A myriad of medications to optimize availability of dopamine or to replace dopamine are administered with the goal of reducing severity of impairments such as rigidity, which may lead to improvements in mobility at the functional level. However, in patients with APDs, medication effectiveness is less than optimal and often leads to only modest changes at the impairment and functional levels. Given the limited effect of pharmacological intervention, rehabilitation may play an even more important role in maximizing function in patients with APDs than idiopathic PD.
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