Parkinson’s Disease

‘Wearing the Pants’ in your Relationship with Parkinson’s Disease: Physical Therapy Putting You in Charge

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“Somedays it takes me about 45 minutes to get on a pair of briefs”, said one of my patients with Parkinson’s Disease (PD). 

As a physical therapist, I knew that we had to solve this problem.  Spending 45 minutes of life donning clothing is no way to live.  

If you are reading this and have PD, you may know what I am talking about.  For those of you who are not as familiar with PD, this is a small window into the world of living with PD.  

And when the problem of donning clothes reaches this level, it significantly reduces quality of life.  It is not only the frustration that the patient with PD experiences, but the further drain on his or her already limited energy.  

Without exception, the number one complaint I get from all of my patients with Parkinson’s Disease is fatigue.  To those of us living outside of the PD world, we might think that the tremors and mobility impairments are the number one complaint—and they are a big deal.  But the fatigue component trumps them all.  Why?  Because fatigue means that one can spend less time in life enjoying the company of others and engaging in activities that bring him or her joy and purpose.  

Why can it be so hard to get briefs on when one has PD?

Stiffness and rigidity: PD causes stiffness and rigidity throughout the body, particularly in the spine and hips.  This can make it difficult and/or painful to bend forward towards the feet or bring a knee up to lift a foot through the leg hole of a pair of briefs.  

Motor initiation, planning, and sequencing:  With PD, some of the tasks that one used to take for granted and didn’t even think about (i.e., putting on clothes, getting out of a chair) become very difficult. Sometimes getting the tasks started is the hardest part.  And when a task involves a series of steps, such as putting on briefs (i.e., orienting the briefs properly, getting legs into the right holes), becomes very difficult.  

Reduced amplitude of movement: Typically, once we learn how to do a motor tasks in our lives, we have an automatic program in our brain as to how much effort or force is needed to accomplish the task.  For instance, getting into and out of a chair is easy because the brain “knows’ how much force should be put through the legs to rise from the chair.  If the chair is exceptionally low, the brain knows that more force is needed through the legs vs. if the chair is a higher.  With PD, people lose that sense of calibration and not enough effort/force is put into the movement and the task is not accomplished. Most of my patients come to physical therapy with complaints of falling back into a chair when they try to come to standing.  Their brains have recalibrated the motor program for getting out of a chair.  This recalibration occurs across all movements including fine motor skills, that are needed to handle a pair of briefs and orient them properly for donning.  

Tremors: Tremors that are characteristic of PD obviously hinder motor tasks—especially fine motor tasks that take precise grip to open up and orient a pair of briefs for donning.  And when a task becomes more difficult, people with PD often experience worsened tremors.  

So what can a physical therapist do for a patient with PD who cannot get his briefs on?  It depends on the individual’s characteristics, but what follows is an outline of the approach that I take:

  1. Determine the patient’s primary limitations in putting on briefs.  Some people exhibit stiffness and rigidity as their primary issue.  If this is the case, we spend time working on mobility and stretching to regain range of motion in the spine, hips and other lower extremity joints.  We make sure the motions of putting on briefs are possible. For other people, they have the available range of motion needed to put on briefs, but they are not putting enough effort or force in to make the task possible.  For example, they cannot lift their foot high enough to get it into the leg hole on the briefs.  For other people, it’s the fine motor skills that are the biggest limiting factor.  Sometimes getting the briefs opened up and properly positioned to facilitate donning is the biggest problem.  And sometimes, it’s a combination of all of these issues.  
  2. Design a rehab program that targets the biggest limitations and practices the skill of putting on briefs.  More than likely, there is combination of limitations described above that need to be addressed.  A comprehensive program might work on fine motor skills with one’s hands, mobility and flexibility and recalibration of force needed to accomplish the task of putting on briefs.  For the latter, LSVT-BIG exercise is a well- researched exercise program that works very well for retraining the brain to initiate movements with greater force to make everyday tasks possible.  LSVT-BIG is backed by over 25 years of U.S. National Institutes of Health research as being effective and can have long-lasting effects post physical therapy treatment.  Weber Physical Therapy and Wellness is one of the only physical therapists in Southeast Idaho to offer LSVT-BIG treatment.
  3. Take comorbidities into consideration that complicate one’s life with PD. In the life of someone with PD, PD often takes center stage.  However, other health issues layered on top, may make things even more difficult.  To maximize the benefit from physical therapy, these other problems need to be taken into consideration. For instance, it is common for people with PD to struggle with dementia, visual deficits, other orthopedic injuries/pain that exacerbate the issues that they already stem from having PD.  

The patient quoted at the top of this article had a unique presentation in that it was actually his comorbidities that were limiting his ability to don his briefs. He saw double up close and had dementia that caused him to hallucinate at times.  He had some motor planning deficits that would get him “trapped” in a position, bent over with the brief only around the tips of his toes.  And that is where he would stay for 35 minutes.  And that was after the 10 minutes it would take him to fiddle with the briefs to open them up and find the leg holes—seeing double makes this very difficult.  As a physical therapist, I cannot fix someone’s vision, but I can adapt a task so that it might get around some of the problem. 

I built this patient a dressing aid that holds his briefs open for him so he can easily see the leg holes.  And since the device holds the briefs open, he doesn’t have to hold onto them and can focus on just getting his legs into the leg holes.  Once his feet are in place, he just has to grab the waist band and pull up.  That’s it. 

This device allows him to get his briefs on in 3 minutes or less.  Saving him 42 minutes to do things that he loves and make his life full.  

Adaptive device for donning briefs, constructed for a patient with Parkinson’s Disease.
Adaptive Device holds briefs open, making it easier for a patient with Parkinson’s Disease to put them on.

If this story sounds similar to your situation or that of someone you love, consider physical therapy.  As a physical therapist I provide tailored, one-on-one services for patient driven success.  You can ‘wear the pants’ again. 

***

Carolyn F Weber, DPT, PhD is one of the only physical therapists in Southeast Idaho who is certified in LSVT-BIG treatment for Parkinson’s Disease.  She provides one-on-one physical therapy and fitness programming for clients with Parkinson’s Disease in the comfort of their homes.  Medicare of Idaho and Railroad Medicare insurances are accepted. You do not need a doctor’s referral to get started—just call or email Carolyn to set up your first appointment. 

Email: cfweberpt@gmail.com

Phone: 505-412-8384 (call or text message)

Carolyn also leads an exercise group on Wednesday’s at 5 PM at the River of Life Church located at 1211 S 5th Ave, Pocatello, Idaho 83201.  This class is FREE, but space is limited.  Email Carolyn for more information or to her know that you want to reserve your space in the class.  

Email: cfweberpt@gmail.com

Carolyn F Weber, DPT, PhD, Physical Therapist of Weber Physical Therapy and Wellness in Pocatello, Idaho

Textured Insoles may assist with Reducing Fall Risk of those with Parkinson’s Disease

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“Fall” is a four-letter word, in more ways than one, especially as people enter their later years.  Most of my older patients know full well that falls can be associated with broken bones and quick decline.  Most of my patients over 70 have some kind of loss of what is commonly referred to as “balance” and this is exacerbated by Parkinson’s Disease.  Balance is one of those things we take for granted until we realize that it is becoming compromised.  The lyrics by Tom Keifer (performed by Cinderella) sum it up pretty well in that regarding balance you “don’t know what you got ‘till it’s gone”.  

Balance is often talked about as one thing, but it’s actually pretty complicated.  To simplify things a bit, your overall ability to maintain your balance (i.e., stay standing upright) is dependent on how well three major things in your body are functioning:

  1. vestibular system.  The vestibular system is located in your inner ear and sends signals to your brain about motion, head position and spatial orientation.  The brain integrates all of this information and then sends signals to the rest of the body to stabilize our head while we move and maintain posture so we don’t fall down. 
  2. somatosensory system.  There are specialized structures located throughout your body that tell the brain where your joints (e.g., knees, hips, ankles) are in space and allow you to feel textures, pressure and temperature on the surface of your skin.  As we will discuss, the working ability of sensory receptors in the soles of your feet play an especially important role in balance because they literally allow your brain to feel what you are walking on and where they are in space.    
  3. visual system. Your eye sight is important for seeing where you are in space and for telling your brain what may exist in your environment that could challenge your ability to stay upright (e.g., slick surfaces, rocks to step over, stairs).  

For more information on the vestibular system:

Your brain is able to integrate signals from the three major systems listed above and then send signals to your muscles (also known as motor output) to adjust your posture, take a step, tilt your head—whatever you need to do to prevent yourself from falling.  This obviously happens very quickly—in a tiny fraction of a second—when working optimally.  For most of our lives this happens without us even thinking about it.  

However, as we age, so does our vestibular, visual and somatosensory systems, and they don’t work quite as well as they used to.  When the systems that control our balance begin to decline, our ability to navigate environments we once used to, such as curbs and bumpy sidewalks, becomes compromised.  Balance is also affected by a person’s mindset, fatigue/attentional capacity, muscle coordination and integrity of the skeletal system.  If you are distracted by someone shouting hello to you or you have lasting effects of injury (limited joint mobility), these are going to further challenge you balance.  Furthermore, when you superimpose disease, such as Parkinson’s Disease, on top of an aging visual, vestibular, and somatosensory system, one’s ability to maintain upright posture—or prevent falls—-becomes even more compromised.  

Although commonly known for its association with advancing type 2 diabetes, peripheral neuropathy has also been noted to be common in people with Parkinson’s Disease (Viseux et al. 2020).  Peripheral neuropathy is characterized by poorly functioning nerve fibers in the soles of the feet that transmit information to the brain, allowing one to experience touch, position in space (proprioception), vibration, pain and temperature.  The transmission of this information to the brain is critical to maintaining your balance and avoiding stepping in places that may cause injury.  Romagnolo et al. (2018) estimates that 55-75% of patients with Parkinson’s Disease who are treated with levodopa (by oral or intestinal infusion) could develop peripheral neuropathy.  The reason for developing peripheral neuropathy is unclear and it may also be linked with vitamin B12 deficiency and/or degradation of nerve fibers in feet and other parts of the body.  

So the question is, how can we best prevent falls for people with Parkinson’s Disease?

Improving balance requires a multi-faceted approach.  Central to this approach is working with a physical therapist to improve strength and ability to use the visual, somatosensory and vestibular systems together to the best of your abilities.  A physical therapist can provide a safe environment in which one’s balance can be challenged, but injury can be avoided.  Optimizing balance also includes a checkup on the three major systems that contribute to balance.  This includes making sure that one is doing everything he or she can to preserve the health of one’s eyes and improve eyesight to the greatest extent possible.  Has a person been putting off dealing with cataracts?  Now may be the time.  How is the health of the vestibular system and ears?  Believe it or not, a buildup of wax in your ears can interfere with balance.  Other more serious problems such as vertigo, Meniere’s Disease, acoustic neuroma, and vestibular neuritis can also interfere with your vestibular system.  If you suspect or know that these are problems, then you need to see an ENT (Ears Nose and Throat specialist), neurologist and may even be referred to a physical therapist depending on the root of the problem. Another piece of the approach is making sure that one is maximizing the sensory information coming up to the brain from their feet to better inform the brain about where the feet are in space and what kind of surface they are standing on. And this is the best news:  recent research has shown that increasing the sensory stimulus to the feet can enhance motor control for improved balance (Viseux et al. 2020).  

Sensory stimulus to the feet can be enhanced through the use of textured insoles.  

Research recently reviewed by Viseux et al. (2020) indicates that textured insoles can help not only people with Parkinson’s Disease improve their walking and balance, but also people with multiple sclerosis and healthy people too.  Wearing textured insoles has been found in studies to decrease body sway from right to left (Qui et al. 2013; Robb and Kelley, 2000), improve postural stability even with eyes closed or standing on foam surfaces (Qui et al. 2013), increase step length (Qui et al. 2013), decrease the number of steps needed to complete a 180 degree turn (Robb and Kelley, 2000), improve functional reach tests (Volpe et al. 2017), improve single leg stance time and muscle activation in the lower leg (Jenkins et al. 2009) and improve ability to feel the bottom of the foot (Lirani-Silva et al. 2017).  

How quickly are results achieved after wearing the insoles?  Studies used different time frames for testing, but improvements in two studies were noted immediately (Jenkins et al. 2009; Qui et al. 2013).  

What’s more is that data indicates that long-term use of insoles may promote increased representation of the bottom of the foot in the primary somatosensory cortex of the brain which improves ability to feel the bottom of the foot (Qui et al. 2013).  

Where can you get such insoles?  Below is a listing of some examples. As a disclaimer, I have no financial connection with any of these companies and I am not necessarily promoting their products—I am merely providing examples:

Happy Feet

Textured insoles from Happy Feet

Naboso

Performance insoles from Naboso

If you are wondering about the specific details of the research studies examining the effects of wearing textured insoles on balance and walking, please see brief summaries below:

Qui et al. 2013: 

Participants: 20 healthy people and 20 people with Parkinson’s Disease

What was done in the study: Participants stood on firm and foam surfaces while barefoot, wearing smooth insoles, and while wearing textured insoles.  While doing this, standing balance was measured using a force plate.  Specifically, the data included measures of anterior -posterior and medial lateral sway.  

Results: Only the textured insoles decreased medial-lateral sway in the Parkinson’s  group on firm and foam surfaces.  

Robb and Kelley 2020:

Participants: 7 people

What was done in the study: The dynamic stability of participants was examined wearing footwear only, footwear with a textured insoles or footwear with a nontextured insoles.  Measurements were collected at the beginning of the study, 4 weeks later and 5 weeks later. 

Results: Improved dynamic stability was noted in the frontal plane and the number of steps required to make a 180-degree turn was reduced in those wearing the textured insoles.  

Volpe et al. 2017:

Participants:  20 people with Parkinson’s Disease

What was done in the study: All participants performed balance training for two weeks (5 days per week).  Half of the participants wore textured insoles.  Measurements on functional reach testing was completed at the beginning of the study, immediately following the 2-week balance training program and 4 weeks after the balance training ended.  

Results: People who wore the textured insoles had improved functional reach tests even after the balance training program had ended.  

Jenkins et al. 2009: 

Participants: 40 people with Parkinson’s Disease and 40 age-matched healthy controls

What was done in the study: Study participants wore ribbed insoles (these are insoles with a ridge around the border of the insole) and regular insoles during separate walking trials. Single leg stance time was measured while walking as well as electromyography measurements of lower leg muscles.  

Results: wearing ribbed insoles improved single leg stance time during walking and anterior tibialis activation was improved according to EMG measurements. 

Lirani -Silva et al. 2017:

Participants: 19 participants with Parkinson’s Disease

What was done in the study: At the start of the study, sensation in the bottom of the participants’ feet was tested using Semmes-Weinstein monofilaments.  At the start of the study, all participants had their walking filmed for stride length measurements.  All participants wore textured insoles for 1 week and the same measurements were taken again.  Participants were instructed to wear regular insoles for the week following the study.  After the week following the study, a third set of measurements was collected. 

Results: After one week of wearing textured insoles, stride length and sensation in the soles of feet were improved.  After one week of wearing regular insoles (following the one week with textured insoles), plantar sensation improvements were still present, but walking improvements were not.  Study authors concluded that continuous use of insoles may be needed to improve gait.  

References:

Jenkins et al. 2009.  Plantar cutaneous sensory stimulation improves single limb support time, and EMG activation patterns among individuals with Parkinson’s Disease. Parkinsonism and Related Disorders. 15:697-702.

Lirani- Silva et al. 2017. Continuous use of textured insole improved plantar sensation and stride length of people with Parkinson’s Disease: A pilot study. Gait and Posture. 58: 495-497. 

Qui et al. 2013.  Effects of textured insoles on balance in people with Parkinson’s Disease. PLoS. ONE: 8(12). e83309. 

Robb and Perry.  2020.  Textured foot orthotics on dynamic stability and turning performance in Parkinson’s Disease. Journal of Motor Behavior. 52: 396-403. 

Romagnolo et al. 2018.  Levodopa-induced neuropathy: a systematic review. Movement Disorders Clinical Practice. 6:96-103. 

Viseux et al. 2020.  Postural instability in Parkinson’s Disease: Review and bottom-up rehabilitative approaches.  Clinical Neurophysiology. 50: 479-487.  

Volpe et al. 2017.  Effects of a sensory-motor orthotic on postural instability rehabilitation in Parkinson’s Disease: a pilot study. Journal of Clinical Movement Disorders. 4:11. 

Respiratory Muscle Training (RMT) for Parkinson’s Disease: Be proactive about respiratory health and quality of life

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Patients with Parkinson’s Disease (PD) often develop respiratory weakness and lower lung capacities. This greatly diminishes quality of life, leading to difficulties with breathing, speaking, and swallowing.  Respiratory weakness can also lead to one of the most common causes of death in people with Parkinson’s Disease –aspiration pneumonia—especially in the late stages of the disease.

Individuals with PD can experience over 50% decreases in maximum inspiratory pressure and maximum expiratory pressure, which is essentially the force with which one can inhale or exhale, respectively (Sapienza et al. 2011).  Poor ability to inhale may be attributable to reduced respiratory muscle strength and increased chest wall rigidity (Sathyaprabha et al. 2005), which are two common characteristics of PD.

In short, living the best possible life with PD includes taking preventative measures to reduce PD’s impact on the respiratory system.  There are currently no standard protocols for respiratory therapy for people with PD, but research is beginning to show some promise for exercising the respiratory system –just like one should exercise the rest of the body.

Respiratory Muscle Training (RMT)

Research on techniques to improve respiratory health is in its infancy, but some studies have indicated that a technique called Respiratory Muscle Training (RMT) may significantly improve respiratory muscle strength (Jones and Busse, 2012).  RMT involves inhaling and/or exhaling against resistance through a device called a respiratory muscle trainer.

ProperPosturewithRespiratoryMuscleTraining

Proper posture for respiratory muscle training (source: Sapienza et al. 2011)

Research has shown that RMT can increase respiratory muscle strength (Sapienza et al. 2011 Reychler et al. 2016).  Put simply, RMT can improves one’s ability to cough, breathe, swallow and talk at normal volume.  This leads to the following improvements in quality of life:

  • A good strong cough = clearing secretions and foreign objects from the airways
  • Ease with swallowing=prevention of choking, aspiration (getting food into the airways) and subsequent infection and pneumonia that could develop.
  • Talking with adequate volume= improved communication and social relationships.

Two forms of RMT have been examined: inspiratory muscle strength training (strength for inhaling) and expiratory muscle strength training (strength for exhaling).

In a study of 60 participants, half of which were randomly chosen to utilize a expiratory muscle strength trainer (EMST) for 4 weeks while the other group utilized a sham device, EMST was found to increase maximum expiratory pressure by 27%, improve swallowing function (Sapienza et al. 2011).  Other studies have also demonstrated that EMST can improve coughing and a reduction in incidence of aspiration (Troche et al. 2010; Pitts et al. 2009).  In short, EMST can make critical improvements in strength that protect lungs from aspiration and subsequent pulmonary complications.

Studies of inspiratory muscle strength training in people with PD are currently underway (Ferro et al. 2019).  However, a study that has been done on healthy adults over the age of 65 does demonstrates that (IMST) may have serious benefits in improving maximum inspiratory pressure (Reychler et al. 2016).  Over the course of a 4-week IMST program, 16 participants were able to increase their maximum inspiratory pressure by 38% (Reychler et al. 2016).  Over the course of the 4 weeks, participants performed 15 minutes of IMST maintaining a respiratory rate of 15-20 breaths per minute; each week of the program, the resistance on their training device was increased (Reychler et al. 2016).

A device on the market that allows one to perform RMT for inspiratory and expiratory muscles is THE BREATHER (click on image below to see in store and purchase):

To see a product demo video of THE BREATHER, click here.

Using such a device, improvements in respiratory muscle strength can seen in as little as 4 weeks, but it must be utilized at high frequency daily.  For instance, in the Sapienza et al. (2011) study, participants performed 5 sets of 5 repetitions of EMST exercise, on 5 days per week.  Although it takes dedication, improvement in respiratory muscle strength can be seen in a little as 4 weeks according to Sapienza et al. (2011).  Similarly, healthy geriatric patients had improved inspiratory muscle strength over the course of 4-weeks when practicing IMST for 15 minutes on 5 days per week (Reychler et al. 2016).

Can other people besides those with Parkinson’s Disease benefit from RMT?

In addition to benefitting those with Parkinson’s Disease, RMT can improve quality of life for those with other neurodegenerative conditions (i.e., ALS (Lou Gherig’s Disease), multiple sclerosis, Huntington’s Disease; Jones and Busse, 2012)—-and even athletes and musicians without neurodegenerative conditions.

Weber Physical Therapy and Wellness can get you started on an RMT program.  As an RMT patient, you can expect the following:

  1. initial evaluation at which you will be trained in and provided with a home exercise program.
  2. one visit with your therapist per week for 4-6 weeks to check in with your progress and to adjust your home exercise program.
  3. Transition to self-guided home exercise program to continue on your own for maintenance and follow up with therapist only if needed.

If you have questions about this program and whether it may be right for you, please get in touch with Carolyn Weber via phone (505-412-8384) or email (cfweberpt@gmail.com).

References: 

Ferro et al. 2019.  Effects of inspiratory muscle training on respiratory muscle strength, lung function, functional capacity and cardiac autonomic function in Parkinson’s disease: randomized controlled clinical trial protocol. Physiotherapy Research Int. 24(3). Doi: 10.1002/pri.1777.

Jones and Busse. 2012. Management of respiratory problems in people with neurodegenerative conditions: a narrative review.  Physiotherapy. 98:1-12.

Pitts et al. 2009.  Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease. Chest. 135(5): 1301-1308.

Reychler et al. 2016.  Randomized controlled trial of the effect of inspiratory muscle training and incentive spirometry on respiratory muscle strength, chest wall expansion and lung function in elderly adults.  Journal of the American Geriatrics Society.    Http://doi.org/10.1111/jgs.14097

Ribeiro et al.  2018. Breath stacking and incentive spirometry in Parkinson’s Disease: randomized crossover clinical trial.  Respiratory Physiology and Neurobiology. 255: 11-16.

Sapienza et al. 2011.  Respiratory strength training: concept and intervention outcomes. Seminars in speech and language. 32(11): 21-30.

Sathyaprabha et al. 2005.  Pulmonary functions in Parkinson’s Disease.  Indian Journal of Chest Disease Allied Sci. 47(4): 251-257.

Troche et al. 2010.  Aspiration and swallowing in Parkinson’s Disease and rehabilitation with EMST: the ASPIRE study. Neurology. 75(21): 1912-1919.