[Neurorehabilitation in parkinsonian syndromes]

Abstract

Parkinson's disease is a frequent and major source of motor disability, for which physical therapies currently involve less than a third of ambulatory patients and are thus underutilized when compared to chemical and surgical treatments. However, dopaminergic therapies alone prove unable to prevent worsening of motor disability after a number of years. There is rising interest about physical neurorehabilitative therapy for Parkinson's disease, for its symptomatic therapeutic properties, but also for its potential neuroprotective effects in the light of compelling, recent animal literature. The approach to therapy in an individual patient may be governed at the most basic level by the disease stage. For moderate stages of Parkinson's disease (ambulatory patients who have retained a certain degree of physical independence), therapy may focus on the teaching of exercises to the patient: strategies established in controlled studies when used over few weeks periods include motor strengthening programs in the lower limb, high intensity aerobic exercises, attentional strategies using in particular verbal instruction sets, sensory cueing, active axial rotation exercises and high-number repetition of specific tasks. A randomized protocol will soon evaluate the concept of asymmetric motor training, combining a strengthening program in extensor, abductor, external rotator and supinator muscles and a stretching program in their antagonists. For advanced stages (individuals with compromised sit-to-stand, ambulation and significant disability), the therapeutic focus may shift to the teaching of compensation strategies to the patient and the caregiver, both to lessen the effects of motor impairment and to optimize safety. A number of these compensatory strategies are reviewed, some being validated in controlled protocols. In idiopathic Parkinson's disease, clinicians must continue evaluating the symptomatic and perhaps neuroprotective value of physical treatment strategies used over the long term. In atypical parkinsonism, physical treatments often remain the only realistic methods to improve motor behavior and reduce functional deficiencies. The relatively short duration of the effects of physical therapies implies that such programs be pursued over long periods of time, or repeated frequently, for their benefits to be maintained over time.