Duchenne Muscular Dystrophy | Understanding Its Complexity And Role Of Physiotherapy Management

 

Duchenne Muscular Dystrophy (DMD) stands as one of the most prevalent and debilitating genetic disorders affecting children worldwide. This progressive neuromuscular condition is characterized by muscle weakness that worsens over time, leading to significant mobility limitations and life-threatening complications. In this comprehensive blog post, we delve into the intricacies of DMD, exploring its pathophysiology, clinical manifestations, and the pivotal role of physiotherapy in managing this challenging condition.

What is Duchenne Muscular Dystrophy?

Duchenne Muscular Dystrophy is an X-linked recessive disorder caused by mutations in the DMD gene, which encodes dystrophin, a crucial protein for muscle function. The absence or deficiency of dystrophin leads to progressive muscle degeneration and weakness. Typically, symptoms manifest in early childhood, with boys being predominantly affected due to the inheritance pattern.

Clinical Traits of Duchenne Muscular Dystrophy

The clinical presentation of Duchenne Muscular Dystrophy is multifaceted, encompassing various musculoskeletal and systemic manifestations:

1: Muscle Weakness: Initially affecting proximal muscles, weakness gradually progresses to involve distal muscles, leading to difficulties in standing, walking, and performing everyday activities.

2: Gait Abnormalities: Children with DMD often exhibit a distinctive waddling gait due to weakened hip and thigh muscles.

3: Contractures: Progressive muscle weakness predisposes individuals to joint contractures, limiting range of motion and exacerbating functional impairment.

4: Respiratory Complications: Weakness of respiratory muscles results in reduced lung capacity and respiratory insufficiency, predisposing individuals to recurrent respiratory infections and respiratory failure.

5: Cardiac Involvement: DMD is associated with cardiomyopathy and cardiac arrhythmias, contributing significantly to morbidity and mortality in affected individuals.

Role of Physiotherapy in DMD Management

Physiotherapy plays a pivotal role in the comprehensive management of Duchenne Muscular Dystrophy, aiming to optimize functional abilities, minimize complications, and enhance quality of life. The multifaceted approach of physiotherapy encompasses various strategies tailored to address the unique needs of individuals with DMD:

1: Preservation of Muscle Function: Physiotherapy interventions focus on preserving existing muscle function and preventing further deterioration through targeted exercises and activities. Strengthening exercises targeting unaffected muscle groups help compensate for weakness and maintain functional abilities.

2: Range of Motion Maintenance: Regular stretching exercises are essential to prevent contractures and preserve joint mobility. Physiotherapists employ passive stretching techniques to maintain flexibility and prevent the development of secondary complications associated with reduced range of motion.

3: Gait Training: Gait abnormalities are a hallmark feature of DMD, significantly impacting mobility and independence. Physiotherapists devise customized gait training programs to optimize walking patterns, improve balance, and enhance overall mobility using assistive devices such as orthoses and walkers when necessary.

4: Respiratory Management: Respiratory complications represent a significant source of morbidity in DMD. Physiotherapy interventions include respiratory muscle training, chest physiotherapy techniques, and breathing exercises aimed at improving respiratory muscle strength, enhancing lung function, and facilitating secretion clearance to reduce the risk of respiratory infections.

5: Cardiac Rehabilitation: Given the high prevalence of cardiac involvement in DMD, cardiac rehabilitation programs supervised by physiotherapists play a crucial role in optimizing cardiovascular health, monitoring cardiac function, and implementing strategies to mitigate the progression of cardiomyopathy.

6: Functional Independence Training: Physiotherapists work collaboratively with individuals with DMD and their families to enhance functional independence in activities of daily living. Adaptive equipment and environmental modifications are utilized to promote autonomy and facilitate participation in social and recreational activities.

Duchenne Muscular Dystrophy poses significant challenges to affected individuals and their families, necessitating a comprehensive and multidisciplinary approach to management. Physiotherapy stands at the forefront of DMD management, offering tailored interventions aimed at optimizing functional abilities, mitigating complications, and improving overall quality of life. Through targeted exercise programs, respiratory management strategies, and functional independence training, physiotherapists play a pivotal role in empowering individuals with DMD to live life to the fullest despite the challenges posed by this debilitating condition.

Relieving Spasticity By Shockwave Therapy | Exploring Its Advancements And Benefits

Spasticity is a common condition that affects many neurological patients. It is characterized by tightness or stiffness in the muscles, which can cause pain and limit mobility. While many treatment options are available, including medications, surgical interventions, exercise therapy, etc, shockwave therapy is emerging as an innovative non-invasive option for many patients, which has been gaining popularity in the field of physiotherapy in recent years. In this blog, we will discuss how shockwave therapy can be beneficial for patients suffering from spasticity.

Spasticity is a common symptom of neurological conditions such as stroke, cerebral palsy, and multiple sclerosis. It is characterized by muscle stiffness, involuntary muscle contractions, and exaggerated reflexes. Spasticity can be painful and can interfere with daily activities such as walking, dressing, and eating. Current treatment options for spasticity include medications and surgical interventions. However, these treatments are not always effective and can have side effects.
A recent study published in the Journal of Neuro Engineering and Rehabilitation evaluated the effectiveness of shockwave therapy in reducing spasticity in individuals with multiple sclerosis. The study included 20 participants who received shockwave therapy to the calf muscles twice a week for six weeks. The results showed a significant reduction in muscle stiffness and an improvement in gait speed and balance.
Another study published in the European Journal of Neurology evaluated the effectiveness of shockwave therapy in reducing spasticity in individuals with cerebral palsy. The study included 24 participants who received shockwave therapy to the calf muscles twice a week for four weeks. The results showed a significant reduction in muscle stiffness and an improvement in range of motion.

What is Shockwave Therapy?
Shockwave therapy is a non-invasive treatment that uses low-intensity sound waves to promote the healing and repair of tissues. The therapy has been used for decades to treat a variety of musculoskeletal injuries including plantar fasciitis, tendinitis, and chronic pain. However, recent research has also shown that shockwave therapy can be an effective treatment for spasticity in neurological conditions. More recently, it has been found to be effective in treating spasticity in neurological patients. In the case of spasticity, shockwave therapy can help to reduce muscle stiffness and improve the range of motion.

How Does Shockwave Therapy for Spasticity Work?
Shockwave therapy for spasticity works by targeting the affected muscles with low-intensity sound waves. The sound waves stimulate new blood vessels growth and improve existing ones' function. This increases blood flow to the affected muscles, which helps to reduce the tightness and stiffness associated with spasticity.

What to Expect During Shockwave Therapy for Spasticity?
A thorough evaluation is done by your physiotherapist to determine if shockwave therapy is appropriate for your specific condition. Following the evaluation, a comprehensive treatment plan that includes shockwave therapy can be developed by your physiotherapist to ensure the best possible outcomes.
Shockwave therapy for spasticity is a simple and painless procedure. During the procedure, a device is used to deliver low-intensity sound waves to the affected muscles. The treatment usually lasts between 15 and 30 minutes, and there is no downtime or recovery period.
Most patients will require multiple treatments, typically spaced one to two weeks apart. The number of treatments needed will depend on the severity of the spasticity and how well the patient responds to the therapy.

Benefits of Shockwave Therapy for Spasticity
Shockwave therapy for spasticity has several benefits over other treatment options.
First, it is non-invasive, meaning there are no needles, incisions, or anesthesia required. This reduces the risk of complications and eliminates the need for a recovery period.
Second, shockwave therapy for spasticity is a long-lasting solution. Unlike medications, which only work for a short period of time and must be taken regularly, shockwave therapy provides a long-term improvement in muscle function.
Finally, shockwave therapy for spasticity is effective for many neurological patients. Studies have shown that up to 80% of patients who undergo shockwave therapy experience an improvement in muscle function and a reduction in spasticity.

If you are a neurological patient struggling with spasticity, shockwave therapy may be an innovative treatment option for you. The therapy is safe and uses high-energy sound waves to stimulate tissue healing and reduce pain, providing a long-lasting improvement in muscle function. 

 

Cerebral Palsy | Improving Functional Mobility by Physical Therapy

Cerebral Palsy is the most common cause of disability in children. It encompasses a wide range of neurological motor impairments and can be severely disabling. Cerebral palsy requires treatment for optimizing an individual's motor functions. Physiotherapy being a part of the rehabilitation program is found to be effective in promoting the brain's ability to make adaptive changes. The more the patient performs an action, the stronger the neural pathways in the brain for that action become. In the same way, neglecting an action may cause its neural pathways to weaken.  Physiotherapy helps to identify the functional disability of the patient that needs help. The physiotherapist improves and develops a personalized rehabilitation plan to help the patient. In this blog, we have discussed cerebral palsy and its physiotherapy management.

 

Cerebral Palsy

Cerebral palsy is a non-progressive, nonfatal, and non-curable, chronic motor disability that results from damage to the growing brain before or during birth, or in the postnatal period. It may be associated with brain damage responsible for some defects of vision and hearing, abnormalities of speech & language and perception, apraxias, (restricted movements such acts as writing, drawing, and construction or even dressing), behavioral problems such as distractibility and hyperkinesia, which are based on the organic brain damage.

 

Physiotherapy Management:

The physiotherapist conducts a detailed assessment to find out the functional capacity of the child and the nature and extent of the motor as well as associated deficits. Physiotherapy involves highly repetitive, task-specific exercises, promotes neuroplasticity and achieves their optimal functional potential.  The aim is to achieve the milestones, maximize the tone, maintain muscle length, correct the posture and teach activities of daily living. Physiotherapy improves the functional capacity of the patient and makes the patient independent as much as possible through a planned intervention program.

 

Assistive aids and modifications

The physiotherapist recommends modifications like two-handled cups, angled spoons, etc. can be made to help the patient, a stiff cloth collar can be used to help provide neck support, old stools and boxes can be adapted to provide support during sitting, parallel bars can be constructed with wood logs to help gait training. The patient can use air beds and continuous change in position for pressure relief through bed positioning and seating adaptations. Many such homemade modifications can be made to prevent deformities to develop in cerebral palsied children.

 

Supportive Aids

Supportive devices like lightweight splints may be required to maintain normal postures. Splinting and exercise programs help to achieve the near-normal posture. Casts and splints should not be used for prolonged periods because they may lead to disuse atrophy of the muscles. AFO and calipers may be required to provide stability to the joints in a child who is learning to stand and walk.

 

Braces

Braces are used to correct deformity, obtain an upright position, and control athetosis. Children with spasticity are provided with muscle braces. Athetoid patients are trained to control simple joint motion. Ataxic patients may be given strengthening exercises for weak muscle groups.

 

Progressive patterns

The patient is taught motion according to the development like head and trunk rotation from side to side, arm on the face side in abduction-external rotation, elbow semi-flexed, hand open, and thumb out towards the mouth.

 

Synergistic Movement Patterns

Reflex responses are used initially and voluntary control of these reflex patterns is used later. Head and trunk control is attempted with stimulation of attitudinal reflexes such as tonic neck reflexes, tonic lumbar reflexes, and tonic labyrinthine reflexes, followed by stimulation of righting reflexes and later balance training.

 

Proprioceptive Neuromuscular Facilitation

Movement patterns are based on patterns observed while functional activities. The movement patterns consist of flexion or extension, abduction or adduction, internal rotation or external rotation, sensory stimuli are skillfully applied to facilitate movement. Stimuli used are pressure, touch, stretch, traction, compression, the proprioceptive effect of muscle contracting against resistance, and visual and auditory stimuli. Resistance to motion is also used to facilitate the action of the muscles, and form the components of the movement patterns.

Techniques used are:

·  Relaxation techniques – Hold Relax & Contract Relax

·  Rhythmic Stabilization

·  Repeated Contractions

·  Stimulation of Reflexes

·  Reversals

 

Neuromotor Development

The child is not permitted to use motor skills beyond his/ her level of development. The child is placed in a normal posture to stimulate normal tone, once postural security is obtained, achievements are facilitated and developmental sequences are followed throughout the training.

 

Reflex Inhibition & Facilitation

Reflex inhibitory patterns are used to inhibit abnormal tone, abnormal movement patterns, and abnormal posture. The reversal or breakdown of the abnormalities gives the child the sensation of a more normal tone and movements. The physiotherapist attempts to change the patterns of spasticity making the child prepared for movement. Mature postural reactions use key points of control like head, neck, shoulder, and pelvic girdles, though work is also done from distal key- points.

 

Sensory Stimulation for Activation & Inhibition

Techniques of stimulation, like icing, heating, brushing, stroking, massage, pressure, slow & quick muscle stretch, joint retraction & approximation, and muscle contractions are used to activate, facilitate or inhibit the motor response.

 

Reflex Creeping & other Reflex Reactions

Creeping patterns involve the head, trunk, and limbs and are facilitated at various trigger points or reflex zones. Touch, pressure, stretch, and muscle action against resistance are used to trigger or facilitate creeping, also resistance is recommended for the action of muscles.

 

Balance Interventions

Patients with cerebral palsy have a disorder with multisystem impairments, that affect the visual, vestibular, and somatosensory, inappropriate sequencing of muscle activity, poor postural control, and postural stability that is frequently interrupted by destabilizing synergistic or antagonistic muscle activity in patients. The physiotherapists work with the patient to manage the balance issues.

 

Electrical Stimulation Techniques

Patients with cerebral palsy should receive neuromuscular electrical stimulation (NMES) or transcutaneous electrical stimulation (TENS) in cerebral palsy physiotherapy.

 

Hydrotherapy

Hydrotherapy helps to learn new movement skills, which leads to increased functional skills, and mobility. The body is immersed in warm water, causing muscle relaxation and reducing spasticity, thus resulting in increased joint range of motion and creating better postural alignment.

The physiotherapist provides advice, education, and supervision regarding cerebral palsy to the patient, his/her family, and caretakers.

 

Multiple Sclerosis: Regaining of Strength and Function by Physiotherapy

Multiple sclerosis (MS) is a chronic neurodegenerative condition that largely affects young adults between the ages of 20-50, and is thus often known as the great crippler of young adults. It is a disabling disease of the brain and spinal cord, in which the immune system attacks the protective myelin sheath that covers nerve fibers and thus causes communication problems between the brain and the body. Slowly, the disease can cause permanent damage or deterioration of the nerves. Symptoms of this disease vary widely depending on the type of nerve affected and the amount of damage. Some people with severe MS might lose the ability to walk independently, whereas others may experience long periods of remission without any new symptoms. There is a range of treatments that may help to treat this condition like medication, hypnosis, tai chi, rehabilitation, etc. Rehabilitation services include a team of professionals working together to provide quality life to the patient. Physiotherapists are one such professional. The physiotherapist helps to create an individualized program that suits the abilities and addresses the goals of an individual. In this blog, we have mentioned a few exercises which are used by physiotherapists to provide education and treatment to promote good health and general conditioning to reduce fatigue and help the patient to feel and function at their best.

 

Multiple Sclerosis

Multiple sclerosis may differ greatly from person to person and the course of the disease depends on the location of the affected nerve fibers. Multiple sclerosis often causes numbness or weakness in one or more limbs that can occur on one side of the body at a time, or the legs and trunk, shock-like sensations that occur on neck movements, especially while bending the neck forward i.e. Lhermitte sign, Tremor, lack of coordination or unsteady gait, vision problems. Patients may also feel slurred speech, fatigue, dizziness, tingling, or pain in parts of the body even problems with sexual, bowel, and bladder function. It can also cause problems with mobility and gait. Some people with MS have a gradual onset and steady progression of symptoms without any relapses, known as primary-progressive MS. And those with relapsing-remitting MS, eventually develop a steady progression of symptoms, with or without periods of remission, within 10 to 20 years from disease onset. This is known as secondary-progressive MS. The rate of disease progression varies among people with secondary-progressive MS.

The causes of multiple sclerosis are unknown. It is an autoimmune disease, in this condition body's immune system attacks its tissues. This immune system malfunction destroys the fatty substance (myelin) that coats and protects the nerve fibers in the brain and spinal cord. When the myelin sheath is damaged and the nerve fiber is exposed, causing the messages that travel along that nerve fiber to slow down or get blocked.

 

Physiotherapy Treatment:

Physiotherapy helps the patient to achieve and maintain optimal function essential for the quality of life. The physiotherapist evaluates and treats the body's ability to move and function by emphasizing pain, strength, walking, balance, fatigue. Most individuals living with MS have difficulty in physical activity.  Physiotherapy treatment includes a combination of exercises, equipment, and management strategies that help the patient. Physiotherapists can keep them moving and prevent the worsening of symptoms.  The therapist designs a treatment plan and a list of recommendations to improve the mobility, strength, and physical wellbeing of the patient. Exercise is not only beneficial for physical well-being but also for emotional and mental health.

 

Balance exercises:

These exercises are given to minimize the increased risk of falls and gait deviations. The physiotherapist provides balance retraining by strengthening and flexibility exercises. Balance can be improved by the use of visual causes or techniques to reduce upper extremity tremors. Balance training focuses on controlling the posture so that the patient can control the body mass more stably. Balance exercises involve standing on one leg at a time and then challenging the balance by performing another movement. For example, balancing in tree pose, or standing on one leg while doing a bicep curl. While maintaining a pose, care should be taken that the individual doesn't fall. Increasing core strength also helps with balance.

 

Mobility exercises:

Walking requires balance, coordination, upper limb control, strength, and endurance. The tools for mobility are now lighter and easier to handle. The physiotherapist can recommend the mobility tools that are appropriate for the patient and also teaches the individual to use them.

 

Strengthening exercises:

Weakness is a common problem in patients with MS. Strengthening training can help improve muscle endurance and strength.  This can help to increase functionality, walking ability, and physical independence. Exercises help to design and execute training program that helps to address areas of weakness and imbalance in the body e.g. marching exercises help to strengthen the legs, improve balance and increase fitness. Resistance training also requires the muscles to work against weight or exterior force, this can be done by using one's body weight, working with dumbbells or resistance bands, and using weightlifting machines. Strengthening exercises can help to retain muscle mass, which is important in maintaining function.

 

Stretching exercises:

Multiple sclerosis patients are characterized by involuntary stiffness or muscle spasms. Spasticity can affect the mobility and independence of an individual. Therefore, proper positioning, stretching, and bracing can be used to help minimize the effects of spasticity. Structured physiotherapy programs are planned to improve mobility, muscle strength, aerobic capacity, and quality of life. Daily stretching can be beneficial as it increases range of motion, improves flexibility, and decreases spasticity. Stretching should be done for 10 to 15 minutes per day, the focus being spastic muscles. The muscles should be moved slowly to give them time to respond to the stretch and hold each stretch for 20 to 60 seconds, but shouldn't be painful.

 

Endurance exercises:

These exercises can improve walking distance and quality of life measures. Physiotherapists can help design a tailored and comprehensive exercise program that can alleviate the effects of fatigue. Modifying exercises to help manage fatigue so that the individual can continue doing the things he/she loves. Endurance exercises can be done to be stronger, but in MS weakness comes not only from the disease but from deconditioning. So if an individual has a lot of fatigue, then he/ she is resting more or is more sedentary. Their muscles become deconditioned, to counter this, 3-4 four days of strengthening training per week should be done.

 

Aerobic exercise:

Aerobic exercises, provide cardiovascular conditioning and is important for cardiovascular health. The physiotherapist recommends doing cardio exercises 3 days a week for 30 minutes each time. Alternatively,

3 -10 minute sessions if 30 minutes is too difficult to maintain. An individual with MS can do low-impact aerobic exercises like walking, bicycling, or using an elliptical machine.

 

Water aerobics:

In water aerobics, water produces force to work against, providing resistance. Because of this, water aerobics is one of the best exercises that can be done in the case of MS.  Water aerobics is a great mode of exercise because of the buoyancy, which makes it easier to move.

 

Functional movement:

Functional exercises are beneficial because these exercises recruit multiple muscle groups at the same time, for example, push-ups, use core, chest, and back muscles. Another benefit is that some of the exercises, like squats, mimic motions that an individual does in daily life like sitting down in a chair or standing up from the chair. These exercises are very helpful, for people with MS, because they train the muscles to perform daily tasks effectively.

Exercises not only help to maintain function but also reduce inflammation in the central nervous system and have a positive impact on the disease. People with MS feel less fatigued and improve their mood after doing resistance training. But patients should keep in mind that results don't happen overnight, they should be followed with a consistent schedule to experience any potential benefits of exercises for MS.

 

Parkinson’s Disease | How to manage it by Physiotherapy?

Parkinson's disease is a complex neurodegenerative disorder that causes motor and non-motor symptoms, including cognitive impairments. Though there is no permanent cure for Parkinson's disease, drug treatments, surgery, and other therapies are employed to relieve these symptoms. However, for most Parkinson's patients, an additional treatment method like physiotherapy is required to aid mobility and boost independence. Exercise of all types is beneficial for patients with Parkinson's disease. The physiotherapist can guide the patient through the right moves to increase mobility, strength, and balance, and help him/her remain independent. In this blog, we have discussed the physiotherapy management of patients suffering from Parkinson's disease. Given below are the benefits and exercise techniques used by a well-trained physiotherapist to manage the symptoms of Parkinson’s disease.

 

What is Parkinson's disease?

Parkinson's disease is linked to disorders of the basal ganglia, basal ganglia are a group of neurons located deep within cerebral hemispheres. The disorders include rigidity, characterized by an increase in resistance and tremors at rest. Parkinson's disease occurs due to dopaminergic cell loss within the substantia nigra, it occurs due to genetic and environmental factors.

 

Benefits of physiotherapy

The main role of the physiotherapist is to maximize the functional ability strength, endurance, flexibility, functional practice, and balance through movement rehabilitation using support and education. Physiotherapy interventions include exercises and movement strategy training.

• Maintains a good breathing pattern,
• Increases muscle strength and joint flexibility,
• Corrects and improves abnormal movement patterns and posture,
• Maintains and improves function and independence, which helps to improve a person's quality of life.

 

Physiotherapy management

The physiotherapist conducts a comprehensive evaluation of the posture, strength, flexibility, walking, endurance, balance, coordination, and attention with movement. Based on these test results physiotherapist develops an exercise program to help stay as active and as independent as possible.

Depending on the nature and severity of the condition, the treatment program is designed that focuses on activities and patient education. It consists of exercises that help to:

 

• Improve fitness level, strength, and flexibility,
• Turnover in bed more easily,
• To get in and out of bed, chairs, and cars,
• Turnover in bed more easily,
• Stand, turn, and change directions more efficiently,
• Improve the smoothness and coordination while walking.
• Improve ability to perform hand movements,
• Improve ability to climb and descend stairs and curbs,
• Perform dual tasks at a time more efficiently,
• Participate in important activities.

Exercise has been proven to maintain health and well-being in Parkinson's patients. Neuroprotection exercises focus on endurance and use of motor learning principles approaches, such as mental imagery and dual-task training. It involves complex, powerful and intensive exercises. Neuroprotection training is effective and should be introduced in the early stages, though it helps at all stages.

 

Aerobic exercises

Physical activity like aerobic exercise helps slow down motor skill degeneration and depression. And also increases the quality of life of patients with Parkinson's. Exercises aimed to improve cardio-pulmonary functioning and improvement in biomechanics, posture, trunk and overall symmetric movement have been found of great advantage in neurodegenerative disorders.

 

Breathing exercises

Breathing exercises like inspiratory muscle training on lung functions in patients with mild-to-moderate Parkinson's are found to be effective. Respiratory complications are found to develop in many patients as their Parkinson's progresses, so attention should be given to managing the progressive weakness of respiratory muscles and rigidity of the thoracic cage. The individual is encouraged to continue being active and participate in physical exercise for as long as possible.

 

Range of motion exercises

To target both motor and non-motor symptoms, correct and proper movement is achieved by improving range of movement and physical capacity in daily activities by walking, incorporating manual activities like holding, grasping, etc.

 

Strengthening exercises

Strengthening exercises are given against an external resistance like weight machines, weight cuffs, therapeutic putty, cycle ergometer, elastic, etc. This also improves balance, overall physical performance. As muscle weakness is a major problem for patients with Parkinson's disease, depending on the stage of the disease, the physiotherapist recommends resistance exercises with light dumbbells or resistance bands. Hydrotherapy, water resistance can also be used to strengthen muscles.

 

Stretching and Flexibility

Parkinson's disease patients tend to develop tightness in the hip flexor, hamstring, calf muscles, etc. To decrease this stiffness, stretching exercises are given at frequent intervals throughout the day.

 

Executing a dual-task

Motor-Cognitive dual-Task training improves dual-task ability and can also improve gait, balance, and cognition. Dual-task like talking while walking is difficult in patients with Parkinson's.

 

Progressive resistance training (PRT)         

Progressive resistance training (PRT) is used to be effective in decreasing bradykinesia and improving functional performance in patients with mild-to-moderate Parkinson's disease.

 

Reciprocal Patterns

Reciprocal movements include left-to-right or side-to-side patterns, such as swinging the arms while taking steps while walking. Parkinson's disease may affect these patterns. The physiotherapist may help reinforce reciprocal patterns by the use of a stationary bike or an elliptical machine, also incorporate walking by keeping in mind the swinging of the arms.

 

Balance Work

Normal balance is an interplay among the visual feedback, the inner ear which helps orient, and how the feet sense the ground beneath them. Parkinson's disease can affect this balance system, making the gait unstable. Gait training can help to improve balance. Physiotherapy combines cognitive movement strategies, cueing techniques, balance exercises, and physical activities. Immediate effects of external cueing and attention can be seen on improving step length, freezing, and turning during walking tasks, and in activities of daily living.

To deliver a patient-centered treatment, it's important to provide patient education, discuss the options, and have an interactive session. Good communication and educating the patient are important as delivering an intervention.