WHAT IS PARKINSON’S DISEASE?
Parkinson’s disease is a chronic, progressive neurodegenerative disorder of the Central Nervous System.
It occurs more commonly in older people, although it may also develop in younger people, and affects men more frequently than women.
The disease is characterised, among other features, by the progressive loss of dopaminergic neurons in the substantia nigra of the brain. The resulting reduction in dopamine affects the neural circuits involved in the control and coordination of movement.
Parkinson’s disease, however, is not confined to the dopaminergic system. For this reason, it causes not only motor symptoms but also a wide range of non-motor symptoms.
WHAT ARE THE MAIN SYMPTOMS OF PARKINSON’S DISEASE?
The principal motor symptoms are:
- bradykinesia, meaning slowness and difficulty of movement,
- muscular rigidity,
- resting tremor.
Tremor does not occur in every patient.
As the disease progresses, abnormalities of posture, balance and gait may also develop, including small shuffling steps, reduced arm swing, difficulty turning and an increased risk of falls.
A characteristic problem in some patients is freezing of gait, a sudden and temporary inability to initiate or continue stepping. It occurs most commonly when starting to walk, when turning or when passing through narrow spaces.
Patients may also develop difficulty with fine hand movements, reduced voice volume, reduced facial expression, and disorders of speech and swallowing.
Parkinson’s disease also frequently causes non-motor symptoms, including:
- reduced sense of smell,
- constipation,
- urinary frequency, urgency, nocturia, particularly when the need to urinate repeatedly interrupts sleep, and, in some patients, incontinence or difficulty emptying the bladder completely,
- orthostatic hypotension and other disorders of the Autonomic Nervous System,
- fatigue,
- sleep disorders,
- anxiety and depression.
In some patients, concentration, attention, information-processing speed, memory, planning and organisational ability and other higher cognitive functions may also be affected.
HOW IS PARKINSON’S DISEASE DIAGNOSED?
The diagnosis of Parkinson’s disease is primarily clinical and is based on the medical history and neurological examination by a doctor with experience in movement disorders.
There is no single laboratory or imaging investigation that, by itself, confirms the diagnosis of Parkinson’s disease.
In some cases, investigations are required to exclude other causes of parkinsonism.
MRI of the brain is used mainly to investigate other possible conditions and does not, by itself, establish the diagnosis.
In selected cases of diagnostic uncertainty, specialised imaging of the dopaminergic system using dopamine transporter scintigraphy (DaT-SPECT) may be used.
HOW IS PARKINSON’S DISEASE TREATED?
At present, no treatment has been proven to halt or reverse the progression of the underlying neurodegenerative disease.
Appropriately individualised medication, however, can effectively control many symptoms and significantly improve functional ability and quality of life.
As the disease progresses, motor fluctuations, periods during which medication becomes less effective, and dyskinesias may develop.
In selected patients with advanced disease, specialised treatments may be used, including:
- Deep Brain Stimulation (DBS),
- continuous subcutaneous apomorphine infusion by pump,
- continuous administration of levodopa using dedicated pump systems.
The choice of treatment is individualised according to the patient’s symptoms, motor fluctuations, comorbidities, cognitive and psychological status and individual needs.
WHY IS REHABILITATION IMPORTANT?
Rehabilitation is an integral part of the overall management of Parkinson’s disease and is not limited to the treatment of walking difficulties.
The aim is to maintain and, where possible, improve mobility, muscle strength, balance, gait, endurance, the ability to perform everyday activities, communication and independence.
Regular exercise is a fundamental part of treatment and includes aerobic exercise, muscle strengthening, flexibility, balance and motor coordination exercises, together with practice of specific everyday activities.
The programme is adapted to the severity of the disease, motor fluctuations, endurance and the individual problems of each patient.
HOW DO WE MANAGE PARKINSON’S DISEASE AT ANAPLASI?
At ANAPLASI, the Multidisciplinary Rehabilitation Team assesses each patient’s motor, functional, cognitive and psychological status and develops an individualised Rehabilitation programme with specific and measurable therapeutic goals and systematic reassessment of progress.
The programme includes:
- physiotherapy,
- muscle strengthening and endurance training,
- balance and gait training,
- specialised aquatic therapy in the Hydrotherapy Pool,
- occupational therapy and training in activities of daily living,
- speech and language therapy for disorders of voice, speech, communication and swallowing,
- Clinical Psychology – Neuropsychology, including assessment and, when required, Rehabilitation of higher cognitive functions and psychological support,
- dietetic assessment and follow-up,
- neuro-urological assessment when urinary disorders are present,
- assessment and management of sexual dysfunction,
- information, education and guidance for the patient and family regarding the course of the disease, the Rehabilitation process and the safe management of functional difficulties.
For inpatients, respiratory physiotherapy is provided from the time of admission, with the aim of maintaining and improving respiratory function, promoting better lung expansion and facilitating the mobilisation and clearance of bronchial secretions.
SPECIALISED GAIT TRAINING AND MANAGEMENT OF FREEZING OF GAIT
Specialised gait training using external cues plays an important role.
Rhythmic auditory cues, such as a steady beat, can help improve step length and cadence and assist in managing episodes of freezing.
Depending on the patient’s needs, visual or verbal cues may also be used, together with specific strategies for gait initiation, turning, negotiating narrow passages and other situations in which freezing occurs.
Training also addresses balance, changes of direction, transfers and the safe performance of everyday activities, with particular attention to the prevention of falls.
SPEECH AND LANGUAGE THERAPY – VOICE, SPEECH AND SWALLOWING
Speech and language therapy addresses reduced voice volume, articulation and communication difficulties and helps the patient maintain the most effective communication possible.
Problems related to saliva management are also assessed when they affect everyday life, communication or patient safety.
When a swallowing disorder is present, specialist assessment and treatment are provided.
At the ANAPLASI Dysphagia Unit, when clinically indicated, Flexible Endoscopic Evaluation of Swallowing – FEES is performed.
The examination uses a thin, flexible endoscope introduced through the nose, allowing direct assessment of swallowing function, secretion management and airway protection.
This enables assessment of the safety and efficiency of swallowing, and the findings are used to guide the individualised planning of treatment, feeding and hydration.
NUTRITION IN PARKINSON’S DISEASE
Dietetic follow-up takes into account nutritional status, body weight, constipation, swallowing function and medication.
Protein-rich foods may, in some patients, affect the absorption and transport of levodopa and reduce or delay its clinical effect.
In patients taking levodopa who experience motor fluctuations, the timing of protein-rich foods in relation to medication may be adjusted when required, under the guidance of the treating doctor and dietitian.
When indicated, this adjustment includes consuming most of the daily protein intake with the evening meal.
This adjustment is made without reducing total daily protein intake, which is necessary to maintain muscle mass and good nutritional status.
MANAGEMENT OF SIALORRHOEA
In Parkinson’s disease, sialorrhoea may occur, usually because of impaired oromotor control and reduced frequency of spontaneous swallowing of saliva rather than increased saliva production.
Posterior flow of saliva towards the pharynx is particularly important because it may increase the risk of aspiration.
Management is individualised and, according to need, includes speech and language therapy interventions to improve oromotor control and swallowing, medication and, in selected patients, botulinum toxin type A injections into the salivary glands, usually under ultrasound guidance.
Botulinum toxin injections into the salivary glands require careful patient selection and close monitoring because, in rare cases, they may cause or worsen difficulties with chewing or swallowing and increase the risk of aspiration.
CLINICAL PSYCHOLOGY – NEUROPSYCHOLOGY
Clinical Psychology – Neuropsychology is an important part of the overall management of Parkinson’s disease.
When difficulties affecting higher cognitive functions are present, neuropsychological assessment examines attention, concentration, information-processing speed, memory, planning, organisation and problem-solving ability.
Where required, an individualised programme for the Rehabilitation of higher cognitive functions is developed, with goals linked to the real demands of everyday life.
Anxiety, depression and difficulties in psychological adjustment to chronic illness are also assessed and treated.
DIGITAL COGNITIVE REHABILITATION SYSTEM RehaCom
At ANAPLASI, when indicated, the programme for the Rehabilitation of higher cognitive functions is supported by the specialised digital cognitive Rehabilitation system RehaCom.
Specially designed exercises are used to train functions such as attention, memory, information-processing speed, executive functions and visuospatial abilities.
The level of difficulty is adjusted to each patient’s needs and performance, allowing individualised and systematic training and monitoring of progress.
RehaCom is used as part of the overall Rehabilitation programme and does not replace neuropsychological assessment or individualised therapeutic intervention.
URINARY DISORDERS
Parkinson’s disease may cause urinary frequency, urgency, nocturia, incontinence and, in some patients, difficulty emptying the bladder completely.
When such symptoms are present, investigation begins with the medical history and clinical assessment and, according to the findings, includes a bladder diary and measurement of post-void residual urine.
Urodynamic assessment is not required in every patient with Parkinson’s disease. It may be performed when symptoms are significant or persistent, when there is difficulty emptying the bladder or when further clarification of the type of dysfunction is required.
Particular attention is required when significant difficulty emptying the bladder or an increased post-void residual volume occurs early in the course of the disease, as investigation for other parkinsonian syndromes, such as Multiple System Atrophy (MSA), may be necessary.
SEXUAL FUNCTION AND REHABILITATION
Parkinson’s disease may affect sexual desire and sexual function through motor symptoms, rigidity, fatigue, disorders of the Autonomic Nervous System, depression, anxiety or other factors.
Erectile dysfunction and difficulties with lubrication or orgasm may occur. In some patients, however, certain medications used to treat Parkinson’s disease may cause an excessive increase in sexual drive or difficulty controlling sexual impulses and behaviour.
Sexual rehabilitation includes individualised assessment, management of the motor and non-motor factors affecting sexual life, review of medication when required, counselling and psychological support and, where indicated, specialist medical treatment.
ROBOTIC REHABILITATION
In appropriately selected patients with significant gait disorders, robotic Rehabilitation systems may be used for controlled and repetitive training in standing and walking.
Robotic technology is used as an adjunct when it serves a specific functional goal and does not replace active therapeutic exercise or specialised gait training.
NEUROMODULATION WITH navigated rTMS
Repetitive Transcranial Magnetic Stimulation (rTMS) is being investigated as an adjunctive intervention in Parkinson’s disease, mainly for certain motor symptoms and, in selected cases, for symptoms of depression.
At ANAPLASI, navigated repetitive Transcranial Magnetic Stimulation – navigated rTMS – is available, allowing stimulation to be delivered accurately to the selected area of the brain.
The method remains adjunctive and investigational and is not an established treatment for Parkinson’s disease itself, nor does it replace medication or a structured Rehabilitation programme.
CREATIVE ACTIVITIES, SPORT AND SOCIAL PARTICIPATION
At ANAPLASI, creative activities, sport and social participation complement the Rehabilitation programme and are adapted to each patient’s motor and functional status, cognitive abilities, interests and therapeutic goals.
Activities include painting, arts and crafts, cooking, music, dance and group activities, adapted sport and participation in cultural and social activities.
The aim is to maintain active participation, social interaction, functional ability and the greatest possible independence in everyday life.
HOW IS REHABILITATION PROVIDED?
Rehabilitation may be provided through Inpatient Rehabilitation, Day Rehabilitation or Rehabilitation at Home, according to the patient’s clinical and functional status and individual needs.
WHAT IS THE AIM OF THE REHABILITATION PROGRAMME?
At ANAPLASI, the aim is to achieve the greatest possible recovery of the patient’s functional ability and independence and to support their active return to personal, family, social and working life.
