Promoting the Popularization of Rehabilitation Therapy for Parkinson’s Disease among Chinese Patients from a New Perspective

HUANG Bo-wen, HUANG Zheng-zheng, CHEN Guo-hua

(1.The First Clinical College of Hubei University of Chinese Medicine, Wuhan Hubei 430060;2. Department of Neurology of Wuhan No.1 Hospital, Wuhan Hubei 430022)

ABSTRACT: As the population ages, the number of Parkinson's disease (PD) patients in China is increasing with each passing year. Drug therapy for PD has been widely used in clinical practice, but rehabilitation therapy after illness remains to be popularized. This paper summarizes the existing effective rehabilitation therapy of PD at home and abroad, which can be innovativelydivided into family rehabilitation therapy(FRT) and hospital rehabilitation therapy(HRT), in order to promote the popularization of the rehabilitation therapy of PD and better service for patients.

KEY WORDS: Parkinson's disease; rehabilitation; family rehabilitation therapy; hospital rehabilitation therapy;deep brain stimulation

0 引言

Parkinson’s disease (PD)，also known as paralysis agitans，is a common degenerative disease ofthe central nervous system inmiddle-agedandelderlypeople，clinically characterized bystatic tremor，bradykinesia，rigidity muscles and postural instability. The prevalence rate of PD among people over 65 years old in China is similar to that in European and American countries，at 170/100，000，and gradually increases with age[1].Currently，the Chinese social population is aging at an accelerated pace，sothe number of people with PD is also increasing. Diagnostic criteria and drug treatments for PD have become widely available to neurologists. However，it’s frustrating that rehabilitation therapy seems still unfamiliar to most clinicians and patients. Although，for now the main therapy for PD is drug therapy，as an economical，effective and long-term beneficial adjuvant therapy，rehabilitation therapy is worthy of popularization among neurologists and patients.

1 Methods

Different from the current popular method，which divides the rehabilitation therapy of PD into rehabilitation therapy of motor symptoms and rehabilitation therapy of non-motor symptoms，based on domestic and foreign research，literature and guidelines in the lastfive years，this paper divides the rehabilitation therapy of PD into family rehabilitation therapy(FRT) and hospital rehabilitation therapy(HRT) from an all-new perspective. In this way，it can help neurologists and patients to choose the appropriate rehabilitation program more quickly and conveniently according to different conditions of patients.

Therapies classified as FRT should meet the characteristics of practicality，safety，and long-term adherence，and commonly include physical therapy and simple occupational therapy.It should be noted that before starting FRT，professional neurologists are required to carry out health education for patients and their families and provide relevant advice on which rehabilitation therapy to choose. The rehabilitation of cognitive dysfunction，mood disorders，as well as rehabilitation that requires professional guidance and/or professional facilities need to be carried out in hospitals，are classified as HRT. Inor dertopromotetheclinicalpopularizationofrehabilitationtherapyof PD，thispaperisaboutto succinctly summarizethecommonlyusedr ehabilitationtherapyofPDbythisclassificationmethod.

2 Family Rehabilitation Therapy

2.1 FRT for Early-stage PD Patients

The common symptoms of patients diagnosed with early PD mainly include static tremor，bradykinesia and rigidity muscles，and for these symptoms，the main family rehabilitation therapies recommended to choose arephysical therapy，simpleoccupational therapy and exercise. A domestic research[2]reported that providing family physical therapy to some PD patients for one year，including physical relaxation exercises，facial rehabilitation training，head and neck rehabilitation training，limb rehabilitation training，posture and gait rehabilitation training，proved that physical therapy is simple and easy to learn，and long-term adherence to it can significantly improve the physical movement disorder of PD patients，and improve self-care ability of daily living. Another domestic study[3]suggested that simple occupational therapy，such as breathing training，speech training，balance training，daily activity training and so on，had a positive impact on patients' quality of life by increasing their physical activity and improving their functional level. And the occupational therapy mentioned above should be taught by an occupational therapist，to ensure that patients can finish it independently at home after discharge.As for complex occupational therapy，it may need to be carried out in the hospital，and we don't reduce it to this category.

In China，tai chi and dancing are popular leisure activities in the elderly population. Somedomestic and foreignresearch[4-6]has shown that tai chi and dancing have a positive role in gait and balance disorder of PD patients. Tai chi involves rhythmic weight shifting，controlled movement to stabilitylimits，stepping，and turning：all of these aspects could have contributed to the improvementsobserved in the participants[5].Another research[6]reported that rhythmic stimulation and dance provide motor，balance and cognitive benefits for participants with PD，sound stimuli and dance offer satisfactory effects for gait，improving cognitive abilities such as motor control and adjustment and spatial memory. In addition，these new treatment modalities stimulate the elderly population to practice physical exercise，generating well-being and helping selfesteem[6].

Physical therapy for PD is diverse，and it’s worth mentioning that evidence from many avenues of scientific investigation argues for ongoing aerobicexercise as a means to slow PD progression[7]. Therefore，for early-stage PD patients，the FRT mentioned above should be routine advice to them.

Furthermore，sleep disorder and constipation are also common symptoms in early-stage PD patients；sometimes they may appear earlier than the typical symptoms of PD. The consensus of Chinese experts on PD rehabilitation released in 2018 recommends that in order to improve patients' sleep，cognitive behavioral therapy should be carried out to restore bed as a function of inducing sleep signals，and the conditioned reflex of bed and sleep should be re-established；as for the rehabilitation therapy of constipation，mainly including abdominal muscle and pelvic floor muscle exercise training，developing the habit of regular defecation，and gradually establishing the defecation reflex[8].

2.2 FRT for Medium-stage PD Patients

As the disease progresses and the patient ages，abnormal gait and balance disorder are the most common symptoms that affect patients' daily life. These symptoms，such as slow gait，festination，freezing gait，difficulty in starting walk and standing up，easy to fall and abnormal gait due to fear of fall，along with static tremor，bradykinesia and rigidity muscles，render the patient unable to live independently，significantly reduce the quality of life of the patients，and often accompanied by cognitive dysfunction.

For the treatment of abnormal gait in medium-stage PD patients，the FRT recommended is treadmill training. Foreign scholar Studer[9]conducted treadmill training on 206 patients with medium-advanced PD，and the results showed that treadmill training has a positive effect on patients' gait (an increase in step length and a reduction of cadence and step variability in the whole sample)，and the safety and feasibility of this therapy are also satisfactory. In terms of the treatment of balance disorder，in recent years，relevant studies[10-12]have found that yoga can improve the balance disorder of mediumstage PD patients in many aspects，mainly including the improvement of body awareness，movement control，motor dysfunction and mobility，so as to improve the balance function of patients and enhance the stability of posture. Furthermore，other benefits have been found，such as improvement in strength of leg muscle[11]，reduction in anxiety and depressive symptoms[12]. At the same time，its feasibility and high-safety have also been proven，suitable for patients to perform at home.

Medium-stage PD patients may also have voice and respiratory impairment due to impaired motor function，resulting in hoarseness，reduced pitch，difficulty in swallowing and other symptoms. And singing therapy has been proved to be a beneficial therapy that，through systematic vocal training，can improve and maintain the function of the PD patient’s vocal cords and respiratory pressure，and improve the patient’s overall quality of life[13].

2.3 FRT for Advanced-stage PD Patients

When the disease progresses to an advanced stage，the patient's motor function is severely impaired，leading to a reluctance to exercise；but because of the reduction in patient’s movement，in turn，it may cause the motor symptom further aggravates，thus forms the vicious circle，until the patient’s body stiffness，unable to move，finally cannot get up，concomitant Disuse syndrome and various complications.Nevertheless，the consensus of domestic experts points out that for patients with advanced PD，exercise and exercise strategies may still be effective，and exercise should be actively supported to avoid further physical degradation[8].

For advanced-stage PD patients，there are few rehabilitation therapies that can be performed at home，so only three relatively feasible therapies are described below.Ambulosono is a gait training method created by Canadian neuroscientists that uses the correlation and plasticity of neurochemical and brain region between music and walking to activate the recombination of brain reward neural networks to achieve gait and stride control autonomy. Ambulosono training can not only improve the walking ability of PD patients，but also transform trot into a pleasure incentive through quantitative and safe training methods，so as to effectively combine rehabilitation and exercise therapy[14].

Based on the theory of mirror neuron system，AOT(action observation therapy)，which conducts movement learning by observing behavior and movement，has been gradually applied to the rehabilitation treatment of balance dysfunction and abnormal gait in PD in recent years，and its efficacy has been confirmed by more and more studies[15]. Foreign studies[16,17]have shown that AOT can improve patients' motor function，walking speed and balance function，and the number of attacks of frozen gait can be significantly reduced. At the same time，it can also improve the mental health status of patients and significantly improve the quality of life score，indicating that AOT is a safe and feasible rehabilitation treatment for PD，and it helps to maintain the level of cognitive function.

Relevant research evidence abroad shows that Motor Imagery recruited a similar subcortical network to Movement Execution[18]，the MIT(motor imagery therapy) proposed on the basis of this theory is widely used in rehabilitation，and it’s also worth trying at home. The mechanism by which PD patients benefit from MIT may be that：before the movement，let the patient imagine the steps and main points of the movement，so as to promote the reorganization of brain function，strengthen the connection between the motor program and the excitation of the neural region[19].

3 Hospital Rehabilitation Therapy

Currently，a considerable number of the large “Three-A”hospitals in China's first-tier cities have been equipped with professional PD rehabilitation facilities and rehabilitation therapists，which can provide PD patients with a variety of rehabilitation treatments. However，nationwide，the group of patients who can receive HRT is still a minority，and HRT needs to be popularized urgently. Compared with FRT，HRT relies on professional places and facilities，and some treatments also need to be conducted under the guidance of professional rehabilitation therapists. In order to facilitate the selection of treatment options for patients，and help lower grade hospitals to select rehabilitation therapy projects that need to be introduced，this paper divides the frequently used hospital rehabilitation therapies of PD into those only requiring professional rehabilitation facilities and those requiring professional rehabilitation facilities and rehabilitation therapists.

3.1 HRT Only Requiring Professional Rehabilitation Facilities

Up to now，the therapy of PD is still dominated by drug therapy，and there are still relatively few kinds of rehabilitation facilities specially designed for the rehabilitation of PD.Therefore，the following is only an introduction to the most commonly used rehabilitation treatment methods of PD in clinical practice with the most research data.

In recent years，based on the reporting guidelines established by a group of European experts on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS) and on evidence published until 2018，rTMS is recommended as a potential therapeutic tool for various neurological and psychiatric disorders[20]. rTMS is a painless and noninvasive brain stimulation method over stimulating selected regions of the brain to treat neurologic and psychiatric disorders including stroke，Alzheimer disease，depression，and PD rehabilitation[21,22].rTMS works by modulating the excitability of the cerebral cortex[23]. Recent studies have found that the benefits of rTMS treatment for PD are mainly manifested in the following three aspects：1.rTMS showed significant therapeutic effects on motor in PD，both high-frequency(HF) rTMS and low-frequency rTMS showed therapeutic effects on motor；stimulation over primary motor cortex (M1)，supplementary motor area，dorsal lateral prefrontal cortex (DLPFC) or M1+DLPFC showed therapeutic effects；stimulation during “on” and “off” states showed therapeutic effects[24]. 2. rTMS，stimulating over left DLPFC，showed significant therapeutic effects on depression in PD，only HF-rTMS showed therapeutic effects，and the therapeutic effects on depression was long term[24]. 3. The significant effect sizes for executive function were found with multiple sessions of HF-rTMS over frontal cortex，especially over DLPFC[25].

Deep brain stimulation (DBS) was first used in the treatment of essential tremor in 1987，and later used in the treatment of advanced PD，andPD is also the most commonly used and wellstudied indication of DBS，especially subthalamic nucleus deep brain stimulation (STN-DBS) is the preferred treatment[26].DBS is a neural regulation therapy that can improve clinical symptoms by stimulating specific areas of the brain to regulate abnormal neural circuits. DBS can effectively improve the motor symptoms and balance function of patients with PD[27]，but cannot clearly improve the gait disorder[28]. Deep brain stimulation of pedunculopontine nucleus (PPN-DBS) in the treatment of PD gait disorder may be effective[29]，but there is a lack of multi-center large-sample clinical studies to verify.

In recent years，with the development of science and technology，some new rehabilitation treatment methods have begun to emerge，while some conventional rehabilitation training methods have obtained better curative effects with the help of new technology. Among the new rehabilitation treatment methods，virtual reality (VR) rehabilitation training is one of the research focuses currently. Relevant research results[30]suggest that VR rehabilitation training can not only achieve the same effect as conventional rehabilitation training.Moreover，it has better performance on gait and balance in patients with PD. When the effect of traditional rehabilitation training on gait and balance of PD patients is not good enough，VR rehabilitation training can at least be used as an alternative therapy.Treadmill training has been proved to be an effective and feasible conventional rehabilitation training method for PD[9]. Anti-gravity treadmill training and VR treadmill training are new rehabilitation training methods developed on this basis. Compared with conventional treadmill training，the improvement of efficacy that patients with medium-advanced PD can benefit from anti-gravity treadmill training and VR treadmill training is mainly reflected in three aspects：freezing of gait (FOG)，postural instability and mobility[31,32]. Especially for patients with FOG，there is a greater reduction of falls after VR treadmill training[32]. There are many similar rehabilitation methods derived from conventional rehabilitation methods，which will not be described here one by one. Since they are new technologies，there are still many points worth exploring and discussing，and they also provide new ideas and possibilities for the future rehabilitation therapy of PD.

3.2 HRT Requiring Professional Rehabilitation Facilities and Rehabilitation Therapists

Part of HRT also needs to be carried out under the guidance of professional rehabilitation therapists，through the communication and collaboration between rehabilitation therapists and patients，it can not only ensure the standardization and effectiveness of rehabilitation treatment，but also guarantee the safety of patients during the process of rehabilitation treatment，and improve the confidence and motivation of patients to insist on rehabilitation therapy at the same time.

The vestibular rehabilitation training is a rehabilitation method used to improve the balance disorder in PD patients，including a series of professional rehabilitation items designed for the recovery of vestibular function. Its characteristic is that the professional rehabilitation therapist develops personalized rehabilitation training programs according to the activity ability of each patient，and controls the training intensity and difficulty. A domestic study[33]proved that individualized vestibular rehabilitation training for patients with PD can help improve patients’ posture balance control ability，improve their daily life activity ability and improve their quality of life.

Maybe due to the effects of static tremor，hand functionality and finger dexterity are impaired in PD patients.These disturbances lead to a dependency in activities of daily living and poor quality of life. Occupational therapy(OT) is recommended to improve this condition by a foreign research[34]. It consists of a group session (1 h/day with no more than 5 patients per session) conducted and monitored by an occupational therapist，which tailors the rehabilitative project taking into account patients’ individual motor and cognitive residual abilities. And the research showed that a specific OT intervention is effective to improve finger and hand dexterity and autonomy in activities of daily living in PD patients，regardless of the disease severity[34].

Transcranial direct current stimulation (tDCS) is a wellstudied rehabilitation therapy. The mechanism by which tDCS improves symptoms is applying a weak current (1～2 mA) at specific sites of the scalp through both positive and negative electrodes to regulate the excitability of the cerebral cortex，thereby affecting the local blood flow in the brain and changing the synaptic performance. tDCS has been used in the rehabilitation of PD for years and has been shown to improve motor symptoms (such as abnormal gait，bradykinesia) and non-motor symptoms (such as cognitive impairment) in PD patients，so as to improve the patients' activities of daily living and quality of life[35]. To increase safety，therapists should be fully prepared and supervise the entire procedure，strictly following all safety measures recommended by the laboratory or the device manufacturer of tDCS，and for repeated tDCS，the interval between two sessions should be long enough to avoid the cumulative effect of adverse reactions[36]. In general，tDCS has the advantages of safety，effectiveness，easy operation，convenience and low price，which is worthy of promotion in hospitals at all levels and PD patients.

4 Discussion

Here，the existing commonly used and effective rehabilitation therapies for PD have been preliminarily reorganized according to the new classification method mentioned above. Due to the limitation of information access and literature reading，it fails to cover all aspects. The previous classification method of rehabilitation therapy for PD is developed from the perspective of medical research and treatment，which mainly serves for scientific research. The new classification method proposed by this paper，dividing the rehabilitation therapy of PD into FRT and HRT，aims to promote the popularity of rehabilitation therapy in PD patients，and provide a convenient reference for patients and neurological physicians to make treatment decisions according to individual circumstances. From the practical point of view，it’s a method worth trying.