Postural instability is created by a pattern of weakness, muscular tightness, and standing alignment changes that diminish the patient's ability to control their center of gravity during transfers and gait. A common presentation is that of a stooped forward posture of the upper body with tight anterior chest wall musculature and a crouched lower body posture. A series of stretching exercises designed to diminish kyphosis of the thoracic spine and increase flexibility in the pectoralis major and minor muscles can lead to improved upper body posture and upper limb function. In the lower aspect of the body, strengthening of the lumbar paraspinal musculature and stretching of the hamstring and hip flexor muscles can be used to improve posture. It is important not only to stretch the key muscles in patients with poor posture, but to also strengthen the appropriate muscles to achieve good biomechanical alignment. To improve muscle length, therapists use several techniques, including heat and cold modalities, stretching postures, bracing, strengthening of antagonist muscles, and proper positioning of the affected limb. Frequently, thoracic extension and scapular stabilization exercises are utilized to assist with correcting a kyphotic posture, and abdominal, paraspinal, and pelvic girdle strengthening exercises are used to help improve trunk control.
Difficulty with bed mobility and transfers is usually the result of trunk rigidity and core weakness. These problems are tackled by exercises to increase trunk flexibility and segmental mobility, and core muscle strengthening of the abdominals, paraspinal, and pelvic girdle muscles.
Many patients with PD present with generalized weakness (1,2). The weakness is often both in strength and endurance. Strength can be targeted with the use of specific exercises for the affected area. Closed kinetic chain functional strengthening is used for lower limb strengthening. Gentle aerobic exercises may also be introduced, once the patient is able to safely tolerate more exercises. This can be helpful not only for strengthening but also for general conditioning. A walking program, utilization of aerobic exercise equipment such as a stationary bike or elliptical glider, or an aquatic conditioning program may all be implemented to address large muscle group weakness and general deconditioning. Simple balance training exercises such as practicing one-legged stance, tandem walking, heel and toe walking, and carioca or "braiding" are often employed to enhance dynamic balance with walking and transfers. Exercise for the PD patient should be individualized to their functional deficits, ROM, and strength and balance deficits.
Safety with ambulation is often an issue for the PD patient (1,2). Dynamic balance, bradykinesia, and postural instability all contribute to impairments with walking and negotiating obstacles in the home and community. PD patients seem to ambulate more easily with external cues that are visual, auditory, or proprioceptive (1).
For example, placing lines on the floor of an appropriate stride length or placing small objects on the floor for the patient to step over help to facilitate a more normal stride length and swing through leg clearance (2). If appropriate, dynamic balance exercises may improve foot placement, center of gravity control, and postural control during the gait cycle. These are typically introduced to the patient in the parallel bars initially, with instruction on how to safely duplicate the exercise activity in the home. Depending on the disease severity, instruction on the use of canes or walkers and evaluation for a manual wheelchair, a motorized scooter, or a motorized wheelchair may be needed.
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