Physical deconditioning of people with Parkinson's – How can this be prevented and addressed, whilst still adhering to local lockdown

This webinar provides practical advice to aid delegates understanding of physical deconditioning in their patients with Parkinson’s, how to identify and prevent this, and then look at the treatment options and strategies available to them to address/prevent deconditioning.

Summary

Physical deconditioning in Parkinson’s disease (PD) is a multifactorial problem that can be difficult to assess and manage, but with the right education and support, it is a problem that can be modified.

What causes deconditioning in PD?

Low activity levels contribute to deconditioning in PD. More than 70% of people with the condition are classed as sedentary, and the literature shows that physical activity levels decline from diagnosis.

The problem has been compounded by Covid-19. The Lancaster study, which was published last year, found that even people with PD who were active before the pandemic had either stopped exercising or had reduced their activity levels.

Julie said: “We already had an inactivity problem… but the last 12 months… have really exacerbated that.

“On top of that, it's been at a time where many of us haven't been able to provide the services we normally use to support people to maintain levels of physical activity.”

Physical deconditioning can also be centrally mediated. PD can reduce muscle strength and reduce muscle force generation and contraction speed, for example, which can contribute to deconditioning.

Factors that can influence decondition in Parkinson’s include:

• Motor symptoms
• Non-motor symptoms
• Secondary symptoms
• Comorbidities
• Normal aging process
• Covid-19

“What might start as a centrally mediated problem can change how people move. It starts a vicious circle where the changes to their movement patterns will predispose them to further restricted movement, reduce muscle strength, and have an impact on functional activity,” explained Julie.

The reasons for deconditioning in PD are multifactorial, which makes it difficult to access, treat, and manage, she added.

Assessment should be individualised, and teams should take a flexible approach to management. Physical activity should be promoted from diagnosis, and any barriers to activity recognised and addressed, she went on.

Identifying deconditioning

While it is challenging to assess deconditioning on a video consultation, there are certain factors to look out for. They include:

• How long does it take them to get out of their chair?
• Do they need to use their arms to get out of their chair?
• How many attempts does it take to get out of their chair?
• If you can see them walking on screen, do they have a shuffling gait pattern?

Julie also suggested sending people questionnaires to complete ahead of the appointment. As well as collecting valuable information, it can help them to reflect on their own activity levels, she said. Useful tools for self-reporting include fitness trackers, including smart phone apps.

Treatments and strategies

“Exercise is associated with improvements in motor and non-motor symptoms… but also, more importantly, at the moment exercise is perceived to be one of the most positive avenues towards disease modification,” said Julie.

Interestingly, she went on, many people with PD see exercise as the key to limiting disease progression and want to be more active, she said.

One of the challenges to meeting that need is that the “optimum dosage and means of delivery of exercise is undetermined” and this makes it hard to prescribe.

No one types of exercise is better than another, and all recommendations should be individualised.

Factors to consider include finding something the patient enjoys, is suited to their symptoms, and fits into their lives.

The Exercise Framework, available on the Parkinson’s UK website, is another useful tool. It advocates twice weekly strength training, balance training two or three times a week, and flexibility training three to four times a week,

“That gives them some kind of format,” said Julie. “People really need to be enabled with a kind of planner that can fit around their lifestyle.”

She went on to say that exercises needed to be prescribed as “part of a package” – people need to understand why.

“What we really want is for people with long-term conditions to be able to manage that exercise independently. Therefore, they also need the strategies to support behavioural change.”

That means looking at service design to support long-term engagement.

“We need to be empowering people to be actively involved in their management, and so we need to be thinking about contextualised and timely education, but they also need access to specialists, exercise prescribers, and to specialist multidisciplinary team members.”

Education

Dr Richard Davenport said there was a lot more to managing PD than drugs, and that a healthy lifestyle was hugely important.

Education is key to avoiding the kind of deconditioning we have seen over the last year reoccurring, he said.

“When I say education, I don’t just mean of patients and their families, I am thinking of healthcare practitioners, particularly doctors,” he explained.

“We are brought up in this medical model, and we spend all our time thinking about whether we should tweak this, or when the next sexy new drug is coming.”

We should be teaching trainees to embrace new evidence such as that which suggests exercise may be disease modifying, he went on.

Richard reiterated Julie’s point on individualising interventions to age, the existence of non-motor symptoms, personal beliefs and preferences, and comorbidities.

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