Review of Literature/Synthesis Paper
Parkinson’s is a neurodegenerative disease affecting a significant percentage of the US population over age 65. This disease particularly affects men at higher rate than women. The patient is afflicted with tremors and muscle rigidity due to an increase in acetylcholine and degeneration of the substantia nigra. Diagnosis requires the presence of two out of four important signs: rest tremor, bradykinesia, rigidity, and impaired postural reflexes (DeMaagd & Philip 2015). The progression of this condition leads to full dependence with possible dementia, and the inability to stand or walk. Dementia and aspiration pneumonia represent the major complications of this condition. Muscle rigidity in the jaw and face lead to pulmonary infections. Theses infection are a common cause of death in individuals with Parkinson’s (Hannon & Porth 2014).
The problem with Parkinson’s is muscle rigidity which progressively causes other problems including decreased mobility. Mobility can be improved by decreasing muscle rigidity which can potentially lead to an improved quality to of life. The current medication of choice used to treat Parkinson’s is Levodopa. Pharmacological treatment is used to address symptoms. Pharmacological treatment currently unable to cure this condition progression. The muscle rigidity eventually causes postural instability which put these patients at risk for fall injuries. These injuries can be threatening or lead to hospitalization. Due to this, physical therapy plays a large part in improving muscle rigidity and therefore an important factor in palliative care.
The purpose of this assignment is to synthesize current information on improving muscle rigidity through physical activity. This muscle rigidity limits the patient range of motion which significantly affects the individual’s ability to perform daily functions. The main factor between the various studies is the level of improvement in muscle rigidity. The population most at risk are older adults over age 65. All interventions focused on improving quality of life and monitored exercise activities. The effectiveness of interventions will be determined by an improvement of ability to perform normal daily tasks. Decrease in muscle rigidity and tremors will also be considered as a sign of improvement. In individuals with Parkinson’s, does exercise improve quality of life and the ability to perform normal daily tasks.
Discussion of Search
A variety of databases were used during this search which included Cumulative Index of Nursing and Allied Health Literature (CINAHL), UMHB OVID Nursing Journal Collection, Cochrane, and MEDLINE with Full- Text. The first key terms were Parkinson’s and exercise, which came up with about 5,000 articles. So, limitations were added to the search parameters. These search parameters included Parkinson’s in the title and exercise in text. This reduce to the number of articles to around fifty in Cumulative Index of Nursing and Allied Health Literature (CINAHL). Ovid actually provided the best results. Four of the seven articles used came from Ovid. Two articles came from Cumulative Index of Nursing and Allied Health Literature (CINAHL).
The articles all needed to meet certain criteria, which included being peer reviewed and published within the last five years. The research in these articles could be conducted by any health care discipline, although two articles had to have a nurse as an author. The research had to be conducted in the United States, United Kingdom, Canada, Australia, or New Zealand. These limitations ensured the research done followed the same protocols in human rights and protections that were required in the United States. These various articles could not be systematic reviews or meta analyses. These requirements allowed the articles used to be reliable in subject matter being reviewed.
Synthesis
All articles used were quantitative studies with the exception of one. Each article focused on a different intervention to prove muscle rigidity and activity. (Combs, Diehl, Chrastowski, Didrick, McCoin, Mox, & Wayman, 2013; Duncan & Earhart, 2014; King, Wilhelm, Chen, Blehm, Nutt, Chen, & Horak, 2015; Kuhman, Hammond, & Hurt, 2018; Mulligan, Armstrong, Francis, Hitchcock, Hughes, Thompson, & Hale 2018; Ventura, Barnes, Ross, Lanni, Sigvardt, & Disbrow, 2016) The other article was a qualitive study done by a nurse in which data was collected through digitally recorded interviews then transcribed and cross checked by three other faculty members (Cleary, 2018). Clients were asked semi-structured open-ended questions. Follow up questions were used to gain further into participant’s perceptions about the intervention. The same interviewer interviewed with each participant (Cleary 2018).
The time period for each study varied from 4 weeks program to a period of 2-year programs. Each study targeted individuals with a current diagnosed of Parkinson’s. All of the studies required participants who could move independently, were able to travel, and spoke English (Combs, et al., 2013; Duncan & Earhart, 2014; King, et al., 2015; Kuhman, et al., 2018; Mulligan, et al., 2018; Ventura, et al., 2016; Cleary, 2018). Two studies used dance as an intervention (Duncan & Earhart, 2014; Ventura, et al., 2016). Two studies used group exercise as an intervention (King, et al., 2015; Cleary, 2018). One study compared group exercise to group boxing (Combs, et al., 2013). On study used walking as an intervention (Kuhman, et al., 2018.)
The main differences in each study were target age and time frame, however all the studies used a randomized clinical trial design. The target age varied but all participants were at least of over 21 years of age with the vast majority of participants being at least 40 year of age and older (Combs, et al., 2013; Duncan & Earhart, 2014; King, et al., 2015; Kuhman, et al., 2018; Mulligan, et al., 2018; Ventura, et al., 2016; Cleary, 2018). Combs, et al. (2013) had 31 participants with date collected one week before beginning and one week after completion of the program. Measurements were randomly ordered using the Berg Balance Scale (BBS), Activities-specific Balance Confidence Scale (ABC), Timed Up and Go (TUG), Dual-task Timed Up and Go (dTUG), gait velocity, 6- Minute Walk Test (6MWT), and Parkinson’s disease Quality of Life scale (PDQL). Duncan & Earhart (2014) had 10 participants in which data was collected at the 12 month and 24-month mark. The average age in this study was 66 years old. Participants baseline was determined using MDS-UPDRS measures. Duncan & Earhart (2014) tested for variations between groups at baseline using independent sample t-tests for age and MDS-UPDRS III scores, and Mann–Whitney U tests for sex and H&Y stage.
King, et al. (2015) had the largest number of participants of all the studies between ages 40 and 80 but was also the shortest study. Participants were recruited from the Movement Disorders Clinic at Oregon Health Sciences University (OHSU) and the local community. This study compared exercise at home, individualized physical therapy, and group class. Participants were assigned in each group through a computer- generated randomized list. Participants were pretest using the Physical Performance test week 1 and then again week 6. In Mulligan, et al. (2018) there were 41 participants all over the age of 60 divided into intervention and control group. Participants completed cognitive and physical outcome measures pre- and post-intervention. Neuropsychological and neuropsychiatric tests were the cognitive measures. The physical measures were the Unified Parkinson’s Disease Rating Scale (UPDRS), the Six-Minute Walk Test (6MWT) and mini-Balance Evaluation Systems Test (mini-BESTest). In Kuhman, et al., (2018) there were 31 participants ages 45 -82 years old. Walking was the exercise intervention used. Participants completed several questionnaires to include the Modified Baecke Questionnaire for Older Adults (MBQOA), Activity-specific Balance Confidence (ABC) Scale, Fatigue Severity Scale (FSS). Participants followed up by completing three over-ground walking trials. In Ventura, et al. (2016), there 15 participants with dance as the exercise intervention whose ages varied from 55- 80 years old. Participants completed several assessments before beginning and after completing 10 dance classes consecutively.
In all studies, participants showed positive results at the conclusion (Combs, et al., 2013; Duncan & Earhart, 2014; King, et al., 2015; Kuhman, et al., 2018; Mulligan, et al., 2018; Ventura, et al., 2016; Cleary, 2018). However, an important limitation was the small size of each study. The size of the study ranged from 10 – 51 participants. Ventura, et al. (2016) findings suggested dance showed improvement and required further investigation. Mulligan, et al. (2018) findings suggested further investigation, however the methods used to capture information may not have been effective. Participants reported improvement. Kuhman, et al. (2018) findings suggested no improvement with walking as an intervention. King, et al. (2015) findings showed exercise was important in overcoming comorbidities. Duncan & Earhart (2014) findings suggested that long term involvement improved both motor and nonmotor functions. Cleary (2018) findings suggested that exercising in a group encouraged participation. Combs, et al. (2013) findings suggested that exercise improved function and quality of life.
Conclusion
Concerning research on improving muscle rigidity and mobility, many articles focused on exercise. There was no conclusive evidence that exercise did in fact decrease muscle rigidity that lead to falls and aspiration pneumonia. There was evidence of improvement in balance and the ability to perform activities of daily living. The recommendation of many of the articles were for further studies and larger clinical trials. Secondly, long term studies were another recommendation. This recommendation is based on accessing cause of death in Parkinson’s after use of interventions. This would provide further evidence as to the effectiveness of physical activity as an efficient intervention in muscle rigidity. Once many of the trials were done there was no further follow up. These limitations leave a variety of questions unanswered. Questions as to whether participants continued. Participation after completion of the study and if they did not continue whether or not mobility increased or decrease. Another question would if they did continue, how long before signs of decreased mobility.
It remains important that health care professionals continue to provide education on the importance of maintaining mobility in these patients. Healthcare professionals need to educate themselves on local activities and programs, so they can provide this information to their clients. Social workers who assist would further need to determine each client’s ability to access these resources. Simply providing education may not be effective enough if the client has no way to access the resources. An important step for many hospitals would be to implement studies and follow ups with individuals who choose to participate in physical therapy and other exercise programs. The at-risk population is gradually increasing and the more data that can obtained is important to future endeavors to find a cure and/or improve therapy.