Neurorehabilitation in Parkinson's disease, multiple sclerosis, and peripheral nervous system disorders. Functional assessment, major rehabilitation problems, and PRM interventions

01Three diseases, one logic

This topic brings together three groups of disease that differ in course but share the same rehabilitation logic: find the problems that limit daily life, measure them, set goals, and use exercise, physical agents, aids and education against each problem.

The goals are the same as in any neurorehabilitation: the most independence possible, strength and endurance, balance, gait and coordination, cognition and communication, no secondary complications, and quality of life.

02Parkinson's disease

What shapes the rehabilitation

In Parkinson's disease the dopamine neurons of the substantia nigra die. The basal ganglia normally act like an autopilot that scales and sequences learned movements without thought; without dopamine the autopilot fails. The results:

• bradykinesia and hypokinesia: movements are slow and get smaller (small steps, small writing, a soft voice);
• rigidity: stiffness through the whole range, which bends the posture forward;
• tremor at rest;
• postural instability and falls, freezing of gait (the feet seem glued to the floor, often at doorways or turns), and festination (small, hurried steps that speed up);
• non-motor problems: low blood pressure on standing, constipation, bladder problems, depression, sleep problems, cognitive decline.

Two facts shape the therapy. First, movement driven by an outside signal or by conscious attention still works, because it uses other pathways; this is why cues and big, deliberate movements help. Second, function swings with the drugs: patients are best trained in the "on" period, when levodopa is working.

Functional assessment

PRM interventions

• Aerobic and strength training: walking, treadmill, cycling. Exercise improves fitness, gait and balance, and may slow functional decline.
• Amplitude training (LSVT BIG): exaggerated, large, whole-body movements repeated many times, to recalibrate the patient's sense of how big a movement should be. Its speech twin, LSVT LOUD, trains a louder voice.
• Cueing strategies for freezing and gait: visual (lines on the floor to step over, a laser on a stick), auditory (a metronome or music), attentional (counting, thinking "big step").
• Cognitive movement strategies: breaking complex movements (turning in bed, rising from a chair) into simple steps done one by one with attention.
• Balance and falls training, dual-task training, tai chi and dance (tango) for balance and rhythm.
• Stretching and extension exercises against the stooped posture; breathing exercises.
• Task-specific training of daily activities, transfers and turning; home exercise and family education.

For rigidity, the lectures list relaxing agents: warm, moist heat, warm water, slow rhythmic movements, prolonged stretching and post-isometric relaxation. They make stretching easier for a while, but they do not change the disease.

Watch blood pressure on standing: orthostatic hypotension is common from the disease and its drugs, so patients rise in stages and exercise is stopped if they feel faint.

03Multiple sclerosis

What shapes the rehabilitation

In multiple sclerosis the immune system strips myelin from nerve fibres in the brain and spinal cord, leaving scars (plaques) and, over years, losing axons. Myelin works like the insulation on a wire, so a demyelinated fibre conducts slowly and is easily blocked. The symptoms depend on where the plaques are, and vary from person to person: fatigue (often the most disabling), weakness, spasticity, ataxia and poor balance, visual loss and double vision, bladder and bowel problems, pain, cognitive problems and low mood.

Two things set multiple sclerosis apart:

• Heat sensitivity (Uhthoff's phenomenon): a small rise in body temperature, from exercise, a hot bath or a fever, makes demyelinated fibres stop conducting, and old symptoms come back for a while. It is not a relapse and does no lasting harm.
• Fatigue: an exhaustion out of proportion to effort, which makes long sessions impossible and calls for planning of energy.

Functional assessment

PRM interventions

• Aerobic and resistance training, at moderate intensity, two to three times a week, in a cool place, in short bouts with rests. Exercise improves fitness, strength, walking, fatigue and mood, and does not increase relapses.
• Energy conservation and pacing: plan the day, do important tasks when energy is highest, sit for tasks, rest before exhaustion.
• Spasticity: daily slow stretching, post-isometric relaxation, standing, positioning, cryotherapy, splints; drugs such as baclofen or tizanidine, and botulinum toxin for focal spasticity.
• Ataxia and balance: balance training, coordination exercises (such as Frenkel's slow, guided movements using vision to replace lost position sense), weighted walking aids.
• Aquatic exercise in cool water, where buoyancy supports weak and ataxic patients.
• Task-specific training of walking and arm function; constraint-induced therapy when one arm is affected.
• Aids: walking aids, an ankle-foot orthosis or FES for foot drop, a wheelchair for longer distances; cooling garments.
• Bladder and bowel programmes, cognitive strategies, psychological support, telerehabilitation and home programmes.

During an acute relapse intensive training pauses; positioning, gentle range and safety continue, and the programme is rebuilt afterwards from the new level.

04Peripheral nervous system disorders

What shapes the rehabilitation

A peripheral nerve carries movement out, sensation in and autonomic signals (sweating, skin) to the limb. When it is damaged, by injury, compression, ischaemia, inflammation or disease, the muscles it supplies weaken and waste, the skin it supplies goes numb and dry, and nerve pain may follow.

The fate of the nerve depends on the damage. In neurapraxia only the myelin is affected and the nerve recovers in days to weeks. In axonotmesis the axons are cut but their sheaths are intact, so they regrow along their old tubes. In neurotmesis the whole nerve is cut and only surgical repair gives a chance of recovery. Regrowing axons advance about 1 millimetre a day, so recovery can take months, and a muscle left without its nerve for too long (over a year or two) is replaced by fibrous tissue and cannot be reinnervated.

Polyneuropathies (diabetic, alcoholic, Guillain-Barré syndrome) affect many nerves, usually the longest first: numb feet, weak ankles, lost position sense and balance.

Functional assessment

PRM interventions

The plan follows the nerve's recovery.

1. 1

   Protect, while the nerve is out

   Splints in a functional position (a wrist cock-up splint for radial nerve palsy, an ankle-foot orthosis for foot drop) stop the weak muscles being overstretched and the joint stiffening. Passive range of motion daily. Skin care and protection of numb areas.
2. 2

   Keep the muscle

   Electrical stimulation of denervated muscle with long, slowly rising pulses (exponential or triangular), which healthy nerve ignores (accommodation); it aims to slow wasting until the nerve returns. Evidence is limited.
3. 3

   Reawaken, as the nerve returns

   Active-assisted then active exercise, PNF (Kabat) patterns, NMES of weak innervated muscle, biofeedback, avoiding fatigue of the weak muscle.
4. 4

   Rebuild and retrain

   Progressive resistance, fine motor and dexterity training, sensory re-education (recognising textures and objects without looking), desensitisation of a hypersensitive scar, nerve gliding (neurodynamic) exercises, and task-specific training for work and daily life.

Physical agents in the lectures and their logic:

In polyneuropathy the focus shifts to balance and falls (balance training, a stick, good light at night), foot care (daily inspection, well-fitting shoes, no heat on numb feet) and, in Guillain-Barré syndrome, breathing, positioning, thrombosis prevention and slowly graded exercise once the patient is stable, without exhausting muscles that are still recovering.

05Prevention of secondary complications

All three groups share the complications of weakness and immobility, and the same preventions apply as after stroke.

The team is the same as in all neurorehabilitation: the physiatrist and neurologist, the physiotherapist, occupational therapist, speech and language therapist, nurse, psychologist, dietitian, social worker, orthotist, and the patient and family, who carry the home programme that matters most in lifelong disease.