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            Parkinson’s disease is a complex neurodegenerative condition that affects people later in life (Sveinbjornsdottir, 2016). Dr. James Parkinson was the first physician to discover and describe the condition. In 1817, he described it as “shaking palsy” (DeMaagd and Philip, 2015). The condition is one of the most common neurodegenerative conditions globally, with its incidences and prevalence being on the rise. In developed nations, the incidence of Parkinson’s disease is 0.3% in the entire population and at least 1% among individuals above the age of 60 (Sveinbjornsdottir, 2016). In America, at least one million individuals have the disease. The incidences of the condition in the US is about 20 per 100,000 individuals annually (DeMaagd and Philip, 2015). The prevalence of Parkinson’s disease increases with age, with Europeans over the age of 80 having a prevalence of over 3.5% (Sveinbjornsdottir, 2016). The condition results in neuropathological brain changes. Researchers have identified the presence of Lewy bodies, which are proteinaceous spherical cells, out of the norm. They have also discovered thread-like branching Lewy neurites in involved nerve cells. The Lewy neurites begin at the induction sites and advance within the nervous system in a topographically predictable sequence (Sveinbjornsdottir, 2016). Parkinson’s disease has six neuropathological stages. The first and second stages involve a lack of symptoms and are called the pre-symptomatic stage.  At the pre-symptomatic stage, the inclusion bodies only exist in the medulla oblongata and the olfactory bulb (Sveinbjornsdottir, 2016). As the disease progresses, other areas of the brain become affected, and patients develop clinical symptoms. Symptoms typically develop when the patient is at stage three or four. At this point, the nuclei of the mid and fore brain become affected by the disease, along with the substantia nigra (Sveinbjornsdottir, 2016). At the end-stage (stages  5 and 6), patients typically exhibit a wide range of clinical symptoms. The most popular symptoms of Parkinson’s disease are motor disturbances and disturbances in the nervous system. Parkinson’s disease does not have an available treatment. However, physiotherapy and dopaminergic treatments can help in the management of the condition (Sveinbjornsdottir, 2016). Neurorehabilitation techniques like visual rehabilitation and music therapy make a real impact on improving Parkinson’s disease patients’ quality of life.

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Understanding Parkinson’s Disease

            Modifying therapy is essential for individuals with Parkinson’s disease (Johnson et al., 2019). Developing rehabilitation therapies is essential, especially since the number of individuals with the condition will double in the next two decades due to an increase in the number of older individuals. In the past, therapies revolved around slowing down the disease progression (Foltynie and Langston, 2018). However, these therapies viewed the condition as uniform and gave all patients the same treatment regimens. The three main factors that contribute to neurodegeneration as a result of Parkinson’s disease are triggers, facilitators, and aggravators. Triggers are those factors that contribute to the disease process initiation (Johnson et al., 2019). For the disease process to start, triggers require the presence of facilitators. The most common facilitators for Parkinson’s disease are genetic factors, which promote neurodegenerative cascade. Male sex and advanced age are also facilitators of Parkinson’s disease. Males with advanced age are hence more likely to get the condition than females (Hayes, 2019). The last of the three factors, aggravators, directly contribute to the neurodegeneration process by worsening the pathology and promoting the disease’s spread past the basal ganglia. The three factors do not have boundaries; rather, they represent a continuum throughout the disease process. Neuroinflammation is a common aggravator of Parkinson’s disease (Johnson et al., 2019). Neuroinflammation typically leads to the activation of glial cells and proinflammatory mediators’ overexpression. In Parkinson’s disease, activated microglia cells contribute to the deletion of neurons and emit levels of cytokines that are harmful to brain cells (Johnson et al., 2019). The microglia also activates the astrocytes to release neurotoxic mediators, which contribute to further neurodegeneration (Johnson et al., 2019). Therapies should hence target patients at all the stages of the disease progression.

Neurological Rehabilitation

            Individuals with Parkinson’s disease experience cognitive impairment, which progresses until the patient gets full onset dementia (Díez-Cirarda, Ibarretxe-Bilbao, Peña, and Ojeda, 2018). Cognitive impairment leads to reduced quality of life of the patients and disability. Researchers have published various research studies proposing and investigating the efficacy of various treatment options to improve cognition in patients. Traditionally, physicians regarded Parkinson’s disease as a motor disorder, with the most common symptoms being rigidity, tremors, and freezing of gait (Lee et al., 2019). Recently, researchers discovered that the condition produces a wide range of symptoms other than motor disorders such as cognitive impairment. Between 20% and 50% of patients with Parkinson’s disease experience cognitive impairment, with some of them experiencing cognitive impairment at the early stages of the disease (Díez-Cirarda, Ibarretxe-Bilbao, Peña, and Ojeda, 2018). The cognitive issues tend to deteriorate until the patient experiences dementia. The cognitive impairment results from grey matter atrophy, the alterations of the white matter, alterations in brain activation, and brain functional connectivity (Lee et al., 2019). Patients with early-onset cognitive impairment have reduced grey matter volumes in the frontal, parietal, and temporal lobes. They also have white matter deterioration and alterations in their brain function. Parkinson’s disease almost always leads to dementia, with research indicating that close to 80% of individuals with Parkinson’s disease getting dementia between 10 and 20 years after their diagnosis (Díez-Cirarda, Ibarretxe-Bilbao, Peña, and Ojeda, 2018). It is hence integral for physicians to focus on cognitive rehabilitation to slow down the progression of the disease (Díez-Cirarda, Ibarretxe-Bilbao, Peña, and Ojeda, 2018). Cognitive rehabilitation also helps reduce incidences of dementia due to Parkinson’s disease.

            Neurorehabilitation can play an important role in helping patients and their families manage Parkinson’s disease, which leads to a decline in their functioning (Ekker et al., 2016). Neurorehabilitation refers to the process of optimizing patients with Parkinson’s disease’s participation in social activities and well-being. Neurorehabilitation plays a huger role in rehabilitating patients, along with other management strategies like pharmacological interventions (Ekker et al., 2016). Neurorehabilitation can focus on a variety of senses, including visual functioning. Additionally, medical professionals are integrating new technology into the field, with exergaming, telemedicine, and wearables helping patients during neurorehabilitation (Ekker et al., 2016). Physicians can use various physiotherapy techniques to manage the conditions of patients.

Music Therapy For Mobility and Stability

            Mr. Parker is currently experiencing neurological deterioration, struggles with upper limb functioning freeze as he walks, and has muscle tremors. Music therapy training can help improve Parker’s mobility and stability (Sander, 2017). Researchers associate listening to music with improved neural connectivity in healthy subjects. Musical activities like singing and playing instruments induce grey and white matter changes in various regions of the brain and increase brain plasticity. Music also enhances neurological rehabilitation by improving pain and anxiety in patients, especially post-operative patients (Sander, 2017). Music-based interventions can either be active or receptive. Active music-based interventions include creating music, playing an instrument, and musical improvisation (Sander, 2017). Receptive music-based interventions involve listening to music, all under the supervision of a qualified music therapist. Mr. Parker’s physiotherapist can use both receptive and active music therapies to help improve his stability and movement.

            Music therapy can help improve the psychological and physiological symptoms in patients like Parker (Raglio, 2015). Parkinson’s disease results from the disappearance of dopamine production, leading to central nervous system changes. As the disease progresses, patients are likely to experience symptoms like balance problems and abnormal gait (Bukowska et al., 2016). Although the condition does not have a treatment, patients can lead quality lives through rehabilitation and pharmacological interventions. Research shows that the areas responsible for rhythm perception relate closely with areas responsible for movement regulation (Raglio, 2015). The regions of the brain responsible for movement regulation are the cerebellum, the basal ganglia, the premotor cortex, and the supplementary motor area. In a healthy individual, a regular pulse activates the basal ganglia. However, in individuals with Parkinson’s disease, the activation does not occur as a result of a regular pulse (Raglio, 2015). Studies suggest that the rhythmical cues as a result of playing music modulate activities in the impaired timing system. Regular rhythmic pulses thus stimulate the activity of the putamen. By facilitating the putamen activity, rhythmic pulses facilitate movement and provide input for impaired automized processes (Raglio, 2015). Additionally, allowing patients like Parker to listen to music or play musical instruments can potentially help compensate for their lack of dopaminergic stimulation. According to research studies, musical rhythm improves limb coordination, balance, and posture control (Raglio, 2015). Mr. Parker has a problem with his gait and mobility. His physiotherapist should hence prescribe active and passive music therapies to improve his quality of life.

            A 2016 study by Bukowska et al. showed that music therapy can improve the gait and rhythmical activities of individuals with Parkinson’s disease. The program involved four weeks of forty-five-minute sessions of music therapy four times every week (Bukowska et al., 2016). The participants did not require knowledge in playing musical instruments or singing. Each of the interventions took place according to the same scheme. The interventions involved practicing daily normal activities, balance, and gait training. Each session involved the use of musical instruments like the Cajon and drums, along with recorded music (Bukowska et al., 2016). Elements of applied music like pitch, tone, and tempo supported the organization of the patients’ movement in time. The physiotherapist selected rhythmical music, mostly Indian and African, to provide rhythmic instructions. The physiotherapist did not ask the patients about their music preferences. The music therapist played mp3 recordings of music and adjusted the volume to fit the needs of the patients (Bukowska et al., 2016). The sessions began with warm-up exercises to increase patients’ range of motion. Warm-up exercises included arm rotations and stretching exercises. The music therapist encouraged the patients to perform movements similar to those of their daily living activities like standing, sitting, and reaching for objects (Bukowska et al., 2016). The final part of the session involved improving gait speed and step length. Some of the activities the patients took part in included walking exercises and breathing exercises. The results of the study indicated that music therapy ameliorates gait, mobility, and stability of patients with Parkinson’s disease (Bukowska et al., 2016). These changes can improve patients’ ability to perform their normal activities. It also indicates that physiotherapists can achieve postural control through the auditory system (Bukowska et al., 2016). Music therapy can hence improve Parker’s cognition, mobility, and posture.

Aquatic Physiotherapy

            Physical activities manage physical disability that results from Parkinson’s disease. Evidence suggests that intense physical activities slow down the progression of Parkinson’s disease symptoms (Cugusi et al., 2019). Aquatic exercise is a form of non-conventional therapy to manage the symptoms of Parkinson’s disease. Aquatic exercises are popular as they offer mechanical advantages as aquatic settings have buoyancy (Cugusi et al., 2019). The buoyancy of aquatic settings offloads weight and, along with the warmth of the water, helps relieve pain and reduce muscle stiffness (Cugusi et al., 2019). Water’s viscous drag facilitates a task for motor training. The viscosity and viscous drag of water improve patients’ postures and stability. Since aquatic settings do not present patients with the risk of falling, they are safe for frail patients with Parkinson’s disease (Cugusi et al., 2019). A 2019 study by Cugusi et al. indicates that aquatic exercises improve patients’ motor skills. The study also indicated that aquatic exercises are more beneficial than land exercises in improving patients’ motor functions (Cugusi et al., 2019). Patients with Parkinson’s disease are more likely to prefer aquatic settings to land exercises as they perceive them as more interesting (Cugusi et al., 2019). If patients prefer aquatic settings, then physiotherapists should consider using hydrotherapy pools, as they are superior to land. Since land exercises put patients in danger of falling, aquatic exercises are ideal for them (Cugusi et al., 2019). In Mr. Parker’s case, he should consider aquatic exercise to improve his motor functions and posture.

Gaming Console for Rehabilitation

            Gaming, such as the use of video games and virtual reality is a relatively new concept in the rehabilitation of patients (Ekker et al., 2016). The technique is common in other patient populations like patients with dementia, stroke, or cancer. Gaming is both enjoyable and its competitive aspect motivates patients. There are two types of gaming therapies for patients with Parkinson’s disease, gaming to improve motor functioning and gaming to motivate patients to take part in physical activities (Ekker et al., 2016). Adding cognitive elements to physical activities is beneficial to patients with the condition. Since video games require both cognitive and physical capacities, they have the potential to improve patients’ motor functioning and cognition (Ekker et al., 2016). Games also enhance experience-related neuroplasticity, thus improving patients’ cognitive and motor control. However, virtual reality and video games have several challenges for physiotherapists and patients (Ekker et al., 2016). Gaming has safety issues, and patients should only take part in virtual reality activities with supervision from professionals. Professionals should ensure they tailor games to ensure they meet the personal needs of patients with Parkinson’s disease (Ekker et al., 2016). A study on the effectiveness of gaming consoles in treating incoordination in patients with the condition. The study used 3 patients with Parkinson’s disease. The patients played catch the ball and obstacle games on Xbox (Ozgonenel, Cagirici, Cabalar and Durmusoglu, 2016). At the end of the study, the patients showed an improvement in their coordination. Rehabilitation using gaming is hence an integral tool in managing balance disorders in patients, which reduces incidences of falls (Ozgonenel, Cagirici, Cabalar and Durmusoglu, 2016). Mr. Parker is having trouble with his mobility and movement. Gaming will help improve his posture to avoid falls in the future. It will also improve his cognition, which will also improve his mobility.

Cueing Through Wearables

External auditory cues like striped bars on floors can help Mr. Parker overcome gait difficulties (Ekker et al., 2016). These tools can do so by bypassing basal ganglia deficient activation and a deficiency in the activation of the supplementary circuit in the motor area. A study evidenced the importance of cueing in improving mobility and gait (Ekker et al., 2016). The study involved a cueing training program delivered to the homes of patients for weeks. The patients exhibited significant improvement during the program (Ekker et al., 2016). However, after discontinuing the program, the patients exhibited decreased improvement. Cues tend to lose their effectiveness once a patient stops using them, and physiotherapists can overcome this by adjusting the nature of cues (Ekker et al., 2016). Cues tend to have different implications for patients as patients respond differently to different types of cues. There is also a need for patients to have portable, affordable, and user-friendly cues to ensure patients can use them continuously (Ekker et al., 2016). The use of smart glasses in patients with the condition can help in neurorehabilitation by supporting patients with visual problems. Such glasses assist by magnifying objects and increasing contrast (Ekker et al., 2016). Such devices can be personalized and cost-effective to encourage patients like Mr. Parker to use them.

Motor Priming

            Priming is a type of learning that involves a stimulus initiating behavioral change (Stoykov and Madhavan, 2015). The technique is a common one in the field of psychology, and rehabilitating researchers believe it can facilitate motor learning. Priming of the motor cortex can lead to a change in brain neuroplasticity, hence improving motor performance (Stoykov and Madhavan, 2015). Motor priming methods common in rehabilitation include movement-based priming, pharmacology-based priming, stimulation based priming, action observation, and motor imagery priming, and sensory input manipulation priming (Stoykov and Madhavan, 2015). Priming can occur after a single episode of learning. Priming-induced learning is not the same as other types of learning as it requires repetition for the patient to acquire skills (Stoykov and Madhavan, 2015). Priming is a restoration intervention that targets underlying neural mechanisms in patients with neurological disorders, thus reducing impairment. Priming stems from the idea that a brain primed by earlier activation is more responsive to subsequent activation (Stoykov and Madhavan, 2015). Studies indicate that priming is effective in improving the conditions of patients with stroke. Data from other studies indicate that motor priming is promising in rehabilitating patients with neurological issues. Patients’ responsiveness to priming depends on a variety of factors, including duration, intensity, and frequency (Stoykov and Madhavan, 2015). Besides, priming during motor training tends to be more effective than priming before training. Priming techniques are cheap and easy to implement as they do not require a specialist. However, there is a need for further studies on the topic, as most findings from motor priming are not conclusive (Stoykov and Madhavan, 2015). Motor priming can hence improve Mr. Parker’s motor functioning.


            Mr. Parker has Parkinson’s disease, a condition that his physicians can manage using neurorehabilitation. To treat Mr. Parker’s mobility issues, physicians can use music therapy, aquatic therapy, motor priming, and gaming console therapies. Music therapy helps improve both the physical and cognitive abilities of patients. Video gaming and aquatic physiotherapy help protect patients from falls which are common inland activities

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