Rehabilitation for People with Movement Disorders

Rehabilitation for neurologic disorders, including movement disorders, has been evolving over the past few decades.¹ Similar to other neurologic disorders, which can be described in terms of positive features, such as spasticity, and negative features, such as weakness, movement disorders can be considered in terms of the duality of hypokinesia and hyperkinesia.² Individuals often have movement disorders as well as motor control deficits, in part because of neuroanatomic overlay.³ Principles of neuroplasticity and motor learning are key frameworks that guide neurologic rehabilitation, including treatment for those with movement disorders.⁴

In the past, rehabilitative therapies for most movement disorders were considered as secondary treatments to supplement medical management, requiring close collaboration between therapists and physicians, but this concept is evolving. The main objectives of neurologic rehabilitation for individuals with movement disorders are twofold: first, to maintain body structure; and second, to maximize functional skills.

Maintaining body structure optimizes potential for performance and can minimize secondary medical complications (for example, pressure injury caused by posturing in spastic dystonia). To maintain the body structure, clinicians should consider range of motion, skin integrity, force production, and cardiovascular fitness. These areas should be assessed objectively using standardized measures, and the therapy plan of care should prioritize maintenance of these systems or improvement, if deficits are present.

Maximizing functional skills facilitates functional independence and quality of life and can decrease caregiver burden. To maximize functional skills, clinicians should tailor therapy to the individual and prioritize areas that will be most meaningful to the individual and care partners. A detailed analysis of movements during functional activities should be integrated into therapy evaluations, including mobility, activities of daily living, and communication. Strategies that address physical, cognitive, and emotional domains may be indicated to maximize motor performance, particularly when an individual is learning new movement strategies or being challenged by therapeutic interventions. Therapeutic efforts also can positively influence an individual’s quality of life overall.

Therapy Considerations: Remediation and Compensation

Rehabilitation for individuals with movement disorders can be viewed through 2 lenses: 1) restoration of normal movement and 2) compensation for impairments and functional limitations resulting from the movement disorder. In terms of restoration, clinicians prioritize principles of neuroplasticity to facilitate optimal recovery of function. Use of task-specific training, repetition, intensity, and salience is applied to physical rehabilitation to optimize neurologic recovery and motor control.⁵ Use of high-intensity training has been found to improve locomotion for individuals with Parkinson disease (PD)⁶ and those with acquired neurologic deficits⁷; thus, intensive ambulation training should be included as an important component of the rehabilitation plan of care. This may be achieved using safety harnesses, body weight support systems, assistive devices, or bracing, or a combination of these strategies (Figure 1).

For individuals who are unable to walk, static upright activity, such as supported standing, should be initiated, as this can address numerous domains of body structure—including range of motion, force production, motor control, and cardiovascular fitness—and contribute to progression to more dynamic upright activity, such as ambulation.

Gait training can improve strength, balance, and endurance, and is therefore efficacious for nonfunctional ambulation.⁸ This is especially pertinent because individuals with movement disorders, including dystonia,⁹ PD,¹⁰ and ataxia,¹¹ often are at increased risk for falling because of their balance deficits. Therefore, gait and balance training to reduce fall risk is recommended.

Goals often include compensatory strategies for the individual’s movement disorder to optimize functional abilities and decrease risk of secondary impairments. An individual may require use of adaptive equipment to compensate for the movement disorder and maximize the ability to perform gait and other functional mobility tasks, which is discussed later in this article. Diagnosis-specific strategies can be applied to minimize the effect of the movement disorder on functional mobility skills: for example, use of external cues for people with PD¹² and alleviating maneuvers (sensory tricks) for people with cervical dystonia.¹³

Therapy Considerations: Rehabilitation Tools Used in Movement Disorders

As mentioned previously, a primary target for rehabilitation for individuals with movement disorders is to optimize functional performance, body structures, and body function, with focus on minimizing secondary impairments. A common functional limitation is impaired ability to walk safely and independently. Clinicians can provide specific strategies to optimize each individual’s gait patterns to decrease caregiver burden and maximize functional abilities. Equipment is chosen to improve the individual’s gait patterns, efficiency, and repetition and decrease caregiver burden (Table). For individuals with hyperkinetic movement disorders, assistive devices, including walkers, rollators, or weighted walkers, can be used as a compensatory strategy to increase stability and maximize independence during walking, ultimately decreasing caregiver burden.^14,15 Body weight–supported treadmill training has been found to lead to improvement in people with PD^6,12 or ataxia¹⁶ and can be used overground. Harness systems without body weight support are a valuable tool for challenging someone’s balance and gait (Figure 2).

Individuals with movement disorders, especially dystonia, can have a range of motion deficits caused by muscle overactivity, which can lead to contractures.¹⁷ Prolonged stretching using serial casting or custom fabricated splints can be a useful intervention to increase range of motion, which may facilitate additional opportunities to address motor control and functional mobility.¹⁸ Serial casting can be especially effective when combined with pharmacologic interventions, such as chemodenervation and nerve blocks.¹⁹ Cardiovascular endurance is another key component to facilitate neuroplasticity for people with neurologic conditions, including movement disorders. A range of equipment appropriate for targeting endurance along the spectrum of physical limitations caused by movement disorders is available, including seated and upright mobility interventions (Table).

Frequency, Duration, and Setting of Care

Individuals with movement disorders may be treated in a variety of clinical settings. People may be treated in an inpatient setting if they had had a recent or serious decline in functional performance, or if an inpatient setting is part of a diagnostic workup. Kaseda et al²⁰ found that individuals with PD benefitted from inpatient rehabilitation to minimize decline in motor function. People with movement disorders also may be treated in an inpatient rehabilitation setting because of complications secondary to their movement disorder. Gerlach et al²¹ found that individuals with PD were often admitted to the hospital because of falling. Individuals with a new onset of a movement disorder secondary to an acquired brain injury may warrant inpatient rehabilitation.

The overall goal of an inpatient rehabilitation course of care is to maximize the individual’s function and decrease caregiver burden to facilitate discharge to home. The length of stay for this population is highly variable, depending on the extent of deficits, funding for rehabilitation, the ability of care partners to provide assistance upon discharge, and availability of other resources (eg, home modifications, equipment acquisition). Individuals with movement disorders often require long-term rehabilitative care, which can include outpatient rehabilitation or home care rehabilitation services. Regular follow-up with physiatry can ensure that additional rehabilitation needs are addressed. Education for the individual, family, and care partners should include information related to long-term needs and empowering the individual and care partners to advocate for their needs over the long term.

Therapy Team Roles

Individuals with movement disorders benefit from an interdisciplinary approach to treatment. In the inpatient and outpatient settings, people with movement disorders may be seen by physicians, physical therapists, occupational therapists, speech therapists, or neuropsychologists, or a combination. Therapists can provide interventions to remediate deficits that are amenable to change and provide compensatory strategies to optimize function and decrease risk for secondary complications. Therapists commonly work closely with physicians to assess the individual before and after medical interventions, such as chemodenervation, medication trials (eg, oral or implanted pumps), or surgical procedures (eg, deep brain stimulation, focused ultrasound); for example, for an individual with PD, the physical therapist may measure the individual’s gait speed on and off medications to assess the effect of the medication on walking ability.²²

Physical therapists and occupational therapists commonly coordinate efforts related to assessment and provision of interventions to improve an individual’s ability to perform activities of daily living (eg, dressing, grooming, feeding, bathing, bed mobility), as performance of these motor skills is often affected by the movement disorder.^15,23 Occupational therapists and physical therapists also work on appropriate positioning in bed and in wheelchair to decrease risk for skin breakdown where limbs may encounter hard surfaces for people with hyperkinetic disorders (eg, dystonia, myoclonus).

People with movement disorders may work with a speech-language pathologist to assess and treat deficits in swallowing, speech, communication, or cognition.¹⁵ Physical therapists and occupational therapists may collaborate with the speech-language pathologist to determine equipment that optimizes positioning of the individual for swallowing, verbalizing, or accessing alternative communication devices.

Physiatrists work to coordinate treatment among the therapeutic disciplines and with other medical specialists who are involved in pharmacologic and surgical treatments. They may also perform chemodenervation procedures with botulinum toxin or peripheral neurolysis with phenol or alcohol to treat muscle overactivity.

All members of the interdisciplinary team should provide education to the individual and care partners regarding various topics related to the movement disorder. The effect of the movement disorder on an individual’s psychological and emotional status, as well as the effects on family dynamics, should not be overlooked. Neuropsychologists and counselors can offer support to help the individual adjust to disability.²⁴ Individuals may also benefit from support groups with peer interactions as a means of building a sense of community.

Conclusion

Rehabilitation management for people with movement disorders is complex and requires an interdisciplinary approach. Therapists aim to optimize the individual’s body structures and function, and prevent subsequent deficits, using remediation or compensatory strategies. Specialized equipment is available to facilitate mobility for people with movement disorders to maximize safety and independence, and decrease caregiver burden. Therapists work closely with physicians to assess the individual’s body structures and functional mobility after medical interventions. Individuals with movement disorders are a highly heterogeneous population and benefit from individualized treatment plans to address the affected body structures and functional deficits as well as the individual’s goals.