Breathe deeper, Breathe better
Respiratory Rehabilitaion in Parkinson Disease
Respiratory Rehabilitaion in Parkinson Disease
Dr. Ditza Gross (MephD)
yael Manor (phD)
Tania Gurevitch(MD)
Respiratory rehabilition unit and unit for Motion dysfunction and the Parkinson disease serviced
Tel Aviv Sourasky Medical Medical Center
In 1917 Jamed Parkinson described a patient who protrayed difficulty breathing by saying "in order breathe I have to catch a breath". Since then several studies were published Parkinson patients having difficulty breathing most likly due to stiff chest wall, slowing down of chest wall motion, tremor and walking disturbances as well as posture dysfunction 1,2,3.4.5,6,7
This breathing disturbance is resulted in restrictive as well as obstructive respiratort condition and a significant lack of coordination between inspiratory and expiratory function (8.9.10). Respiratory muscle exercises were demonstrated to significantly improve respiratory muscle strength and endurances as well as lungs and chest wall flexibility, hence improvement in effective speech, chough and swallowing capacity (11,12,13,14,15,16).
Breathing is performed during inspiration by contracting the respiratory muscles, producing a negative pressure (a vacum) within the chest wall, followed by flow of air into the lungs. During quiet breathin in normal healthy individuals is done passively.
In Parkinson disease respiratory load is elevated by increased stiffness of the chest wall and lack of coordination between inspiratory and expiratory phases of breathing. Consequently, the respiratory muscles are required to harder and within a disadvantageous mechanical setting. Therefore, these muscles work less effectively which in turn enhance the development of fatigue. With time these muscles become weaker.
In addition in Parkinson disease the expiration against a load is performed actively requiring more oxygen and more energy products. Due to all the above factors the breathing becomes shallow and more energy is required.
The signs of breathing difficulty in Parkinson patients includes; general fatigue, shortness of breathing, particularly during exertion, shortness off breath in a supine position, morning headaches, decreased concentration, restlessness, decreased appetite, behavioral changes, weak and ineffective cough as well as decrease in loudness and clarity of speech.
Often these symptoms are seen ad reflecting other problems and the breathing dysfunction is not being investigated or treated. Based on respiratory investigation it is possible to plan an individually tailored management program of respiratory rehabilitation.
The respiratory capacity can be evaluated by a simple test that can be performed within the clinic. In this test of simple pulmonaray function, inspiratory and expiratory force as well as levels of oxygen and CO2 (all done noninvasively). On the basis of the results it is possible to plan an individually tailored program of respiratory rehabilitation that will strengthen the respiratory muscles, improve flexibility of the lungs and chest wall thus, improve the patient's breathing and general functional capacity.
Respiratory rehabilitation program includes
1. Several test to evaluate the respiratort capacity of the patient using various devices.
2. Breathing exercise with or without specific repsiratory muscle training devices that strengthen the respiratory muscles, improve the flexibility of the lungs and chest wall, which in turn improve the effective cough and speech. This treatment has been proven to be effective in healthy individuals , in patients diagnosed with COPD, Asthma, Neuromuscular diseases, Cardiac patients and Oncology patients.
3. Management of muscus accumulation by diluting the mucus by inhalation and/or medication. It is possible to get a prescription from the treating physician. In addition it is advisable to use physiotherapy for secretion clearance.
4. Cough; Parkinson patients, at times, have difficulty in mucus clearance. For this purpose there is a device called coufflator or In-Exufflator that simulates the act of coughing noninvasively or if neccessary via the tracheostomy (This device is included in the health basket).
5. Ventilatory support; At night and when necessary during the day it is possible to ventilate a patient noninvasively via a mask. Using this method it is possible to assist the patients ventilation at night or during the day and allow the respiratory musxles to rest, hence prevent the development of respiratory muscle fatigue. By doing this quality of life is enhanced. The titration of these devices can be done only be a professional with experience with noninvasive ventilation. This treatment should be done at the right time and the proper titration.
Respiratory Rehabilitation for Parkinson patients is usually combined with physiotherapy and speech therapy as well as proper communication a dietitian. In patients with decreased breathing capacity below 60%, it is recommended to apply the use of ventilator support at night.
Pysiotherapy; physiotherapy is essential in the management of Parkinson patients. It is particularly important to improve flexibility and compliance of the chest wall and the lungs. In addition it is important to do active as well as passive work to improve range of motion of arms and legs.
Nutrition and Swallowing; Around 90% of Parkinson patients experience swallowing difficulty of various levels. Consequently these patients decrease the nutritional intake resulted in complications including respiratory shortness of breath as well as increased exposure to infections. Diagnosis and treatment of disturbances in swallowing is performed by a speech therapist who will also give solution to the problem. After a complete evaluation the patient is referred to a dietitian for an appropriated and personally suitable diet.
Speech; Respiratory capacity has a direct influence on quality of speech and voice. 80% of Parkinson patients develop speech disturbances (dy sarthria). Weak sound (hypophonia), occurs frequently and quite early after diagnosing the disease, in these patients. In addition, we observe monotonous voice in terms of loudness of voice, horseness, and disturbances of rate of speaking as well as slurred speech. The coordination of speech with breathing is disturbed and it affects the tone as well as clarity of speech.
As a result of the speech dysfunction patients have difficulty in communicating hence, social life. In order to maintain proper speech it is neccessary to undergo speech therapy combined with pulmonary rehabilitaton progrem run by speech therapist with pulmonary rehabilitation specialist.
Parkinson patients undergoing resiratory rehabilitation program indicate improved quality of sleep, quality of speech leading to improve quality of life.
In conclusion respiratory rehabilitation plays an importand role in the multidisciplinary management of Parkinson patients. Therefore, it is recommended to include respiratory rehabilitation program as part of the management of these patients as early as possible. Thus, slow down the deterioration of the daily function of such patients and improve their quality of life.
This breathing disturbance is resulted in restrictive as well as obstructive respiratort condition and a significant lack of coordination between inspiratory and expiratory function (8.9.10). Respiratory muscle exercises were demonstrated to significantly improve respiratory muscle strength and endurances as well as lungs and chest wall flexibility, hence improvement in effective speech, chough and swallowing capacity (11,12,13,14,15,16).
Breathing is performed during inspiration by contracting the respiratory muscles, producing a negative pressure (a vacum) within the chest wall, followed by flow of air into the lungs. During quiet breathin in normal healthy individuals is done passively.
In Parkinson disease respiratory load is elevated by increased stiffness of the chest wall and lack of coordination between inspiratory and expiratory phases of breathing. Consequently, the respiratory muscles are required to harder and within a disadvantageous mechanical setting. Therefore, these muscles work less effectively which in turn enhance the development of fatigue. With time these muscles become weaker.
In addition in Parkinson disease the expiration against a load is performed actively requiring more oxygen and more energy products. Due to all the above factors the breathing becomes shallow and more energy is required.
The signs of breathing difficulty in Parkinson patients includes; general fatigue, shortness of breathing, particularly during exertion, shortness off breath in a supine position, morning headaches, decreased concentration, restlessness, decreased appetite, behavioral changes, weak and ineffective cough as well as decrease in loudness and clarity of speech.
Often these symptoms are seen ad reflecting other problems and the breathing dysfunction is not being investigated or treated. Based on respiratory investigation it is possible to plan an individually tailored management program of respiratory rehabilitation.
The respiratory capacity can be evaluated by a simple test that can be performed within the clinic. In this test of simple pulmonaray function, inspiratory and expiratory force as well as levels of oxygen and CO2 (all done noninvasively). On the basis of the results it is possible to plan an individually tailored program of respiratory rehabilitation that will strengthen the respiratory muscles, improve flexibility of the lungs and chest wall thus, improve the patient's breathing and general functional capacity.
Respiratory rehabilitation program includes
1. Several test to evaluate the respiratort capacity of the patient using various devices.
2. Breathing exercise with or without specific repsiratory muscle training devices that strengthen the respiratory muscles, improve the flexibility of the lungs and chest wall, which in turn improve the effective cough and speech. This treatment has been proven to be effective in healthy individuals , in patients diagnosed with COPD, Asthma, Neuromuscular diseases, Cardiac patients and Oncology patients.
3. Management of muscus accumulation by diluting the mucus by inhalation and/or medication. It is possible to get a prescription from the treating physician. In addition it is advisable to use physiotherapy for secretion clearance.
4. Cough; Parkinson patients, at times, have difficulty in mucus clearance. For this purpose there is a device called coufflator or In-Exufflator that simulates the act of coughing noninvasively or if neccessary via the tracheostomy (This device is included in the health basket).
5. Ventilatory support; At night and when necessary during the day it is possible to ventilate a patient noninvasively via a mask. Using this method it is possible to assist the patients ventilation at night or during the day and allow the respiratory musxles to rest, hence prevent the development of respiratory muscle fatigue. By doing this quality of life is enhanced. The titration of these devices can be done only be a professional with experience with noninvasive ventilation. This treatment should be done at the right time and the proper titration.
Respiratory Rehabilitation for Parkinson patients is usually combined with physiotherapy and speech therapy as well as proper communication a dietitian. In patients with decreased breathing capacity below 60%, it is recommended to apply the use of ventilator support at night.
Pysiotherapy; physiotherapy is essential in the management of Parkinson patients. It is particularly important to improve flexibility and compliance of the chest wall and the lungs. In addition it is important to do active as well as passive work to improve range of motion of arms and legs.
Nutrition and Swallowing; Around 90% of Parkinson patients experience swallowing difficulty of various levels. Consequently these patients decrease the nutritional intake resulted in complications including respiratory shortness of breath as well as increased exposure to infections. Diagnosis and treatment of disturbances in swallowing is performed by a speech therapist who will also give solution to the problem. After a complete evaluation the patient is referred to a dietitian for an appropriated and personally suitable diet.
Speech; Respiratory capacity has a direct influence on quality of speech and voice. 80% of Parkinson patients develop speech disturbances (dy sarthria). Weak sound (hypophonia), occurs frequently and quite early after diagnosing the disease, in these patients. In addition, we observe monotonous voice in terms of loudness of voice, horseness, and disturbances of rate of speaking as well as slurred speech. The coordination of speech with breathing is disturbed and it affects the tone as well as clarity of speech.
As a result of the speech dysfunction patients have difficulty in communicating hence, social life. In order to maintain proper speech it is neccessary to undergo speech therapy combined with pulmonary rehabilitaton progrem run by speech therapist with pulmonary rehabilitation specialist.
Parkinson patients undergoing resiratory rehabilitation program indicate improved quality of sleep, quality of speech leading to improve quality of life.
In conclusion respiratory rehabilitation plays an importand role in the multidisciplinary management of Parkinson patients. Therefore, it is recommended to include respiratory rehabilitation program as part of the management of these patients as early as possible. Thus, slow down the deterioration of the daily function of such patients and improve their quality of life.
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