Parkinson’s disease (PD) is an archetype of complexity, as it affects various bodily, mental, and behavioural functions, leading to functioning profiles that differ in severity and progression.
Numerous individual and environmental factors, including exposure to climate changes and pandemics, may shape these profiles, and influence the patient’s response to rehabilitation. While evidence supports the effectiveness of motor training, rehabilitation results can vary significantly across individuals.
This is even more relevant when we look at the epidemiology of Parkinson’s disease, the second most common neurodegenerative disease after Alzheimer’s disease: around 10 million people worldwide are living with Parkinson’s disease and this number is expected to double by 2050.
The challenge of a multi-faceted progressive disease
As the number of people affected increases, so does the need for interventions to help them cope with a lifelong condition that can manifest and evolve in many ways. Parkinson’s disease is not only impactful at the individual level due to ongoing disability progression and quality of life erosion but also at the social level, with the family members suffering the burden of caring.
The impact of environmental factors: life at the time of COVID-19
In 2020, the world was hit by the diffusion of SARS-COV-2 that, up to now, has progressively infected around 777 million cases worldwide. Strict mobility restrictions represented the first and necessary reaction against the spread of the virus . Our research group delved into the impact of COVID-19 and the lockdown policies on people living with Parkinson’s disease. In this study, we looked at the clinical records of around 230 patients, regularly assessed from 2018 to 2021, i.e., from the years preceding the pandemic to the time of the virus’s first diffusion and the response period. Patients were clinically examined every six months. They received a thorough neurological and functional assessment, tracking complications, rehabilitation treatment and hospitalisations.
Lockdown and rehabilitation shortage affected people with Parkinson’s disease
The COVID-19 pandemic represented a breakthrough in the evolution of Parkinson’s disease.
Our study reported that the average number of rehabilitation sessions per person fell from 87% in 2018-2019 to 29% in 2020, matching the downturn in the number of follow-up visits.
Concurrently, all clinical and functional scores worsened after 2020. Interestingly, the milder the disease, the higher the clinical and functional status decline. Based on these results, we hypothesized that the mobility restrictions imposed by the lockdown acted as determinant modifiers of health status in people with even a mild disability. This hypothesis was supported by the finding that the minority of patients who could access rehabilitation in 2020 experienced a less severe deterioration in their clinical and functional status.
Regular exercise prevents disability progression in people with Parkinson’s disease
Our findings shed light on the importance of regular clinical monitoring and rehabilitation delivery for people with PD, starting in the early stages of the disease. Several studies have highlighted the importance of aerobic and task-oriented exercise on many pathways. It improves motor circuits, the expression of neurotrophic factors, blood flow and neurogenesis. In addition, exercise plays a crucial role in promoting neuroplasticity at the level of cortical-thalamic-basal connections, which enhances motor and cognitive behaviour in people with PD.
Not all training is equal: Personalized Care for Optimal Recovery
A multimodal and intensive rehabilitation treatment has the potential to help people with PD to achieve long-lasting benefits in any disease phase and subtype.
However, the outcome after any rehabilitation approach largely varies across patients exhibiting different demographic, motor, and non-motor features. Currently, there is no agreement on the recommended levels of physical activity/motor/cognitive training benefit people in different disease phases, with various clinical features and disability levels. Variable combinations of robot-assisted motor training, action observation techniques, virtual reality-enhanced sensory feedback, and non-invasive brain stimulation have been proposed to support motor relearning.
Although continuity of care is the key to effective chronic care, involving patients in cycles of intensive rehabilitation at regular intervals is a challenge given the number of individuals with rehabilitation needs and the the poor availability of rehabilitation professional resources. In this perspective, telerehabilitation has grown in appeal, presenting as a likely cost-effective approach to help people with PD or Parkinsonism to be empowered on their own health. The efficacy of any telerehabilitation approach for patients mostly lies in their compliance with the recommended levels of training, and compliance largely varies according to individual and clinical variables.
In a multifaceted scenario of several factors affecting disability progression, clinicians are frequently challenged by the need to recognize and correctly discriminate which patients will benefit from costly (namely, robotic rehabilitation) and demanding (namely multimodal intensive training) rehabilitation interventions, also combined with the best available drug treatment or with functional neurosurgery. A refined predictive ability will avoid delaying proper treatment in people with a less aggressive disease while also excluding from invasive approaches those who exhibit multiple factors of poor responsiveness to any intervention and would deserve palliative care.
Last but not least, rehabilitation treatment is a complex and multimodal intervention delivered through a multidisciplinary approach, whose outcomes are easily influenced by clinical, social and personal factors, including education, employment, perceived health and well-being, participation and social networks, and service availability.
How can we deal with this variability and predict the disease trajectory? How can we tailor a rehabilitation program to the actual and future patient’s needs? PREPARE-Parkinson is designed to answer these questions.
With information collected from more than 1000 people in any PD stage and with an average follow-up of 7 years, the PREPARE project will train a Clinical Decision Support System, aimed at helping clinicians deal with the needs of older people with a multi-faceted neurodegenerative disorder, like Parkinson’s disease, handle the several predictive factors of disease trajectory and design rehabilitation protocols tailored to the subject’s needs.
Authors: Maria Gabriella Ceravolo, Marianna Capecci, Elisa Andrenelli, Nicolò Baldini, Gianmatteo Farabolini, “Politecnica delle Marche “ University.