Environmental Physiotherapy for Parkinsons Disease

Original Editor - Vivek Ramanandi Top Contributors - Aparna Bachkaniwala, Vivek Ramanandi and Vidya Acharya

Introduction to Parkinson's Disease (PD)

Parkinson disease (PD) is a chronic, progressive, neuro-degenerative disease of the central nervous system (CNS) affecting Basal Ganglia. It is associated with motor symptoms (slow movement, tremor, rigidity, walking and imbalance) and a wide variety of non-motor complications (cognitive impairment, mental health disorders, sleep disorders and pain and other sensory disturbances).

Figure:1 Components for Defining Parkinson’s Disease

From 1990 to 2015, the number of people with Parkinson disease doubled to over 6 million. Driven principally by aging, this number is projected to double again to over 12 million by 2040. Additional factors, including increasing longevity, declining smoking rates, and increasing industrialization, could raise the burden to over 17 million. The disease usually occurs in older people, but younger people can also be affected. Men are affected more often than women.

The cause of PD is unknown but people with a family history of the disease have a higher risk. Exposure to air pollution, pesticides and solvents may increase risk. Patients face similar diagnostic and treatment gaps and lack of access to medication for PD, particularly in low- and middle-income countries (LMIC).

The book “Ending Parkinson's Disease: A Prescription for Action” calls Parkinson's a man-made pandemic. Parkinson's is caused by factors such as urbanization, aging populations, globalization, and the widespread availability of unhealthy products like fast food. It is like an infectious pandemic because it seems to be spreading as industrialization expands.

Parkinson disease results in high rates of disability and the need for care. W.H.O. has launched a technical brief entitled "Parkinson disease: a public health approach" which highlights the global burden of Parkinson's disease (PD) and the treatment gaps that exist, particularly in low- and middle-income countries (LMIC). Three key takeaways from the brief include:

• The global prevalence of PD has doubled in the past 25 years, with over 8.5 million individuals living with the disease in 2019
• Disability and death due to PD are increasing faster than for any other neurological disorder.
• There is inequality in the availability of resources and services to provide treatment and care, with low-income countries having significantly fewer neurologists per capita than high-income countries.

In May 2022, the World Health Assembly endorsed the Intersectoral global action plan, address the challenges and gaps in providing care and services for people with PD worldwide to ensure a comprehensive, coordinated response across sectors. This includes raising policy prioritization and strengthening governance; providing effective, timely and responsive diagnosis, treatment, and care; implementing strategies for promotion and prevention; fostering research and innovation and strengthening information systems.

For most of human history, Parkinson has been a rare disorder. However, demography and the by-products of industrialization have now created a Parkinson pandemic that will require heightened activism, focused planning, and novel approaches.

Role of Environmental changes in Development and Progression of Parkinson's Disease (PD)

Aquatic pollutants, pesticides, heavy metals, and other environmental toxins can contribute to the development and progression of Parkinson's Disease (PD). Here are some key environmental changes that may play a role:

Exposure to pesticides:

Pesticides like Rotenone, Paraquat, and Maneb have been linked to an increased risk of developing PD. Various mechanisms including oxidative stress, dopaminergic neurodegeneration, mitochondrial dysfunction, inflammation, and occupational exposure among farmers, agricultural workers, and pesticide applicators have been proposed to increase the risk of developing PD. The geographic areas where high pesticide usage has been reported also showed increased PD incidence.

Heavy metal exposure:

Manganese, lead, arsenic, cadmium, and mercury exposure have been reported to be associated with PD risk. These heavy metals are proposed to lead to oxidative stress, mitochondrial dysfunction, dopaminergic neuro-degeneration, inflammation, and protein misfolding leading to PD. Though the heavy metal exposure is linked to PD, the relationship is still being researched, and more studies are needed to fully understand the mechanisms involved.

Air & water pollution:

Long-term exposure to poor air quality increases PD risk. Particulate Matter (PM2.5 and PM10), Nitrogen Dioxide (NO2), Ozone (O3), Carbon Monoxide (CO), and Volatile Organic Compounds (VOCs) are implicated. Mechanisms of affection of nervous system by air pollution include oxidative stress, inflammation, mitochondrial dysfunction, and dopaminergic neurodegeneration. Also because of the disruption of blood-brain barrier toxins are allowed to enter the brain easily.

Contaminated water sources, like wells and aquifers, may contain toxins that contribute to PD. Heavy metals, pesticides, industrial chemicals, and microorganisms are implicated for the adverse effects on nervous system. The mechanisms explained are same as the causative factors mentioned as above.

Figure:2 Effects of environmental Factors on Parkinson’s Disease (Generated using Microsoft Designer from the Prompt Parkinson's Disease and Environmental Hazards)

Lack of green spaces:

Reduced access to green spaces and natural environments may contribute to PD risk. Lack of green spaces limits opportunities for exercise, contributing to sedentary lifestyle and increased PD risk. Urban environments without green spaces can exacerbate stress, which is linked to PD development. The areas with limited green spaces typically have higher air pollution levels, which is a PD risk factor. educed sunlight exposure in urban environments can lead to vitamin D deficiency, potentially increasing PD risk. Lack of community green spaces can contribute to social isolation, exacerbating PD-related cognitive decline.

Climate change:

Climate change may cause effects such as extremes of temperatures, air pollution, weather related stress, changes in sunlight exposure, shifts in infectious disease patterns, and altered environmental toxin levels, increasing PD risk. Environmental changes can disrupt the gut microbiome, potentially contributing to PD. Please note that while climate change is linked to PD, the relationship is still being researched, and more studies are needed to fully understand the mechanisms involved.

Epigenetic modifications & gene-environment interactions:

Environmental toxins can cause epigenetic changes, influencing gene expression whereas genetic predispositions can interact with environmental factors, increasing PD risk. Epigenetic changes such as, DNA methylation, histone modification, and non-coding RNA regulation may contribute to PD pathophysiology. Gene-environment interactions during conditions like pesticide exposure, heavy metals, air pollution, etc. also leads to activation of pathophysiological processes including mitochondrial dysfunction, oxidative stress, neuro-inflammation, and autophagy which may influence PD risk.

Role of Environmental Physiotherapy in managing patients with Parkinson's Disease

Environmental physiotherapy plays a crucial role in managing patients with PD by adapting the environment to promote independence, mobility, and quality of life. By adopting eco-friendly practices, physiotherapy clinics can reduce their environmental footprint while providing quality care to patients. By integrating environmental conservation into their practice, physiotherapists can promote sustainability while improving the lives of patients with PD.

Figure:3 Environmental Physiotherapy Services for Patients (Generated using Microsoft Designer from the Prompt Conservation of the environment while providing physiotherapy services)

Physiotherapists can integrate conservation of the environment while managing Parkinson's patients in the following ways:

Home visits & assessments:

Conducting home visits to reduce carbon footprint and assess patients' home environments for safety and accessibility improves patient care. Physiotherapists assess patients' homes and identify potential hazards and recommend modifications for safety and accessibility.

Virtual sessions:

Virtual sessions facilitate connecting with the patients while reducing travelling needs for both patients as well as therapists thereby limiting carbon footprint. Also, promoting digital connectivity induces flexibility and ease of access while simultaneously making service provision convenient. Patients from rural or distant areas who may not have access to specialized physiotherapy services will be benefitted by ensuring quality service and care while simultaneously reducing appointment wait time.

Virtual sessions can help in creating opportunity for guidance on equipment and adjustments to the home environment, and provides opportunities for family education and support, creating a collaborative approach for patient care.

Sustainable exercise equipments & supplies:

Use of sustainable exercise equipment, like resistance bands made from recycled rubber; exercise mats made from natural fibers or bioplastics; dumbbells and other exercise equipments made from recycled metal; exercise balls made from eco-friendly PVC; treadmills with sustainable wood frames; etc. can be used to minimize waste.

Using eco-friendly therapy supplies such as cleaning products for equipment; reusable bottles; sustainable exercise clothing (e.g., recycled polyester); recycled paper or digital exercise charts; etc can increase sustainability in physiotherapy practice for patients with PD.

Outdoor therapy sessions:

Outdoor activities significantly promote neuroplastic changes across various neurological conditions and promoting connection with nature. These activities stimulate sensory and motor pathways, enhance the release of neurotrophic factors such as BDNF and NGF, and encourage the reorganization of neural circuits crucial for recovery.

Incorporating outdoor environments into neurological rehabilitation provides both physical and psychological benefits, making it an essential component of comprehensive recovery plans across these conditions.

Modifications to increase energy-efficiency:

Use of electricity in hospitals and clinics, to power diagnostic and therapeutic equipments are one of the major sources of direct heat emission causing increased carbon footprint of healthcare service provision. Energy-efficient modifications at home as well as clinics such as, LED lighting, supports goals of sustainable physiotherapy services for patients' independence.

Eco-friendly assistive devices:

Prescribing use of eco-friendly assistive devices, like reusable canes or walkers, made from sustainable wood (e.g., bamboo, reclaimed wood); eco-friendly metals (e.g., aluminum, stainless steel); recycled or bioplastics; etc. will reduce waste.

Community-based programs:

Develop community-based programs, such as group exercise sessions; injury and fall prevention workshops; and Parkinson’s patient outreach programs will facilitate increased accessibility and affordability; community engagement and empowerment; and reduced healthcare costs. This will lead to improved health outcomes; increased community participation; reduced healthcare utilization; and enhanced quality of life. In addition, this will promote collaboration with local healthcare providers; community outreach and engagement; and, cultural sensitivity and diversity training.

Environmental cueing:

Use of visual, auditory, tactile, and spatial cues improves mobility and balance; enhances cognitive functions; increases independence; reduces fall risk; and improves adherence to exercise program. Use of various cueing-based techniques, promote patients' independence and safety thereby reducing need for frequent or regular visits to hospitals and clinics. This reduces the healthcare utilization and associated cost while simultaneously significantly reducing carbon footprint of physiotherapy care for patients with PD.

Patient and caregiver education:

Patient centered care model emphasizes role of providing education in patients' overall well-being. Including the aspects environmental care and sustainability such as environment modification at home; encouraging participation in telehealth and community health programs; reducing travelling or using public transportation/ shared transportation methods to reduce waste; use of sustainable exercise and mobility/assistive equipments at home; etc. will increase the impact of environmental conservation practices in physiotherapy.

By adapting the environment to meet the unique needs of patients with Parkinson's Disease, environmental Physiotherapy improves their overall function, safety, and quality of life.

How environment conservation can positively impact Parkinson's Disease?

Based upon above discussion it can be interpreted that environment conservation shall positively impact Parkinson's Disease in several ways:

Reduced exposure to toxins:

Minimizing exposure to environmental toxins, like pesticides and heavy metals, can reduce the risk of developing Parkinson's.

Improved air quality:

Cleaner air reduces oxidative stress, which can contribute to Parkinson's progression.

Increased physical activity:

Access to green spaces encourages physical activity, essential for Parkinson's management.

Stress reduction:

Nature exposure reduces stress, which can exacerbate Parkinson's symptoms.

Social connections:

Community gardening and environmental initiatives foster social connections, vital for emotional well-being.

Cognitive stimulation:

Environmental engagement can stimulate cognitive function, potentially slowing disease progression.

Access to natural light:

Natural light exposure regulates circadian rhythms, improving sleep and overall health.

Reduced medication use:

By reducing exposure to environmental toxins, patients may require lower medication doses.

Improved mental health:

Environmental conservation activities promote mental well-being, reducing depression and anxiety.

Increased sense of purpose:

Participating in environmental initiatives can give patients a sense of purpose, boosting motivation and overall quality of life.

Conclusion

Parkinson’s disease is a major cause of disability across globe. Various environmental factors are proposed to be playing crucial role in development and progression of the disease. Physiotherapy is one of the essential components for maintaining and improving quality of life of such patients. Conservation of the environment while providing physiotherapy services to patients by using eco-friendly practices and minimizing waste can be achieved by various means such as digital documentation; following the policy of reduce, reuse and recycle; increasing use of energy efficient equipments and sustainable materials; adapting sustainable transportation practices; minimizing packaging and cleaning waste; using environmental friendly cleaning practices and minimizing water usage; and environmental education. This indicates that environmental physiotherapy practice along with education and promotion of environment conservation can help us provide sustainable solution for creating a healthier environment for everyone, including those living with Parkinson's Disease.