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Movement deficits in Parkinson's disease and restorative occupational therapy.

Abstract

This paper focuses on movement deficits that interfere with smooth execution of movement following Parkinson's disease. Difficulty in initiating, slowness in executing, inhibition of a current movement and preparation for a new movement as well as, switching between sets of movements, and freezing are explained.

Effectiveness of occupational therapy has been difficult to establish with methodological flaws in research. However, measurements that quantify movement deficits and the neuroinvestigative evidence based activities and contexts in occupational therapy could restore movement capabilities. Such focussed movement restitution in occupational therapy would, in turn, increase participation in daily life and improve the quality of life.

Key words

Parkinson's disease, movement deficit, occupational therapy, measurement outcome

Parkinson's disease (PD) is a chronic progressive neurological condition with reported incidence of 1:5 in western nations and a condition commonly requiring occupational therapy. A review of occupational therapy literature indicated there is a vast amount of information available on many aspects of PD. This includes: cardinal symptoms, self-care ability, ability to interact with the environment, home health and general care, nutritional matters, medications, coping, functional therapies, family education, general fitness, person and occupational centred occupational therapy, and overall quality of life (College of Occupational Therapists, 1996; Deane, Ellis-Hill, Dekker, Davies, & Clarke, 2003; National Parkinson Foundation, 2002). The above approaches utilise compensatory or adaptive methods such as independence in activities of daily living despite the loss suffered by PD, to improve the quality of life of the persons with PD. New pharmaceutical agents, surgical approaches, and brain stimulation focus on movement deficit restitution. However there is practically no information on specific aspects of restorative occupational therapy addressing the type, the degree, or the quality of deficit in movement ability, its measurement and the neurological basis of intervention.

Therefore this paper focuses on: (i) movement deficits and resulting impairments (ii) the need for quantifiable assessments to show a specific change in the quality of movement performance, and (iii) the restorative approaches in occupational therapy as they relate to restoring the quality of the movement deficits. Awareness and application of quantifiable assessments and intervention strategies are vital for occupational therapists to positively impact neurological recovery. This restorative focus in turn will allow increased participation in daily occupations and improved quality of life in persons with PD.

Movement deficits in Parkinson's disease

To explain restitution of movement deficits in Parkinson's disease, this section focuses on the deficits, mechanisms of the deficits, the deeper brain nuclei associated with the execution of smooth movement, and measuring the quality and neurological evidence for activity based occupational therapy.

Akinesia refers to difficulty in initiating movement and paucity of self-generated voluntary movement (Bear, Connors, & Paradiso, 2001) whereas bradykinesia from strial dopamine deficiency results in slowness in executing movement. The slowness comes from increased reaction time, delayed correction of an inaccurate attempt, prolonged time to recommence correct movement, and easy fatigability. Akinesia and bradykinesia are closely related but can be independent, and present in the absence of rigidity (Paulson & Stern, 1997). With Akinesia, automatic execution of learned motor plans is altered, but with dyskinesia resulting from the administration of neuroleptics, the motor plan could be executed by alternative movement strategies. This indicates that in dyskinesia, the form of motor plan is preserved but individual motor programs, which make up the motor plan, are distorted (Bear, Connors & Paradiso, 2001; Marsden, 1994). Due to deficits in movement preparation, persons with PD are unable to transform general goals into specific motor actions. This movement execution difficulty is thought to result from the lack of control of muscle activation and regulation (Paulson & Stern, 1997).

In normal voluntary movement, the movements and their components are in sequence, making the voluntary movement a smooth and fluent or a skilled movement. However, a lack of ability to sequence movements, to access motor plans, to temporally progress and to provide spontaneity by determining precisely where one muscle contraction should end before the next muscle contraction begins, manifests in robotic-type sequences with one movement requiring completion before the emergence of the next.

Once the reverberating circuit (nerve fibres that arise, synapse, and finally end in the same area of the cortex) or their interlinking pathways from cortex to substantia nigra, substantia nigra to pallidum, pallidum to thalamus, and thalamus back to cortex, is damaged, learned responses must be brought back to conscious effort. Damage to this reverberating circuit results in lack of excitation of the gamma (?) motor system. As a result a person with PD is required to make an increasingly forceful effort to drive the uninterrupted innervations. Such forceful efforts exhaust the remaining intact nervous structures (De Goede, Keus, Kwakkel, & Wagenaar, 2001).

Persons with PD also have difficulty inhibiting a current movement and preparing a new movement in the opposite hemisphere (Johnson et al., 1998). These deficits are due to a lack of pre-programming of a new sequence. There is also reduced ability to switch rapidly between sets of movements such as picking up and placing or pronating and supinating (De Goede et al., 2001). Stelmach and Phillips (1992) identify arrest of motor activity as difficulty in turning, circling around the base of support, chewing, licking and swallowing and attribute these to the modifications of cortically induced movements.

The slowness of movement in akinesia also affects participation in structured activity or occupation that require persons with PD to initiate reaching, standing, or walking and manifests as difficulties in generating a sequence of submovements, preparing for movement, and executing movement. Further, damage to the pedunculopontine nucleus may be responsible for the deficits in initiating programmed movements (Pahapill & Lozano, 2000).

The paucity of self-generated movements becomes more pronounced when more than one act is requested, such as getting up from a chair and extending a hand to greet someone, talking on the phone and writing a message, preparing a meal and responding to a dialogue, or turning around on a base of support to pick up an ingredient while stirring a hot meal. Paucity of movement in such activities is attributed to difficulty in recruiting the peripheral nervous system following altered [[gamma].sub.2] innervation.

Motor control of released movements by the caudate nucleus enhances excitatory neurotransmitter glutamate and nigrostriatal inhibitory dopaminergic effects. This becomes evident when one examines the anatomical processing of stimuli relevant to motor actions or the single neuron responses (Connor & Abbs, 1990), or the above motor release control. These observations imply that striatum contributes to the resulting modulation on the spinal cord with the corticospinal and other descending pathways. Firing of the efferent pathways from basal ganglia activates the supplementary motor area followed by the primary cortex and then travel back to the final pathway in the anterior horn to pre-prepare for the demands imposed by activities and occupations.

The automaticity and spontaneity required in motor tasks is provided by the supplementary motor area's ability to prepare for the next movement that has been rehearsed (Fahn, 1999). The automatic functions and deficits in motor control are somatotopically organized in the sensory motor cortex with leg and arm control in the globus pallidus and neck and head control in the substantia nigra (Kishore, Panikar, Balakrishnan, Joseph, & Sarma, 2000).

Activation of basal ganglia nuclei such as the caudate and substantia nigra, precedes limb movements indicating their involvement in preparing for movement that require alterations to axial postural muscles prior to activating limb movements. The putamen, its cortical projections, and supplementary motor areas are functional system components for the required limb activation. The putamen is involved in behaviour of all movements that are associated with rewards. However, if there is no goal to be attained such as in repetitive exercises, or if a response is required without motivation then the putamen activation is not evoked. Substantia nigra cells show no phasic activity to peripheral stimulation; however, the subthalamic nuclei show phasic activity somototopically. Globus pallidus firing is variable with some firing proceeding phasic or dynamic activity, some firing occurring after movement has commenced and the rest of the firing is in relation to each discrete movement (Gold & Kalwani, 2004; Weiner, Duncan, Chandler, & Studenski, 1992).

Thus, the cortex, basal ganglia, cerebellum, and the thalamus have highly specific afferent, efferent, interneuronal, and commissural connections. This linking of neuronal information makes it possible to divide one of the cortex to striatum to palladium to thalamus to cortex loop, into motor functions feedback circuit and other loops for occulomotor and orbitofrontal functions (Parent et al., 2000). A behaviour generated and released by the cortex is then filtered and sorted out by the basal ganglia so that unwanted movements are checked to allow the desired motor actions to be executed. Once planned movements are released from the striatum, the pallidum executes these with spontaneity, swiftness, automaticity and ease. When damaged as in PD, the person reverts to slower, consciously deliberate, less accurate and less automatic movements.

The above suprasegmental control and corticomotor connections then travel down the CNS to influence the final common pathway in two ways. Direct influence is via alpha ([alpha]) motor neurons and indirect influence via gamma ([gamma]) motor neurons for precise augmentation. However, in many instances [gamma] innervations precede [alpha] innervation, providing a kind of a starter function. In PD [alpha] and [gamma] balance is altered: [gamma] is depressed and [alpha] is enhanced leading to freezing and a lack of initiation from tonic exaggeration (Parent et al., 2000). Reduced dopamine has the same effect on the movement ability.

Assessments in PD with focus on the quality of movement

Quantifying clinical disorders resulting from damage to deeper cortical structures such as PD is difficult. Conditions that affect those structures and cause movement disorders do not selectively damage one region but affect multiple areas and thus have implications for occupational therapy (Corbett, 1998).

Standardised assessments for PD presented here focus primarily on quantifying various elements of movement deficits. Cognitive and perceptual abilities; activities of daily living (ADL); instrumental ADL (IADL) abilities; and global quality of life outcome measures allow the therapist to choose an appropriate aspect of the movement deficit measure. They can also evaluate whether the outcomes in improved motor control abilities is interrelated or is independent of ADL, IADL, and overall quality of life outcomes.

Lang (1991) suggests that when measuring, therapists should be aware of the progressive disease related consequences. Medication-related fluctuations and psychosocial effects of the disease account for possible variations in items within the scales. Recent research has reported sudden onset sleepiness (McConnell, 2002; Ondo et al., 2001) in persons with PD during occupational therapy assessment i.e. ADL and driving. Therefore therapists need to be aware of the side effects of drugs when treating executive functions, and commencing movement restitution, since the person might not be able to concentrate on the task at hand (Ivanzo, Valldeoriola, Santamaria, Tolosa, & Rumia, 2002; Pharmacia Corporation, 2003; Short, 2002).

Simple (time taken to see a stimulus and responding) and chosen (time taken to select a choice from a number of possible choices) reaction times for movement preparation require a person to select a movement or combination of movements among the repertoire of possibilities. Movement performance times are particularly important when pre-test/post-test changes need definitive evaluation to determine the swiftness and spontaneity with which the movement is initiated (Cohn, 2003). These reaction-time paradigm preparatory processes are also required to determine the extent of pre-movement abnormalities. For example the person with PD is slower in planning a movement, choosing between response alternatives from the repertoire of rehearsed options, or in the use of advance information from previous rehearsals.

Electromyographic analysis of the movement deficit can determine whether the deficiencies are due to lack of force, increased amplitude from excessive force, or diminished voluntary movement control. It can also determine whether the ballistic movements are conceptualised as agonist or antagonist or an agonist sequence of muscle action (Silwa, 2000).

Kinematic analysis evaluates the external or internal forces causing that motion. This evaluation determines the speed, angle and height or amount of joint movement. In PD, one can evaluate if movements have one cycle of acceleration and deceleration or if there is irregularity, asymmetry, variation in frequency of cycles, or lack of precise control over termination or commencement trajectories (Duncan, Studenski, Chandler, & Prescott, 1992; Melnick, Radtka, & Piper; 2002).

More recently a number of video protocols have been developed to measure kinematic and other movement deficit related outcomes. Chang, Guan, and Burne (2002) use video monitoring software with 90% accuracy to quantify posture and movement changes without the usual joint position markers used in virtual reality. Lang (1991) developed a videotaping method and a videotape analysis system to quantify the impact of movement deficit, while Graziano (2003) developed a video technique to identify and address mobility problems. Spyers-Ashby, Stokes, Bain, and Roberts (1999), utilize 3Space Fastrak[R] multidimensional movement analysis system to differentiate limb tremor over six degrees of freedom and to differentiate between postural tremor in unimpaired persons and persons with PD. Such video analyses are useful not only as an objective clinical tool to record progress in occupational therapy but also as a diagnostic tool to determine the degree of improved movement ability.

With the movement disorder in PD, falling is a major problem (Copperman, Forwell, & Hugos, 2002; Gaudet, 2002). Multiple internal and external factors are involved in the falls e.g. progression, freezing, step length, turning around the base of support while attempting a task at hand, cognitive and attention deficits flexibility, and weakness (Behrman, 2002). External factors include lighting, wet floors, loose carpet. While one test alone could not determine all elements involved in falls, the Functional Reach Test is recommended for identifying patients at risk of falling. A reach of 17.78 cm according to this test is regarded as a good marker of frailty. For people 70 years and over a reach of 25.4 cm indicates a risk of recurrent falls (Behrman, 2002).

The Disability and Distress Index (Rosser & Kind, 1978) has four domains of concern: self-care, social and personal relations, mobility, and usual activities. The responses are combined and scores converted to a formula. The Euroqol System (EQ-5D) (Equol Group, 1990) has multidimensional items including self-care, mobility, pain and discomfort, usual activities, anxiety and depression. Responses are combined to produce a summary score. Health and Utilities Index II (HUI) (Glaser, Furlong, & Walker, 1999) has items on sensation, emotion, cognition, self-care, mobility, pain, and fertility. Its scoring system converts responses to a numerical score. The PD Questionnaire-39 (PDQ-39) is a disease-specific quality of life instrument with eight domains. These include self-care, mobility, emotional well-being, stigma, cognition, communication, bodily discomfort, and social support (Paulson & Stern, 1997). Siderowf, Cianci, & Rorke (2001), state that in a cost cutting climate, utilizing expensive neurosurgical and other interventions need to be justified and that occupational therapists should undertake cost-effectiveness analysis using such quality of life measures.

A number of measures have been used to assess the degree of functional deficit and resulting dependency needs. The Unified PD Rating scale (UPDRS) (Fahn, 1999; Stern, 1987) covers cognition, ADL, and motor function. The scores are added to create a composite score and the higher the score the greater the disability. Its use is widespread (Gaudet, 2002) yet the reliability, validity, and summing multidimensional items from a single dimension have not been adequately addressed.

The Hoehn and Yahr Scale (1967), provides severity categories of the PD ranging from (i) unilateral symptoms (ii) unilateral and axial (iii) extremities bilaterally (iv) bilateral with impairment of postural reflexes (v) severe disability and, ambulatory, to wheelchair-bound, and bedridden. This scale lacks the discriminative quality of a Likert scale and has not kept pace with the current advances in the care of persons with PD. However therapists need to be aware of this scale as its application in clinical trials is popular in physician led studies.

The Likert-type five-point Modified Barthel Index is an empirically derived scale which measures performances in 10 daily functions (Shah, Vanclay, Cooper, 1989). This determines dependency needs and is widely used as a reliable tool (Slade, Fear, & Tennant, 2004).

The Moss Kitchen Assessment Revised (Harridge & Shah, 1995) IADL measure gauges community functioning of persons with PD using six hierarchical task levels. The performance is evaluated on a 5-point Likert-type scale. Meal preparation ability is considered basic and fundamental yet complex. It correlates strongly with other IADL abilities such as shopping, going to a place of worship, managing house chores, managing money and medication.

As a chronic progressive disorder predominantly found in older people, the cognitive and perceptual aspects of PD may impact focussed movement performance and confound the outcome necessitating these assessments. The Barry Rehabilitation In-patient Screening of Cognition (BRISC) requires less than 30 minutes and is a valid neurological assessment battery with established psychometric properties (Barry, Clark, Yaguda, Higgins, & Mangel, 1989). It assesses reading, design copy, verbal concepts, orientation, mental imagery, mental control, initiation, and memory with normative data for older age groups. The computer-based Brain Train[R] software for cognitive testing and training was developed by Sandford, Browne, and Turner (2003). It evaluates attention skills, visual motor skills, conceptual skills, and has higher faculty modules with progression from simple to complex built in. The Burke Perceptual Profile Screen, has been successfully used to evaluate perceptual deficits and how these affect daily function (Shah, Cooper, & Maas, 1993). This test consists of six reliable and valid domains of picture sequences including, body puzzle, 3-D space visualization, block design, figure-ground, and fine motor planning

While the objective measures discussed above are important, so too are observations. Teive and Sa (2002), report on a person who was late for appointments when his self-winding wristwatch was worn on the left wrist but was never late when he wore his watch on the right wrist or when he used a battery for his watch. Reporting observations of the first signs of deficits in natural arm movement during walking, foot drag leading to tripping, a slight intentional tremor when drinking water, or difficulty during shaving are of paramount importance in detecting the possible development and progression of the PD (Baylor Neurology, 2002).

Restorative occupational therapy for the movement deficits

Occupational therapy is participatory and usually requires persons with PD to take responsibility for their personal well-being and to participate in decision making (Poglar & Landry, 2003). Based on occupational therapy practice framework (American Occupational Therapy Association [AOTA] 2002) occupation is everything people do to occupy themselves. It may be looking after oneself, interacting with the environment, or contributing to the social and economic good of the community. Restorative (preparatory) activities are regarded as goal directed human actions. It is the sum of these engagements in activities or tasks or subsets of occupations that lead to increased occupational participation. These preparatory activities help to minimize the effects of impairment, disability, limitations, and restrictions imposed by the movement deficits.

The suggested preparatory activities below are not meant to be prescriptive or exhaustive, but are examples of tasks or subsets of occupations that require: (i) a degree of planning (ii) recruiting of the learnt movement programs (iii) actions that last less than a second (iv) decisions that need to be made quickly or else the target is lost (v) the brain to plan every detail of movement before acting it out; and (vi) reaching a velocity at the right time and at an appropriate angle.

Each stage of PD (severity and recovery) will require a proportion of preparatory activities for learning movement control, goal-directedness and progression to increased occupational functioning. Occupations that allow persons with PD to engage in goal-directed activities are advocated when ballistic or open-loop type and corrective or closed-loop type components of voluntary movements are required (De Goede et al., 2001; Zelu & Sale, 1994)). The control of movement would then lead to engagement in meaningful activities. Thus preparatory activities are components of performance skills that prepare people to isolate and develop mastery in performing essential ingredients of purposeful occupations (Hinojosa & Youngsman, 2002).

When it is difficult to perform a movement, the slowness of movement can be influenced by an application of a peripheral external stimulus such as high intensity brushing and rapid icing. Optimal use of therapeutic activities will facilitate movement to the required level of spontaneity in performance (Forminaso, Pratesi, Modarelli, Bonifati, & Meco, 1992).

Performing preparatory tasks by persons with PD is also marred by increased reaction times, greater firing rate, and an increase in movement amplitude. These movement components cannot be varied according to task demands, and are limited in spontaneity, until the person is systematically retrained during restorative occupational therapy. In acquiring control, persons with PD first need to understand the overall requirements for accomplishing the task before acquiring the necessary speed, force, and duration of each of the movement components (AOTA, 2002; Christiansen & Townsend, 2003; Vandenberg, Beek, Wagennar, & Van Wieringen, 2000).

Control of goal directed motor activities during 'on' periods (when the effect of a drug is working) such as drawing non-geometrical paint strokes, finger painting, cutting paper with scissors, hammering a nail, shooting a basketball, throwing darts, punching a bag, and other ballistic movement tasks become an integral part of occupational re-education. In turn this would facilitate participation in occupations that are meaningful to the person with PD and match their performance expectations. It may further facilitate engagement in leisure, work, home and occupational pursuits (Edwards, 1999; Gold & Kalwani, 2004; Law, 2002; Zelu & Sale, 1994).

Planned activities excite intact reverberating circuits that activate [[gamma].sub.1] and [[gamma].sub.2] motor neurons (Kannenberg & Greene, 2003), minimize inhibitory influences of the damaged neurons, and allow the intact cells to be efficiently utilized (Gold & Kalwani, 2004). As these tasks are mastered, automatic corrections are performed using a closed-loop control where persons with PD focus and visually ascertain each element of movement. As the akinesia improves in occupationally embedded tasks, movements become automatic and ballistic with decreased reaction time, minimal use of closed-loop, and increased spontaneity (De Goede et al., 2001; Lang, Godde, & Braum, 2004; Marsden, 1994).

Hocherman and Aharon-Peretz (1994) first identified difficulty in performing dynamic tasks such as manual tracking as against static and tonic activity. They also highlighted the need for practice in the preparatory phase of task mastery. The need to use dynamic tasks was further substantiated by Carey, Deskin, Josephson, and Wichmann (2002) and Protas, Stanley, and Jandovic (1996). These efforts maintain and increase range and strength, increase speed of muscle contraction, and prevent contractures, phlebitis, and other inactivity-related complications from developing.

Fine finger facility, manipulative ability, individual, isolated, and combined finger movements; accuracy; and preciseness are improved with individualized, goal-directed activities. Examples of these include spool knitting, cane work, bench and assembly work, use of personal diaries, keyboard applications, and the use of immersive virtual reality (wearing a head mounted devise and entering a virtual world to facilitate functioning in the real world). Manual dexterity is further enhanced with ballistic and purposeful activities such as using pegs in solitaire, folding and putting a letter in an envelop, using scissors, hammering nails, dribbling and shooting a basketball, passing a football, shovelling dirt, and throwing darts (Lang et al., 2004; Vandenberg et al., 2000; Zelu & Sale, 1994)

Persons with PD need to participate in activities that require movement sequence as a whole because it helps: elements of one movement to finish before commencing another; maintain the computed force; initiate and increase variability of movements; and utilize visual guidance. When difficulties are encountered, observing and copying another person, receiving verbal or tactile cues, imagining and/or visualizing an object, may be required to perform a functional task (Majsak, Kaminsla, Gentile, & Flanagan, 1998). Likewise writing, drawing non-geometrical designs, and performing tasks that require a quick response may improve movement sequence. Such activities allow progression from unstructured control of the upper limb to precise manipulative skills.

Experiments to produce peak forces reveal that PD does not impair intention rather the rate at which force develops, the initiation, timing, and spacing needed to intentionally alter these. Sequence of movements performed at a fast or a slow pace improves the force of muscle contraction, maximises recruitment of motor units, and controls amplitude of movement (Haaland, Harrington, & Knight, 2002). In micrographia, the ability to maintain the required amplitude rather than the duration for which the force has to be maintained, the time between the forces generated for one movement and the next, as well as the ability to maintain speed are vital. It might become necessary to increase pauses between movements for increased accuracy. Practicing non-geometrical shapes prior to controlled writing minimize these difficulties. Based on inverted writing in non-mirror transformations, such tasks excite supplementary motor areas (Zelu & Sale, 1994).

While restorative occupational therapy is considered beneficial in PD, some researchers (Platz, Brown, & Marsden, 1998) have expressed reservations and suggested that the motor learning itself could be affected. However, the same authors contend that manual pursuits and sequencing a task could be learned thus negating the reservation expressed. Platz et al. (1998) and Nieuwboer et al. (2001) investigated the question of restorative practices leading to increased movement speed and its contribution to visually guided movement. They found that training to either move fast or move accurately but not both, quickly and accurately helped persons with PD. Use of spatial, temporal, and force-monitored movements were learned or transferred via cerebellar and cortical areas and further facilitated by auditory cues during rehearsal.

Deficits in force requirements for acceleration and deceleration and sensory-motor integration are facilitated by initial adjustment, early preplanning, and by fine-tuning final corrective movement requirements. Initially the movements that require repetitive performances are performed with vision occluded to utilise available propriocetive awareness in the limb. Then Rascol et al. (1998) recommend people with PD learn to decrease their movement time when visually guided occupations are used. The untrained opposite limb also shows significant improvement in anticipation of movement initiation. Auditory cues did not specifically help in this experiment, but humans are capable of activating [alpha] motor neurons because the final common pathways are directly innervating the extrafusal skeletal muscles in gross movement and in strong muscle contractions. However, when fine, precise, and delicate, manipulatory movements are required (Jankovic & Stacy, 1999), [gamma] motor system has to be activated.

During focussed movement re-education, translational activities for increasing overall participation could be commenced. For example: introducing group or individual relaxation and activities using music, hand clapping to music, rhythm, and movement, gentle rocking, and rotation of trunk and extremities can improve entire body range of motion. Hand clapping helps decrease cortical inhibition and abnormal EMG activity, and music facilitates movements. If the speed of movement is increased along with precision, dexterity, and coordinated tasks, overall performance is enhanced. Keeping people as physically active as possible, learning to stop movements at precise moments, and using ball games or musical chairs maintains health status and agility. Games and leisure activities requiring spontaneity of movement, paying bills, balancing budget, writing checks, figuring taxes, using the internet further advance patients' ability to master cognitive and daily skills. Heightening abilities facilitates coping with the progressive nature of the disease and improves quality of life (Wilcock, 1999).

Canadian occupational and physical therapists designed an excellent self-referral plan for patients and their spouses to bring about health behaviour changes by problem-solving the needed aspects of education and exercise. The program emphasizes self-management to affect quality of life by prioritising activities so people can adjust their life style to control fatigue and encourage ease and endurance of daily tasks (Brownbridge, 1999; Shah, Cooper, & Lyons, 1992). IADL such as preparing a meal facilitates interaction between voluntarily moving the body, [alpha] and [gamma] co-activation, cognition, and sensory-perceptual patterns. The goal-oriented retraining helps neurons to recruit and fire at a high level; develop synchronic patterns: and reinforce basic, fundamental, natural, instinctive central pattern generators (Melnick et al., 2002). In addition, sequential processes in occupational performance reinforce the functions facilitated by the globus pallidus i.e. pre-movement programming; ability to initiate movement; the speed with which movement is executed; and finally how body posture is maintained and movement elicited (Finch, Brooks, Stratford, & Mayo, 2003; World Health Organization [WHO], 2001).

While ample neurological evidence of the relationship between occupation and context of activity has been presented, clinical research studies have shown inconclusive evidence (Deane et al., 2003). Deane et al. (2002) compared seven published trials and concluded that because of methodology limitations and extreme variations in treatments, the data did not support or refute the effectiveness of therapeutic interventions. In a systematic review of 23 studies, researchers found that heterogeneous intervention methods and methodological flaws required further trials (Deane et al. 2001). Murphy and Tickle-Degnen (2001) concluded that interventions have positive effects based on 63% improvement with restorative occupational therapy compared to 31% without.

Conclusion

In this paper, the authors have outlined postulated movements deficits, integrated these with current neurological knowledge, and provided clinical reasoning. They suggest (i) evaluations using a variety of measurement tools, and (ii) available neurological evidence to develop best practice interventions for improving movement deficits. Engagement in tasks and occupational subsets that become engagement in occupation and activities are conceptualised. Furthermore experimental evidence shows the importance of engaging persons in goal directed preparatory activities to build strength and endurance, control and coordination, speed and accuracy of individual and combined movements, and cognitive functioning following therapeutic interventions

Equipped with current knowledge of motor deficits, assessment protocols, and neurophysiological evidence-based restorative approaches, new trials that combine neuroscience and clinical outcomes should yield more conclusive evidence of the effectiveness of occupational therapy in restoring movement deficits. Participation by persons with PD in restorative occupational therapy (Montgomery, 2001) including: activities of daily living, instrumental activities of daily living, and leisure and work activities, is essential for a fuller and improved quality of life (Law, 2002; Majsak et al., 1998).

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Surya Shah PhD, M Ed, OTR, FAOTA

Professor, Occupational Therapy and Neurology

University of Tennessee Health Science Centre

930 Madison Avenue, Suite 618

Memphis TN 38163, USA

Ann Nolen Psy D, OTR

Chair and Associate Professor, Occupational Therapy

University of Tennessee Health Science Centre

930 Madison Avenue, Suite 601

Memphis TN 38163, USA

Address for correspondence: Professor Surya Shah

Tel: + 901 448 8763

Fax: + 901 448 7545

Email: sushah@utmem.edu
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Publication:New Zealand Journal of Occupational Therapy
Date:Sep 1, 2006
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