In the last twenty years, great progress has been made in understanding the functional mechanism of Parkinson's patients and the implications for the nature of the recommended physical activity. The need for activity stems from its effect on slowing down the signs of the disease and encouraging functional independence and a better quality of life for those affected by it.

Dr. Eli Carmeli, geriatric rehabilitation specialist;
The Zinman College of Physical Education and Sports at the Wingate Institute;
Department of Physiotherapy, Tel Aviv University

introduction
The clinical syndrome of Parkinson's disease was first diagnosed by James Parkinson in 1817. The sufferer of the disease loses some sensorimotor functions.

The primary pathology in Parkinson's is in the "black area" in the midbrain (Substancia Nigra), an area where the dopaminergic neurons (that secrete dopamine) are destroyed, and the fibers of the tracks called Nigra-Striatal Tracts are damaged. The result is a lack of dopamine - an essential chemical - in the "basal nuclei" (Garcia, 1986; Marsden, 1982). But Parkinson's disease is not so simple and includes structural changes in the brain and the nervous system.

The connections between the cerebral cortex, the basal ganglia,
The nuclei of the thalamus and the brainstem

To understand the problematic nature of movement control in Parkinson's, the following facts must be kept in mind:

The motor control systems in our body do not function independently or on their own. Motor control is done through many interdependent systems (the cerebrum, cerebellum, senses, sensations, reflexes, muscles and joints).
Understanding motor function is a product of combining knowledge from different fields: neurology (the structure of the nervous system and its function), physiology (of the muscle), biomechanics (of the joints) and behavioral science (motivation, perception, emotion, cognition and movement memory). An understanding of these fields of science and their functional implications are necessary for understanding motor control in Parkinson's disease.
Traffic control is actually a task that is carried out continuously, sequentially and by combining the various systems.
The functional categories that make up motor control include joint range of motion, muscle tone, muscle strength, sensation, endurance, speed, posture, balance, spatial orientation, and emotion. A defect in one of these components may interfere with the execution or control of the movement. Such disturbances may occur already in the preparation for the movement, at its beginning, during it, at its end and even in its results.

Although the disease is characterized as a syndrome that interferes with movement function, the disease also has characteristics that are not directly related to movement: blood pressure that changes with a change in body position (Orthostatic Hypotension), increased sweating, oily skin (due to overactivity of the mammary glands), difficulties in controlling Body temperature, disturbances in bladder and sphincter control, as well as sexual dysfunction. Sensory symptoms such as diffuse pain, numbness of the hands and feet, numbness, tingling and burning sensation in the limbs are common in Parkinson's disease. In this disease, there may also be disturbances in certain senses such as the sense of smell and balance (Blaszczyk, 1998; Miller and Dehlund, 1988). The disease is also characterized by a wide range of behavioral changes such as depression (Starstein et al., 1998), passivity, memory deficits (dementia) and hallucinations (Halland et al., 1997). The extent of the syndrome's effect on the patient's functioning and on these autonomic changes is of great importance regarding the nature of physical activity for Parkinson's patients (Shaneman and Butler, 1989).

The ways of treating the disease are according to its severity, and include, among other things, physical activity, physical therapy, drugs (Kison, 1998; Keston et al., 1995) and surgeries (Kraus Vinovic, 1996)

Motor characteristics in Parkinson's disease
The motor manifestation of Parkinson's disease is mainly "resting tremor" (Resting Tremor), which is characterized by a tremor known as Pill Rolling; But also muscular stiffness, decreased movement (hypokinesia), changes in posture and balance and walking disorders. It should be noted that there are sometimes additional tremors in Parkinson's patients such as "Intentional Tremor", which manifests itself while performing a voluntary or coordinated movement, and "Postural Tremor", which appears when the patient tries to maintain his posture (Posture) or Maintain a stable position. These tremors may interfere with the performance of various functions such as moving from the chair to the bed, maintaining balance and walking. Below is the breakdown of the main disorders:

Muscle stiffness (Rigidity)
Muscle tone disorders are of two different types, but they are interdependent. Muscle stiffness in Parkinson's is described as increased resistance to movement during passive movement. Such resistance is described as a "cogwheel", and it manifests itself in stiffness in both directions of movement (during bending and lunging) or in one direction only. The degree of irritability varies from time to time and depends on behavioral variables such as emotions (sadness, joy, anxiety, pain), weather, fatigue, hunger or thirst. The Kishion phenomenon causes not only a bent posture, a disturbance in the elasticity of soft tissues and difficulties in breathing and walking, but also a slowing down of the speed of movements and reactions, as well as the use of "abnormal" compensatory movements in the body and limbs (for example, "hunched" sitting, standing on a narrow base). All of these worsen the degree of stiffness and make movement even more difficult (Baradali et al., 1983).

Reduction in the amount of movement (Hypokinesia)
The Parkinson's patient is characterized by "poor movement", that is, his range of movements is limited. This limitation is the most significant for the movement problems in Parkinson's. Decreased movement has broad meanings in terms of their effect on motor control. Here are some examples: lack of spontaneous movements, absence of a smile ("mask face or "poker face"), delay in the onset of movement and a sudden stop in the middle of it, decrease in movement fluctuation (such as short walking steps) and inability to maintain repetitive movements. The most common problem in Parkinson's is the difficulty In the beginning of a movement. In Parkinson's patients, the phase between the thought and the execution of the movement is prolonged (Blazik, 1998; Bloxham et al., 1997; Lagopoulos et al., 1997; Stern et al., 1983; Rogers and Chan, 1988; Rothwell et al. ', 1983).

Gait characteristics
Parkinson's gait is characteristic and unique (Walker and Gerhard, 1998). The steps are short, fast and dragging (Shuffing Steps), the hands do not move, the shoulder blades are fixed, and there is difficulty starting to walk and difficulty stopping (Rozin et al., 1997).

In a biomechanical analysis it can be seen that the range of motion in all the joints of the lower limb is minimal, and is performed mainly in the transverse plane. There is also a lack of abduction movement in the hip and knee joints (perhaps due to a reduction or shortening of the tissues of the hip and leg flexors), a lack of lateral and dorsiflexion in the ankle, a decrease in rotational movement in the pelvis and thorax (Weinrich et al., 1988), a decrease in vertical movements of the body ( the body almost does not rise or fall while walking) (Kozkenny et al., 1987), abnormal position of the foot while walking and spending a lot of time on both feet.

A Parkinson's patient develops a contracted and bent posture,
which aggravates the way he walks
Lack of response to movement (Akinesia)
This phenomenon can be clearly identified when the subject is asked to perform a complex movement task that can be performed in different ways, such as moving from a chair to a bed or moving from sitting to standing (Bank et al., 1986; Fay and Rogers, 1990). Reaction time is prolonged when a Parkinson's patient performs a complex and coordinated movement. The reason for this is, apparently, a central disorder related to the movement control process, which depends on the identification of different stimuli and the selection of appropriate responses (meaning - a deficiency in motor planning).

slowness of movement (Bradykinesia)
The typical clinical picture in which a Parkinson's patient moves slowly and mechanically (like a "robot") is well known and familiar. The Parkinson's patient is not able to control the speed of the movement, its rate and fluctuation, therefore the movement is slow, cumbersome, in a small and large range of motion and without coordination between the two hands. The explanation for the phenomenon lies in a defect in movement control at the central level (the extrapyramidal system) and at the peripheral level where the motor nerve does not suppress the contraction of the antagonist muscle when the agonist is contracting, and vice versa (ReciprocalInhibition Mechanism). For example in Parkinson's, the flexors and extensors of the wrist contract uncoordinated and out of synchronization, and in fact they interfere with each other in their action. The result is "economy and stinginess in traffic".

Freezing Phenomenon
The stagnation phenomenon is expressed in a sudden cessation of movement and especially of rhythmic movement such as walking, talking and writing. This phenomenon is indeed related to kishon, but it can be diagnosed while performing repetitive movements. For example - difficulty saying "la, la, la, la, la" or a sudden stop while walking. The explanation for the phenomenon probably lies in the disturbance in the ability to create a uniform rhythm and maintain it. On the other hand, when talking or walking is accompanied by external stimulation - visual or auditory - it is more fluent. By the way, from here you can also learn about the importance of these two senses in maintaining and controlling the pace of movement (White et al., 1983; Lambati et al., 1997).

Difficulties with posture and balance
Maintaining balance is a function of many motor and sensory systems, both at the level of the brain and at the level of the periphery (Reichert et al., 1982). In Parkinson's the following situations can be expected:

Bent and kiphotic posture, round shoulders and arms stretched forward.
Decrease in accompanying movements. For example, the arms do not move while walking.
Absence of posture feedback (Righting Reactions) Information about the position of the head in relation to the body and limbs in space during posture and movement. In Parkinson's patients, the body moves as one division.
"Complete fixation" or lack of separation between the near part (the proximal segment) and the far part (the distal segment) during movement. For example: difficulty in fixing the neck will interfere with speaking, eating or peripheral vision. The fixation of the pelvis and lower limb makes it difficult to walk smoothly and fluently, especially during turns and turns. "Full fixation" causes deficiencies in maintaining posture and balance, which may end in a fall (and fracture) and the development of scoliosis and dystonia (abnormal tone) of the hands and feet.
Principles of exercise for Parkinson's patients
Since the motor syndrome is varied and different between Parkinson's patients, physical activity and its nature also differ from person to person. Here are some principles of physical activity for a Parkinson's patient:

The activity should include training for motor control of the limbs and torso and should be done every day.
The nature of the activity is first aimed at releasing and relaxing the stiffness of the joints and muscles. This goal is achieved through passive stretches, slow and uniform in their oscillation, accompanied by rotational movements of the torso and limbs.
The following types of exercises should be increased: breathing exercises to increase mobility in the chest and controlling the movements of the diaphragm muscle to improve the quality of breathing.
Postural exercises to prevent stiffness or scoliosis.
Flexibility exercises and stretching of soft tissues to prevent contractions.
walking exercises on plains and in different terrain conditions (such as slope, grass, sand, asphalt, stairs, moving track) (Hashi, 1997); Walking at a variable pace (big steps, changes of direction) and in changing environmental conditions (at home, on the street, in daylight and at night, in the wind, etc.); Walking combined with another task such as talking. In the process - use of various aids (walker, cane, different pair of shoes) (Senvison et al., 1997).
Care should be taken to recruit as many motor units in the muscle as possible, in order to perform an active movement in a maximum range of motion. Such recruitment is made possible mainly through muscle strengthening, which is characterized by dynamic (concentric) contraction and through the practice of functional motor tasks from light to heavy, while emphasizing the quality of the movement and not its quantity.
It is highly recommended to increase the use of various aids such as balls, ropes, balloons, scarves, etc., in order to practice correct movement timing, rhythm, fluency, accuracy and hand-eye contact.
Dynamic balance must be practiced, using biomechanical principles, i.e. a structured and gradual change of the center of gravity and the base of support, weight bearing and weight transfer.
It is recommended to increase the practice of repetitive movements, using visual or auditory stimuli (Brown and Marsden, 1988).
It is generally recommended to use music to provide rhythm, and in mild cases even dance with simple steps.
In any case, do not tire the patient - physically or mentally.
Summary
Although it is not possible to stop the progression of Parkinson's disease, physical activity has the ability to greatly reduce the degree of symptoms of the disease, thereby helping the sufferer and encouraging him to live a more independent and creative life. The activity should start as early as possible, immediately after the medical diagnosis

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From "Physical Education and Sports"
Volume 3 2000, Adar XNUMX-XNUMX XNUMX, February XNUMX
Published by the Wingate Institute of Physical Education and Sports