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An Osteopathic, Non Pharmacologic Approach to Parkinson's Disease

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An Osteopathic, Non Pharmacologic Approach to Parkinson's Disease 30 Osteopathic Family Physician (2017) 30 - 38 Osteopathic Family Physician | Volume 9, No. 6 | November/December, 2017 REVIEW ARTICLE An Osteopathic, Non Pharmacologic Approach to Parkinson’s Disease, Restless Leg Syndrome & Essential Tremor Matthew S. Goldfinger, OMS III, Shannon Moriarty, OMS III, Kristina DelPlato, BS, Sheldon C. Yao, DO, Adena Leder, DO, & Jayme D. Mancini PhD, DO New York Institute of Technology College of Osteopathic Medicine Keywords: Movement disorders are a heterogeneous group of complex sensorimotor neurological conditions involving involuntary abnormal movements, defciencies or changes in normal motion. Parkinson’s Osteopathic disease, restless leg syndrome, and essential tremor are the most common movement disorders, and Manipulatve Medicine their prevalence is increasing with the growth of the aging population. These neurological conditions Osteopathic affect multiple body systems and are best managed with a multifaceted treatment approach. Behavioral, Manipulatve Treatment lifestyle, and/or psychosocial modifcations and treatments for sleep, mood, exercise, and nutrition to meet the increased metabolic demands are critical. Evidence suggests that osteopathic manipulative Movement Disorder medicine may improve gait and motor function in Parkinson’s disease as well as quality of life in restless leg syndrome. In addition, osteopathic manipulative medicine may be used to treat many of the common Parkinson’s Disease symptoms in these patients such as constipation, rib dysfunction, back pain, and tendonopathy in the Restless Leg Disorder same way as in patients without movement disorders. The normalization of autonomic nervous system function through manipulation of the suboccipital area, cervical myofascia, and rib raising would be Essental Tremor particularly benefcial in these disorders. Integration of the fve models of osteopathic care by the family physician can improve symptom management and overall quality of life. Neurology INTRODUCTION Movement disorders are a heterogeneous group of complex sen- The central tenets of osteopathic medicine provide a framework sorimotor neurological conditions that are classifed as having for utilizing osteopathic diagnosis and manipulative techniques either a general increase in movement, hyperkinetic, or a paucity to improve our patients’ natural physiologic functions. Conditions of movement, hypokinetic. The frequency of most movement dis- involving decreased joint range of motion or musculoskeletal pain orders tends to increase with age. With the increasing size of the are often manageable by techniques which improve mobility or re- elderly population, the prevalence of most movement disorders is duce excessive muscle tone. Similarly, an infectious process of the expected to double by the year 2050.1 Movement disorders that lower respiratory tract may beneft from increased mobility of the are routinely seen in a primary care setting include Parkinson’s dis- thoracic cage and improved lymphatic fow. 2,3 The purpose of this ease (PD), restless leg syndrome (RLS), and essential tremor (ET). article is to guide the family physician in an osteopathic approach Each of these conditions can negatively impact a patient’s quality to the care of PD, RLS and ET in addition to pharmacologic therapy. of life. Early diagnosis by osteopathic family physicians and educa- tion regarding treatment options may improve care, particularly in THE FIVE MODELS OF the awareness of the early symptoms that are often not attributed OSTEOPATHIC TREATMENT to a neurological disorder and their osteopathic treatment. Inte- gration of osteopathic manipulative medicine (OMM) provides The fve models of osteopathic care provide physicians with a patients an adjunctive, non-invasive treatment option which may framework to integrate osteopathic manual treatments (OMT) improve symptoms and quality of life. for PD, RLS, and ET. Application of direct active techniques can be helpful in engaging the patients’ musculoskeletal system. Indirect passive techniques should be applied if the patient is too fatigued, unable to follow commands, or direct techniques are too painful to perform. The models may also aid the physician in providing CORRESPONDENCE: patient education regarding goals of treatment and potential side Jayme D. Mancini PhD, DO | [email protected] effects prior to consent. The particular osteopathic techniques are outlined to the right. Osteopathic neuromusculoskeletal treat- Copyright© 2017 by the American College of Osteopathic ments may ease pain, provide symptomatic relief, and decrease the Family Physicians. All rights reserved. Print ISSN: 1877-573X need for higher-risk medications or invasive procedures. Goldfinger, Moriarty, DelPlato, Yao, Leder, Mancini Parkinson's Desease, Restless Leg Syndrome, and Essential Tremor 31 BIOMECHANICAL MODEL chronic diseases. It is important to counsel patients and their fam- ily on behavioral interventions to decrease the stressful impact of The biomechanical model looks at the body as interconnected chronic diseases. levers, pulleys, compression, and tension elements to address so- matic dysfunctions of the musculoskeletal system. The hyperki- METHODS netic and hypokinetic control of movements frequently impacts the musculoskeletal system and connective tissues. Goals of OMT PubMed and Google Scholar databases were searched for guide- in this domain include restoring normal muscle tone, joint range of lines in the diagnosis and treatment of PD, RLS, and ET. The second- motion, natural alignment, and decreasing nociception from syno- ary texts An Osteopathic Approach to Diagnosis and Treatment, Foun- vial joint distortion. dations of Osteopathic Medicine and Atlas of Osteopathic Techniques and primary research articles on multidisciplinary and osteopathic NEUROLOGICAL MODEL care for PD, RLS, and ET as well as their most common symptoms (tremor, constipation, mood disorders, daytime fatigue and som- The neurological model addresses sensorimotor and autonomic nolence, mobility, and pain) were reviewed. The most recent lit- nervous system (ANS) control of the body by both the central and erature on these topics was selected for review. The information peripheral nervous systems, all of which are pertinent to PD, RLS, was evaluated utilizing concepts from Grading of Recommenda- and ET. OMT for the nervous system relies on inherent refexes, tions Assessment, Development and Evaluation (GRADE) as well and it can be applied at the end muscle/organ or centrally at the as the authors’ experience from a clinical and research perspective spine or head. OMT to normalize ANS tone may decrease the need on treating people with these neurological conditions.4 Concepts for pharmaceutical interventions. from GRADE utilized in the selection of key references included RESPIRATORY-CIRCULATORY MODEL outcomes of interest being important to patients, greater beneft than risk, and relation to the target audience of providers. OMT The respiratory-circulatory model focuses on the proper motion of modalities were chosen based on clinical research and clinical ex- intra- and extravascular fuid around the body as well as optimizing perience from practicing physicians who treat these disorders. breathing. The focus of OMT is on cardiovascular and pulmonary health, fow of blood and lymph, and motion of the associated mus- culoskeletal structures. The major musculoskeletal structures fa- PARKINSON’S DISEASE cilitating pulmonary ventilation are the diaphragm, ribs and spine. Parkinson’s disease is a neurodegenerative disorder that affects These and the lower leg muscles also facilitate blood and lymph millions of people worldwide. There are approximately 1 million circulation. Improved lymphatic fow decreases local pooling of people in the United States living with PD, and over 60,000 new infammatory mediators and metabolic waste products. These fac- cases are diagnosed each year. 5 Research suggests that PD is as- tors may play roles in the etiology and/or progression of PD and sociated with a variety of external risks factors, including head RLS. Decreasing edema tends to improve pain. Improvement in tis- trauma, exposure to pesticides, drug use, and others (Table 1).5 sue perfusion may aide in supporting the excess cellular respiration Emerging theories implicate breakdown of the blood brain barrier demands. In conditions that disrupt sleep, PD and RLS, improving in many of these etiologies.6 Less than 30% of PD cases are associ- respiration may reduce nighttime awakenings, muscular pain in the ated with a genetic susceptibility.5,7,8 morning, and daytime somnolence. Parkinson’s disease is a hypokinetic movement disorder currently METABOLIC-ENERGY MODEL diagnosed clinically by its characteristic motor features of brady- kinesia including decreased facial expression, rigidity of the mus- The metabolic-energy model takes into account the biochemical, culoskeletal system, postural instability, and sometimes tremor potential and kinetic energy dynamics aspects of physiology. The (Table 2). Non-motor symptoms may be the initial presentation of main goal of this model is to improve energy production and meta- the disease. Some common non-motor symptoms include loss of bolic effciency. Daytime fatigue is frequently problematic in RLS smell (anosmia), REM sleep behavior disorder, constipation, mood and PD. Changes in neuromuscular physiology may prevent eff- disorders, or autonomic nervous system (ANS) dysregulation of cient coordination of concentric and eccentric muscle contraction
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