Continuation of full time employment as an inhibiting factor in Parkinson’s disease symptoms

Abstract

BACKGROUND: Parkinson’s disease (PD) is a neurodegenerative disease. Due to a constantly growing incidence rate and lowering age of PD patients it is becoming a more serious social problem.

OBJECTIVE: The aim of this study was to determine the effectiveness of physiotherapy procedure of patients with PD depending on their working status.

METHODS: The research was carried out on 89 people with diagnosed PD of IInd stage according to the Hoehn and Yahr classification. They were divided into two groups: working professionally and non-working. The Unified Parkinson’s Disease Rating Scale (UPDRS) was used to estimate patients’ clinical status while the PDQ-39 (Parkinson’s Disease Questionnaire) scale evaluated quality of life. Patients took part in rehabilitation activities twice a week for a period of 20 weeks. In both groups an improvement in physical activity and a quality of life were achieved.

RESULTS: Better effects were observed in the group of working patients. Statistically significant differences were notice in part II UPDRS (p = 0.001), part I, II and III total of UPDRS (p = 0,001) and in the PDQ-39 test (p = 0.003).

CONCLUSIONS: Employment and participation in properly planned physiotherapy help reduce the symptoms and improve the quality of life in people with Parkinson’s disease.

Keywords

Occupational activity Parkinson’s disease physiotherapy

1 Introduction

Parkinson’s disease (PD) is a neurodegenerative disease. Due to a constantly growing incidence rate and lowering age of patients, PD is becoming a more and more serious social problem. It is estimated that PD affects about 0.3% of population and the percentage increases with age up to 1.4% in people over 55 years of age, and up to 3.4% in people over 75 years of age. The first symptoms most often appear between 58 and 62 years of age, however, in 5–10% of diagnosed people the age is under 40 [1 –3]. In Great Britain there are about 24,000 PD patients under 40 years of age [4]. Taking into consideration a dynamically rising average life expectancy, a further increase in number of ill people should be expected.

The etiology of PD remains unknown [5]. Developing slowly, it is unavoidably going to disturb every aspect of patients and their families’ lives. Along with the beginning of disease the level of fitness, cognitive and emotional abilities decrease. Clinical features of disease include ridigity of muscles, bradykinesia, tremor, impaired posture and balance [6], which lead to a decrease in functional condition of people with PD. The symptoms cause problems in carrying out simple everyday life motor activities such as walking, standing up from a chair, or getting dressed. As a result, PD leads to the loss of independence and a considerable worsening of the quality oflife.

Changes of mood are one of the first symptoms and may be accompanied with depression [7]. Progressing disability can be reduced or limited by applying pharmacotherapy. Implementing drug treatment does not completely diminish motor symptoms, which can intensify at different paces depending on patients’ predisposition. In spite of applying more and more modern surgery and medical procedures, increasing disability, along with the duration of illness is being observed. Physiotherapy is believed to be one of the complementary forms to the drug treatment in people with PD [8 –10].

On account of a slowly progressive nature of the disease, physiotherapy of PD patients differs in form from physiotherapy in other diseases [11]. It is the physiotherapist’s role to maximise functional abilities and minimise secondary complications [12]. It is easier to maintain a level of functioning than to rebuild the loss of functions due to the lack of exercise. Therefore, PD requires an early, continuous and systematic rehabilitation [13].

Taking into consideration a progressive character of the disease and the significance of physiotherapists in reducing the pace of increasing motor symptoms in PD patients, the aim of this study is to determine the effectiveness of physiotherapeutic proceedings in PD patients with regard to their professional status.

2 Materials and methods

In the beginning the research was carried out on 89 people with diagnosed idiopathic PD who were treated in the Clinic of Neurology of Medical University of Silesia in Katowice. The technique of purposive sampling was used. Nine people refused to participate in the study, another 10 were excluded from the analysis due to missing class. For the statistical analysis the results from 70 people were used. A Committee of Bioethics of Academy of Physical Education in Katowice gave consent for carrying out the examinations. All examined patients were informed about the purpose and the course of examinations as well as gave written consent for their participation. The examined did not have other coexisting neurodegenerative diseases.

PD was diagnosed according to the United Kingdom Parkinson’s Disease Society Brain Bank criteria. Patients with PD of II^nd stage according to the Hoehn and Yahr classification were included in the research [14]. The examined were divided into two groups: A – working professionally and B – not working. Group A consisted of 32 full time working people (9 women, 23 men) aged 60.20 ± 4.75 years and disease duration of 5.03 ± 2.27 years. Working was defined as physical presence at work, not the fact of being employed e.g. a long term sick leave. The examined performed jobs for which they received salaries. The majority of patients (51.2%) were employed in private companies, 38.4% of them in state-owned ones, while 10.4% of them worked in their own companies. The respondents had high school education (55.1%) and university graduate (45.9%). Their level of professional physical activity was rather low.

Group B consisted of 38 people (13 women, 25 men) aged 61.31 ± 3.42 years and disease duration of 5.84 ± 2.01 years. The examined in group B stopped working due to increasing PD symptoms; all of them had worked before.

In the examinations an experimental method directed at tracking connections and cause-and-effect dependences was applied. UPDRS scale was used to describe the clinical condition of patients, part I (intellectual condition), II (everyday life activities and PD symptoms), III (motor evaluation) [15]. The quality of life in Parkinson’s disease (PDQ-39) was estimated [16]. The scale is comprised of 39 questions set in 8 subscales: mobility – 10 questions, activities of daily living – 6 questions, emotional well-being – 6 questions, stigma – 4 questions, social support – 3 questions, cognitions – 4 questions, communication – 3 questions, general discomfort – 3 questions. There is a five-point scoring system ranging from 0 to 4 points (0–never, 1–rarely, 2–sometimes, 3–often, 4–always). The questions concern the last month and are directly connected with PD. Each question begins with the following words: “Because of PD how often in the last month … ?” The questionnaire was filled by patients personally or with some help of a guardian. The score was calculated for each subscale (domain) separately with the use of the following formula: points in a given subscale multiplied by 100/4 and a number of questions in a given subscale. An aggregated result of the questionnaire was given in the form of so called Summary Index (SI) according to the formula: PDQ - SI = sum of points / 8. The total number of points gained in a given subscale was 100 and it identified the worst quality of patient’s life. The tests were filled in before and after a 20-week participation in examinations.

The patients took part in rehabilitation activities, lasting 45 minutes, twice a week for 20 weeks, which were performed at the gymnasium. The examined had not participated in any form of physiotherapeutic procedure concerning PD before. Every exercise had its functional grounds and was aimed at the ability of dealing with everyday activities. Rehabilitation proceedings were directed at specific symptoms. In bradykinesia and impairment posture – they aimed at the optimal use of still existing patterns for acquired and automatic movements [17, 18]. Proceedings included: frequent repetitive moves, coupling moves with an acoustic initiator of move (step), repeating moves with a different frequency, leading free movements with stimulating mechanisms: control signals (visual, aural, sensory), notional stimulation of move before making it, triggering equivalent reflexes, making the patients aware of abnormalities of posture and their correction [19 –22]. In case of stiffness the rehabilitation treatment concentrated not that much on fighting the stiffness, as reducing its negative influence [23, 24].

Exercises in lying position on the back (attention is paid to stretching side muscles of torso, increasing rotation of torso through moving it in the opposite direction of a lower limb and upper limb on the same side). Exercises in side-lying position (aiming at anti rotations of pelvic girdle versus shoulder girdle). Exercises in chest-lying position (aiming at learning the rotation movement). Exercises in long leg sit (pike sit) with transition to side sit which aim at improving fitness, reaching, and coordination. Transition from a side sit to hand support kneeling (with and without additional support). Transition from hand support keeling to standing position as a reaction to therapist’s commands and independently by the patient himself [13].

Exercises directed at learning to walk comprise – length of steps and the distance foot – ground, expanding the base of the gait, change of direction concentrating first on curling the head, shoulder girdle, then pelvic girdle in the set direction of movement. Using visual control signal (tapes, boxes arranged on the floor). Learning to walk with a change of pace imposed by a therapist (aural control signal – clapping). Facilitators initiated the move by using sensory control signals while exercises were directed at walking with the use of other motor programmers (sticks, skittles, balloons) [25, 26].

Exercises correcting the body posture with applying cognitive strategies relied on the concentration and deliberate holding of a straightened position of the body.

When tremors occurred a strategy to decrease them was developed. The examined were then taught the ways of stopping the tremors through intentional movements [27 –30].

Additionally, the examined received a set of simple exercises (depicted with illustrations) to be done at home daily.

The program lasted 20 weeks. Basic descriptive statistics were calculated. In the compared groups homogeneity of the variance was examined with the use of Levene’s test and normal distribution of features with the Kolmogorov-Smirnov’s test.

In order to evaluate statistically significant differences between the tested groups before examination, independent t-test was used. One-way analysis of variance was applied to assess differences in results of patients in given scales, before and after a 20-week period of rehabilitation. Depending on the significance of main effects and interactions a post hoc analysis by Bonferroni test was used. P < 0.05 was accepted as statistically significant.

3 Results

A conducted statistical analysis showed that compliance of the achieved results with the normal distribution, as well as met the conditions of the homogeneity of one-way analysis of variance.

The results of the Student’s-t distribution test demonstrated the lack of statistically significant differences between the examined groups before the accession to experiment taking into account results of all conducted tests (Table 1).

The conducted analysis of variance showed statistically significant difference between the examined groups before and after the experiment in each of conducted tests. For determining differences between the groups post-hoc tests were applied. Comparison of the results before and after the research with the division into groups is presented in Table 2.

In the group of patients working professionally (A) a statistically significant difference was noted in point values of scales before and after a 20-week rehabilitation. In all cases the differences were statistically significant. The largest change of 42.46% was registered in the quality of life, which was assessed with the PDQ-39 test.

In the group of people non-working professionally (B) when analysing results in percentage values the improvement in the efficiency was also noted, but not in all cases were the differences statistically significant. The largest difference appeared when comparing average values in absolute values were registered in UPDRS Part III, 25.21%.

For determining the effectiveness of the applied exercise program in both groups (employed on full time basis and unemployed), achieved results were compared after a 20-week period of rehabilitation (Fig. 1).

As a result of conducted examinations in both groups an improvement in the motor efficiency and quality of life was achieved. Definitely greater effects were achieved in the group of people working professionally. Comparison of the results in relative values of all of the conducted tests, showed a smaller increase of illness manifestations after 20 weeks of exercises in the group of working people. Statistically significant differences occurred in the UPDRS part II (p = 0. 001), parts I, II and III totally UPDRS (p = 0.001) and in the PDQ-39 test (p = 0.003).

4 Discussion

In recent years, numerous publications indicate the important role of rehabilitation as part of interdisciplinary cooperation in the process of healing and rehabilitation of patients with PD. Available results of examinations [8, 30] clearly indicate positive effect of performed physical exercises, diminishing pace of PD symptoms. However, in spite of that, increase in disability is observed during development of disease. Successive loss of independence due to progressing disease can turn out to be particularly difficult inpeople working professionally [31]. Martikainen et al. [32] carried out research on the influence of Parkinson’s disease (PD) on the ability to work among members of the Finnish association and found out that irrespective of age, after 7.3 years from falling ill only 16% of people worked; 12% of them on full time basis and 4% part time. Among the people who retreated exclusively on account of PD the average age was 53.4 and resignation came after 1.7 years since the diagnosis. When PD patients worked part time, they were able to continue their work on average of 4.3 years. However, Murphy et al. [33] stated that on average it took the patients 7 years from diagnosing the disease to the loss of employment. After 5 years only 40% of the examined still worked, and after 10 years only 14%. Longer time of employment was not related to sex, education or character of work, and correlated with an early age of appearing of the first symptoms, as well as the early diagnostic testing and high vigour.

Schrag et al. achieved similar results [34]. Among British patients, the average age of retirement is 55.8 years, in comparison to the average retirement age of 62 in the population of Great Britain. The average time until the loss of employment amounted to 4.9 years. The time until job loss was correlated negatively with age of incidence. There were not any differences due to sex, domicile (village, city), type of work, marital status, or having children. Other factors were concluded to influence the duration of employment after diagnosing the disease.

A reduction in the severity of symptoms in both groups as a result of applied rehabilitation program was observed in research, which may indicate an important role of rehabilitation activities as a factor slowing down the disease development, and thus prolonging the time of employment.

Scientific researchers have proved [8 , 13] that proper physiotherapy correlated with drug treatment can delay increasing symptoms of the disease. Motor classes, conducted in this research, aimed at dealing with everyday activities triggered the improvement in both the motor efficiency as well as the quality of life.

Extending the time of professional work can benefit not only the patient’s career but also have an economic dimension. It is estimated, that in 2010 in the United States there were 630,000 people with diagnosed PD, which burdened the budget by about 14.4 billion of dollars [35].

All the authors have stated [32 , 36], that the increase of main motor disease symptoms such as slowing down, the tremors and the rigid muscle were the reasons for retiring or being dismissed [37]. In case of younger people, additionally more serious psychosocial problems were encountered than in case of older people [38]. Younger people to a larger extent are exposed to anxiety states, depression and cognitive disorders [39].

In carried out research, higher efficiency in improvement in the group of working people was noticed, which leads to the conclusion that employment can be a factor influencing the effectiveness of rehabilitation in patients with PD. It could be an effect of additional motivation for exercising resulting from the fear of its loss.

Conducted tests showed, that people working professionally limited to a large degree the disease symptoms through following the physiotherapeutic program. This can delay the disease’s symptoms and lengthen the duration of employment [40]. However, it should be remembered that the positive attitude to work can also play an important role in the continuation of employment and in spite of increasing difficulties cause desire for further work.

Professional work, appropriate education of patients and their families as well as physiotherapy can considerably decrease the fear of the future. Professional activity and participation in properly planned physiotherapy helped reduce the symptoms and improved the quality of life of people with Parkinson’s disease.

Conflict of interest

The authors have no conflict of interest to report.

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