Jump to content

Deconditioning in Parkinsons

Original Editor - Ewa Jaraczewska

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Deconditioning is common in Parkinson's and can contribute to disability. Its causes are multiple, but it can be improved with sustained, targeted activity. This page outlines the causes, consequences, and simple outcome measures you can use across most settings to help track deconditioning in people with Parkinson's.

What Is Deconditioning?

Deconditioning is the loss of physical fitness (muscle strength, cardiovascular capacity, flexibility, and motor control) that results from reduced activity rather than from disease pathology alone.[1]

It is a systemic response to prolonged inactivity, bed rest, or a marked reduction in physical activity. It can affect anyone who becomes sedentary, not only people with a specific diagnosis like Parkinson's.[2] When the body is not regularly challenged by physical activity, systems that are no longer being stressed downregulate, and overall function declines.[3] The decline typically spans several interconnected systems:[1][4][5][6]

  • Musculoskeletal: muscles atrophy (loss of muscle mass) and weaken, particularly antigravity muscles, such as the calf muscles and quadriceps. Bone density may also decrease over time due to reduced mechanical loading.
  • Cardiovascular: the heart becomes less efficient, and the total blood plasma volume often decreases. Orthostatic intolerance is common as blood pressure regulation changes.
  • Metabolic: deconditioning impairs the body’s ability to process glucose and lipids. Insulin sensitivity decreases, which can increase the risk of developing metabolic issues, even in previously healthy individuals.
  • Neuromuscular: balance and coordination can decline, with some loss of proprioception (the sense of body position). This can create a "vicious cycle" where the individual feels less confident in their movement, moves even less, and subsequently becomes further deconditioned.

Understanding deconditioning is important because it can be prevented and at least partly improved through regular physical activity.[3]

Drivers of Deconditioning in Parkinson's

People with Parkinson's are markedly less active than their peers, and this inactivity increases as the condition progresses.[7] Inactivity contributes to muscle weakness, reduced aerobic endurance, joint stiffness, and impaired balance, which further limits activity.[7]

Motor- and Non-Motor Drivers

In Parkinson's, both motor and non-motor symptoms can reduce everyday activity.[8][9] Motor symptoms leading to deconditioning in Parkinson's include bradykinesia and rigidity, which reduce the amount and amplitude of movement, lowering daily energy expenditure well below that of age-matched peers.[10] [11] Postural instability and gait changes also contribute; because walking and other activities become more effortful, people with Parkinson's tend to do less.[12]

Non-motor contributors include fear of falling, frailty, fatigue, apathy, and cognitive changes.[13] [14] Fear of falling develops early and is a powerful independent driver of activity avoidance. While it is usually related to a genuine gait and balance impairment, in some people fear of falling exceeds their measured physical risk, and this mismatch is itself associated with falls.[15] This can lead to a fear-avoidance cycle that increases sedentary behaviour and further reinforces the deconditioning cycle.[16] Cognitive changes can further suppress motivation and activity initiation, which are already affected by dopaminergic loss.[17]

Situational and Systemic Drivers

Even short periods of bed rest or reduced mobility can cause marked functional loss in someone with Parkinson's, because their reserve capacity is already reduced. This may follow acute illness, injury, hospital admission, or surgery.[18]

Interruption or delayed/reduced access to rehabilitation services also contributes, for example, waiting weeks for therapy or speciality services, or being discharged from services once "medically stable".[19]

Environmental and social factors include the loss of a walking or exercise companion, reduced transport, caregiver over-assistance, or a home environment that limits opportunities for activity.[8]

Consequences of Deconditioning in Parkinson's Disease

Table 1 summarises domains where deconditioning can add to the challenges already caused by Parkinson's.

Domain Effect of deconditioning
Musculoskeletal[20] Loss of muscle strength and power (particularly antigravity and extensor muscles), reduced joint range, increased stiffness, and altered muscle architecture with prolonged flexed postures
Cardiovascular[21] Reduced aerobic capacity and endurance, with increased fatigue at lower workloads
Balance and falls risk[22][23] Slower postural reactions, reduced ability to manage dual tasks, and increased fall frequency and severity
Functional/ADL[24] Reduced independence in transfers, dressing, bathing, housework, and community mobility
Psychological[25][26] Increased anxiety, low mood, reduced self-efficacy, and worsening fear of falling
Cognitive[27] Reduced capacity for dual-tasking; exercise has a protective/ameliorating effect that is lost with inactivity
Quality of life and participation[28] Reduced social engagement, loss of roles and independence, and greater caregiver burden
Systemic/medical[29] Increased risk of secondary complications, such as pressure injuries, chest infections, contractures, constipation, deep vein thrombosis (DVT), particularly after any period of prolonged inactivity

Deconditioning Assessment in Parkinson's

A functional assessment should combine validated outcome measures with clinical observation of posture, movement strategy, and effort. The sit-to-stand and timed up and go are particularly useful because they are quick, require no specialised equipment, and are sensitive to change with deconditioning and with rehabilitation.[30] Performance on both can decline with Parkinson's itself, as well as with deconditioning, so repeating these tests under consistent conditions tracks change over time.

Sit-to-Stand

The sit-to-stand test measures functional lower-limb strength and power, postural transitions, and the ability to generate anti-gravity force. Sit-to-stand performance in PD is shaped by several factors, including bradykinesia, rigidity, reduced lower-limb strength and power, and postural-control deficits, with deconditioning adding to these. Features you may see include:[31][32][33][34]

  • Slower overall time, with increasing reliance on upper-limb push-off or momentum rather than true leg extensor power.
  • Reduced velocity of the "stand" phase specifically, reflecting loss of explosive/power-type strength, which often declines earlier than maximal strength with inactivity.
  • Increased trunk flexion and forward weight transfer strategies to compensate for weak hip and knee extensors, often visible as an exaggerated forward lean before rising.
  • Greater variability between repetitions and increasing fatigue across the five (or thirty-second) trials.

Clinical cut-offs to guide interpretation:

  • A five times sit-to-stand (FTSTS) time of ≥16 seconds has been identified as a threshold associated with increased falls risk in people with Parkinson's.[35]
  • Interrater reliability and test-retest reliability are high, so the FTSTS remains a useful measure to re-test at review.[35]

Clinical tip: Watch the strategy, not just the stopwatch. Two patients can produce the same time but have very different movement quality. One patient may be limited by a strength deficit, another primarily by bradykinesia/freezing at initiation. This distinction should shape whether treatment focuses on strength/power training or on cueing and initiation strategies.

EmbedVideo is missing a required parameter.

[36]

Timed Up and Go

The timed up and go (TUG) is a timed test of functional mobility that combines the sit-to-stand transition, gait, turning, and return to sitting, making it a useful global marker of everyday mobility and fall risk.[37] Several features of TUG performance are commonly affected in PD:

  • Increased overall time, with disproportionate slowing through turns (turning requires more postural control and is often where freezing and instability are most apparent).
  • Reduced gait velocity and shortened stride length during the walking component.
  • Increased number of steps to turn, and greater use of compensatory strategies (widened base, multiple small steps, hand use on furniture).
  • Marked decline when a cognitive or manual dual task is added (TUG-cognitive), reflecting reduced capacity to allocate attention to both movement and task at the same time.

Clinical cut-offs to guide interpretation:[38]

  • Total TUG time helps discriminate fallers from non-fallers in Parkinson's. Nocera et al. proposed a cut score of around 11.5 seconds. Reported thresholds vary between studies and testing conditions. These numbers should be treated as indicative and always be interpreted alongside history of falls and clinical presentation.
  • Adding a cognitive dual task (e.g. counting backwards by threes) may improve detection of fall risk compared with the single-task TUG, and it is recommended as part of a broader falls risk assessment rather than as a stand-alone screen.[39]

Clinical tip: Repeat the TUG (and dual-task TUG) at intervals through a rehabilitation programme. Even a few seconds improvement often corresponds to real gains in confidence and independence, and is a useful way to show progress to the person, family, and referrers.

Watch these videos if you would like to learn more about the TUG and Dual-Task TUG testing:

EmbedVideo is missing a required parameter.
[40]
EmbedVideo is missing a required parameter.
[41]


Other Tests in Parkinson's Disease-Related Deconditioning Assessment

Sit-to-stand and TUG testing go well alongside:[42]

No single test captures everything. Using a small, repeatable battery allows you to compare functional change over time.

Clinical Implications for Practice

  • Screen early, not just after a fall or admission. Deconditioning can be present well before it becomes obvious, and waiting until a crisis means working from a lower baseline.
  • Separate disease progression from deconditioning where you can. A sudden or disproportionate functional drop, especially after illness, hospitalisation, or a period of reduced activity, should raise suspicion of deconditioning rather than being assumed to be disease progression alone. This can shape the expectations you set and the interventions you choose.
  • Target both strength/power and cardiovascular capacity. Evidence supports exercise not only for functional and symptomatic benefit but as a possible disease-modifying influence on Parkinson's itself, alongside benefits for mood, cognition, and sleep.
  • Address fear of falling directly. Psychological and physical deconditioning reinforce one another, and confidence-building (graded exposure, success experiences, environmental adaptation) should run in parallel with physical rehabilitation.
  • Re-test under consistent conditions. Sit-to-stand and TUG scores are only useful if repeated the same way each time. Build re-testing into your review structure from the outset so change is demonstrable, not assumed.
  • Think across settings. Deconditioning risk and its assessment/management apply equally whether you see someone in clinic, in their own home, or in a care setting. The principles, such as early identification, targeted exercise, confidence-building, and regular re-testing, do not change regardless of the testing environment.

Resources

References

  1. ↑ 1.0 1.1 Welch C, Chen Y, Hartley P, Naughton C, Martinez-Velilla N, Stein D, Romero-Ortuno R. New horizons in hospital-associated deconditioning: a global condition of body and mind. Age Ageing. 2024 Nov 1;53(11):afae241.
  2. ↑ Westlake M, Cowley A, Robinson K, Gordon AL. Towards a common definition of hospital-acquired deconditioning in adults: a scoping review. BMJ Open. 2025 Jan;15(1):e086976.
  3. ↑ 3.0 3.1 Hart DA. Learning From Human Responses to Deconditioning Environments: Improved Understanding of the "Use It or Lose It" Principle. Front Sports Act Living. 2021 Dec 3;3:685845.
  4. ↑ Arun B, Lewis SHM. Frailty and deconditioning on the acute take. Clin Med (Lond). 2026 Mar;26(2):100548.
  5. ↑ Hart DA. Learning From Human Responses to Deconditioning Environments: Improved Understanding of the "Use It or Lose It" Principle. Front Sports Act Living. 2021 Dec 3;3:685845.
  6. ↑ Lair B, Le Roux E, de Glisezinski I, Larrouy D, Harant I, Bareille MP, et al. Five days of physical inactivity induced by dry immersion alter skeletal muscle metabolism and whole body glucose tolerance in healthy men. J Appl Physiol (1985). 2026 Jan 1;140(1):279-293.
  7. ↑ 7.0 7.1 van Nimwegen M, Speelman AD, Hofman-van Rossum EJ, Overeem S, Deeg DJ, Borm GF, van der Horst MH, Bloem BR, Munneke M. Physical inactivity in Parkinson's disease. J Neurol. 2011 Dec;258(12):2214-21.
  8. ↑ 8.0 8.1 Ahn S, Springer K, Gibson JS. Social withdrawal in Parkinson's disease: A scoping review. Geriatr Nurs. 2022 Nov-Dec;48:258-268.
  9. ↑ Khan A, Ezeugwa J, Ezeugwu VE. A systematic review of the associations between sedentary behavior, physical inactivity, and non-motor symptoms of Parkinson's disease. PLoS One. 2024 Mar 29;19(3):e0293382.
  10. ↑ Bologna M, Paparella G, Fasano A, Hallett M, Berardelli A. Evolving concepts on bradykinesia. Brain. 2020 Mar;143(3):727-50.
  11. ↑ Narita M, Sakano K, Nakashiro Y, Moriwaka F, Hamada S, Okada Y. Factors Associated With the Decline in Daytime Bed Mobility Independence in Patients With Parkinson's Disease: A Cross-Sectional Study. J Mov Disord. 2025 Jul;18(3):231-243.
  12. ↑ Nelson AK. The effects of rigidity on energy expenditure during walking in Parkinson Disease. Electronic Theses and Dissertations. 2021. The University of Memphis. 2167.
  13. ↑ Hernández-Triana D, Páez-García S, Mena A, Gimeno M, Soto-Leal A, Rodríguez-Oroz MC, Borda MG. Parkinson’s disease and frailty: a two-way link across aging. Journal of Clinical Medicine. 2025 Dec 22;15(1):63.
  14. ↑ Kong J, Yang Z, Liu Y, Chen W. Apathy and Reduced Voluntary Activity in Older Adults with Parkinson's Disease: Mechanisms, Clinical Assessment, and Rehabilitation Implications. Clin Interv Aging. 2026 Jul 9;21:620247.
  15. ↑ Longhurst JK, Hooyman A, Landers MR, Mancini M, Franzén E, Leavy B, et al. Discordance between balance ability and perception is associated with falls in Parkinson's disease: a coordinated analysis. Neurorehabil Neural Repair. 2025 Feb;39(2):114-125.
  16. ↑ Landers MR, Nilsson MH. A theoretical framework for addressing fear of falling avoidance behavior in Parkinson's disease. Physiother Theory Pract. 2023 May;39(5):895-911.
  17. ↑ Santos García D, de Deus Fonticoba T, Suárez Castro E, Borrué C, Mata M, Solano Vila B, et al. Non-motor symptoms burden, mood, and gait problems are the most significant factors contributing to a poor quality of life in non-demented Parkinson's disease patients: Results from the COPPADIS Study Cohort. Parkinsonism & related disorders. 2019 Sep.
  18. ↑ Veilleux Carpentier A, Malaty IA, LeWitt PA, Azmi H, Brooks A, Pollak E, Air EL, Simpson H, Thomas J, Thomas FP, Cocoziello L. A systematic review of the Parkinson's Foundation hospital care recommendations. Movement Disorders Clinical Practice. 2026 Jan;13(1):29-43.
  19. ↑ Read J, Cable S, Löfqvist C, Iwarsson S, Bartl G, Schrag A. Experiences of health services and unmet care needs of people with late-stage Parkinson’s in England: A qualitative study. Plos one. 2019 Dec 30;14(12):e0226916.
  20. ↑ Murphy KT, Lynch GS. Impaired skeletal muscle health in Parkinsonian syndromes: clinical implications, mechanisms and potential treatments. J Cachexia Sarcopenia Muscle. 2023 Oct;14(5):1987-2002.
  21. ↑ Suttman EM. Cardiovascular Autonomic Regulation and Exercise in Parkinson’s Disease. Doctoral dissertation, 2025, The University of Utah.
  22. ↑ Mylius V, Maes L, Negele K, Schmid C, Sylvester R, Brook CS, Brugger F, Perez-Lloret S, Bansi J, Aminian K, Paraschiv-Ionescu A, Gonzenbach R, Brugger P. Dual-Task Treadmill Training for the Prevention of Falls in Parkinson's Disease: Rationale and Study Design. Front Rehabil Sci. 2022 Mar 2;2:774658.
  23. ↑ Kim SD, Allen NE, Canning CG, Fung VS. Postural instability in patients with Parkinson’s disease: Epidemiology, pathophysiology and management. CNS drugs. 2013 Feb;27(2):97-112.
  24. ↑ Deal LS, Flood E, Myers DE, Devine J, Gray DL. The Parkinson's Disease Activities of Daily Living, Interference, and Dependence Instrument. Mov Disord Clin Pract. 2019 Sep 6;6(8):678-686.
  25. ↑ Rider JV, Longhurst JK, Lekhak N, Young DL, Landers MR. Fear of falling avoidance behaviour assessment and intervention in parkinson’s disease: a scoping review. Research and Reviews in Parkinsonism. 2022 Jan 1:1-7.
  26. ↑ Wang Z, Wei H, Xin Y, Qin W. Advances in the study of depression and anxiety in Parkinson's disease: A review. Medicine (Baltimore). 2025 Mar 7;104(10):e41674.
  27. ↑ García-López H, de Los Ángeles Castillo-Pintor M, Castro-Sánchez AM, Lara-Palomo IC, Obrero-Gaitán E, Cortés-Pérez I. Efficacy of Dual-Task Training in Patients with Parkinson's Disease: A Systematic Review with Meta-Analysis. Mov Disord Clin Pract. 2023 Jul 4;10(9):1268-1284.
  28. ↑ Sánchez-Herrera-Baeza P, Rodríguez-Pérez Mª, Fernández-Gómez G, Bustamante-Palomo N, Serrada-Tejeda S, Obeso-Benítez P, Morales-Cabezas M, Martínez-Piédrola RM, Pérez-de-Heredia-Torres M. The Impact of Social Distancing Due to COVID-19 on Activities of Daily Living in Parkinson’s Disease. InHealthcare 2023 Jun 8 (Vol. 11, No. 12, p. 1688). MDPI.
  29. ↑ Docu Axelerad A, Stroe AZ, Arghir OC, Docu Axelerad D, Gogu AE. Respiratory Dysfunctions in Parkinson's Disease Patients. Brain Sci. 2021 May 4;11(5):595.
  30. ↑ Martignon C, Pedrinolla A, Ruzzante F, Giuriato G, Laginestra FG, Bouca-Machado R, Ferreira JJ, Tinazzi M, Schena F, Venturelli M. Guidelines on exercise testing and prescription for patients at different stages of Parkinson’s disease. Aging clinical and experimental research. 2021 Feb;33(2):221-46.
  31. ↑ Inkster LM, Eng JJ. Postural control during a sit-to-stand task in individuals with mild Parkinson's disease. Experimental brain research. 2004 Jan;154(1):33-8.
  32. ↑ Iwai M, Tanabe S, Koyama S, Takeda K, Hirakawa Y, Motoya I, Okuda Y, Kikuchi Y, Sakurai H, Kanada Y, Kawamura M. Clinical and biomechanical factors in the sit‐to‐stand decline in Parkinson's disease. Movement Disorders Clinical Practice. 2025 Oct;12(10):1539-50.
  33. ↑ Mak MK, Hui-Chan CW. The speed of sit-to-stand can be modulated in Parkinson's disease. Clin Neurophysiol. 2005 Apr;116(4):780-9.
  34. ↑ Baltasar-Fernandez I, Parrino R, Strand K, Signorile JF. Differences in power and performance during sit-to-stand test and its relationships to functional measures in older adults with and without Parkinson's disease. Exp Gerontol. 2024 Oct 1;195:112542.
  35. ↑ 35.0 35.1 Duncan RP, Leddy AL, Earhart GM. Five times sit-to-stand test performance in Parkinson's disease. Arch Phys Med Rehabil. 2011 Sep;92(9):1431-6.
  36. ↑ American Academy of Orthotists and Prosthetists. Five Time Sit to Stand Test (FTSST). Available from: https://www.youtube.com/watch?v=_jPl-IuRJ5A [last accessed 17/8/2026]
  37. ↑ Agathos CP, Velisar A, Shanidze NM. A comparison of walking behavior during the instrumented TUG and habitual gait. Sensors. 2023 Aug 18;23(16):7261.
  38. ↑ Nocera JR, Stegemöller EL, Malaty IA, Okun MS, Marsiske M, Hass CJ; National Parkinson Foundation Quality Improvement Initiative Investigators. Using the Timed Up & Go test in a clinical setting to predict falling in Parkinson's disease. Arch Phys Med Rehabil. 2013 Jul;94(7):1300-5.
  39. ↑ Vance RC, Healy DG, Galvin R, French HP. Dual tasking with the timed "up & go" test improves detection of risk of falls in people with Parkinson disease. Phys Ther. 2015 Jan;95(1):95-102.
  40. ↑ Mission Gait. Timed Up and Go (TUG) Test - Setup and Instruction. Available from: https://www.youtube.com/watch?v=brhnt4KM_Oc [last accessed 17/8/2026]
  41. ↑ Medbridge. Dual-Task Training - The Impact of Aging on Functional Mobility and Gait- Julie Ries | MedBridgeAvailable from: https://www.youtube.com/watch?v=mjzHZHE83mc [last accessed 17/8/2026]
  42. ↑ Krzysztoń K, Stolarski J, Kochanowski J. Evaluation of balance disorders in Parkinson's disease using simple diagnostic tests—Not so simple to choose. Frontiers in neurology. 2018 Oct 31;9:932.
  43. ↑ Lindholm B, Nilsson MH, Hansson O, Hagell P. The clinical significance of 10-m walk test standardizations in Parkinson's disease. J Neurol. 2018 Aug;265(8):1829-1835.
  44. ↑ Qutubuddin AA, Pegg PO, Cifu DX, Brown R, McNamee S, Carne W. Validating the Berg Balance Scale for patients with Parkinson's disease: a key to rehabilitation evaluation. Arch Phys Med Rehabil. 2005 Apr;86(4):789-92.
  45. ↑ Franchignoni F, Giordano A, Ronconi G, Rabini A, Ferriero G. Rasch validation of the Activities-specific Balance Confidence Scale and its short versions in patients with Parkinson's disease. J Rehabil Med. 2014 Jun;46(6):532-9.
Retrieved from "https://www.physio-pedia.com/w/index.php?title=Deconditioning_in_Parkinsons&oldid=382072"