Parkinson's Lifestyle Medicine - Art-based or Expressive Therapies and Self Management Strategies

Original Editor - Thomas Longbottom based on the course by Z Altug

Top Contributors - Thomas Longbottom, Carin Hunter, Ewa Jaraczewska and Tarina van der Stockt  

Introduction[edit | edit source]

Approximately 10 million people around the world are currently living with Parkinson’s.[1] Meta-analysis of worldwide data reveals that the prevalence of Parkinson’s increases with age, quadrupling from a level of almost 0.5%  in the seventh decade of life to approximately 2% for those over the age of 80.[2] Other sources report that Parkinson's affects 1.5-2% of the population over the age of 60.[3] Parkinson’s is associated with the loss of dopamine-producing neurons in the substantia nigra of the midbrain, and it is typified clinically by resting tremor, rigidity, and bradykinesia along with a number of non-motor features such as anosmia, sleep behaviour disorder, depression, autonomic dysfunction, and cognitive dysfunction.[4] The aetiology of this disease is not fully understood, but there is some combination of environmental and genetic factors presumed to be causative.[4] Among these are various lifestyle factors such as tobacco use, dietary intake, and physical activity.[5][6]

File:Parkinson's Wellness Diagram.png
Components of Parkinson's Lifestyle Wellness[7]

According to the Lifestyle Medicine Handbook, Lifestyle Medicine involves the use of evidence-based lifestyle therapeutic approaches to treat, reverse, and prevent lifestyle-related chronic disease.[8] These include:

  1. A predominantly whole food, plant-based diet
  2. Regular physical activity
  3. Adequate sleep
  4. Stress management
  5. Social connections
  6. Avoidance of risky substance abuse[8]


The aim of Lifestyle Medicine is to treat the underlying causes of disease rather than just addressing the symptoms. This involves helping patients learn and adopt healthy behaviours. Lifestyle interventions have the potential to impact the prognosis of many chronic diseases, leading not only to a better quality of life for many but also potentially reducing their costs to the healthcare system.[9] While a tendency to think of Lifestyle Medicine as being the domain of the physician is understandable, other providers such as dietitians, social workers, behavioural therapists and lifestyle coaches are also integral.[9] It is also well within the scope of the physiotherapist, with diet and nutrition being key elements in many of the conditions managed by physiotherapists, with physiotherapists poised as experts in exercise and movement, and with the prevention, health promotion, fitness and wellness being crucial aspects of physiotherapy care.[10]

The focus of this module will be on discussing how art-based therapies and self-management strategies for persons with Parkinson's can address anxiety, mood, and stress, and improve physical, cognitive, emotional and social function.

Art-based/Expressive Therapies[edit | edit source]

Painting with watercolors.

What are art-based and expressive therapies and how can they be useful for persons with Parkinson's? Art therapy, according to the American Art Therapy Association, is the use of art and the creative process to "explore... feelings, reconcile emotional conflicts, foster self-awareness, manage behaviour and addictions, develop social skills, improve reality orientation, reduce anxiety, and increase self-esteem"[11] in order to improve function and well-being. Persons with Parkinson’s can experience blurred vision, dry eyes, and visuospatial perception deficits, potentially leading to limitations with reading, driving, walking, and postural control.[12][11] Preliminary evidence supports that art therapy can produce improvements in visuospatial skills in persons with mild to moderate levels of impairment related to Parkinson’s.[13] Clay art therapy improves hand dexterity, self-expression, mood and quality of life in persons with Parkinson’s.[14] Cognition, functional mobility and gait can be improved in persons with Parkinson’s by music and dance therapy.[15][16] There is some evidence that participation in activities like theatre and drum circle classes is beneficial for the quality of life in this population.[17][18]

Playing in a Drum Circle

How does one determine which art-based therapy may be right for a person with Parkinson’s? This decision can be based on the impairment being addressed or the specific outcomes desired, such as improvements in visual perception, mood or depression, dexterity, or overall quality of life. The clinician should be mindful of what areas garner the most interest on the part of the patient. Consider also that these interventions may require interdisciplinary collaboration, with referrals to other providers as appropriate.[19]Regardless of the choice of activities, it is worth remembering that the potential benefits include not only effects on the motor and non-motor symptoms of the disease, but benefits to the person in terms of emotional and social well-being.[11]

[20]

Self-Care and Self-Management Strategies for Persons with Parkinson's[edit | edit source]

Self Care word cloud.jpeg

'What is self-care/self-management? Self-care can be defined as “the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health and well-being.”[21] Similarly, self-management refers to the behaviours and skills needed for risk factors and chronic condition management on the path to wellness.[8] Key areas for consideration are medication management, physical exercise, self-monitoring techniques, psychological strategies, maintenance of independence, social engagement, and the acquisition, maintenance and application of knowledge.[22] A unique programme in Sweden was designed to offer persons with Parkinson’s and their carers training in self-management, addressing self-monitoring strategies, stress management, education regarding depression and anxiety, education in communication strategies, and instruction for participation in enriching activities. Trainees participated in group sharing of helpful strategies during the program. These efforts resulted in improvements in health status and self-management skills among those participants with the disease.[23]

7 Key Areas to consider for self-management for persons with Parkinson's:[22]

  1. Medication Management
  2. Physical Exercise
  3. Self-monitoring Techniques
  4. Psychological Strategies
  5. Maintaining Independence
  6. Encouraging Social Engagement
  7. Providing Knowledge and Information

Self-management: monitoring medication[edit | edit source]

Keeping track of taking one's medications can be a problem for anyone, particularly for individuals dealing with difficulties like memory loss, vision deficits, difficulty swallowing, mobility issues and transportation issues. Inadequate medication adherence can cause worsening health and increased hospital admissions or even mortality.[24]See the following suggestions to help with self-management of medications:

  • Use a medication management app, such as Medisafe or Express Scripts.
  • Use a pillbox to organize medications by day.
  • Use a printable medication log such as this one from 101Planners.com.
  • Try setting alerts on a smartphone.

Self-management: fall prevention[edit | edit source]

Falls can be a significant problem for persons with Parkinson's, leading to injury, limited mobility, reduced life expectancy, and reduced quality of life.[25]Fall prevention is thus an important endeavour, and there are a number of strategies to employ for this purpose. These include factors such as keeping up with medications, monitoring blood pressure, and working on balance training with a physiotherapist. See the following suggestions for helpful strategies a clinician can provide a person with Parkinson's to help reduce fall risk:

  • Don't be in a rush. Walk at a comfortable, controllable pace.
  • Scan the environment for potential hazards or obstacles.
  • Avoid walking with hands in pockets.
  • Make sure pathways are clear, rearranging furniture and clearing clutter as needed.
  • Use the handrails on stairs.
  • Ensure there is adequate lighting on the stairs and throughout the home.
  • Remove throw rugs that could be tripping hazards.
  • Remove electrical cords that could be a source of tripping.
  • Avoid highly polished or slippery floors, and avoid walking around in socks for the same reason.
  • Avoid climbing ladders or standing on top of chairs to reach for items overhead.
  • Use care when carrying large items (such as a laundry basket) that may obstruct the view of the walking path.
  • Avoid walking and talking while on the phone as distracting attention could be a hazard.
  • Change positions slowly to allow blood pressure to stabilize and avoid feeling lightheaded.
  • Have vision and hearing checked routinely.
  • Take medications as directed by the physician, and be sure to make the physician aware of any symptoms of dizziness, lightheadedness, weakness, confusion or excessive sedation from the medications.
  • Avoid excess alcohol consumption.
  • Don't wear reading-only glasses while walking.
  • Wear low-heeled/comfortable shoes with good support and non-slip soles.
  • Use non-slip mats or adhesive traction strips in the bathtub or shower.
  • Use a tub bench or shower chair to enable sitting while bathing.
  • Have night lights for lighting the pathway to the bathroom for those nighttime trips.
  • Engage in an exercise program to improve and maintain strength, flexibility, endurance, and balance.[19]

Self-management: nonpharmacologic management of constipation[edit | edit source]

Constipation, where an individual has less than 3 bowel movements in a week's time, is a common symptom with Parkinson's. Things like stress, dehydration, a lack of exercise, inadequate dietary fibre, and medication side effects can contribute to this problem. See the following suggestions of self-management strategies for nonpharmacologic management of constipation:

  • Maintain a regular bowel habit schedule and avoid delaying the urge for bowel movements.
  • Engage in a regular exercise program for chronic constipation.
  • Try changing the posture on the toilet to one with more trunk and hip flexion. This can be aided by a device such as the Squatty Potty.
  • Try selected exercises such as supine diaphragmatic breathing, supine repeated single and double knee to chest, quadruped heel sits, and/or full squats.
  • Try self-acupressure techniques.[26](Download the electronic supplementary material for the appendices demonstrating a technique for both male and female patients.)
  • Consume probiotic-containing foods.
  • Speak with the primary physician or dietitian about eating dried plums or prunes.
  • Try yoga. Selected yoga practices and poses may help constipation.[27]
  • Try self-abdominal massage techniques.[28] Here is a video from a physiotherapist, and another video from a yoga practitioner, demonstrating different techniques.
  • Refer the patient to a physiotherapist specializing in pelvic health if this type of practice is outside of one's comfort level or competency base. A pelvic health specialist can help provide specific interventions and exercise to help manage the problem of constipation.

Hypnosis: An Adjunct Therapy[edit | edit source]

While there is limited research available regarding the impact of hypnosis, there is some case-study level evidence that clinical hypnosis and self-hypnosis education may serve as a useful adjunct therapeutic approach for Parkinson's, increasing relaxation and decreasing resting tremors..[29][30]

Considerations for Choosing Strategies[edit | edit source]

A review of this page along with the other pages related to Parkinson's Lifestyle Medicine makes apparent there are many options and strategies to consider as interventions for a person with Parkinson's. How does one decide which options to use? The clinical judgment and evaluation skills of the provider are important, and the clinician will need to base decisions on subjective and physical assessments to help prioritize the intervention. Once an area of need is identified, whether it is sleep, stress management, nutrition, exercise, substance abuse, or socialization, the provider should discuss the options for specific areas to address and techniques to be used. This patient-centred focus will be helpful in building the therapeutic alliance.

It can also be crucial to consider some of the potential barriers the patient may face.

  1. Is the patient even interested in exploring adjunct strategies and treatments? This can be determined early in the therapist/patient interaction with good communication.
  2. Is the program being recommended financially feasible for the patient?
  3. Will there be any concern about transportation related to the suggested treatment or strategy? It may not make sense to recommend a dance class or an outdoor nature hike if the patient has no way to access these.
  4. Are the services being recommended available in the patient's community?
  5. Is there a potential for a language barrier for the patient with the recommended treatment option? If so, is there a way to surmount this obstacle?

Resources[edit | edit source]

References[edit | edit source]

  1. Statistics [Internet]. Parkinson's Foundation. [cited 2021Dec28]. Available from: https://www.parkinson.org/Understanding-Parkinsons/Statistics
  2. Pringsheim T, Jette N, Frolkis A, Steeves TDL. The prevalence of Parkinson's disease: A systematic review and meta-analysis. Movement Disorders 2014;29(13):1583–90.
  3. Venes D, Taber CW. Taber's Cyclopedic Medical Dictionary. Philadelphia, PA: F.A. Davis; 2021.
  4. 4.0 4.1 Simon DK, Tanner CM, Brundin P. Parkinson Disease Epidemiology, Pathology, Genetics, and Pathophysiology. Clinics in Geriatric Medicine 2020;36(1):1–2.
  5. Ritz B, Ascherio A, Checkoway H, Marder KS, Nelson LM, Rocca WA, et al.. Pooled Analysis of Tobacco Use and Risk of Parkinson Disease. Archives of Neurology [Internet] 2007;64(7):990.
  6. Paul KC, Chuang Y, Shih I, Keener A, Bordelon Y, Bronstein JM, et al.. The association between lifestyle factors and Parkinson's disease progression and mortality. Movement Disorders 2019;34(1):58–66.
  7. Z Altug. Parkinson's Lifestyle Medicine - Nutrition and Sleep Hygiene. Physioplus Course. 2021.
  8. 8.0 8.1 8.2 Frates B, Bonnet JP, Joseph R, Peterson JA. Lifestyle Medicine Handbook: An introduction to the power of Healthy Habits. Monterey, CA: Healthy Learning; 2021.
  9. 9.0 9.1 Bodai B. Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival. The Permanente Journal 2017;22(1).
  10. Worman R. Lifestyle medicine: The role of the physical therapist. The Permanente Journal. 2020;24:18.192.
  11. 11.0 11.1 11.2 Art as therapy in Parkinson's disease [Internet]. APDA. 2019 [cited 2021Dec30]. Available from: https://www.apdaparkinson.org/article/art-therapy-parkinsons-disease/
  12. Eye & Vision issues: American Parkinson disease assoc. [Internet]. APDA. 2019 [cited 2021Dec30]. Available from: https://www.apdaparkinson.org/what-is-parkinsons/symptoms/eye-vision-issues/
  13. Cucca A, Di Rocco A, Acosta I, Beheshti M, Berberian M, Bertisch HC, et al.. Art therapy for Parkinson's disease. Parkinsonism & Related Disorders 2021;84:148–54.
  14. Bae Y-S, Kim D-H. The Applied Effectiveness of Clay Art Therapy for Patients With Parkinson’s Disease. Journal of Evidence-Based Integrative Medicine 2018;23:2515690X1876594.
  15. Pereira APS, Marinho V, Gupta D, Magalhães F, Ayres C, Teixeira S. Music Therapy and Dance as Gait Rehabilitation in Patients With Parkinson Disease: A Review of Evidence. Journal of Geriatric Psychiatry and Neurology 2019;32(1):49–56.
  16. Dos Santos Delabary M, Komeroski IG, Monteiro EP, Costa RR, Haas AN. Effects of dance practice on functional mobility, motor symptoms and quality of life in people with Parkinson’s disease: a systematic review with meta-analysis. Aging Clinical and Experimental Research 2018;30(7):727–35.
  17. Modugno N, Iaconelli S, Fiorlli M, Lena F, Kusch I, Mirabella G. Active Theater as a Complementary Therapy for Parkinson's Disease Rehabilitation: A Pilot Study. The Scientific World Journal 2010;10:2301–13.
  18. Pantelyat A, Syres C, Reichwein S, Willis A. DRUM-PD: The Use of a Drum Circle to Improve the Symptoms and Signs of Parkinson's Disease (PD). Movement Disorders Clinical Practice 2016;3(3):243–9.
  19. 19.0 19.1 Z Altug. Parkinson's Lifestyle Medicine - Art-based or Expressive Therapies and Self Management Strategies. Physioplus Course. 2021.
  20. Why Dance for PD®? Mark Morris Dance Group. Available from https://youtu.be/4LwWkFHpve0 [last accessed 1/1/2022]
  21. Orem DE. Nursing concepts of Practice. St. Louis, MO: Mosby; 1995.
  22. 22.0 22.1 Tuijt R, Tan A, Armstrong M, Pigott J, Read J, Davies N, et al.. Self-Management Components as Experienced by People with Parkinson’s Disease and Their Carers: A Systematic Review and Synthesis of the Qualitative Literature. Parkinson's Disease 2020;2020:1–10.
  23. Hellqvist C, Berterö C, Dizdar N, Sund-Levander M, Hagell P. Self-Management Education for Persons with Parkinson’s Disease and Their Care Partners: A Quasi-Experimental Case-Control Study in Clinical Practice. Parkinson's Disease 2020;2020:1–3.
  24. Shruthi R, Jyothi R, Pundarikaksha HP, Nagesh GN, Tushar TJ. A Study of Medication Compliance in Geriatric Patients with Chronic Illnesses at a Tertiary Care Hospital. Journal of Clinical and Diagnostic Research 2016:10(12)40-43.
  25. Falls prevention [Internet]. Parkinson's Foundation. [cited 2022Jan2]. Available from: https://www.parkinson.org/pd-library/fact-sheets/Falls-Prevention
  26. Abbott R, Ayres I, Hui E, Hui K-K. Effect of Perineal Self-Acupressure on Constipation: A Randomized Controlled Trial. Journal of General Internal Medicine  2015;30(4):434–9.
  27. Yoga for constipation: 8 poses for quick relief [Internet]. Medical News Today. MediLexicon International; [cited 2022Jan2]. Available from: https://www.medicalnewstoday.com/articles/327086
  28. Mcclurg D, Walker K, Aitchison P, Jamieson K, Dickinson L, Paul L, et al.. Abdominal Massage for the Relief of Constipation in People with Parkinson’s: A Qualitative Study. Parkinson's Disease 2016;2016:1–0.
  29. Elkins G, Sliwinski J, Bowers J, Encarnacion E. Feasibility of Clinical Hypnosis For The Treatment of Parkinson's Disease: A Case Study. International Journal of Clinical and Experimental Hypnosis  2013;61(2):172–82.
  30. Wain HJ, Amen D, Jabbari B. The effects of hypnosis on a parkinsonian tremor: A case report with Polygraph/EEG Recordings. American Journal of Clinical Hypnosis. 1990;33(2):94–8.