Fitness and Exercise Strategies for Persons With Parkinson’s

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

Top Contributors - Thomas Longbottom, Stacy Schiurring, Kim Jackson, Jess Bell and Lucinda hampton  

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, as well as 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 some combination of environmental and genetic factors are believed to be involved.[4] Among these are various lifestyle factors such as tobacco use, dietary intake, and physical activity.[5][6]

Lifestyle Medicine Fitness Strategies for Persons with Parkinson's Disease (PWP)[edit | edit source]

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.[7] 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[7]
Components of Parkinson's Fitness

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, but also potentially reducing their costs to the healthcare system.[8] While there may be a tendency to think of Lifestyle Medicine as being the domain of the physician, other providers such as dietitians, social workers, behavioural therapists, and lifestyle coaches are also integral.[8] It is also well within the scope of the physiotherapist for the following reasons:[9]

  • Diet and nutrition are key elements in many of the conditions managed by physiotherapists
  • Physiotherapists are considered experts in exercise and movement
  • Prevention, health promotion, fitness and wellness are crucial aspects of physiotherapy care

Mind-Body Fitness[edit | edit source]

A mind-body fitness regimen can include a variety of activities that combine body movement with mental focus. The practice of controlled breathing is often a feature.

  • Yoga is one such practice. It involves assuming and holding various physical postures while performing coordinated, diaphragmatic breathing.[10] There is evidence that yoga may help manage depression, reduce fall risk, and improve motor function in PWP.[11][12][13]
  • Traditional martial arts such as tai chi and karate may improve balance, fall prevention and quality of life.[14][15] Tai chi, also known as shadow boxing, involves gentle, slow movements and stretching combined with controlled breathing and meditation. Karate, Japanese for "empty hand", involves the practice of specific stances along with kicking, striking, and defensive blocking movements using the extremities. Qigong is another Chinese martial art form which combines gentle flowing exercises with mindfulness. A particular form of qigong is Ba Duan Jin, meaning the "Eight Section Brocades". Ba duan jin uses a combination of eight movements with deep, slow breathing. It is considered a form of medical qigong intended to improve health.[16] There is evidence that qigong and ba duan jin qigong may improve gait and sleep quality in PWP.[17][18]
  • Pilates, initially developed for dancers, is an exercise method that emphasises abdominal and low back / hip muscle tone.[19] It can improve balance and physical function in a person with Parkinson's.[20]
  • The Feldenkrais Method is another mindful movement practice. It has an emphasis on the quality of movement, and it may result in improved quality of life for PWP.[21] A similar method is the Alexander technique. This technique puts more focus on dynamic posture. There is some evidence that PWP may experience improvements in self-rated disability after practising the Alexander technique.[22]
  • Meditative or reflective walking is another approach to mind-body fitness that may have positive effects on mood, affect and cognition.[23][24] This activity can be as simple as walking outdoors while focusing on the sights, sounds and smells of nature, of feeling the wind in your face or the sensations through the feet.[10] Use of a labyrinth walking path is a novel way to participate in reflective walking.[25]

Aerobic Fitness[edit | edit source]

Aerobic exercise can be performed a variety of ways, including treadmill or overground walking, stationary cycling, elliptical rowers, seated reciprocal stepping, upper limb cycling, swimming, and even dancing.[10] There is evidence that high-intensity exercise can result in significant improvements in functional mobility.[26] A brisk walking programme and balance training can improve motor function and gait ability in PWP.[27] Aerobic exercise may also be beneficial in terms of having protective effects against depression[28] and enhancing motor memory consolidation.[29]

American College of Sports Medicine (ACSM) aerobic exercise guidelines:[30]

  1. Exercise frequency - 3 to 4 days per week
  2. Exercise duration - 30 minutes of continuous or accumulated exercise
  3. Exercise intensity - to be determined by the healthcare or fitness professional

Strength[edit | edit source]

Strength exercise, including resistance training on weight machines, elastic resistance exercise, free weight (e.g. dumbbells) and bodyweight exercise, can lead to improvements in strength, enhanced physical function, reduced depression, and improved overall quality of life in PWP[31][32]

American College of Sports Medicine (ACSM) strength exercise guidelines:[30]

  1. Exercise frequency - 2 to 3 days per week
  2. Exercise duration/repetition - 1 to 3 sets of 8 to 12 repetitions, beginning with 1 set and building to 3 sets
  3. Exercise intensity - to be determined by the healthcare or fitness professional

Flexibility[edit | edit source]

A flexibility programme for a person with Parkinson's can include slow static stretches for all major muscle groups. Flexibility exercises can improve functional performance and activities of daily living in PWP, enhancing an individual's capability for bending to tie shoes, donning and doffing clothing, and reaching for items either overhead or on the floor.[10][33]

American College of Sports Medicine (ACSM) flexibility exercise guidelines:[30]

  1. Exercise frequency - 2 to 3 days per week
  2. Exercise duration/repetition - 10- to 30-second holds with 2 to 4 repetitions of each stretch
  3. Exercise intensity - stretch to the point of slight discomfort

Neuromotor Function[edit | edit source]

Exercise to improve neuromotor function may include balance training (e.g. Otago balance program), agility work, coordination practice, gait training, and dual task training (e.g. walking while throwing a ball). Balance training could include activities such as multidirectional stepping, and anticipatory and reactive postural adjustment training, for example. Specific balance training is effective at improving postural control for PWP.[34] Other exercise programmes, such as tai chi, yoga, boxing, and dancing, also fit within this category. There is evidence that ai chi, a form of water-based tai chi, is effective at improving balance, mobility, motor function, and quality of life for PWP.[35]

Video demonstration of balance training (see dual task training starting at 6:51):

Task-Specific Circuit Training[edit | edit source]

Circuit training can be an effective approach to engaging the PWP in a variety of exercise activities, potentially contributing to enhanced motor learning. This approach involves moving between multiple activities with varying amounts of rest or stretching between.[10] Using variable practice and performance in a distributed versus blocked practice manner may be beneficial in terms of motor learning. Evidence supports that task-oriented circuit training can improve balance and gait performance and, by extension, balance confidence and quality of life for PWP.[36]

Sample Circuit Training Programme:[10]

  1. Start with a 5-minute warm-up on a stationary bike or treadmill
  2. Perform sit to stand x 10 repetitions
  3. Perform sit to stand and walk 6 metres
  4. Walk up and down incline surfaces
  5. Step up and down from varied-height surfaces
  6. Walk while weaving back and forth between cones for 6 metres
  7. Walk up and down stairs
  8. Reach in multiple directions in sitting and standing
  9. Step in multiple directions in standing
  10. Perform boxing movements
  11. Finish with a 5-minute cool-down on a stationary bike or treadmill

Leisure Fitness[edit | edit source]

Activities that could be considered leisure fitness activities include Nordic walking, dancing, table tennis, and video exergames. These have the advantage of being fun, which encourages increased adherence and participation.

  • Nordic walking employs the use of trekking poles for a total-body version of walking that encourages greater use of the upper and lower extremities while facilitating trunk rotation. It is effective at improving motor function, as well as some of the non-motor symptoms associated with Parkinson's, such as apathy, depression, and fatigue.[37]
  • Dancing also has the potential to improve gait, cognition, balance, functional mobility, and fatigue.[38][39]
  • Participation in table tennis has the potential to improve motor function and activities of daily living in PWP.[40]
  • Participation in video exergames that involve various physical components of activity beyond just playing the game, along with facilitating dual-task engagement, can improve motor function, balance, cognition and executive function, and processing speed.[41]

2024 Update: Clinical Practice Guidelines for the Treatment of PWP[edit | edit source]

The American Physical Therapy Association (APTA) published clinical practice guidelines for treating PWP in 2022. The guidelines are based on a systematic review of current evidence and accepted approaches for PD clinical management. The guidelines are meant to be an educational tool to enhance the clinical decision-making of qualified clinicians providing care for PWP based on the best available evidence. Their goal is to improve the quality and efficiency of care for PWP while reducing unnecessary variations in care across rehabilitation settings and locations. The majority of the studies used in the creation of these guidelines apply to patients in early to mid-stages of PD (measured by Hoehn & Yahr stages 1-3) and may not be appropriate to generalise to patients with more advanced PD ( Hoehn & Yahr stages 4-5).[42]

Many of these more “traditional” rehabilitation intervention categories share treatment roots and techniques found within the integrated lifestyle medicine model. It should be noted that the guidelines cannot provide information or recommendations on intervention dosing, frequency or intensity due to the wide variability found in the systematic review.[42] Rehabilitation professionals should use their best clinical judgment and screening tools to assess an individual patient’s ability and fitness when creating a therapy plan of care.

Table 1. A summary and details from the APTA clinical practice guidelines for treating PWP[42]
Intervention Quality of Evidence Strength of Recommendation Recommendation Examples of Interventions
Aerobic exercise High Strong Rehabilitation professionals should implement moderate- to high-intensity aerobic exercise to improve VO2, reduce motor disease severity, and improve functional outcomes in PWP[43]
  • Treadmill walking
  • Stationary bike

Clinical decision-making and proper screening procedures are important.  For example, selecting cycling over walking for those PWP with a high risk of falls or freezing of gait

Resistance Training

“Strength and Power”

High Strong Rehabilitation professionals should implement resistance training to reduce motor disease severity and improve strength, power, nonmotor symptoms, functional outcomes, and quality of life in PWP
  • Progressive resistance training[44]
  • Tai chi
  • Power yoga

Improvements in outcomes are likely dose-specific, and outcomes may differ if assessments were completed when “on” versus “off” medication state

Balance Training High Strong Rehabilitation professionals should implement balance training intervention programmes to reduce postural control impairments and improve balance and gait outcomes, mobility, balance confidence, and quality of life in PWP
  • Multidirectional stepping
  • Motor agility
  • Anticipatory postural control
  • Reactive balance
  • Fall-prevention training
  • Integration of wearable sensors
  • Aquatic-based balance exercises
  • Research shows providing greater levels of supervision has better outcomes
Flexibility exercises Low Weak Rehabilitation professionals may implement flexibility exercises to improve ROM in PWP
  • Spinal flexibility
  • Ridigity is a prominent symptom of PD, which can lead to limited ROM, so general stretching and flexibility training for PWP may be performed at all stages of the disease
External cueing High Strong Rehabilitation professionals should implement external cueing to reduce motor disease severity and freezing of gait and to improve gait outcomes in PWP
  • Rhythmic auditory cues
  • Visual cues
  • Verbal cues
  • Somatosensory cues
  • Attentional cues
  • Active music therapy
  • LSVT

Dosing recommendations for cueing could not be provided, but it was found that the positive effects appear to dissipate as cues are removed

Community-based exercise High Strong Rehabilitation professionals should recommend community-based exercise to reduce motor disease severity and improve nonmotor symptoms, functional outcomes, and quality of life in PWP
  • Yoga
  • Dance
  • Pilates
  • Tai chi
  • Qigong
  • Nordic walking
  • Strengthening and balance classes
  • (Noncontact) boxing[45][46]
  • Meditation
  • Feldenkrais method
Gait training High Strong Rehabilitation professionals should implement gait training to reduce motor disease severity and improve stride length, gait speed, mobility, and balance in PWP
  • Treadmill gait training
  • Downhill and curved path gait training
  • Robotic-assisted gait training
  • Treadmill training with virtual reality goggles
  • Body weight support gait training
  • Obstacle courses
  • Use of smartphone application that “offered positive and corrective feedback during gait”
Task-specific training High Strong Rehabilitation professionals should implement task-specific training to improve task-specific impairment levels and functional outcomes for PWP
  • Mental imagery
  • Upper extremity training
  • Turning training
  • Fall prevention training
  • Dual-task training
  • Bladder training

Patient input and preference should be taken into consideration when selecting task-specific training

Behavior-change approach High Moderate Rehabilitation professionals should implement behavior-change approaches to improve physical activity and quality of life in PWP
  • Goal setting
  • Action planning
  • Coaching
  • Provision of feedback
  • Problem-solving
  • Use of mobile health technology and/or smartphone applications
Integrated care High Strong Rehabilitation services should be delivered within an integrated care approach to reduce motor disease severity and improve quality of life in PWP
  • Multidisciplinary
  • Interdisciplinary
  • Interprofessional health care teams to include but not limited to physiotherapists, movement disorder specialists, neurologists, rehabilitation medicine providers, nurses, social workers, speech language therapists (pathologists), occupational therapists, psychologists

Team communication and coordination is vital to prevent overburdening the PWP or their care partners

Telerehabilitation Moderate Weak Rehabilitation services may be delivered via telerehabilitation to improve balance in PWP[47] For these purposes, telemedicine/rehabilitation is defined as “the exchange of information via telecommunication systems between the provider and the patient to improve a patient’s health.”

2024 Update: Rehabilitation Care Pathways[edit | edit source]

Research supports referral to rehabilitation services for individuals soon after they have been diagnosed with PD. However, systemic reviews show that rehabilitation services are greatly underutilised for this patient population. Rehabilitation professionals can play a proactive role in the care of PWP at all stages of disease severity. Research also shows that rehabilitation professionals who are specialty-trained and experienced in the management of PWP can reduce overall healthcare costs for those patients[48]

A treatment framework has been suggested by Rafferty et al.[48] This framework attempts to streamline clinical practice guidelines for the effective delivery of rehabilitation care, taking into account how therapy treatment goals differ across the stages of PD.[48]

Table 2. A summary and rehabilitation examples at different stages of PD[48]
Stage of PD Early-Stage Mid-Stage Late-Stage
Care Paths Consultative, proactive therapy
  • 1-4 visits with 6-12 month re-evaluations
Restorative therapy
  • 2-4 visits/week for less than 4 months
Skilled Maintenance
  • 1 visit every 1-3 months ongoing
Example rehabilitation plan of care at each stage
  • Assess baseline functional ability
  • Delay onset of activity limitations and encourage continued activity via exercise prescription and coaching
  • Address fear of movement or falling
  • Improve physical capacity
  • Address pain
  • Assess functional ability
  • Prescribe exercise to address impairments
  • Address walking, balance, transfers, manual activities, and motor function problems
  • Train movement strategies
  • Assess function as needed
  • Support exercise to minimise reduction in physical capacity
  • Correct body posture in bed/wheelchair
  • Support periodic changes in position
  • Involve and support care partners and nursing staff in the interventions
  • Maintain vital functions; prevent complications such as pressure sores and contractures
Occupational therapy
  • Assess, and provide education and advice on motor and nonmotor symptoms
  • Provide education on continuing to participate in meaningful activities and occupations
  • Provide education on how to manage and adapt to future limitations with work, leisure, and activities of daily living (ADLs)
  • Assess motor and nonmotor symptoms
  • Improve and/or maintain ADL skills
  • Address difficulties with activities of daily living using PD-specific strategies
  • Modify activities and the environment to improve occupational performance
  • Assess symptoms as appropriate
  • Modify activities and environment to improve occupational performance
  • Use adaptations
  • Support care partners
Speech Language Therapy (Pathology)
  • Assess and advise on voice, swallowing, and cognition
  • Possible short, intensive treatment with LSVT if there is mild to moderate hypokinetic dysarthria
  • Assess and treat speech, swallowing, saliva control, and cognitive limitations
  • Improve vocal pitch and range with intensive treatment
  • Care partner training and support
  • Assess speech, swallowing, saliva control, and cognition
  • Advise and/or support the use of alternative communication for severe dysarthria
  • Instruct conversation partners in cues or strategies
  • Modify food consistency and educate on cues and safety for individuals with moderate to severe dysphagia

Resources[edit | edit source]

Patient Resources[edit | edit source]


Clinical Resources[edit | edit source]

References[edit | edit source]

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