Parkinson's Lifestyle Medicine - Wellness and Lifestyle Strategies

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

Top Contributors - Thomas Longbottom, Wanda van Niekerk, Jess Bell, Tarina van der Stockt and Kim Jackson  

Introduction[edit | edit source]

Approximately 10 million people around the world are currently living with Parkinson’s Disease.[1] Meta-analysis of worldwide data reveals that the prevalence of Parkinson’s Disease 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 aged over 60 years.[3] Parkinson’s is associated with the loss of dopamine-producing neurons in the substantia nigra of the midbrain. It is typified clinically by resting tremor, rigidity, and bradykinesia, and other 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 it is believed that some combination of genetic and environmental factors are causative,[4] including various lifestyle factors such as tobacco use, dietary intake, and physical activity.[5][6]

Components of Parkinson's Lifestyle Wellness: Stress Management, Conventional Exercise, Mind-Body Exercise, Nutrition, Sleep Hygiene, Avoidance of Risky Substances, Self-Care Strategies, Expressive Therapies, Nature-Based Activities, and Social Connections
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 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 prevention, health promotion, fitness and wellness being crucial aspects of physiotherapy care.[10]

The aim of this page is to discuss strategies for persons with Parkinson's, including stress management, the avoidance of risky substance abuse, and the improvement of social connections, along with the benefits of being in outdoor environments.

Strategies for Stress Management[edit | edit source]

What is stress? Per Taber's Cyclopedic Medical Dictionary, it is "any physical, physiological or psychological force that disturbs equilibrium."[3] These disturbances in a person with Parkinson's Disease can have some particular effects. Stress can reduce the effectiveness of levodopa in the medical management of persons with Parkinson's Disease.[11] The ability to cope with stress may help prevent exacerbations of parkinsonian tremors caused by the stress.[12] Chronic stress also has the potential to increase susceptibility to depression and anxiety in persons with Parkinson's.[13] Strategies for stress management can thus be impactful for the person with Parkinson's.

Stress Graphic.jpeg

What causes stress? Determining the factors creating stress can be the first step in managing it. Consider the following potential causes of stress:[14]

  1. Financial concerns
  2. Family matters
  3. Work matters, including long commutes to work
  4. Medical concerns, including lack of quality information regarding the medical condition
  5. Personal relationships
  6. Lack of socialisation
  7. Pressure while studying or preparing for a career
  8. Facing major life changes, such as losing a loved one, changing jobs, or moving to another location
  9. Times of uncertainty, such as living during a global pandemic


What are some strategies to manage stress? Once the source of the stress is identified, select strategies may be applied to manage that stress. However, it is important to realise that not all approaches will be appropriate for every person.

Sample patient education strategies to help manage stress:

  1. Try conventional exercise such as walking, biking, hiking, swimming, etc.
  2. Try mind-body exercises such as tai chi, qigong, or yoga.[15][16][17]
  3. Try engaging in more outdoor activities.[18]
  4. Try various types of meditation.
  5. Try progressive muscle relaxation techniques.
  6. Try massage therapy.[19]
  7. Try listening to music.
  8. Try guided imagery with music.[20]
  9. Try painting or drawing.
  10. Try including more laughter into daily life through television, books, or other media.[21]
  11. Try singing, whistling, or humming.
  12. Try dancing.
  13. Try participating in a drama class at a local school or community theatre.
  14. Try a weighted blanket.[22]
  15. Try playing with pets.

One other strategy that should be considered is to reduce near point visual stress. The near point is the closest point at which an object can remain in focus on the retina of the eye, and activities requiring prolonged near point focus can cause eye fatigue, eye strain, and headaches.[23] These activities might include close work on computers, phones, books, or other desktop activities. To reduce this stress, try looking away from close work every 10-20 minutes, try using larger font sizes on screens and on patient education/home exercise materials and try offsetting the close work by taking breaks to exercise outdoors or focus the eyes in the distance.[24][25]

If the above strategies are not effective enough, consider referring the patient to a stress management specialist, psychologist or counsellor.

Reducing Risky Substance Abuse[edit | edit source]

Breaking the Habit.

It should come as no surprise that harmful use of both alcohol and tobacco can have negative effects on health. According to the World Health Organization, alcohol use is a factor in over 200 disease and injury conditions.[26] Alcohol consumption is also associated with increased risk for progression of Parkinson's. Smoking is associated with an increased risk of mortality, and in persons with Parkinson's, it is associated with an increased risk of cognitive decline.[6] It stands to reason that smoking cessation, then, can reduce the risk for cognitive impairment in Parkinson's, and this is supported by the evidence.[27]

Treatment for Alcohol Use Disorder: While the ideal mode of exercise, along with intensity, frequency, and duration, is not known, it is clear that exercise can be an effective treatment for alcohol use disorder.[28] Consider exercise prescription for Parkinson's patients also dealing with alcohol use, designing fitness programmes and/or encouraging their use of fitness centres.[14]

Strategies for Smoking Cessation: One strategy to aid smoking cessation is the use of a yoga routine, with evidence supporting its positive effect on successful abstinence from smoking.[29] The practice of yoga potentially aids efforts at cessation through addressing factors such as stress, cravings, and mindfulness.[29] In the supporting study, the subjects participated in an Iyengar Yoga routine consisting of 5 minutes of breath work, followed by 45 minutes of dynamically linked postures, and then 5-10 minutes of resting meditation.[29] Another resource the physiotherapy may recommend to their patients are the Smokefree Apps available via smokefree.gov.[14]

Improving Social Connections[edit | edit source]

Social connections can have positive influences on health and wellness.[30] Community-based exercise tends to supplement the exercise benefits with social connection, providing a platform for learning coping strategies from one another and meeting emotional, as well as physical needs.[31] This can lead to more positive attitudes about life in a population that tends to face physical challenges and restrictions in societal participation.

The physiotherapist may attempt to increase patients' social interaction by recommending community-based exercise participation. This could include dance classes, fitness classes, and other programmes designed specifically for persons with Parkinson's such as Rock Steady Boxing, which is available in many international locations. Programmes like Dance for PD are available in many parts of the world as well, and also offer classes streamed over the internet or available on DVD.

Other Patient Education Strategies to Improve Social Connection:[14]

  • Try group singing, music, dancing or art classes available in the local community.
  • Join a fitness centre.
  • Join a self-help group.
  • Join or create a group gardening club.
  • Take a class at a local community college or school.
  • Take live online classes or play live online games.
  • Get involved at a local community centre.
  • Explore volunteer opportunities to teach, coach, or mentor.
  • Stay connected with family and friends on social media or via video conferencing.

Benefits of Outdoor Environments[edit | edit source]

There is some compelling evidence supporting the encouragement of more outdoor activities and interactions with nature. Time spent outdoors can help reap the benefits of fresh air, sensible amounts of sunshine, exposure to natural light, enable an individual to practise manoeuvring on varied terrain, and increase socialisation. These benefits might include reductions in stress, anxiety, and depression, and an increase in overall well-being.[14] Encountering the smell of plants and natural sounds from a garden may help stress reduction and enhance mental health.[32][33] Exercise outdoors, in natural environments, can result in a better sense of revitalisation, engagement, and energy, along with less of the negative feelings of tension, anger and depression.[34]

While recommendations for outdoor exercise are commendable, it is important for the clinician to keep in mind strategies for keeping patients safe. Consider the following suggestions:

  1. Use the buddy system. Exercise with a friend for fun and safety.
  2. Wear appropriate clothing (such as a wide brim hat to protect the face and neck, or long sleeves to protect the arms) to guard against excess sun exposure.
  3. Dress in layers in order to adjust to changing outdoor temperatures.
  4. Avoid exercise in areas of air pollution such as from smoke, car exhaust, or industrial emissions.
  5. Be aware of extreme temperatures and allergy season.
  6. Bring helpful items such as a cell phone, walking stick, and water.

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. 3.0 3.1 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. 6.0 6.1 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 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. Zach H, Dirkx MF, Pasman JW, Bloem BR, Helmich RC. Cognitive Stress Reduces the Effect of Levodopa on Parkinson's Resting Tremor. CNS Neuroscience & Therapeutics 2017;23(3):209–15.
  12. Jankovic Joseph. Physiologic and pathologic tremors. Annals of Internal Medicine. 1980;93(3):460.
  13. Heide A, Meinders MJ, Speckens AEM, Peerbolte TF, Bloem BR, Helmich RC. Stress and mindfulness in parkinson's disease: Clinical effects and potential underlying mechanisms. Movement Disorders. 2020;36(1):64–70.
  14. 14.0 14.1 14.2 14.3 14.4 Z Altug. Parkinson's Lifestyle Medicine - Wellness and Lifestyle Strategies. Physioplus Course. 2021.
  15. Kwok JYY, Kwan JCY, Auyeung M, Mok VCT, Lau CKY, Choi KC, et al.. Effects of Mindfulness Yoga vs Stretching and Resistance Training Exercises on Anxiety and Depression for People With Parkinson Disease. JAMA Neurology 2019;76(7):755.
  16. Wang F, Lee E-KO, Wu T, Benson H, Fricchione G, Wang W, et al.. The Effects of Tai Chi on Depression, Anxiety, and Psychological Well-Being: A Systematic Review and Meta-Analysis. International Journal of Behavioral Medicine 2014;21(4):605–17.
  17. Wang C-W, Chan CH, Ho RT, Chan JS, Ng S-M, Chan CL. Managing stress and anxiety through qigong exercise in healthy adults: a systematic review and meta-analysis of randomized controlled trials. BMC Complementary and Alternative Medicine. 2014;14(1):8.
  18. Triguero-Mas M, Donaire-Gonzalez D, Seto E, Valentín A, Martínez D, Smith G, et al. Natural outdoor environments and mental health: Stress as a possible mechanism. Environmental Research. 2017;159:629–38.
  19. Angelopoulou E, Anagnostouli M, Chrousos GP, Bougea A. Massage therapy as a complementary treatment for parkinson’s disease: A systematic literature review. Complementary Therapies in Medicine. 2020;49:102340.
  20. Beck BD, Hansen ÅM, Gold C. Coping with work-related stress through guided imagery and music (GIM): Randomized Controlled Trial. Journal of Music Therapy. 2015;52(3):323–52.
  21. Bennett MP, Zeller JM, Rosenberg L, McCann J. The effect of mirthful laughter on stress and natural killer cell activity. Alternative Therapies in Health and Medicine. 2003;9(2):38-45.
  22. Eron K, Kohnert L, Watters A, Logan C, Weisner-Rose M, Mehler PS. Weighted blanket use: A systematic review. The American Journal of Occupational Therapy. 2020;74(2).
  23. Devora. Near point visual stress (NPVS) [Internet]. Optometrists.org. 2021 [cited 2021Dec30]. Available from: https://www.optometrists.org/vision-therapy/vision-therapy-for-children/checklist-for-parents-2/near-point-visual-stress-npvs/
  24. Birnbaum MH. The Use of Stress Reduction Concepts and Techniques in Vision Therapy. Optometry & Visual Performance. 2018Dec;6(6):223–7.
  25. Birnbaum MH. Nearpoint visual stress: Clinical implications. Journal of the American Optometric Association. 1985;56(6):480–90.
  26. Alcohol [Internet]. World Health Organization. World Health Organization; [cited 2021Dec30]. Available from: https://www.who.int/news-room/fact-sheets/detail/alcohol
  27. Guo Y, Xu W, Liu FT, Li JQ, Cao XP, Tan L, et al. Modifiable risk factors for cognitive impairment in parkinson's disease: A systematic review and meta‐analysis of prospective cohort studies. Movement Disorders. 2019;34(6):876–83.
  28. Lardier DT, Coakley KE, Holladay KR, Amorim FT, Zuhl MN. Exercise as a useful intervention to reduce alcohol consumption and improve physical fitness in individuals with alcohol use disorder: A systematic review and meta-analysis. Frontiers in Psychology. 2021;12.
  29. 29.0 29.1 29.2 Bock BC, Dunsiger SI, Rosen RK, Thind H, Jennings E, Fava JL, et al.. Yoga as a Complementary Therapy for Smoking Cessation: Results From BreathEasy, a Randomized Clinical Trial. Nicotine & Tobacco Research 2019;21(11):1517–23.
  30. Holt-Lunstad J. Loneliness and social isolation as risk factors: The power of Social Connection in Prevention. American Journal of Lifestyle Medicine. 2021;15(5):567–73.
  31. Claesson IM, Ståhle A, Johansson S. Being limited by parkinson’s disease and struggling to keep up exercising; is the group the glue? Disability and Rehabilitation. 2019;42(9):1270–4.
  32. Pálsdóttir AM, Spendrup S, Mårtensson L, Wendin K. Garden smellscape–experiences of plant scents in a nature-based intervention. Frontiers in Psychology. 2021;12.
  33. Cerwén G, Pedersen E, Pálsdóttir A-M. The Role of Soundscape in Nature-Based Rehabilitation: A Patient Perspective. International Journal of Environmental Research and Public Health. 2016;13(12):1229.
  34. Thompson Coon J, Boddy K, Stein K, Whear R, Barton J, Depledge MH. Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review. Environmental Science & Technology. 2011;45(5):1761–72.
  35. Osborne JA, Botkin R, Colon-Semenza C, DeAngelis TR, Gallardo OG, Kosakowski H et al. Physical therapist management of Parkinson Disease: A clinical practice guideline from the American Physical Therapy Association. Phys Ther. 2021 Dec 28:pzab302.