by Tyler Tice, PT, DPT, MS, ATC
Over the last few decades, the treatment options for Parkinson’s disease (PD) has significantly improved, resulting in effectively prolonged period of time people with PD live with disability. Due to this, the role of effective physical therapy (PT) and rehabilitative management for people with PD has greatly increased. PD affects dopamine within the brain, resulting in the presence of motor symptoms such as tremors and bradykinesia (slow movement) and non-motor symptoms such as changes in mood and changes in sense of smell. Diagnosis of PD is usually made after the classical motor signs of bradykinesia, rigidity, tremor, and postural instability (balance issues) emerge. Currently, there is no neuroprotective treatment for PD available so medical treatment is focused on treating the symptoms. As PD is projected to continue affecting higher numbers of our population as well as younger individuals, there is a need for effective non-pharmacological treatment early in the course of the disease. This review investigates the effects of a variety of modes of exercise and PT in the treatment of PD.
Moderate to high intensity aerobic training may be the most beneficial in managing motor symptoms, improving physical function, and reducing disability in persons with PD. Studies where treadmill training was completed demonstrated better results regarding improvements in walking, most likely due to the intensity in which it could be completed, however, cycling is a viable option for persons with PD where walking may not be a safe option when initially beginning aerobic exercise. Additional research needs to be completed regarding the effect of aerobic exercise on non-motor symptoms, however existing research is promising as one study showed an improvement in executive function (higher level thinking needed to plan and carry out tasks), attention, and memory after one month of treadmill training.
Moderate to high intensity resistance exercise focused on movement speed or muscle power production may be beneficial in reducing disease severity, improving physical function, and reducing disability. One study demonstrated an improvement in cognition in addition to strength and mobility after the 2-year course of the study, suggesting long-term motor and non-motor benefit of participating in resistance exercise. Multiple studies also demonstrated benefit of resistance exercise when specific functional limitations such as climbing stairs or standing from a chair were targeted. Additional research is still needed to investigate the benefit of resistance exercise, especially in relation to their effects on non-motor symptoms.
For persons with mild to moderate PD, balance training has demonstrated a significant ability to reduce fall rates. Additionally, studies that were clinic-based rather than home-based provided a greater level of supervision and intensive training, resulting in greater reductions in fall rates. Balance training also improved non-motor symptoms such as reductions in pain, depression, and apathy. However, it is important to note that in patients with severe PD appeared to have an increase in falls rate following participation in balance training. What causes this increase is unknown but may be attributed to increased gait-related mobility without an improvement in postural control or increased exposure conditions that challenge the individual’s balance without having the skills to manage these challenges.
Gait training is effective in improving various aspects of walking in persons with PD. Treadmill training and moderate intensity overground walking have been shown to improve gait speed, walking capacity, and step/stride length. This is important as gait is not primarily impacted by current pharmacological treatments for PD. Providing cueing while ambulating has also been shown to improve various aspects such as giving auditory cues for gait speed or auditory and visual cues for freezing of gait. Dual-tasking such as walking and talking or walking and carrying an object is an aspect of ambulation that can be difficult for persons with PD. Practicing dual-tasking in a safe and controlled environment is effective in improving walking under dual-tasking conditions.
Despite the evidence that supports early and regular exercise intervention in persons with PD, the utilization of PT services in the US is remarkably low. There are many factors that may contribute to this such as insurance coverage and other medical provider knowledge on the benefit of exercise and PT in persons with PD. Typically, to justify the need for PT to insurance companies, the patients must demonstrate functional improvement in order to continue with PT, however, policy and guideline changes have been implemented to improve access to PT for persons with PD. By initiating PT earlier in the disease process, more preventative measures can be taken, which ultimately will positively impact the quality of life of the individual.
Secondary Prevention Model:
Once initially diagnosed with PD, patients consult with a PT with expertise in PD. The PT performs what is referenced as a clinical battery of tests to establish a baseline level of function that can be tracked throughout the disease course. In the first few visits, the PT will prescribe an exercise program that is tailored to the individual and give them the tools to be success in consistently completing the program. A critical element of this approach is regular follow-up visits. Just as regular visits to the neurologist are necessary for reassessment of PD symptoms so appropriate adjustments to medication can be made, regular follow-up visits to a PT allow for reassessment of functional status and necessary adjustments to their exercise program to address changes in symptom presentation. There has also been an increase in community-based exercise programs, which further expands access to physical activity. These exercise programs can vary in intensity, however regular follow-up visits to PT can allow PTs to assist in finding programs that appropriately challenge their patient.
Take Home Message:
Regular exercise is highly beneficial for persons with PD. The advantage of beginning PT early in disease progression is that it can help mitigate the extent to which the motor and non-motor symptoms impact daily life. Additionally, if there were to be a change in function, receiving PT treatment can directly help with being able to successfully complete functional tasks such as climbing stairs to promote safe independence of persons with PD.
Ellis, T. D., Colón-Semenza, C., DeAngelis, T. R., Thomas, C. A., Hilaire, M. S., Earhart, G. M., & Dibble, L. E. (2021). Evidence for Early and Regular Physical Therapy and Exercise in Parkinson’s Disease. Seminars in neurology, 41(2), 189–205. https://doi.org/10.1055/s-0041-1725133