Physiotherapy management in people with Parkinson’s includes a detailed assessment to identify their symptoms, physical status and function. The staging of disease progression allows for a tailored rehabilitation programme consisting of education, movement strategies, exercises and a home exercise programme.
Physiotherapy management aims to improve strength, balance, optimize gait patterns and other movements, conditioning, posture and reduce falls risk. These improvements would help maintain or enhance levels of function and independence, which in turn helps to improve their overall quality of life and mental health.
Recommendations:
High intensity aerobic exercise may provide disease-modifying effects in people with early PD.
People with early PD benefit from regular, high-intensity aerobic exercise to improve their fitness, potentially optimising brain health and reducing the speed of symptom decline. Increased neurotrophic factors, improved angiogenesis, reduced inflammation, immune factors and improved mitochondrial function are all potential mechanisms contributing to the exercise related improvements in brain health. People with early PD also benefit from increased dopamine release in the caudate nucleus and improved activation of the ventral striatum which is depleted in people with PD contributing to sensorimotor coordination issues. (Sacheli 2019).
A randomised controlled trial showed favourable outcomes with exercise and horticultural intervention programs for older adults with depression and memory problems (Makizako 2020).
Moderate intensity progressive resistance training can result in significant strength, balance and motor symptoms gains in people with early to moderate PD
Resistance training is shown to enhance muscle strength, balance and reduce parkinsonian motor symptoms. It is suggested that moderate intensity progressive resistance training, 2-3 times per week over 8-10 weeks can result in significant strength, balance and motor symptoms gains in people with early to moderate Parkinson’s disease. (Chung 2015)
A 2022 meta-analysis found that progressive resistance training in persons with Parkinson’s improved freezing of gait, increased muscle strength and improved reported quality of life during rehabilitation.(Yang and Wang, 2023)
Potential neuroprotective effects with exercises in people with PD
The role of exercise is to maintain health and enhance well-being in people with PD across the different disease stages. Exercise not only produces neuronal and mitochondrial protection, it also boosts nigrostriatal neurotrophic factor levels in the chronic parkinsonian mice with moderate neurodegeneration. Therefore, modifying lifestyle with increased exercise activity would be a non-pharmacological neuroprotective approach for averting neurodegenerative processes, as demonstrated in experimental chronic parkinsonism. (Lau 2011)
Balance training needs to be complex and challenging to have optimal effects in people with PD
Balance training is effective in people with mild to moderate PD with optimal effects demonstrated from training that is supervised, highly challenging, delivered frequently and long term. Research suggests that programs of highly challenging balance training delivered two to three times a week for 10 weeks can result in improvements in balance (Sparrow 2016, Conradsson 2017), but without maintenance these gains may be lost within six months (Wallen 2018). Physiotherapists are able to design exercises to include dual task training and incorporate environmental challenges to simulate daily activities.
Visual or auditory cues in movement training for freezing of gait in PD
European guidelines (Keus 2014) report strong evidence for cueing such as visual (eg, stepping over strips of tape on the floor) or auditory (eg, using a metronome at frequencies around 10 per cent below baseline preferred walking cadence), to improve attention, step length, freezing and turning during walking tasks.
Whilst the most effective dose is unknown, it needs to be tailored and intensive enough to consolidate learning and regular follow up is recommended (Cosentino 2020)
Recent evidence confirms that freezing of gait can be triggered by motor, cognitive or emotional challenges alone or in combination (Ehgoetz Martens 2018) Being able to identify the triggers would allow better targeted management.
Falls can be prevented with appropriately prescribed exercise in people with mild to moderate PD
People with PD commonly develop motor symptoms such as rigidity and bradykinesia. These changes contribute to the risk of falls. Exercises that target mobility, specifically challenge and strengthen balance are able to address axial rigidity and improve flexibility. This will help maintain postural stability and mobility to prevent falls. Understanding how people with PD across the spectrum of disease severity differ in their postural motor learning ability and response to different fall prevention interventions.
A systematic review showed that exercise reduces the frequency of falls in PD by 60 per cent (Shen 2016). The understanding of people with PD across the spectrum of disease severity and the assessed risk of falls allows interventions to be refined and optimized to minimize falls and their negative sequelae associated. (Paul 2018)
Inspiratory muscle training for respiratory function
Looking after the respiratory system may be helpful for people with PD. A randomised controlled clinical trial protocol to evaluate the effect of inspiratory muscle training on respiratory function in patients with mild-to-moderate Parkinson’s suggests that inspiratory muscle training improves respiratory muscle strength, lung function, thoracic mobility and functional capacity (Ferro 2019). Similarly, a systematic review of research on the application of Respiratory Muscle Strength Training to Parkinson’s Disease rehabilitation found that respiratory muscle training is a useful therapy for managing decreased respiratory muscles, dysphagia, ineffective coughing, speech disorders, and cardiorespiratory dysfunction in people with Parkinson’s, with prolonged positive impact on respiratory muscle strength, swallowing function, and cardiovascular autonomic function (Zhuang 2022).
