Physical Therapy and Exercise Guidelines for Parkinson Disease

Educational Objectives

The goal of this program is to improve management of patients with Parkinson disease with physical therapy. After hearing and assimilating this program, the clinician will be better able to:

1. Design exercise programs of frequency and intensity appropriate to patient needs.
2. Apply treatments to ameliorate symptoms of Parkinson disease.

Summary

Introduction: the first exercise recommendations for Parkinson disease (PD) were stretching and relaxation movements; life expectancy of patients increased after introduction of medications (eg, levodopa and carbidopa); research in the last decade suggests that exercise can effect changes to the brain; exercise cannot reverse or stop PD; data to support disease-modifying effects of exercise is not available; research supports symptom-modifying effects of exercise

Exercises for PD: exercise selection is related to task specificity; treadmill walking improves speed of gait; dance improves motor symptoms, balance, and the cadence of walking; programs should include a wide selection of exercises, because PD is multifactorial; clinical practice guidelines were drafted based on the quality of evidence for different modes of exercise; the benefits of, eg, aerobic exercise, strengthening, balance training, community-based programs, gait training are supported by clinical evidence; one or all may be appropriate for each individual patient; no single modality is considered superior for patients with PD; research is not available for efficacy of telerehabilitation; stretching does not improve functional mobility; the Parkinson’s Foundation and American College of Sports Medicine (ACSM) produces a handout with general exercise recommendations; aerobic activity, strength training, balance and agility exercises, and stretching are outlined; the recommended duration and intensity of training is included; 150 min/wk of moderate to vigorous exercise is suggested; exercise may appear to be ineffective for many patients because they are exercising less than the suggested amount

High-intensity exercises: produces superior outcomes, according to current research; the safety of high-intensity exercises for patients with PD has been established; patients with cardiac and musculoskeletal issues must be cleared before beginning a program of exercise; Schenkman et al (2018) found high-intensity exercise may slow the worsening of symptoms; symptoms were measured using the United Parkinson Disease Rating Scale (UPDRS) which assesses tremors, rigidity and bradykinesia; participants engaging in high-intensity exercise had a net change of zero over 6 mo in their UPDRS score; UPDRS scores declined in participants engaging in moderate intensity exercises; symptoms worsened the most in patients who did not exercise; patients who start an exercise program early in the course of the disease obtain better results; patients may be advised to work out at an intensity level of 7 to 8 on a scale of 1 to 10; heart rate may be used as a guide (ie, a target maximum heart rate of 220 minus the age of the patient); however, the autonomic system dysfunction characteristic of PD may invalidate heart rate as a measure of intensity; rate of perceived exertion may be used; patients should almost be uncomfortable and short of breath while exercising; speaking in short sentences should be possible, but not full conversations

Exercise recommendations: exercise may begin at an intensity level of 2 to 3 and slowly increase to 4 to 6; the goal is to reach a level of 7 to 8; for aerobic exercise, 3 sessions of 30 min per wk are suggested; warm up and cool down periods should be included; adhering to an exercise regimen should become a permanent lifestyle change for patients; exercise classes are often locally available; the exercises most enjoyed by patients may be identified through motivational interviewing; patients are more likely to follow a program if it is enjoyable

Contributors to poor outcomes from exercise: benefits may be reduced in patients with cognitive disabilities, non-motor symptoms, or experiencing side-effects of medications; comorbidities may affect a patient’s ability to follow a home exercise program; a physical therapist (PT) may become involved at this stage

Involving specialists: research suggests that PTs, occupational therapists (OT) and speech therapists may be involved throughout all stages of PD; early stage — PTs may establish baseline abilities and assess any existing issues (eg, knee pain); referrals to other specialists may be made; patients may be provided education on the benefits of exercise and involved in the planning of an exercise program; mid-stage — functional mobility may be impacted by, eg, motor issues, bradykinesia, postural instability, cognitive issues, fatigue; exercise programs often need to be modified at this stage

Falls: providers should attempt to determine and remedy what lead to a patient falling; falls are often multifactorial; patients may be experiencing, eg, side-effects of medication, orthostatic hypotension, neuropathy; the patient’s home may be evaluated for safety; posture and balance should be assessed and PT exercises prescribed

Assisted devices: canes or trekking poles may be used; poles promote an upright posture and help with arm swing; walkers may be introduced as balance becomes compromised; front-wheel walkers may cause falls and are not recommended; 4-wheel walkers with large wheels, handbrakes, and a seat are superior; a stabilizing walker with a laser and metronome (U-Step) may be appropriate for patients with freezing of gait or festination; patients can be outfitted with protective equipment, eg, knee pads, hip protection (SAFEHIP), helmets; patients with urinary incontinence and constipation may benefit from pelvic floor treatment by PTs; transcutaneous tibial nerve stimulation (TTNS) or percutaneous tibial nerve stimulation may be employed; PTs often use TTNS with a transcutaneous electrical nerve stimulation (TENS) unit placed on the ankle for neural modulation of the bladder

Functional mobility recommendations: strengthening or stretching exercises help with routine movements; patients may have trouble getting out of bed or a chair; the correct sequence of movements may be forgotten; PTs may need to reteach movements by breaking it down into individual steps; patients must be strong enough to complete the action; the need for a high chair or a lift chair should be assessed; a hospital bed may be necessary for patients to independently get out of bed

Pain management: patients may experience chronic pain throughout all stages of PD, but especially in later stages; back pain and joint pain is common; research suggests that patients who exercise have less pain; manual therapy may reduce pain; pain caused by musculoskeletal issues may be resolved by PTs; care partners may be taught different techniques for pain management; coordination among the patient’s medical team to optimize medications may lower pain levels

Insurance: commercial insurance may cover PT; patients may use “direct access” to visit a PT without a referral from a physician; a referral is needed for home visits and is fully covered by Medicare A; patients must be classified as home bound

Referrals for PT: appropriate for pain management, falls, exercise programming, equipment recommendations; a checkup every 6 mo is recommended because PD is a neurodegenerative disease and patients may decline between visits

Readings

Alberts JL, Rosenfeldt AB. The Universal Prescription for Parkinson's Disease: Exercise. J Parkinsons Dis. 2020;10(s1):S21-S27. doi:10.3233/JPD-202100; Araujo TG, Schmidt AP, Sanches PRS, Silva Junior DP, Rieder CRM, Ramos JGL. Transcutaneous tibial nerve home stimulation for overactive bladder in women with Parkinson's disease: A randomized clinical trial. Neurourol Urodyn. 2021;40(1):538-548. doi:10.1002/nau.24595; Ni M, Hazzard JB, Signorile JF, et al. Exercise guidelines for gait function in Parkinson's disease: a systematic review and meta-analysis. Neurorehabil Neural Repair. 2018;32(10):872-886. doi:10.1177/1545968318801558; Penko AL, Barkley JE, Koop MM, Alberts JL. Borg scale is valid for ratings of perceived exertion for individuals with Parkinson's disease. Int J Exerc Sci. 2017;10(1):76-86. Published 2017 Jan 1; Schenkman M, Moore CG, Kohrt WM, et al. Effect of high-intensity treadmill exercise on motor symptoms in patients with de novo Parkinson disease: a phase 2 randomized clinical trial. JAMA Neurol. 2018;75(2):219-226. doi:10.1001/jamaneurol.2017.3517; van der Kolk NM, King LA. Effects of exercise on mobility in people with Parkinson's disease. Mov Disord. 2013;28(11):1587-1596. doi:10.1002/mds.25658.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Jennifer L. Wilhelm was recorded at the 29th Annual Internal Medicine Review, held virtually April 14-15, 2022, and presented by Oregon Health and Science University. For further information about future activities from this presenter, please visit https://www.ohsu.edu/school-of-medicine/cpd. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

IM693302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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