Rehabilitation in Parkinson's disease

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Parkinson's disease (also known as Parkinson disease, Parkinson's, idiopathic parkinsonism, primary parkinsonism, PD, hypokinetic rigid syndrome/HRS, or paralysis agitans) is a degenerative disorder of the central nervous system. The motor symptoms of Parkinson's disease result from the death of dopamine-generating cells in the substantia nigra, a region of the midbrain; the cause of this cell death is unknown. Early in the course of the disease, the most obvious symptoms are movement-related; these include tremors or shaking, rigidity, bradykinesia (slowness of movement), loss of postural control, difficulty with walking, and gait.[1] Later, cognitive and behavioural problems may arise, with dementia commonly occurring in the advanced stages of the disease.

Studies of rehabilitation in Parkinson's disease are scarce and are of low quality.[2][3]


Regular physical exercise with or without physiotherapy can be beneficial to maintain and improve mobility, flexibility, strength, gait speed, and quality of life.[3][4] In terms of improving flexibility and range of motion for patients experiencing rigidity, generalized relaxation techniques such as gentle rocking have been found to decrease excessive muscle tension. Other effective techniques to promote relaxation include slow rotational movements of the extremities and trunk, rhythmic initiation, diaphragmatic breathing, and meditation techniques.[5] Common changes in gait associated with the disease such as hypokinesia (slowness of movement), shuffling and decreased arm swing are addressed by a variety of strategies to improve functional mobility and safety. Goals with respect to gait during rehabilitation programs include improving gait speed, base of support, stride length, trunk and arm swing movement. Strategies include utilizing assistive equipment (pole walking and treadmill walking), verbal cueing (manual, visual and auditory), exercises (marching and PNF patterns) and varying environments (surfaces, inputs, open vs. closed).[6]

Strengthening exercises have led to improvements in strength and motor functions in patients with primary muscular weakness and weakness related to inactivity in cases of mild to moderate Parkinson’s disease.[4] Patients perform exercises when at their best, 45 minutes to one hour after medication.[7] An 8-week resistance training study geared towards the lower legs found that patients with Parkinson's Disease gained abdominal strength, and improved in their stride length, walking velocity and postural angles.[8] Also, due to the forward flexed posture and respiratory dysfunctions in advanced Parkinson’s disease, deep diaphragmatic breathing exercises are beneficial for improving chest wall mobility and vital capacity.[9] Exercise may correct constipation.[10]

Exercise training on a vibratory platform, also called whole body vibration (WBV) training, has been recently introduced as a training tool complementing standard physical rehabilitation programs for people with Parkinson’s disease. Compared to no intervention, single sessions of WBV have resulted in improved motor ability, as reflected by Unified Parkinson's Disease Rating Scale (UPDRS) tremor and rigidity scores.[11][12] However, longer-term (3–5 weeks) WBV programs have not led to improved UPDRS motor scores compared to conventional exercises.[13][14] Furthermore, multiple sessions of WBV have failed to enhance mobility measures (i.e., the Timed Up and Go Test and 10-Meter Walking Test) in people with Parkinson’s disease.[13][14] A recent review deemed that the evidence of the effects of WBV training on sensorimotor and functional performance remains inconclusive.[15]


Visual, auditory, and somatosensory cuing devices have also been used [16] in conjunction with walking aids to improve gait in individuals with Parkinson’s disease. These cuing strategies have been implemented in an 'app' called Parkinson Home Exercises.[17]

Given the challenge that this clinical population may have with initiating motor movements during gait (e.g., freezing gait) [1], these devices provide external stimulation to cue for the next step to take place.[18]

Gait training[edit]

Gait impairment in people with Parkinson's Disease occurs when they generate an inappropriate stride length.[19]

Task-specific gait training may also lead to long-term gait improvement for patients with Parkinson's disease. Previous research studies have utilized body weight support systems during gait training, where individuals are suspended from an overhead harness with straps around the pelvic girdle as they walk on a treadmill. This form of gait training has been shown to improve long-term walking speed and a shuffling gait following a one-month intervention period.[20]

Studies are also looking at the effect of tai chi on gait performance, and balance in people with Parkinson's Disease.[21][22] The first study concluded that tai chi was ineffective since there was no improvement on gait performance and no improvement on the Part III score of the Unified Parkinson's Disease Rating Scale (UPDRS).[21] The second study found that patients taking tai chi improved on their UPDRS score, Timed Up and Go test, six-minute walk and backwards walking.[22] It did not however, show any improvements on their forward walking or their one leg stance test.[22]

Speech and occupational therapy[edit]

One of the most widely practiced treatments for speech disorders associated with Parkinson's disease is the Lee Silverman voice treatment (LSVT).[2][23] Speech therapy and specifically LSVT may improve speech.[2]

A study was conducted to determine if LSVT was beneficial in improving sentence intelligibility of 8 speakers with Parkinson's Disease, according to normal-hearing listeners.[24] The study concluded that after LSVT, there was a significant improvement in the percentage of the words understood by the listeners.[24] Even though the LSVT was not beneficial for 2 of the speakers, the treatment did increase their vocal loudness.[24] Therefore, LSVT has shown that it can improve speech and voice impairments in people with Parkinson's Disease.[24]

Occupational therapy aims to promote health and quality of life by helping people with the disease to participate in as much of their daily routine as possible.[2] There is indication that occupational therapy may improve motor skills and quality of life for the duration of the therapy.[2][25]

Music Therapy[edit]

Studies are considering whether music therapy can have a beneficial effect on people with Parkinson's Disease.[26] A 3-month study investigated whether there was any motor benefit of music therapy and physical therapy on Parkinson's Disease patients, and whether the therapies had any effect on their emotional well being and their quality of life.[26] The music therapy consisted of choral singing, voice exercise and rhythmic and free body movements, whereas the physical therapy consisted of stretching exercises, specific motor tasks and ways to improve balance and gait.[26] The study concluded that music therapy had a beneficial effect on the patient's emotions, it showed an improvement in bradykinesia, and in quality of life.[26] Music therapy however lacked any motor benefit, whereas physical therapy showed that it improved the rigidity of the patients.[26]


  1. ^ Gleb DJ, Oliver E, Gilman S (1999). "Diagnostic criteria for Parkinson's disease". Arch Neurol. 56 (1): 33–9. doi:10.1001/archneur.56.1.33. 
  2. ^ a b c d e The National Collaborating Centre for Chronic Conditions, ed. (2006). "Other key interventions". Parkinson's Disease. London: Royal College of Physicians. pp. 135–46. ISBN 1-86016-283-5. 
  3. ^ a b Goodwin VA, Richards SH, Taylor RS, Taylor AH, Campbell JL (April 2008). "The effectiveness of exercise interventions for people with Parkinson's disease: a systematic review and meta-analysis". Mov. Disord. 23 (5): 631–40. doi:10.1002/mds.21922. PMID 18181210. 
  4. ^ a b Roeder, Luisa; Costello, Joseph T.; Smith, Simon S.; Stewart, Ian B.; Kerr, Graham K. (2015-07-06). "Effects of Resistance Training on Measures of Muscular Strength in People with Parkinson's Disease: A Systematic Review and Meta-Analysis". PLoS ONE. 10 (7): e0132135. doi:10.1371/journal.pone.0132135. PMC 4492705free to read. PMID 26146840. 
  5. ^ O'Sullivan & Schmitz 2007, pp. 873, 876
  6. ^ O'Sullivan & Schmitz 2007, p. 879
  7. ^ O'Sullivan & Schmitz 2007, p. 877
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  9. ^ O'Sullivan & Schmitz 2007, p. 880
  10. ^ Barichella, M; Cereda, E; Pezzoli, G (Oct 15, 2009). "Major nutritional issues in the management of Parkinson's disease.". Movement disorders : official journal of the Movement Disorder Society. 24 (13): 1881–92. doi:10.1002/mds.22705. PMID 19691125. 
  11. ^ Haas, C.T., Turbanski, S., Kessler, K., & Schmidtbleicher, D. (2006). The effects of random whole-body-vibration on motor symptoms in Parkinson's disease. NeuroRehabilitation, 21: 29–36.
  12. ^ King, L.K., Almeida, Q.J., & Ahonen, H. (2009). Short-term effects of vibration therapy on motor impairments in Parkinson's disease. NeuroRehabilitation, 25: 297–306.
  13. ^ a b Arias, P., Chouza, M., Vivas, J., & Cudeiro, J. (2009). Effect of whole body vibration in Parkinson's disease: a controlled study. Movement Disorders, 24: 891–898.
  14. ^ a b Ebersbach, G., Edler, D., Kaufhold, O., & Wissel, J. (2008). Whole body vibration versus conventional physiotherapy to improve balance and gait in Parkinson's disease. Archives of Physical Medicine and Rehabilitation, 89: 399–403.
  15. ^ Sitjà Rabert, M., Rigau Comas, D., Fort Vanmeerhaeghe, A., Santoyo Medina, C., Roqué, I., Figuls, M., Romero-Rodríguez, D., & Bonfill Cosp, X. (2012). Whole-body vibration training for patients with neurodegenerative disease. Cochrane Database of Systematic Reviews, 15(2): CD009097.
  16. ^ van Wegen et al 2006; Nieuwboer et al. 2007
  17. ^ "Parkinson Home Exercises App". European Foundation for Health and Exercise. Retrieved 4 December 2015. 
  18. ^ Pongmala, C., Suputtitada, A. & Sriyuthsak, M. (2010). The study of cuing devices by using visual, auditory and somatosensory stimuli for improving gait in Parkinson’s patients. International Conference on Bioformatics and Biomedical Technology
  19. ^ Morris ME, Iansek R, Matyas TA, Summers JJ (1996). "Stride length regulation in Parkinson's disease.Normalization strategies and underlying mechanisms". Brain. 119 (2): 551–68. doi:10.1093/brain/119.2.551. 
  20. ^ Miyai I.; Fujimoto Y.; Yamamoto H.; et al. (2002). "Long-term effect of body weight-supported treadmill training in Parkinson's disease: a randomized controlled trial". Arch Phys Med Rehabil. 83 (10): 1370–1373. doi:10.1053/apmr.2002.34603. 
  21. ^ a b Amano S, Nocera JR, Vallabhajosula S, Juncos JL, Gregor RJ, Waddell DE, Wolf SL, Hass CJ (2013). "The effect of Tai Chi exercise on gait initiation and gait performance in persons with Parkinson's Disease". Parkinsonism Relat Disord. 19 (11): 955–60. doi:10.1016/j.parkreldis.2013.06.007. 
  22. ^ a b c Hackney ME, Earhart GM (2008). "Tai Chi improves balance and mobility in people with Parkinson disease". Gait & Posture. 28 (3): 456–60. doi:10.1016/j.gaitpost.2008.02.005. 
  23. ^ Fox CM, Ramig LO, Ciucci MR, Sapir S, McFarland DH, Farley BG (November 2006). "The science and practice of LSVT/LOUD: neural plasticity-principled approach to treating individuals with Parkinson disease and other neurological disorders". Semin. Speech. Lang. 27 (4): 283–99. doi:10.1055/s-2006-955118. PMID 17117354. 
  24. ^ a b c d Cannito MP, Suiter DM, Beverly D, Chorna L, Wolf T, Pfeiffer RM (2012). "Sentence Intelligibility Before and After Voice Treatment in Speakers With Idiopathic Parkinson's Disease". Journal of Voice. 26 (2): 214–19. doi:10.1016/j.jvoice.2011.08.014. 
  25. ^ Dixon L, Duncan D, Johnson P, et al. (2007). Deane K, ed. "Occupational therapy for patients with Parkinson's disease". Cochrane Database of Systematic Reviews (3): CD002813. doi:10.1002/14651858.CD002813.pub2. PMID 17636709. 
  26. ^ a b c d e Pacchetti C, Mancini F, Aglieri R, Fundaro C, Martignoni E, Nappi G (2000). "Active Music Therapy in Parkinson's Disease: An Integrative Method for Motor and Emotional Rehabilitation". Psychosomatic Medicine. 62 (2): 386–93. doi:10.1097/00006842-200005000-00012. 


  • O'Sullivan, Susan B; Schmitz, Thomas J (2007). "Parkinson's Disease". Physical Rehabilitation (5th ed.). Philadelphia: F.A. Davis. pp. 856–7.