Vol.2, No.4, 118-120 (2013) Advances in Parkinson’s Disease
A prescription for physical therapy and exercise in
Parkinson’s disease
Marie Saint-Hilaire,Theresa Ellis
School of Medicine, Boston University, Boston, USA; neuromsh@bu.edu
Received 15 August 2013; revised 16 September 2013; accepted 25 September 2013
Copyright © 2013 Marie Saint-Hi laire, Theresa Ellis. This is an open access article distributed unde r the Creative Commons Attrib ution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
The rate of progression of Parkinson’s Disease (PD)
varies among individuals living with the disease. How-
ever, there comes a time, later in the course of the disease,
when most patients with PD develop balance impair-
ments and falls. Unfortunately, these symptoms do not
respond well to dopaminergic medications or deep brain
stimulation. Typically, this is when the clinician caring
for the patient initiates a referral to physical therapy (PT).
There is accumulating evidence revealing the benefits of
PT and exercise in reducing disability in persons with PD
[1]; however, PT is often not recommended un til the later
stages of the disease when disability levels are substan-
tial. The data from epidemiological studies randomized
controlled clinical trials (RCT’s) and studies in animal
models of PD suggest that PT and engagement in exer-
cise should be initiated early to reduce disability and
optimize quality of life.
Although one early epidemiological study on the ef-
fect of exercise on the risk of developing PD failed to
show a benefit [2], two larger prospective studies found a
positive impact of exercise [3,4]. In the most recent pro-
spective study of 213,000 participants in the NIH-AARP
Diet and Health Study Cohort, a higher level of moderate
to vigorous physical activity between ages 35 and 39, or
in the past 10 years, was associated with a decreased risk
of developing PD [3]. Individuals with consistent and
frequent participation in moderate to vigorous physical
activity in both periods had a 40% lower risk of devel-
oping PD compared to those who were inactive. This
study was significantly larger than the previous ones, and
data about exercise was uniformly collected.
Several clinical trials have shown that PT reduces dis-
ability in patients with PD. A recent Cochrane review
identified 33 RCT’s with 1518 subjects examining the
benefits of PT compared to no-intervention in persons
with PD [1]. Results revealed significant improvements
in gait velocity, functional mobility, balance and activi-
ties of daily living following PT compared to no inter-
vention. Improvements in quality of life, measured by
the Parkinson Disease Questionnaire-39, were seen fol-
lowing a 6-week RCT using a self-management ap-
proach to rehabilitation which persisted at the 6-month
follow-up visit [5]. This indicates the potential impor-
tance of helping people with PD learn the skills (i.e., the
importance of regular exercise) they need to manage the
disease over the long-term. Falls are common and poten-
tially life threatening in PD, and there has been little
evidence that exercise reduces falls [1]. However, a re-
cent study investigating the benefits of 24 weeks of Tai
Chi in patients with mild to moderate disease, showed
significant improvements in balance, function al capacity,
and reduced falls compared to resistance training and
stretching conditions [6].
Studies in animal models of PD suggest several poten-
tial mechanisms to explain the beneficial effect of physi-
cal activity. These include secretion of neurotrophic fac-
tors, enhanced neurogenesis, angiogenesis, and neuro-
plasticity [7]. In a recent study of the 6-OHDA lesioned
rat model of PD, treadmill exercise was found to signifi-
cantly increase the number of tyrosine hydroxylase posi-
tive neurons in the lesioned substantia nigra, compared to
the control group [8]. There was also significantly less
muscle atrophy following exercise.
Another potential benefit of physical activity is its ef-
fect on cognition. Cognitive difficulties are frequently
observed in PD as the disease progresses and people with
PD have a six-fold increase in the risk of dementia [9]. A
meta-analysis of prospective cohort studies revealed that
physical activity reduced the risk of dementia by 28% in
the general population, although this had not been dem-
onstrated in a PD population [10]. A number of mecha-
nisms have been proposed such as promotion of vascular
health, decrease in inflammatory markers, and improve-
ment of endothelial function.
Despite the evidence revealing the beneficial effects of
exercise, studies reveal the profound inactivity among
persons with PD. In a cross-sectional study comparing
physical activity levels among persons with PD and
Copyright © 2013 SciRes. OPEN A CCESS
M. Saint-Hilaire,T. Ellis / Advances in Parkinson’s Disease 2 (2013) 118-120 119
older adults living in the co mmunity, persons with PD (n
= 699) were found to be almost 1/3 less active than age
matched older adults (n = 1951) [11]. Levels of physical
activity decreased with d isease progression—a decline of
13% from H&Y 1 to 2 and 21% from H&Y 1 to 3 [11].
This highlights the need for initiation of an exercise pro-
gram early in the disease. In a longitudinal study exam-
ining physical activity levels at baseline and one year
later, results revealed that persons with PD walked 12%
fewer steps and had a 40% reduction in the number of
moderate intensity steps (>100 steps per minute) indi-
cating a substantial decline in physical activity levels
over a one year period [12]. A decline in walking ability
has also been identified as a clinical “red flag” and a
marker of emerging disability further emphasizes the
need for early rehabilitation to optimize function and
reduce disability [13].
Physical activity must be continued regularly for its
benefit to be sustained [14]. Studies in persons with PD
have identified low self-efficacy and outcome expecta-
tion as significant barriers to engaging in exercise [15,
16]. Programs to increase physical activity among per-
sons with PD should include strategies to promote be-
havior change. The ParkFit Trial (n = 586) was a 2-year
multicenter RCT comparing PT with a specific emphasis
on promoting a physically active lifestyle (ParkFit Pro-
gram) to matched PT with specific emphasis on safety
and quality of performing ADL’s (ParkSafe Program)
[17]. The ParkFit program specifically focused on in-
ducing a lasting change in exercise behavior through
goal setting, overcoming barriers to engaging in exercise,
recruiting social support, coaching by the PT, and use of
an activity monitor with visual feedback regarding daily
activity levels. Physical activity, measured using an ac-
tivity monitor, revealed a significant increase in activity
level (12%, 95% CI = 7% - 16%) over 24 months in the
ParkFit condition compared to the ParkSafe condition
[18]. Activity diaries also revealed an increase of ap-
proximately 90 minutes per week of physical activity
compared to 30 minutes in the ParkSafe condition. No
differences between groups were found using a physical
activity questionnaire.
Innovative approaches (e.g., virtual coaches, dance
programs) designed to meet the needs and preferences of
individual patients with PD are important to facilitate
sustained engagement in exercise in the community [19,
20]. Physical therapists (PT’s) are uniquely positioned to
design an exercise program tailored to the individual
with PD with the goal of enhancing function and reduc-
ing disability. PT’s can then refer patients with PD to
community exercise programs that are appropriate given
their level of function, individual preferences and goals.
Regular follow-up visits with the therapist over the
course of the disease allows for re-assessment of func-
tion (i.e., gait, balance, moving in bed) and further tai-
loring of the exercise program to prevent or slow the
onset of disability.
In conclusion, studies reveal profound sedentary life-
styles among persons with PD. There is a growing body
of literature demonstrating the benefits of physical ther-
apy and exercise in reducing disability in these patients.
The animal literature suggests a potential disease modi-
fying effect. For these reasons, PT should be part of the
standard management of PD early in the course of the
disease. Studies have shown that individual patient needs,
preferences, and action directed toward realistic goals are
fundamental to successful rehabilitation outcomes and
should be considered to optimize long-term engagement
in exercise.
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