Move Forward Guide
Physical Therapist's Guide to
Parkinson's disease (PD) is the second most common degenerative brain disorder, after Alzheimer's disease. PD is more common in men than in women. People of all ethnic groups can develop PD, but it is less common among African-American and Asian populations. Most often, symptoms begin when people are around 60 years of age. Symptoms typically include stiffness (rigidity), shaking (tremor), slowness with movement, and balance problems. Because of these symptoms, people with PD are at risk of falling and breaking their bones. Treatment includes a combination of medication and physical therapy – and, in some cases, surgery.
What is Parkinson's Disease?
Parkinson's disease is related to a loss of nerve cells in your brain that produce a chemical called dopamine. Dopamine is an important factor in controlling movement.
The exact cause of PD is not yet known. Family history, aging, or exposure to certain environmental toxins may contribute to the onset of PD. It is a chronic degenerative disease, which means that it gets worse over time; however, people usually do not die from PD.
The severity and type of symptoms of PD can vary widely. Some people have the disease for 20 to 30 years and have a slower progression and decline in mobility over a long period of time. For others, the disease progresses more quickly, and they may experience difficulty with mobility within 5 to 10 years.
Signs and Symptoms
The symptoms of PD can be very mild at first. A common early symptom is a tremor in one hand, most often when you are at rest. It might look like you are rolling a pill between your thumb and forefinger. Tremors also can occur in your legs or jaw when you are at rest. Since the tremors are most apparent during rest, they usually go away when moving and typically don't interfere substantially with daily function.
As the condition progresses, you may notice other symptoms:
- Your movements may become smaller, possibly resulting in:
- shuffling when you walk, end of a sentence.
- arms swinging less when you walk, and
- your handwriting trailing off at the end of a sentence.
- You may develop a feeling of stiffness or rigidity in your muscles, causing discomfort in your neck, trunk, or shoulders.
- You may have postural instability, resulting in poor balance and a greater risk of falling.
- Your movements may become slower when doing daily activities such as dressing, showering, or moving in bed.
- You might feel as though your feet "freeze" to the floor, making it hard to take a first step.
- You may develop a stooped posture.
- You may find it physically difficult to speak loudly.
- Family and friends might notice that you show less expression in your face.
You might find it difficult to do things that you were once able to do easily, such as gardening or playing tennis or golf.
Other symptoms might include:
- Difficulty paying attention to a task for a long period of time or dividing attention between more than one task
- Lack of motivation
How Is It Diagnosed?
There is no specific “test” like an x-ray or head scan that can be used to identify PD, so it can be difficult to diagnose. A diagnosis is usually made based on your medical history and a neurological examination. If your physical therapist suspects that you have symptoms of PD, you may be referred to a neurologist for further examination.
A diagnosis of PD may be made if you have the following:
- At least 2 of the key signs of PD — tremor when resting, slowing of motion, or muscle rigidity
- A significant improvement in your symptoms when taking levodopa, a medication to treat PD
- Initial symptoms on 1 side of the body only
How Can a Physical Therapist Help?
Because PD affects each person differently, your physical therapist will partner with you to manage your specific situation — now and as your condition changes. You are not alone!
Your treatment plan will be developed after an extensive evaluation by your physical therapist. The examination will include many questions about how your PD affects your life. Tests will be conducted to examine your posture, strength, flexibility, walking, balance, and coordination.
Your physical therapist will help you stay as active and as independent as possible. You will be taught special exercises and techniques to combat the symptoms of PD. Depending on the nature and severity of your condition, your treatment program may focus on treatment to help you:
- Improve your fitness level, strength, and flexibility
- Develop more effective strategies to get in and out of bed, chairs, and cars
- Turn over in bed more easily
- Stand and turn to change directions more efficiently
- Improve the smoothness and coordination of your walking
- Improve your ability to perform hand movements
- Decrease your risk of falling
- Climb and descend stairs and curbs
- Do more than 1 task at a time more efficiently
- Participate in activities that are important to you
Some of the medications that are used to manage PD symptoms may have an immediate effect. For example, movement is typically much easier shortly after you begin taking certain PD medications. Your physical therapist will know how to time treatments, exercise, and activity based on both the schedule and the effects of your medications to get the best results.
Parkinson disease can make daily activities seem frustrating and time-consuming. Your physical therapist will become a partner with you and your family to help you combat and manage the symptoms of PD. As your condition changes, your treatment program will be adjusted to help you be as independent and as active as possible.
Some people with PD benefit from using a cane, a walker with wheels, or a walker with a laser beam. Your physical therapist can work with you to determine if any of these devices may be helpful to you. If you need physical assistance to help you with moving in bed or getting out of a chair, your physical therapist can team with you and your family to teach strategies to make moving easier and help prevent injury. In addition, your physical therapist can make suggestions on changes to your home environment to optimize safe and efficient daily function at home.
Can this Injury or Condition be Prevented?
To date, there is no known way to prevent PD. Studies have shown improved walking, balance, strength, flexibility, and fitness in people with PD who participated in an exercise program. However, these studies also indicated that people with PD gradually lost the gains they had made when their supervised exercise program ended. It’s important to work with your physical therapist to help develop good long-term exercise habits.
Real Life Experiences
Bob Z. is a 58-year-old man who was diagnosed with PD 6 months ago. He reports slowness with walking, a tendency to drag his left leg, and limited swinging of his left arm when he’s walking. His neurologist started him on 1 mg daily of Azilect, a drug that helps relieve tremors early in the course of the disease. Bob works full time and does not currently exercise. He heard that exercise may be helpful for people with PD but doesn’t know which exercises are best for him and how much he should exercise.
Bob's physical therapist conducts a full physical examination. This includes an evaluation of walking, balance, turning, and rising from a chair. In addition, she tests his strength, flexibility, and cardiovascular responses to exercise. She also administers standardized tests that measure quality of life, walking, balance, and neurological signs to determine Bob's baseline status and to help set goals.
The physical therapist develops an individualized exercise program to help Bob improve his walking and prevent the onset of weakness, reduced flexibility, and deconditioning. She recommends that Bob start a brisk walking program using a metronome for 30 minutes, 3 times per week. A metronome is a device that produces regular, metrical ticks, beats, or clicks. Bob walks to the "beat" of the metronome, resulting in faster walking with less leg dragging and better arm swing. The therapist also shows Bob 3 exercises for strengthening and flexibility.
Bob is carrying out his exercise program successfully. He consults with his physical therapist about every 6 months to monitor his progress and to adjust his exercises if needed. After 1 month of exercising, Bob's walking is faster, his leg is dragging less, and his arm is swinging better. He thinks that the exercises are helping, and he is more confident in his ability to exercise on a regular basis.
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat patients with PD. You may want to consider:
- A physical therapist who is experienced in treating people with neurological disorders. Some physical therapists have a practice with a neurological focus.
- A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in neurologic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with PD.
During your first visit with the physical therapist, be prepared to describe your concerns in as much detail as possible, and let the physical therapist know what you would like to accomplish by going to physical therapy.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of PD. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.
Schenkman M, Ellis T, Christiansen C, et al. Profile of functional limitations and task performance among people with early- and middle-stage Parkinson disease. Phys Ther. 2011;91:1339–1354. Article Summary on PubMed.
Allen NE, Sherrington C, Paul SS, Canning CG. Balance and falls in Parkinson's disease: a meta-analysis of the effect of exercise and motor training. Mov Disord. 2011;26:1605-1615. Article Summary on PubMed.
Morris ME, Martin CL, Schenkman M. Striding out with Parkinson disease: evidence-based physical therapy for gait disorders. Phys Ther. 2010;90:280-288. Free Article.
Morris ME, Iansek R, Kirkwood B. A randomized controlled trial of movement strategies compared with exercise for people with Parkinson's disease. Mov Disord. 2009;24:64-71. Article Summary on PubMed.
Thacker EL, Chen H, Patel AV, et al. Recreational physical activity and risk of Parkinson's disease. Mov Disord. 2008;23:69-74. Article Summary on PubMed.
Ellis T, de Goede CJ, Feldman RG, et al. Efficacy of a physical therapy program in patients with Parkinson's disease: a randomized controlled trial. Arch Phys Med Rehabil. 2005;86:626-632. Article Summary on PubMed.
Tillerson JL, Cohen AD, Philhower J, et al. Forced limb-use effects on the behavioral and neurochemical effects of 6-hydroxydopamine. J Neurosci. 2001;21:4427-4435. Free Article.
Acknowledgement: Terry Ellis, PT, PhD, NCS
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.