A prescription for physical therapy and exercise in Parkinson’s disease

doi:10.4236/apd.2013.24023

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Vol.2, No.4, 118-120 (2013) Advances in Parkinson’s Disease

http://dx.doi.org/10.4236/apd.2013.24023

A prescription for physical therapy and exercise in

Parkinson’s disease

Marie Saint-Hilaire,Theresa Ellis

School of Medicine, Boston University, Boston, USA; [email protected]

Received 15 August 2013; revised 16 September 2013; accepted 25 September 2013

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

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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