Parkinson's Disease: Moving ForwardPage 12 of 17

10. Rehabilitation

Because Parkinson’s disease impairs speech, swallowing, limb function, gait, and balance, it affects all aspects of daily living. Even with optimal medical management these deficits cannot be controlled satisfactorily in the vast majority of individuals (Fox et al., 2013).

A growing body of evidence has emerged revealing significant and clinically meaningful benefits of exercise for addressing PD-related problems. A critical review of the literature identified 23 randomized controlled trials demonstrating that patients who participated in exercise programs had better quality of life, walking ability, balance, strength, flexibility, and cardiovascular fitness compared to those who did not exercise (Dibble et al., 2010).

Exercise studies of both rodent and primate models of PD have demonstrated increased survival of nigrostriatal dopaminergic neurons, suggesting a potential protective effect of exercise as well. Furthermore, a prospective epidemiologic study revealed significant decreased risk of developing PD in people who participated in moderate to vigorous exercise (Dibble et al., 2010).

The impact of exercise is being increasingly considered in studies that have explored drive activity-dependent neuroplasticity (modifications in the central nervous system in response to physical activity) such as specificity, intensity, repetition, and saliency (Fox et al., 2013). These findings have emphasized the important role of exercise and rehabilitation in the overall management of PD.

Unfortunately, rehabilitation programs have traditionally been offered in the later stages of PD or as reactive referrals for treatment of secondary impairments, such as aspiration due to swallowing dysfunction, or hip fracture due to falling. Today, such therapeutic options are increasingly being prescribed early in the course of PD and may potentially contribute to slowing of motor symptom progression.

Therapeutic Exercise and Motor Training

There are a number of randomized controlled trials that have assessed the effects of exercise and motor training in people with Parkinson’s disease. Overall, these trials support exercise and motor training as beneficial in improving walking, balance, muscle strength, and the performance of functional tasks in people with mild to moderate PD (Allen et al., 2012).

Gait Training

Gait impairments in PD are an important target of therapeutic interventions because of their prevalence and consequences. The use of cognitive processes to consciously attend to and modify gait parameters is a key strategy for gait rehabilitation in PD. For example, people with PD can increase gait speed and stride length when instructed to focus on taking longer strides. Such cognitive strategies improve walking under single-task conditions, but the evidence for transfer to dual-task walking conditions is mixed. The ability to improve dual-task walking using cognitive strategies requires that people with PD focus on walking while also directing cognitive resources or processes to the performance of a concurrent cognitive or motor task (Kelly et al., 2012).

Progressive Resistance Strength Training

Progressive resistance strength training is an exercise therapy that can increase the ability of muscles to generate force. Strength is reduced in many people with PD, most likely because hypokinesia and aging lead to reduced physical activity and disuse. There is preliminary evidence that progressive resistance strength training for people with Parkinson’s can result in increased muscle strength and hypertrophy, improved walking ability, and enhanced balance (Morris et al., 2012).

Movement Strategy Training

There are several approaches to physical therapy that can be delivered within the home. One effective method, known as movement strategy training (MST), teaches the individual to compensate for the disabling movement disorders that occur in PD. These approaches teach people to use attentional strategies to consciously bypass the basal ganglia instead using the frontal cortex to initiate and execute functional activities (Morris et al., 2012).

Motor performance is enhanced by the use of structured practice, which breaks down complex movement sequences into segments and focuses attention on each segment before practicing the activity as a whole. Additional components of movement strategy training are the mental rehearsal of forthcoming movements, conscious focus on the movement as it occurs, and the use of supplementary visual or auditory cues (Morris et al., 2012).

Agility Boot Camp

The theoretical basis for a novel, the sensorimotor Agility Boot Camp (ABC) exercise program is based on research from Oregon Health and Science University and others that identified the primary neurophysiologic constraints that limit balance and mobility in PD. The exercises are designed as a circuit with six types of sports skill activities focused on improving basic postural systems:

  1. Pre-Pilates
  2. Kayaking to improve biomechanical constraints on joint flexibility, muscle strength, and postural alignment
  3. Tai chi to improve kinesthesia and increase functional limits of stability
  4. Boxing to improve anticipatory postural adjustments prior to stepping in multiple directions
  5. Lunges to improve the speed and size of automatic stepping for postural correction
  6. Agility course to improve stability and coordination during gait that is challenged by quick changes in direction, avoiding or overcoming obstacles, and simultaneously performing a secondary cognitive or motor task (King et al., 2013)

Each activity is engaged for 10 minutes with rest periods, and systematically progressed from beginning to intermediate to advanced levels by:

  1. Challenging sensory integration (altering vision and/or surface conditions)
  2. Adding a secondary, cognitive task
  3. Limiting external cues
  4. Increasing speed and resistance

Cool-down activities at the completion of the circuit included adapted floor Pilates: stretching of flexors and rotators, strengthening of extensors, and practice of transitional activities such as rising from a chair, getting onto the floor, rolling, and coming to stand from the floor (King et al., 2013).

Powering Forward: Boot Camp for People with Parkinson’s [1:02]


Treadmill Training

In study at Oregon Health and Science University, treadmill training was used to address gait and mobility. The training consisted of fast walking on a treadmill for up to 30–45 minutes as tolerated per session, with an additional 10 minutes of warm-up and cool-down of adapted Pilates. Treadmill intensity was started at 80% of each participant’s natural over-ground gait velocity and increased to 90% after a week. Natural gait velocity was measured at the beginning of each week with a stopwatch prior to each treadmill training by asking participants to walk 25 feet. From the third week of training, the treadmill speed was gradually increased to reach a goal of 5% to 10% above that week’s over-ground walking speed. Participants are allowed to hold onto the railing to focus on gait training. Therapists encouraged participants to increase stride length and height and to keep their upper body erect during the training period but were not allowed to work with the patient on any direct aspects of balance beyond that used for walking on a treadmill. Safety harnesses were worn at the discretion of the physical therapist and none of the participants used a body weight support harness (King et al., 2013).

Multi-Modal Exercise Programs

A Brazilian study looked at the effects on idiopathic PD patients of a multi-modal exercise program addressing functional mobility and cognitive parameters. The aim of the multi-modal exercise program was to develop the patients’ functional capacity, cognitive functions, posture, and locomotion through a program that is primarily aerobic. It comprised a variety of activities that simultaneously focused on the components of functional capacity, such as muscular resistance (specific exercises for large muscle groups), motor coordination (rhythmic activities), and balance (recreational motor activities). These components were selected because they seem to be those most affected by PD (Gobbi et al., 2011).

The multimodal program took place over a 6-month period (72 sessions, 3 times a week, and 60 minutes per session). Each session consisted of five components (warm-up, pre-exercise stretching, the main exercise session, cool-down, and post-exercise stretching). All sessions were conducted in the morning, in the ‘‘on” medication state, between 1 and 1½ hours after participants’ first morning dose of medication. The program was designed in six phases and each phase was composed of 12 sessions and lasted approximately one month (Gobbi et al., 2011).

At the end of each phase there was a progressive increase of load. Heart rate during the sessions remained between 60% and 80% of maximum heart rate, which characterizes training with aerobic predominance. The exercise program was supervised by at least three physical education professionals at any one time. Each participant was required to attend at least 70% of the sessions in order to be included in the data analysis (Gobbi et al., 2011).

A clinical assessment was performed using the Unified Parkinson’s Disease Rating Scale, Mini-Exam of Mental Status, and Hoehn and Yahr. Higher scores on the UPDRS and Hoehn and Yahr indicate more severe disease. Conversely, higher scores on the Mini-Exam of Mental Status indicate a more preserved cognitive function. Basic functional mobility and cognitive function was assessed using standardized tests (Gobbi et al., 2011).

The purpose of the study was to demonstrate the effectiveness of a long-term multi-modal exercise program in improving clinical parameters, functional mobility, and cognitive function in people with PD. The results showed a clear maintenance level in disease stage and severity, with an increase on both balance control and functional mobility. Also observed was the maintenance of both the executive functions and the short-term memory (Gobbi et al., 2011).


One rehabilitation approach for those with Parkinson’s disease is the Lee Silverman Voice Treatment (LSVT) Programs—LSVT LOUD for speech and LSVT BIG for motor systems. These programs focus on increasing the amplitude of movements, use an intensive mode of treatment delivery, and teach individuals with PD to recalibrate their sensorimotor systems using self-cueing and attention to action, which may be important for generalization and long-term maintenance of treatment effects (Fox et al., 2012).

LSVT LOUD and Speech Therapy

Recent investigations consistently report speech symptoms in the early stages of PD. Self-report data from individuals with PD has indicated that voice and speech changes are associated with inactivity, embarrassment, and withdrawal from social situations. Nearly 90% of individuals with PD have speech and voice disorders that impact communication. This includes:

  • Reduced vocal loudness
  • Monotone, hoarse, breathy voice quality
  • Imprecise articulation (perceived as mumbling)
  • Rate-related features, such as hesitations and short rushes of speech (Fox, et al, 2012)

LSVT LOUD is a standardized, research-based speech treatment protocol with established efficacy. LSVT LOUD, which focuses on increasing vocal loudness, was developed for the treatment of voice and speech impairment in individuals with PD. The treatment protocol involves intensive treatment delivery (a 1-hour session, 4 days a week for 4 weeks). Positive changes have been noted not only for vocal loudness but also for many other speech dimensions, including intonation (Whitehall et al., 2011).

LSVT LOUD targets vocal loudness in order to enhance the voice source. It uses vocal loudness as a trigger for distributed effects (eg, improved articulation, vocal quality and intonation, reduced rate) across the speech production system. It also seeks to recalibrate sensorimotor perception of improved vocal loudness. Finally, it trains a single self-cue and attention to action to facilitate generalization of treatment effects into functional communication.

Although LSVT LOUD is a standardized treatment protocol, the materials used during treatment and the homework and carryover exercises are tailored to each individual to facilitate motivation, engagement, and the potential to drive neuroplasticity (Fox et al., 2012).

Alan: Living with Parkinson’s

Another positive is that I have been accepted in a voice therapy program at Mayo Clinic. It is an hour session four days a week for four consecutive weeks and is specifically designed for Parkinson’s speech problems.

When I have completed the sessions, you should be able to hear me better. That’s a good thing, since many of my boomer friends have hearing problems! Maybe it was listening to Jimi Hendrix, the Stones, and Iron Butterfly all those years ago when we were young.

LSVT BIG and Physical/Occupational Therapy

In LSVT BIG, training of amplitude rather than speed is the main focus of treatment to overcome bradykinesia and hypokinesia. Training of velocity can induce faster movements but does not consistently improve movement amplitude and accuracy. Training to increase velocity of limb movements may result in hypokinetic (reduced) movement amplitude. In contrast, training of amplitude not only results in bigger but also faster and more precise movement (Fox et al., 2012).

In LSVT BIG, individuals perform movements that are hesitant (akinesia), slow (bradykinesia), and with reduced amplitude (hypokinesia). Changing from one motor program to another (set-shifting) may be disturbed and sequencing of repetitive movements may occur with prolonged and irregular intervals and reduced and irregular amplitudes. External cues may exert disproportionate influences on motor performance and can trigger both motor blocks and kinesia paradoxica (Fox et al., 2012).

The goal of LSVT BIG is to overcome deficient speed-amplitude regulation leading to underscaling of movement amplitude at any given velocity. Continuous feedback on motor performance and training of movement perception is used to counteract reduced gain in motor activities resulting from disturbed sensorimotor processing (Fox et al., 2012).

Most current therapies rely on compensatory behavior and external cueing in order to bypass deficient basal ganglia function. Other protocols focus on retraining of deficient functions. Task-specific, repetitive, high-intensity exercises for individuals with PD include treadmill training, training of compensatory steps, walking, and muscle strengthening. LSVT BIG belongs to the latter restorative approaches and is aiming to restore normal movement amplitude by recalibrating the patient’s perception of movement execution. LSVT BIG differs from other forms of physiotherapy in PD in its training of movement amplitude as a single treatment parameter through high effort and intensive treatment, with a focus on recalibrating sensory perception of normal amplitude of movements (Fox et al., 2012).

Therapeutic Exercise and Dyskinesia

A considerable number of studies have shown that exercise is effective in improving gait, balance, freezing, and motor performance in PD. In particular, recent studies on animals allow hypothesizing a direct action of physical activity on the mechanisms responsible for dyskinesias (Frazzitta et al., 2012).

In an Italian study, 10 parkinsonian patients underwent a 4-week intensive rehabilitation treatment. Patients were evaluated at baseline, at the end of the rehabilitation treatment, and at 6-month followup. Outcome measures were the Unified Parkinson’s Disease Rating Scale—parts II, III, and IV—and the Abnormal Involuntary Movement Scale. At the end of the intensive rehabilitation treatment, levodopa dosage was significantly reduced, dropping from 1016 mg/day to 777 mg/day. All outcome variables improved significantly by the end of intensive rehabilitation treatment. At followup, all variables still maintained better values with respect to admission. In particular, Abnormal Involuntary Movement Scale scores improved decreasing from 11.90 at admission to 3.10 at discharge and to 4.27 at followup. The results suggest that it is possible to act on dyskinesias in parkinsonian patients with properly designed rehabilitation protocols. Intensive rehabilitation treatment, the acute beneficial effects of which are maintained over time, might be considered a valid noninvasive therapeutic support for parkinsonian patients suffering from dyskinesia, allowing a reduction in medication dosage and related adverse effects (Frazzitta et al., 2012).

The Stigma of Impaired Movement

Given the nature of some symptoms of PD, people with the disease may be subject to stigmatization and discredited because of negative societal perceptions of bodily movement. The more visible and less “normal” the symptoms of PD are, the more likely they are to be judged as socially unacceptable or threatening by people who do not have PD (Simpson et al., 2013).

Research findings offer insights into the nature of stigma associated with movement difficulties. For example, in one study researchers found that women who experienced PD reported discomfort during social interactions because “involuntary movements of arms and legs make them feel especially conspicuous.” Participants reported that friends and family could be uncomfortable because they lacked understanding of the physical symptoms and so would make comments and ask questions (Simpson et al., 2013).

Such experiences extended to public situations; studies have found that participants with PD experienced other people staring at them or directly expressing irritation at PD symptoms. Furthermore, people with PD movement difficulties can be viewed as less socially desirable, and this may manifest as hurtful comments or avoidance (Simpson et al., 2013).

In addition, movement difficulties may be misinterpreted by people who are not aware that they are due to PD (eg, mistaken for being drunk). Furthermore, research has demonstrated that judgments about the unacceptability of movement difficulties may be influenced by the age of the person experiencing PD. One study suggested that PD may be viewed as socially unacceptable because it involves a presentation, such as slowness of movement, that is suggestive of older age. Indeed, aging alone can be a source of stigma, with discrimination occurring toward people when they are seen as less competent (Simpson et al., 2013).

Additionally, people may try to conceal an illness due to fear of stigma. Indeed, some research participants have described trying to hide symptoms of PD by not talking or by trying to control body movement. “Passing” in this manner can have negative psychological consequences; hiding the effects of impairment to pass as normal takes physical and emotional effort, and the person is always at risk of exposure if disability status is suddenly revealed (Simpson et al., 2013).

Alan: Living with Parkinson’s

I was taking 39 pills a day for the various Parkinson’s conditions at the time of my surgeries. I am now down to four.

What I was not prepared for was the withdrawal from all that medication! A friend gave me an article comparing the withdrawal from Sinemet—the main drug used for Parkinson’s—to that from cocaine. I felt confused and foggy headed.

I mentioned these conditions to my neurologist at my six-month surgical followup.

As for the confusion and fogginess, he said, “After all, you had brain surgery. You just have to give it time!”

Don’t get me wrong, for all of these inconveniences I have experienced, the benefits of DBS surgery far outweigh the negatives. My wife says I laugh more and have more expression in my face. The tremors and dyskinesia are gone or very minor. And I am eating more protein, which makes me happy.