According to KNGF Guidelines for physical therapy in people with Parkinson’s, the goals of physiotherapy will vary according to the phase of Parkinson’s being experienced.

Early stage:

The key aim in the early stage of the condition is to prevent inactivity and to improve physical ability in terms of aerobic capacity, muscle strength and joint mobility. Your physiotherapist may provide an exercise programme that you can follow on your own or in a group, with suggestions and advice on maintaining your fitness levels.

Mid stage:

In this stage physiotherapy will aim to improve upper limb function, in particular reaching and grasping, as well as improving posture, balance, gait and transfers. Your physiotherapist may suggest a range of exercises to help with these activities, including hand exercises to help with manual dexterity so you can more easily button a shirt, for example. He or she may also collaborate with an occupational therapist to ensure that your home is safe and to reduce the risk of you falling.

Cueing strategies may also be suggested to improve gait and overcome freezing – for more information on cueing see Freezing and Gait. In addition, cognitive movement strategies may be taught which allow you to break down complex movements into a sequence of individual movement that you can focus on following step by step, for example when transferring from a bed or a chair and you need to move to the edge, bend knees, place hands by your side to push up, lift your bottom etc.

Late stage:

In this stage, physiotherapy aims to prevent complications that may arise as a result of using a wheelchair or being bedridden. This includes maintaining your breathing, preventing pressure sores and working with carers to ensure that they position you correctly and avoid injuring themselves when lifting.

Physiotherapy and Carers

Physiotherapists can also advise your carer and family how to help you stay as independent as possible. In addition, they can advise carers and family on ways to look after their own health, for example their back, if they help you with getting out of bed, chair or car.

It is thought that people with Parkinson’s are around a third less active than the general population of the same age. Not exercising can harm your health and you are more likely to develop other conditions such as heart disease, type 2 diabetes and osteoporosis. You should therefore try to make exercise part of your regular routine, choosing types of exercise to suit your individual abilities and needs. It is a good idea to ask your physiotherapist or doctor for advice before starting any new exercise regime.

The following tips should help you to exercise effectively and safely:

• Try to exercise for at least 150 minutes each week. During each session you should aim to get warm, sweat lightly and be out of breath to the point that it is hard to keep up a conversation. How you make up the total time is up to you; you could try 5 sessions of 30 minutes but if that is too long at once, then repetitions of say two 15-minute periods or 3 bursts of 10 minutes each is also fine. It is better to exercise two or three times a week for shorter periods than just a long session at weekends.
• Reduce the amount of time you sit each day, for example by walking rather than driving short distances, getting off the bus one stop early or making a walk part of your daily routine. Where possible, take the stairs rather than a lift or escalator.
• Make sure you include different styles of exercise that will extend your endurance, build and maintain muscle strength, and maintain joint flexibility and your ability to stretch.
• Improve your functional mobility, for example try making large movements when you are sitting, lying down, standing or walking. These will help with daily activities such as walking and balance.
• Enjoy. Develop an exercise programme that includes exercise you enjoy and which suits your daily routine and physical capabilities. You are far more likely to maintain your regime if you enjoy what you are doing and feel able to cope!
• Use the buddy system. An exercise ‘buddy’ or group sessions can add a welcome social dimension and motivation. Consider joining organised or group classes at your local gym or other public venues, particularly if they are Parkinson’s specific or provide recognised benefits for people with Parkinson’s such as dance or Tai Chi.
• Choose your time. Exercise when medication is working well and you are feeling rested as movement will then be easier for you.
• Know when to stop. It is normal to feel tired and sweat when exercising but stop if anything hurts or feels uncomfortable. You should talk to your doctor if you experience any of the following when exercising: pain, nausea, light-headedness, dizziness, a tight chest for more than a few minutes, or if you feel your heart missing or adding beats. Listen to your body and learn to recognise when to stop.
• Consult your doctor. If you have recently had a heart attack, have any other heart problems or have been told that you are a risk of heart disease then you should consult with your doctor before you embark on an exercise programme. You should also talk with your doctor before exercising if you have been inactive for a long time.

For more information on the benefits of exercise and how tips for exercising safely see Exercise. Remember too that the range of Apps and technology-based exercise is ever-increasing, so be open to trying new ways to extend and enjoy exercise.

A physiotherapist can provide advice and suggest strategies to help you at any stage of your Parkinson’s. If appropriate, a physiotherapist can provide treatment to prevent, stabilise or reduce any problems you experience relating to your general mobility and the way you function in your daily activities.

It is recommended that you talk with a physiotherapist as soon as possible after your diagnosis so that they can support you to self-manage your Parkinson’s.

You should also talk with a physiotherapist if:

• you find regular exercise difficult or you are uncertain about what type of exercise to do
• you have queries on the frequency, intensity and safety aspects of exercising
• you experience walking problems, for example slowness, shuffling, hesitation or ‘freezing’ (when your feet feel glued to the floor)
• you experience balance problems resulting in falls, nearly falling or fear of falling
• you find it difficult to get out of a chair, bed or car, or if turning in bed is difficult
• you experience pain, for example in your neck, back or shoulders.

You should always let your neurologist know if you are seeing a physiotherapist.

Your physiotherapist will assess your mobility, and specifically if you have difficulties with walking, transfers, balance and falls, your manual dexterity and your physical capacity, and why these problems occur. He or she may assess your ability to perform activities of daily living. This may take one or two appointments and your physiotherapist may want to assess you at home if problems mainly occur there.

Your physiotherapist, with your input, will set goals according to your specific needs and jointly you will agree a treatment plan. Generally this will be a combination of advice and education, plus an exercise programme and strategies to better manage your daily activities. When and how often you see your physiotherapist will depend on your individual goals and treatment plan.

Before your appointment

• Write a list of any problems you experience and questions you want to ask, leaving space to write notes when you talk with your physiotherapist. The Pre-assessment Information Form (PIF) within the European Physiotherapy Guideline for Parkinson’s Disease will help you to prepare.

During your appointment

• Be honest. Your physiotherapist can only act on the information you provide, so let them know how you really feel.
• If you don’t fully understand something, ask the physiotherapist to explain again.
• Consider taking a friend or carer with you who can help take notes or prompt you on questions to raise if you find it difficult. Make sure they understand what you want to say so that they can help to explain things if necessary.
• Be prepared to explain your key problems and how they affect your daily life. It’s useful to think in advance how to describe difficulties as it’s easy to get tongue-tied when under pressure during an appointment.
• Be clear what you hope to gain from your appointment and treatment plan.
• Let your physiotherapist know if you have had any treatment before or tried different methods to overcome these problems, and explain how effective these were.
• If your physiotherapist is unable to help with a particular problem, he or she will be able to suggest other healthcare professionals who may be able to help.

You and your physiotherapist are partners in managing your Parkinson’s. Here are some aspects of your care you might both want to focus on:

• Jointly agree on your goals of treatment, in particular what you should achieve and when.
• Agree on a treatment plan that is tailored to your daily routine and abilities.
• Agree how to liaise on an ongoing basis, including follow-up appointments which enable you to ask for feedback, for example if you want to check that you have been doing exercises properly. Always get in touch between scheduled follow-up appointments though if you have any queries.
• Discuss any problems you have with adhering to your agreed programme so that it can be adjusted to enable you to continue properly.
• Plan in advance how you will maintain an exercise regime independently once your treatment has finished.
• Agree on what information your physiotherapist will share with your doctor.

For more information and advice see Appointments with your healthcare team.

As Parkinson’s is complex to manage, it is important to be seen by a physiotherapist who has experience of the condition. If you cannot find a physiotherapist with Parkinson’s experience, you may want to share with the physiotherapist the European Physiotherapy Guideline for Parkinson’s Disease and Pre-Assessment Information Form (PIF).

Referral procedures depend on the country in which you live; in some countries physiotherapy is prescribed by a doctor but in others you can contact a physiotherapist direct. Depending on where you live, treatment may or may not be accessible through your country’s national health system. In some countries you need to be referred by your neurologist in order to get the cost of physiotherapy reimbursed.

Training and accreditation varies throughout Europe so you should always check the experience of anyone you consult and the likely costs before treatment starts.

Your national Parkinson’s organisation may be able to provide information based on members’ experiences. See also, Other Parkinson’s organisations.

Lee Silverman Voice Treatment Big (LSVT BIG) is an intensive treatment involving 16 individual sessions over a month (4 hourly sessions per week). The main focus is movement amplitude (making movements ‘big’). This amplitude-oriented treatment seems to be effective in improving motor function in Parkinson’s¹.

For more information and to find a trained clinician see www.lsvtglobal.com/clinicians.

Reference:

1. McDonnell, M.N., et al., Lee Silverman Voice Treatment (LSVT)-BIG to improve motor function in people with Parkinson's disease: a systematic review and meta-analysis. Clin Rehabil, 2017: p. 269215517734385.

• VIDEO – CNS Academy: Physical Exercises in Parkinson's Disease
  

Articles from Parkinson's Life online magazine

• Alexander Reed, founder of the European Parkinson Therapy Centre, tells us why the treatment system in Italy needs to radically change
• Could physical therapy be the future of specialised Parkinson’s care in Brazil?
• Move to the beat: meet the Parkinson’s physio behind award-winning mobility app
• Your gym or mine: accessing specialised community Parkinson’s exercise programmes
• VIDEO: Watch Parkinson’s patient walk again after hearing favourite song
• Which physiotherapy treatment is right for you?