Benefits of Physical Therapy: From

Early Stages to Late Stages of

Parkinson’s Disease

Alejandra Lopez SPTA, Michelle Ang SPT

 Patient case:
Fred Flint was admitted to LCMH…
Age: 51, Sex: Male
Primary problem: generalized weakness and abnormal
gait
History: Hypertension, Diabetes Mellitus, Asthma, Family
history of PD
Brain MRI: Significant cerebral and cerebellar atrophy,
Lewy body congestion, highly suggestive of PD
What can be considered during evaluation, treatment and
plan of care?
 What is Parkinson’s Disease?

Parkinson’s is a disorder of the central nervous system

that affects gait, movement, coordination and causes motor impairments
such as tremors. It’s when nerve cell damage happens in the substantia
nigra of the midbrain causing dopamine levels to drop.
Parkinson’s Disease: Potential Impairments
Motor:

- Bradykinesia, rigidity, gait disturbances, postural instability, lack of

motor coordination (gross and fine-motor movements)

Non-motor (Neuropsychological):

- Anxiety, depression, cognitive decline, sensory issues, autonomic

issues
 Who is at risk for Parkinson’s?

● People usually start having symptoms if they are over 50 years old.
● Parkinson affects more men than women.
● Although there is not enough information as to what causes Parkinson’s, scientists
believe it can be a combination of genetics and environmental factors.
 parkinson’s
-Symptoms and the disease progression are unique to each person. Most likely the diagnosis will be done
about a year or 2 later after the symptoms have started.

-It is difficult to accurately predict the progression of Parkinson’s disease. Some patients may experience
changes slowly within 20 or more years. While others may notice that the disease progressed faster, within less
time.

-At the time of diagnosis, patients may be placed on medication such as Levadopa to help treat the side effects.
Some patients respond well to the medication, others not so much. That being said, it is important for patients
to maintain ongoing communication with their physicians in order to change the dose of medication to best suit
the patient.
Stages:
Stage 1: Mild symptoms mostly won’t interfere with daily activities. Tremors or other movements will occur only on one
side of body. You will notice changes in the person’s posture, gait, and different than normal facial expressions.

Stage 2: Symptoms have worsened and affect both sides of the body or more towards midline. Gait and poor posture
are more apparent. Person is able to live alone but will have some difficulty completing daily tasks.

Stage 3: Symptoms are mild-moderate. Their loss of balance is greater, they fall more often. Motor symptoms worsen
continuously. They are still physically capable of leading an independent life though they might be functionally
restricted with ADL’s.

Stage 4: Person’s symptoms have fully developed, and severely disabled the person. They can still walk but will need
assistance and an assistive device. It is not recommended for patients to live alone at this time and will become
dependent of caregiver some ADL’s.

Stage 5: At this point the disability is most advanced and debilitating. The patient is completely dependent of caregiver
for ADLs and other activities. Due to extreme stiffness of the legs they're not able to walk, and will be either bedridden
or confined to a chair.
 Benefits of Therapy in Early Stages (peer review article)

Although not enough studies have been done, the recent studies have
shown that those with Parkinson’s Disease have improved their ability
to move, walk, balance, coordinate, complete ADL’s, and decrease
their risk of falling through therapy. “Overall, there are too few studies
on specific exercise programs to be able to say whether certain
exercises are more effective than others. The most suitable choice of
exercises will depend on the person’s personal preferences and their
individual physical and mental state. For example, more strenuous
exercises are possible in earlier stages of the disease.”
https://www.youtube.com/watch?v=jEY2hS9mLVg
Parkinson’s in the Acute Setting: Statistics

● There is a relative scarcity of literature ● Patients with PD had significantly increased risk of
pertaining to reasons for ER evaluations and urinary tract infections and aspiration pneumonia.
hospitalization in patients with PD.

● Patients with PD are hospitalized ● A trend toward increased risk for postoperative
approximately 1.5 times more frequently delirium, hypotension, and acute myocardial infarction.
than non-PD patients.

● While 16% to 45% of patients with PD visit ● Patients with PD had significantly longer acute hospital
an ER yearly, 7% to 28% of patients are being stays that were 2.3 days longer than non-PD patients.
hospitalized.

● Approximately 50% of admissions for PD ● Patients with PD are more commonly discharged to
involve patients in an advanced stage of the nursing home care after their hospital stay.
disease.
Interventions: Exercises to focus on
Strengthening exercises Aerobic exercises Balance
❏ Weight machines for UE/LE Weight shifting
❏ Running ❏
❏ Resisted walking UE/LE
❏ Swimming ❏ Large movements
❏ Using dumbbells/ankle
weights for UE/LE ❏ Cycling ❏ Multi-directional stepping
strengthening ❏ Walking ❏ Dynamic balance activities

Stretches should be included at the patients discretion given their pain tolerance, flexed posture, and osteoporosis.
Inventions (continued)
● Early intervention: consult rehabilitation services soon after admission
○ Mobility as soon as possible
● Diligence with medication management and adjust medication if needed
○ Early administration of Anti-Parkinson’s medication
● Initiate fall precautions, aspiration precautions
● Recommend early neurological consult
● Training:
○ Balance - side walking, unstable surfaces, narrow vs wide BOS
○ Amplitude - large, exaggerated, loud movements (retrains muscles to slow progression of
hypokinesia)
○ Reciprocal - use of auditory signals, metronome
○ Cognitive - attention/working memory, calculation skill, visual-spatial (reproducing images)
 Objective Measures

● Berg Balance (Short Form, 3 point)* ● 39-Parkinson’s Disease Questionnaire*

● Tinetti Falls Efficacy Scale* ● Parkinson’s Disease Questionnaire*

● Functional Independence Measure ● Profile PD*

● AMPAC
 Physical Therapy in Late Stage of PD (peer
review #2)

Given to the nature of the progressive disease, patients and

family are introduced to palliative care. Even though most of the
information found regarding physical therapy in this stage
focuses on providing comfort and is medication based. Some
physicians do agree and would like to continue to promote as
much independence as possible till the patients final day. The
main goal at this point is motor and non motor impediments.
Meaning us as therapists should work with patients on PROM to
assist with contractures, assisted bed mobility for repositioning,
prevention of bedsores, stretches for comfort, stiffness, and pain
control.
“The Placebo Effect”
Paul is a patient that had been living with parkinson disease for about 10 years,
getting out of the couch and walking was already a big problem for him. One day
at home his grandson was coming down the stairs and he saw he was going to fall
and without thinking it, Paul got up and ran towards his grandson. Him and his
wife were very surprised Paul had just been able to do that. This story was very
familiar to professor and chairman of neurobiology at the university of Pittsburgh
and scientific director of the university of Pittsburgh brain institute, Peter Strick.
He stated that what Paul had experienced was a paradoxical kinesia, something
he was studying. ”Paradoxical kinesia refers to the sudden ability of a person with
Parkinson's to move quickly and fluidly, the way they did before the disease eroded a brain
area involved in movement. The phenomenon is a variation of the placebo effect. But instead
of being induced by the belief that a sugar pill is really medicine, it tends to appear in
situations that involve stress or a strong emotion.

The report has a video of a guy put on a bike riding around the hospital parking lot
without a problem. After getting off his posture changes the tremors on hands
came back and his gait shuffling steps.
Consider

It treating and managing Parkinson’s Disease, it takes a village:

- Medication and systemic management:

- Physicians
- Pharmacologists

- Rehabilitation:

- Physical therapy
- Occupational therapy
- Speech therapy
 Citations
https://www.parkinson.org/understanding-parkinsons/what-is-parkinsons/stages

https://www.npr.org/sections/health-shots/2022/02/07/1076359099/a-brain-circuit-tied-to-emotion-may-lead-to-bett
er-treatments-for-parkinsons-dis

InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-.
Parkinson’s disease: Can exercise help? 2009 Mar 10 [Updated 2019 Jul 4]. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK293708/

Lokk, J., Delbari, A. Clinical aspects of palliative care in advanced Parkinson’s disease. BMC Palliat Care 11, 20 (2012).
https://doi.org/10.1186/1472-684X-11-20

Monticone M, Ambrosini E, Laurini A, Rocca B, Foti C. In-patient multidisciplinary rehabilitation for Parkinson's disease: A
randomized controlled trial. Mov Disord. 2015;30(8):1050-1058. doi:10.1002/mds.26256