PHYSICAL THERAPY INTERVENTION FOR
PARKINSON’S DISEASE (LAB)
Parkinson’s Disease Stages, Common
Impairments and Activity Limitations, and
Intervention Strategies
STAGE
Early/Mild
PD
COMMON
IMPAIRMENT
and ACTIVITY
LIMITATIONS
 Few/minimal
impairments
and activity
limitation with
independence
maintained
 Movement
symptoms
present but do
not interfere
with daily
activities
 Movement
symptoms,
often tremor,
occur on one
side of the
body
 Changes
noted in
posture,
walking ability,
or facial
expression
 Parkinson’s
medications
effectively
suppress
movement
symptoms

Middle/
Moderate
PD

INTERVENTION
STRATEGIES

Preventative and
Restorative
 Regular exercise
to improve/
maintain motor
performance,
strength,
mobility,
flexibility, range
of motion
(ROM), balance,
locomotion,
endurance, and
perceived quality
of life (QOL)
 Community
classes to
improve/maintain
socialization,
camaraderie,
positive outlook
and life purpose.
Compensatory
 Patient/family/ca
regiver
education about
disease process,
rehabilitation,
energy
conservation
 Determine need
for adaptive and
assistive devices
 Determine need
for
environmental
modification of
home/workplace

Provide
psychological
support with
early referral to
support groups
for patient and
family/caregiver
 Referral to other
health care
professionals as
needed.








Late/
Advance
PD

Increasing
number and
severity of
impairments
Minimal to
moderate
activity
limitations,
participation
restrictions
Movement
symptoms
occur on both
sides of the
body
The body
moves more
slowly against
increasing
stiffness
ADL with
modified
dependence
(assistance)
Difficulty with
balance,
postural
instability;
stooped
posture;
increasing
number of falls
Gait
impairments
evident;
freezing
episodes may
occur
Locomotion
with modified
dependence
(assistance)
Parkinson’s
medication
may “wear off”
between
doses
Parkinson’s
medications
may cause
side effects,
including
dyskinesias
Numerous
impairments
with increasing
severity
Severe activity
limitation with
dependence in
most activities
Preventative and
Restorative
 Regular
exercises to
maintain/
improve motor
performance,
strength,
mobility,
flexibility, ROM,
balance,
locomotion,
endurance ad
perceived QOL
 Community
classes to
improve/maintain
socialization,
camaraderie,
positive outlook
and life purpose
Compensatory
 Assistive devices
to maintain
function
 Wheelchair for
community
mobility
 Environmental
modifications at
homes
 Patient/family/ca
regiver
education and
training
 Psychological
support for
patient and
family/caregiver
 Referral to other
healthcare
professionals as
needed;
occupational
therapy may
provide
strategies for
maintaining
independence.
Preventative
 Maximize upright
posture, out-ofbed time
 Maximize
participation in
activities of daily

Great difficulty
walking;
typically in
wheelchair or
bed most of
the day
 Assistance
needed with
all ADL
 Severe
participation
restrictions;
o Not able to
live alone
o Typically
requires full
time
assistance
or
placement in
chronic care
facility
 Social
interactions
restricted
 Cognitive
problems may
be prominent,
including
dementia,
hallucinations,
and delusions
 Increasing
medication
intolerance
with
dyskinesias
 Balancing the
benefits of
medications
with their side
effects
become more
challenging

living
Prevention of
contractures,
pressure
wounds,
pneumonia, and
so forth
Compensatory
 Family/caregiver
education and
training: safety
education,
transfers,
positioning,
turning, skin care
 Pressure
relieving devices
 Hospital bed,
wheelchair,
mechanical lift
 Psychological
support for
patient and
family/caregiver
 Referral to other
healthcare
professional as
needed
MOTOR LEARNING STRATEGIES
Elements of Practice
 Large number of repetitions.
 Focus full attention on the desired
movement.
 Modify the environment/reduce clutter.
 Breakdown tasks.
 Minimize competing cognitive demands
(dual tasking).
 Blocked practice order
 Structured instructional sets*

Repetitive drill-like practice + caregiver
training
Instructions:
 “Swing your arms”
 “Walk fast”
 “Take large steps”
 Cueing is very important because patients
with PD have problems with their BG
 We may provide auditory cues, verbal cues,
and visual cues in order to improve their
movement
External Cues
 Visual cues - markers on floor/ stickers in
order for them to know where they should
step
 Rhythmic auditory stimulation (RAS) metronome – beeping sound every second
 Auditory cues - Verbal cues i.e. “Walk fast”
 Multisensory cues- mixture of the cues, can
be visual and auditory at the same time to
maximize the use of external cues.
EXERCISE TRAINING
"Training Big Program"/Lee Silverman Voice
Treatment (LSVT) Big Program
 Repetitive high-amplitude movements
 Repeat with large movements
 High intensity (8/10 Borg's RPE Scale) for 1
hour 4 times a week for 4 weeks with large
amplitude, multiple repetitions, and whole
body movements that increase in
complexity.
 Ask the pt. to spread her arms at the UE and
lunge for the LE
 Example: Gait training- even though we only
use minimal arm swing we can ask the pt. with
PD to EXAGGERATE the movements
 Happening here is that your stocking up all the
movement before they lose it (“Use it or Lose
it” principle)
 Make sure the movement is big and done in
multiple times
RELAXATION EXERCISES
Relaxation Exercises
 Can be done for preparation of exercises. For
example: pt. is stiff
1. Gentle rocking
 Swing forward/backward
2. Rocking chair
 induces relaxation effect
 management for stiffness
3. Hook-lying
 Supine with the hips and knees
flexed
4. Lower trunk rotation
 Since they become rigid on the axial
parts of the body
5. Side Lying rolling
6. Rhythmic initiation
 PROM → AAROM→ ARROM →
AROM
7. DBE during exercise
 Inhale through the nose, exhale
through the mouth
8. DBE + Bilateral Symmetrical PNF D2F
(inhale) + D2E (exhale)
9. Cognitive imaging and meditation
techniques
10. Stress management
11. Lifestyle modification and time management

4 repetitions per stretch held for 15 to 60
seconds
 Imagine patients with PD, the areas where
they have RESTRICTIONS
Areas of
Limitation
Cervical
retraction
Cervical
rotation
Suggested Stretching Exercises



Shoulder
flexion with
trunk
extension


Elbow
extension

Trunk
extension



Trunk
rotation



FLEXIBILITY EXERCISES
Flexibility exercises
 Stretching exercises
 PROM, AROM, Facilitated PNF Exercises
 2 to 3 days per week and ideally 5 to 7
days per week
Hip
extension




Sitting, back against wall (or
supine), head retractions (chin
tuck position)
Sit (or supine), with head
retracted, head turns side-toside
Sitting, hands clasped together,
overhead arm lifts with thoracic
extension
Supine, pillow under thoracic
spine, hands clasp together,
overhead arm lifts with thoracic
extension
Sitting (or standing, modified
plantigrade) weight-bearing with
both upper extremities (UEs),
elbow extended
Sitting, thoracic extension over
the back of a chair with elbows
bent and shoulders retracted
Prone lying, prone push-ups
(press-ups)
Standing trunk extension, hands
positioned on hips
Supine, upper trunk rotation,
hands clasped together (or
holding a small ball), arms
move with trunk rotation side-toside
Hook lying, lower trunk
extension, knees move with
trunk rotation side-to-side
Sitting or standing, both arms
out to one side (clasped
together or holding a small ball),
arms move with trunk rotation
side-to-side
Supine with one low extremity
(LE) over edge of mat (hip
extended, knee flexed), other
knee held to chest
Supine, hip and knees extended
Hook-lying bridging
Standing, active hip extension
or forward lunge
High-kneeling with hips
extended

Supine, one LE extended and
abducted, other LE in hooklying
Knee
 Standing, forward lean with wall
extension
push-ups
 Standing, both forefeet on edge
of step or block, heels off step,
lower heels down with light
Ankle
touch-down support of both
dorsiflexion
hands
 Standing, forward lean with wall
push-ups
 15-60 secs hold x 4 reps x 1 set
 15 secs hold x 5 reps x 1 set
 30 secs hold x 3 reps x 1 set
Hip
abduction
Adho Mukha Svasana
(Downward-Facing Dog)
1. Start in the
tabletop position
2. As you exhale lift
your knees and
torso from the
ground forming
an inverted “V”
3. Push your
shoulder blades
against your
back and heels
to the ground
Anjaneyasana
(Low Lunge)
1. Step your right
foot forward and
maintain your left
knee on the
ground
2. As you inhale
raise your arms
to the sky and
stretch your torso
forward
Virabhadrasana II
(Warrior II Pose)
1. Rise up from low
lunge
maintaining the
right knee bent
and the left knee
straight
2. Right foot should
be straight ahead
and the left foot
should be turned
out 90 degrees
3. Ensure that
outside border of
the left foot stays
on the ground
4. With the right
arm straight
forward and the
left arm straight
back sink into the
pose looking
over the fingers
of your right
hand.
YOGA SEQUENCE FOR
EARLY/ MILD PARKINSON’S DISEASE
Marjaryasana
(Cat Pose)
1. Start on your
hands and
knees. Tabletop
position.
2. As you exhale
round your spine
toward the
ceiling. Hold for 5
seconds
Bitilasana (Cow Pose)
1. As you inhale lift
your sitting
bones and chest
toward the
ceiling. Hold for 5
seconds
Bhujanga (Cobra Pose)
1. Lie on your
stomach with
your hands under
your shoulders
2. As you inhale
press the
shoulders and
torso off the mat
and look up. Hold
for 5 seconds.
YOGA SEQUENCE FOR
LATE PARKINSON’S DISEASE
Marjaryasana
(Chair Cat Pose)
Bitilasana
(Chair Cow Pose)
Parighasana
(Chair Gate Pose)
1. Start perch
sitting (body at
front of chair),
sitting tall and
hands on the
side of your head
2. As you exhale
round your spine
toward the back
of the chair, bring
your shoulders
and head
forward while
bringing your
elbows wide.
Hold for 5
seconds
1. As you inhale
arch your back
and look up to
the sky. Open
your chest and
spread your
elbows wide.
Hold for 5
seconds.
1. Start sitting tall
with your right
hand on the chair
and left arm
raised to the sky
palm facing in
2. Inhale deeply
3. As you exhale
side bend your
torso to the right
and look up to
your left hand.
Hold for 5
seconds
4. Repeat on the
opposite side
Ardha Matsyendrasana
(Chair Spinal Twist)
1. Start sitting tall
with your hands
on the side of
your head
2. Inhale deeply
3. As you exhale
rotate to one
side. Hold for 5
seconds
4. Repeat on the
opposite side
Eka Pada Rajakapotasana
(Cahir Pigeon Pose)
1. Start sitting tall
with your legs
crossed, right
ankle on top of
left knee
2. As you exhale
lean forward
from the hips
keeping your
spine long. Hold
for 5 seconds
3. Repeat on the
opposite side
Anjaneyasana
(Modified Low Lunge)
Variation A (Advanced)
Variation B
(Beginner)
Variation A:
1. Stand holding
onto a stable
surface for
stability
2. Left foot
supported on
chair behind you
3. With a tall upright
spine exhale,
and bend the
right knee while
moving the pelvis
forward. Hold for
5 seconds
4. Repeat on the
opposite side.
Variation B.
1. Stand holding
onto a stable
surface for
stability. Left foot
forward and right
foot back
2. With a tall upright
spine exhale
while bending
the left knee and
maintaining the
right leg straight.
Hold for 5
seconds
3. Repeat on the
opposite side
Utthita Parsvakonasana
(Modified Extended Side
Angle Pose)
1. Hold on to a
stable surface
with your right
hand, left foot
forward and right
foot back
2. While
maintaining a
long spine bend
the left knee
moving the pelvis
forward and
keeping the right
knee straight
3. As you exhale
raise the left arm
to the sky and
turn your hand to
the left looking
up to your left
hand. Hold for 5
seconds
4. Repeat on the
opposite side.
 Example:
o After you do the cat pose, then the cow
pose, then cobra pose
o Or ask the pt. to do the cat pose for 10
reps then move to cow pose 10 reps
again
 5 secs hold x 10 reps x 1 set per pose
 It’s better if you can do it with them or if you’ve
observed that the pt. is unable to balance you
can assist the pt.
 You can ask the pt, to hold the position for 5
seconds then incorporate DBE
 The reps and sequence would depend on you,
it can be done continuously or 10 reps per
poses
PNF
PNF

UE
○
●
Bilateral symmetrical D2 flexion
patterns
 This position would
counteract all the stoop
position of the pt. all in one
pattern
LE
○ D1 extension pattern
 If the pt. is immobilized for a long
time it would be possible that the pt.
has edematous on the LE and that
would put the pt. at risk for injuries
and tissue damage.
● Contract-Relax Technique
○ 6-second contraction followed by a
10- to 30-second assisted stretch
 Avoid ballistic stretching (big
movements but not ballistic)
because it would increase fall and
increased risk for injury.
 Moderate intensity must be applied.
“Think BIG, and move through the whole range”
POSITIONING
Positioning
● Prone lying position
● Side lying with a small pillow under the
lateral trunk
o Positional stretching: 20 to 30
minutes
● Tilt table
o make sure that strap is secure, hip
and knees extended, ankles neutral
o You can also apply toe wedge in
order to stretch the ankle
plantarflexors further
RESISTANCE TRAINING
Resistance training
 PD patients exhibits primary muscles
weakness, impaired motor recruitment, rate of
force development, disused muscle weakness
with prolonged inactivity that’s why they
become weak.
●
●
Antigravity extensor muscles.
Progressive overload principle:
o Load: resistance machines, free
weights (can be bandaged to
secure), elastic resistance brands,
manual resistance.
o Older adults: RPE of somewhat
hard, 5-6 on a 10-point scale
o Progression as tolerated
o 10-12 reps per set
o 10 seconds hold per repetition
o 2 days per week
o Patients with more advanced
disease: Exercise machine > Free
weights
 Exercise machine is
predictable and more safe for
the pt. to use
o Isometric training is generally
contraindicated.
 A pt. with PD has stiffness
and if we applied isometric
training/exercises, it would
induce stiffness causing it to
harden more.
o Exercise training should be timed for
"on" periods (45 minutes to 1 hour
after medication has been take)
o
o

FUNCTIONAL TRAINING
Functional Training
● Exercise program should be based on
focused practice of functional skills.
 Skills that are to be used by the pt.
in real life
● Emphasis on improving mobility of axial
structures.
 Head, spine, and proximal joints of
the body because most of the time
there is stiffness in these areas
causing them to have difficulty
moving.
 Bed mobility skills
o Segmental Rolling
 Can be done: first move the
upper trunk and upper ext then
the lower ex or lower ext first
then the upper ext and trunk

Bridging
 Very important especially if pt. is
bedridden, it can be used when
you’re putting a container
underneath for the pt. to release
fluids (because usually they
don’t get to go to the CR
anymore)
Supine-to-sit transitions
 Pt. can start in supine then ask
to roll on one side then use one
hand to lift her body up the bed,
in LE the pt. can drop one foot
from the bed to make it easier for
the pt. to sit
Sitting (10repsx3sets)
o Ant & Post pelvic tilts
o Side-to-side tilts
o Pelvic clock exercises
 While the pt. is sitting, ask the pt.
to imagine that he/she is facing a
clock then ask the pt. like
“Position your pelvis on 12:00,
6:00, or 9:00” for the mobility of
the pt. in sitting.
o Weight-shifting + upper trunk
rotations + reaching
 Weight-shifting can be used to
relieve pressure especially if pt is
on a wheelchair (2 minutes per
side maintain.)
 If weight shifting with reaching
and other actions reps can be
used.
Sit-to-stand
o Scooting to the edge
 Teach the pt. on how to scoot
forward
o Forward trunk flexion
 To be used in preparation for
standing
o Cueing
o Standing up from raised seat
o

Standing
o Fully upright position with
symmetrical weight-bearing over the
BOS
 Straight body and equal
weight on both L/R
 If you notice that there is a
problem with the posture,
you can advice the pt. to
incorporate movement
o Tactile cueing or light resistance on
anterior pelvis
o Weight-shifts and rotational
movements of the trunk
 Weight shifting R/L
 Reciprocal arm swings
 To simulate walking
 Exaggerate the
movement in order for
them to remember
 Reaching movements
 Use of cones to simulate
trunk rotation
o Step-ups (10 reps x 3 sets)
 Forward
 Forward/backward and
backward forward
 Lateral
 Left/right and right/left
 Left up, right up, left
down, right down
o Backward stepping
 May engage the pt. to extend
the trunk and hips, it may
counteract backward
stepping with stoop posture
of the pt.
o Stepping + elastic resistive bands
 Can tie a thera band on the
LE for added resistance
while doing the stepping
exercise




Standing with UEs extended and
hands WB on wall
 To introduce trunk extension
and prevent stoop posturing
How to Get Up after a Fall
o Quadruped creeping
 Teach the pt. on how to do
sidelying, then ask to do the
quadruped
 Quadruped would be the
initial position for the pt to
creep
 Ask the pt. to creep towards
a stable surface to hold on
assist in standing
o Quadruped > Half-kneeling >
Standing using UE support
Mobilizing facial muscles
o Massage
 To reduce stiffness or rigidity
of the face
o Stretch
 When the face is blunt, you
can introduce this by holding
the position for a few
seconds
o Manual contacts
 Tap it to initiate the
movement
o Verbal cueing
Practice:
o Lip pursing
o Movements of the tongue
o Swallowing
o Facial movements; smiling,
frowning, etc.
Mirror
 Will serve as a visual cue for the pt.
or to observe if the action is wrong.
BALANCE TRAINING
Balance Training
● Task and context-specific variety of
activities that alter task demands and
expose the patient to varying environmental
conditions.
● Focus on:
○ Center of Mass (COM)
 Higher=more stable
 Lower= less stable
○ Limits of Stability (LOS)
 To make sure that the
patients balance is ok
 Challenge through reaching
exercises since it can help in
widening the LOS
● Improve postural alignment
● Verbal, tactile, and proprioceptive cues

Kneeling (10 reps x 3 sets)
○ From short kneeling to toe kneeling


Half-kneeling
Standing on a disc
“Sit tall”
“Stand tall”
Seated Activities
 Weight shifts (7secs hold x 10 reps x 1set)
 Alternating unilateral weight-bearing
 Reaching (dynamic balance)
 Axial rotation of the head and trunk
 Axial rotation combined with reaching
Dynamic stability tasks
 Sitting on a compliant surface (inflatable
disc)
 Sitting on a therapy ball
Challenges to Balance can be introduced in:
 Quadruped (10 reps x 3 sets or with hold)
○ Dynamic balance is preferable than
static because they become too stiff
○ Therapy ball for support, ask the pt.
to do alternating movement of the
UE and LE
Progression
 Altering arm positions (10 reps x 3 sets)
o Arms out to side

Arms sideward
o Arms folded across chest

No external support
o Reaching



Cones
Altering foot/leg positions
o Feet apart (more stable)
o Feet together
Adding voluntary movements
o Overhead clapping
o Head and trunk rotations (while
sitting or standing)
o Single leg raises (supine or
standing)
o Stepping or marching in place
Other considerations:
 Faster initiation and execution of
movements supported by appropriate
cueing strategies
 Externally induced perturbations are
contraindicated (could induce stiffness)
Strategies for varying environmental demands
 Altering support surface
o Standing on foam
 Visual inputs
o Reduced lighting
o Eyes closed
 Challenging the patient with a variable
open environment:
o Busy clinic setting
Kitchen sink exercise (10 reps x 3 sets)
 Heel-rises
 Toe-offs
 Partial squats
 Chair rises
 Single limb stance with side-kicks or backkicks
 Marching in place
Locomotor training
 Transverse visual-spatial cues more
beneficial than parallel visual cues
 Floor markers or footprints on the floor
 Marching in place progressing to walking
using an exaggerated high stepping
pattern
 Brisk marching music
 Sidestepping
 Crossed-step walking
LOCOMOTOR TRAINING
Locomotor Training
● Focus on reducing primary gait impairments
and increasing the patient’s ability to safely
perform functional mobility activities and
prevent falls.
○ Reduce gait impairments such as
slowed speed, decreased stride
length, lack of heel-toe sequence
with forward progression
characterized by shuffling gait,
diminished contralateral trunk
movement and arm swing, and
stoop posture
“Walk tall”
“Walk fast”
“Take large steps”
“Swing both arms”

Pt. can do it with 2 vertical poles while
walking


Braiding
 Forward stepping, side stepping
alternating
Juggling scarves while stepping and
balancing


Gait training using two dowels
Locomotor training on motorized treadmill
with an overhead harness
Walking Task
 Walking on a tile floor
 Walking on carpet
 Walking on sidewalk
 Walking on grassy terrain
Walking in the community
 Variable open environment
 Stair climbing
 Up and down curbs
 Ramp walking