Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association

Key points

• Physical therapists should implement moderate- to high-intensity aerobic exercise, resistance training and balance training in people with Parkinson disease (strong recommendations, high-quality evidence).
• External cueing, gait training, task-specific training and community-based exercise are also strongly recommended, and services should be delivered within an integrated care approach.
• Behavior-change approaches carry a moderate recommendation to improve physical activity and quality of life.
• Flexibility exercises (to improve range of motion) and telerehabilitation (to improve balance) are weak recommendations.
• Most studies included early to mid-stage disease (Hoehn & Yahr stages 1 to 3), so recommendations may not generalize to stages 4 to 5.

Overview

This American Physical Therapy Association guideline gives 11 recommendations for physical therapist management of adults with idiopathic, typical Parkinson disease, based on a systematic review of randomized controlled trials published between January 1, 1994, and June 16, 2020. It was developed by a group of physical therapists and a neurologist using APTA and American Academy of Orthopaedic Surgeons methodology, and the body of evidence comprised 242 articles.

Aerobic exercise

Moderate- to high-intensity aerobic exercise is recommended to improve oxygen consumption, reduce motor disease severity and improve functional outcomes. Many studies showed benefit with at least 3 days per week of 30 to 40 minutes; most defined moderate intensity as 60% to 75% and high intensity as 75% to 85% of maximum heart rate. Because some patients have a blunted heart rate response, perceived exertion should also be used to monitor intensity, and cycling may be safer than treadmill walking for those at high fall risk or with freezing of gait. The guideline group recommends prescribing aerobic exercise very early in the disease.

Resistance and balance training

Resistance training is recommended to reduce motor disease severity and improve strength, power, nonmotor symptoms, function and quality of life; many studies used 1 to 2 days per week for 30 to 60 minutes, with 80% of the repetition maximum for strength and 40% for power. Balance training is recommended to improve postural control, balance, gait, mobility, balance confidence and quality of life; benefits were seen with 2 to 3 sessions per week for 16 to 30 total hours over 5 to 10 weeks, and it should be considered early in the disease.

Cueing, gait and task-specific training

External cueing is recommended to reduce motor disease severity and freezing of gait and to improve gait outcomes. Gait training is recommended to reduce motor disease severity and improve stride length, gait speed, mobility and balance, and task-specific training to improve task-specific impairments and function. Physical therapists should also recommend community-based exercise.

Frequently asked questions

How strong is the evidence behind these recommendations?

Nine of the 11 recommendations rest on high-quality evidence; flexibility exercises are based on low-quality evidence and telerehabilitation on moderate-quality evidence, both with weak strength.

Do the benefits of exercise last after stopping?

For aerobic and resistance exercise, gains appear to dissipate if exercise is discontinued, suggesting regular, long-term engagement is needed to sustain the benefit.

Source

Osborne JA, Botkin R, Colon-Semenza C, DeAngelis TR, Gallardo OG, Kosakowski H, et al. Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association. Physical Therapy 2022;102(4):pzab302. https://doi.org/10.1093/ptj/pzab302. Open access under a CC BY-NC licence; a correction was published in Physical Therapy 2022;102(8):pzac098. This summary was prepared by Medpresso from the original publication and is not a substitute for the full text or medical advice.