Physiotherapy for Parkinson's disease · home visits across Hong Kong
Physiotherapy for Parkinson's disease,
keeping the patient mobile
Parkinson's disease slowly reduces a patient's walking, balance and ability to look after themselves. However, international research shows that continuing suitable exerciseat home can slow the worsening of movement symptoms when the medicine has worn off (the "off" medication state). Our registered physiotherapists visit the home and work on the body functions affected by Parkinson's disease through LSVT BIG, gait training, balance training for fall prevention, and coordination and flexibility training.
- Registered physiotherapists in Hong Kong
- Home visits across Hong Kong
- 1 hour $1,000 · 1.5 hours $1,300
- LSVT BIG, gait, balance and coordination training
Why falls and stiff movement happen
Common misunderstandingsabout Parkinson's disease
Parkinson's disease is the second most common neurodegenerative disease in the world. Besides tremor, muscle stiffness, slow movement and difficulty with balance, the size of the patient's movements also becomes smaller without the patient noticing. Medicine can control symptoms, but the brain's sense of what a normal movement size is grows weaker, so the steps get smaller and smaller when walking. Turning is no longer smooth either, and the patient needs many small steps to get round. Balance is also more than whether the patient can stand still. It is whether the body's reaction is half a beat late when turning, reaching for something, or being nudged lightly. Patients often fall because the size of movement has become smaller, the balance reaction has become slower, or they are doing two things at once, and not because of a lack of strength. Ordinary strengthening exercise alone may therefore not solve the problem. Exercise training for Parkinson's disease works alongside medicine, and deals with the problems of movement control that medicine cannot help.
- Only riding an exercise bikeStaying active is good, but ordinary walking does not train starting to walk and turning, the movements most likely to cause a fall.
- Only training the musclesEven when muscle strength increases, the patient may still get stuck when starting to walk or turning.
- Practising balance by standing still while holding onStanding steadily does not mean the patient will stay balanced when walking or turning.
- Only massage and stretchingKeeping the joints flexible matters, but it matters more that the patient can actively make large movements.
- Functional exerciseMore functional exercise aimed at daily movements is better at meeting the needs of real life.
- Coordination and controlMuscle strength is only the base. Knowing how to control force and movement size matters more.
- Dynamic balanceThe focus is training the feet to step out in time to steady the body when the centre of gravity moves towards the edge.
- Combining passive stretching with active trainingStretching, coordination training and weight training each have a role and need to work together.
Aerobic exercise and resistance training are also supported by research. In the Park-in-Shape trial, for example, patients rode an exercise bike at home with remote monitoring and intensity targets, and after six months their motor score in the "off" medication state improved by 4.2 points. Another study also showed that patients who did two years of progressive resistance training improved their motor scores by 7.3 points more than the control group (Corcos 2013). The point is not which type of exercise is chosen, but whether a professional helps to adjust the training intensity. In both studies the patients did not simply exercise on their own. There was a clear exercise prescription, monitoring and a schedule for progression. We therefore do not ask patients to give up aerobic and strength training. We combine them with Parkinson's-specific training aimed at movement size, rhythm, balance and fluency of movement.
Training methods aimed at the underlying problems
Main areas of interventionin physiotherapy for Parkinson's disease
Our six training items all target the movement control that is damaged in Parkinson's disease. This goes beyond ordinary exercise. It is about retraining the brain and body to produce movements of the right size.
Copying movements and adjusting their size
The physiotherapist first demonstrates the movement, the patient follows it, and posture and movement size are corrected on the spot.
Rhythmic cueing for gait at home
In the places where the patient actually starts walking and turns, we use a metronome or tape lines on the floor to train walking rhythm and step length. The effect fades slowly once practice stops, so these cues need to be built into daily life and followed up.
Dynamic balance and postural reaction training
In the fraction of a second before a fall, the body normally takes an automatic step to save itself. This automatic reaction is what is damaged in Parkinson's disease. It becomes slower and smaller, and often the patient hits the ground before there is time to react. Training therefore creates a loss of balance within a safe range: a gentle push, a sudden stop, an abrupt change of direction. This lets the body relearn the speed of stepping to rescue itself and recover the centre of gravity.
Trunk rotation and arm and leg coordination
When people with Parkinson's disease turn, the head, shoulders and pelvis often turn together, and the body cannot rotate in separate parts. One turn is then broken into many small steps, and turning is when falls are most likely. The arm swing while walking also becomes smaller, and the steps get smaller and smaller. We therefore retrain the separate turning of the trunk, and the alternating rhythm of the arms and legs.
Dual-task coordination training
Patients often fall because they are walking and doing something else at the same time, for example carrying a cup while walking, or answering a question while walking. We therefore add other tasks to the walking training. At first this is counting while walking, and later it builds up to chatting while walking, or even turning in the middle of the walk, so that the patient can practise staying steady when attention is divided in daily life.
Dealing with freezing of gait
At the doorway or toilet door, where the patient most often feels the feet are stuck to the floor, we teach the patient to stop and reset first (stop–reset), shift the body weight, and then restart with a cue. We also teach the family when to call out a cue and when not to rush in to support, so that the family knows what to do.
Why therapy at home
Home training settingsfor Parkinson's rehabilitation
The symptoms of Parkinson's disease often depend on the surroundings. For example, freezing of gait most often happens at doorways or in narrow places at home, and may not appear in a spacious clinic. Parkinson's disease also mainly calls for training in coordination and balance, including making large movements, turning, and walking while doing something else. The difficulty of this training has to be set very precisely: if it is too easy there is no progress, and if it is too hard the patient is more likely to fall. Whether the medicine is working (on) or wearing off (off) can also make the patient's performance very different within the same day, and a movement that was possible today may not be possible tomorrow. With one-to-one home training, the physiotherapist stays beside the patient to protect them and can safely set the difficulty at a level that is just within reach, then raise it step by step. Practising at home with familiar objects also makes the skills learned easier to apply when getting up, walking and turning in daily life. Four places in the home are where we carry out home physiotherapy.
Training map of the home HOME SETTINGS
Clinical evidence
The researchon physiotherapy for Parkinson's disease
Randomised controlled trial data EVIDENCE
The improvements in these studies are mostly small to moderate, and some are short term. This means physiotherapy works through training that is continuing, of sufficient amount and fitted to the individual, and one or two sessions are unlikely to make a difference. The UK National Institute for Health and Care Excellence (NICE) guideline (NG71) recommends referral for physiotherapy earlyin Parkinson's disease, and specific training for patients with balance or movement problems.
If you are not sure whether you or your family member is suited to training, contact us and tell us the situation. A physiotherapist will answer your questions.
WhatsApp for a free enquiry and quoteFrom the basics to the detail
Physiotherapy for Parkinson's disease: further reading
To learn about the causes of Parkinson's disease, the situation at different stages, and how each type of training is done, see the following articles.
Understanding Parkinson's disease 01
Symptoms and stagesThe five Hoehn & Yahr stages, and motor and non-motor symptomsFAQ · cost and results
Physiotherapy for Parkinson's disease: frequently asked questions
Is physiotherapy useful for Parkinson's disease? How large is the effect?
There is evidence for it. A Cochrane review combining 39 randomised controlled trials and 1,827 patients showed that physiotherapy improves walking speed, walking endurance and balance (for example, the Berg Balance Scale improved by an average of 3.71 points and the Timed Up & Go was about 0.63 seconds shorter). The UK NICE guideline (NG71) also recommends Parkinson's-specific physiotherapy for patients with balance or motor function problems. Note that the benefits are mostly small to moderate and partly short term, so continuing, sufficient training matters.
Is exercising at home different from exercising at a hospital?
Home exercise has evidence too. In the Park-in-Shape randomised controlled trial (Lancet Neurology 2019), patients with mild Parkinson's disease did aerobic exercise at home for six months, and their MDS-UPDRS motor score in the "off" medication state improved by 4.2 points more than the control group. A Cochrane review of treadmill training also showed better walking speed with no increase in adverse events, so it is safe. For patients with limited mobility who find it hard to travel to and from hospital, practising at home with their own belongings makes it easier to carry the results into daily life.
Which exercise is best for Parkinson's disease (tai chi, resistance or gait training)?
There is no single best option, and the choice depends on the goal. For balance and fall prevention, tai chi in a New England Journal of Medicine study improved the limits of stability by nearly 12 percentage points and reduced falls. For motor symptoms (UPDRS-III), two years of progressive resistance training improved scores by 7.3 points more than the control group (Corcos, 2013). For gait and freezing, rhythmic cueing training helps. A home-visit therapist chooses a suitable combination according to the patient's stage and needs.
Can physiotherapy help with freezing of gait while walking?
Yes. In the RESCUE trial (Nieuwboer, 2007), patients did three weeks of rhythmic cueing (auditory and visual cueing) training at home. Posture and gait scores improved by about 4.2%, freezing severity fell by about 5.5% in patients who had freezing, and walking speed, stride length and balance also improved. The effect fades after training stops, so the cueing strategies need to be built into daily life and followed up.
People with Parkinson's disease fall easily. How much do balance and coordination training help?
There is evidence, but it helps to understand how falls happen in Parkinson's disease. Usually it is not simply a matter of being unsteady on the feet. When turning, reaching or doing two things at once, the automatic postural correction that the body should make becomes slower and smaller. Patients also tend to turn "all in one piece" (without separate rotation of the head, shoulders and pelvis), so one turn is broken into several small steps, which is the moment when falls are most likely. Training therefore targets dynamic balance, rescue steps and trunk rotation coordination, and not just practising balance while standing still. On the figures: a Cochrane review of 39 randomised controlled trials showed that physiotherapy raised the Berg Balance Scale by an average of 3.71 points and shortened the Timed Up & Go (which includes getting up and turning) by about 0.63 seconds. For tai chi, a New England Journal of Medicine study showed that the limits of stability improved by nearly 12 percentage points and falls were reduced. The benefits are mostly small to moderate and need continuing training to maintain.
When should physiotherapy for Parkinson's disease start?
The earlier the better. The NICE guideline (NG71, recommendation 1.7.2) recommends considering referral to a physiotherapist with experience of Parkinson's disease early in the disease, for assessment, education and advice on keeping active. For people who already have balance or motor function problems (recommendation 1.7.3), Parkinson's-specific physiotherapy should be offered. Early intervention helps to maintain mobility and build an exercise habit.
What does home physiotherapy for Parkinson's disease cost? Is there a minimum spend?
Physiotherapy costs HK$1,000 for 1 hour and HK$1,300 for 1.5 hours. There is no minimum spend, and a single session can be booked as needed. Transport is included in the main areas of Hong Kong Island, Kowloon and the New Territories. Remote areas (such as the outlying islands, Ma On Shan and Sai Kung) may carry a transport surcharge of $100–200. See the pricing page for details.
To find out whether the service suits the patient, you are welcome to send us a message.
WhatsApp for a free enquiry and quote1 hour $1,000 · 1.5 hours $1,300 · no minimum spend · Prices for all services
Disclaimer: This article is general health information and is not professional medical advice. If you have any health concerns, please consult a qualified healthcare professional.
References
- Tomlinson, C. L., Patel, S., Meek, C., et al. (2013). Physiotherapy versus placebo or no intervention in Parkinson's disease. Cochrane Database of Systematic Reviews, (9), CD002817. Cochrane
- Mehrholz, J., Kugler, J., Storch, A., et al. (2015). Treadmill training for patients with Parkinson's disease. Cochrane Database of Systematic Reviews, (9), CD007830. PubMed
- van der Kolk, N. M., de Vries, N. M., Kessels, R. P. C., et al. (2019). Effectiveness of home-based and remotely supervised aerobic exercise in Parkinson's disease: a double-blind, randomised controlled trial. Lancet Neurology, 18(11), 998–1008. PubMed
- Corcos, D. M., Robichaud, J. A., David, F. J., et al. (2013). A two-year randomized controlled trial of progressive resistance exercise for Parkinson's disease. Movement Disorders, 28(9), 1230–1240. PubMed
- Li, F., Harmer, P., Fitzgerald, K., et al. (2012). Tai chi and postural stability in patients with Parkinson's disease. New England Journal of Medicine, 366(6), 511–519. PubMed
- Nieuwboer, A., Kwakkel, G., Rochester, L., et al. (2007). Cueing training in the home improves gait-related mobility in Parkinson's disease: the RESCUE trial. Journal of Neurology, Neurosurgery & Psychiatry, 78(2), 134–140. PubMed
- Strouwen, C., Molenaar, E. A. L. M., Münks, L., et al. (2017). Training dual tasks together or apart in Parkinson's disease: Results from the DUALITY trial. Movement Disorders, 32(8), 1201–1210. PubMed
- Ebersbach, G., Grust, U., Ebersbach, A., et al. (2015). Amplitude-oriented exercise in Parkinson's disease: a randomized study comparing LSVT-BIG and a short training protocol. Journal of Neural Transmission, 122(2), 253–256. PubMed
- Domingos, J., Keus, S. H. J., Dean, J., et al. (2018). The European Physiotherapy Guideline for Parkinson's Disease: Implications for Neurologists. Journal of Parkinson's Disease, 8(4), 499–502. DOI
- National Institute for Health and Care Excellence. (2017). Parkinson's disease in adults (NICE guideline NG71), rec. 1.7.2 & 1.7.3. NICE