When a family member is diagnosed with Parkinson's disease, the question many Hong Kong families ask most directly is: "Can physiotherapy really help?" This article answers it through three anonymised real cases. Following the Hoehn & Yahr (H&Y) stages, it shows how a physiotherapist designs training for each patient. In the early stage (Mr Chan) the focus is on improving gait and training large-amplitude movement. In the middle stage (Mrs Lee) it is on freezing of gait and preventing falls. In the late stage (Mr Wong) it turns to maintaining existing function and training carers. Every treatment method mentioned comes with supporting research literature. It must be said frankly, however, that the results of the cases are individual real experiences, vary from person to person, and are not a guarantee for every patient.
The medical evidence for physiotherapy in Parkinson's disease
Before looking at the real cases, it helps to consult the higher-level medical evidence. A Cochrane meta-analysis compared physiotherapy with no intervention and found that physiotherapy improved several measures of function: walking speed rose on average by +0.04 metres/second, walking distance increased by +13.4 metres, the Timed Up and Go test (TUG) was shorter by −0.63 seconds, the Berg Balance Scale went up by +3.71 points, and the Freezing of Gait Questionnaire (FOG-Q) fell by −1.41 points (Tomlinson, 2013). In addition, the long-term review by Mak and colleagues pointed out that exercise and physiotherapy aimed at gait, balance, resistance and cueing bring lasting motor and functional benefits and so should be kept up for the long term (Mak, 2017).
An important precondition: the three cases below are all real experiences with the real names removed. The treatment effect is affected by the individual constitution, how the illness develops and whether the patient keeps practising, and does not mean that every person with Parkinson's disease will get the same result.
How to read the "research data" below. These figures are the average trial results (research data) for the whole group of participants in the medical literature, used to show the scientific basis of each treatment method. They are not the results of our centre, and not a promise of effect for any individual patient.The Cochrane report also reminds us that the overall size of improvement from physiotherapy is small to moderate, and that treatment methods differ between studies. Physiotherapy is a useful supporting method, but it cannot cure Parkinson's disease (Tomlinson, 2013).
Research data at a glance: the effect of physiotherapy on Parkinson's disease
The sizes of effect recorded in the research literature for each treatment method are listed below (these are group or trial data, and not a guarantee of effect for an individual):
Case 1: early stage (H&Y 2). Mr Chan's gait and large-amplitude movement training
Patient background
Basic details
- Name: Mr Chan (pseudonym)
- Age: 68
- Diagnosis: Parkinson's disease (Hoehn & Yahr stage 2)
- Duration: diagnosed 3 years ago
- Medication: levodopa, three times a day
Main problems
- Small shuffling steps when walking (festinating gait)
- Difficulty starting to walk (start hesitation)
- Loses balance easily when turning
- Fell twice in the past 6 months
- Afraid to go out
Treatment frequency: home physiotherapy twice a week, 60 minutes each time, for 12 weeks.
Treatment focus and home practice arrangements
- 1External cueing trainingVisual cues (stickers on the floor) and auditory cues (a metronome) help the patient to take the first step more easily.
- 2Large-amplitude movement trainingFollowing the principles of LSVT BIG, the focus is on practising big steps and big swings of the arms.
- 3Dual-task trainingPractising walking while answering questions or doing a hand movement.
Improving the home environment
- Coloured horizontal lines stuck on the corridor floor as a visual cue
- Contrasting-colour tape on the thresholds
- Handrails fitted and non-slip mats laid in the bathroom
- Rugs and clutter removed to reduce the chance of tripping
Home exercise prescription
- Practise walking with big steps for 15 minutes every day
- Practise standing balance (single-leg standing, heel-to-toe standing)
- Upper-body rotation stretching exercises
- Practise the walking rhythm along with a metronome
The research behind visual and auditory cues and big-step training
The difficulty starting and the small shuffling steps that Mr Chan faces are a typical sign of the "failure of internal rhythm" in Parkinson's disease. Because the basal ganglia of the brain can hardly produce a steady beat for movement on their own, the therapist uses external cues (such as horizontal lines on the floor and a metronome) to "borrow" a rhythm from outside and bypass the failing internal timing system. The RESCUE home cueing trial (153 patients) showed that cueing training at home improved posture and gait (posture-gait score up +4.2%, p=0.005) and reduced the severity of freezing of gait. The study also found, however, that the benefit faded at the 6-week follow-up, which is exactly why cueing has to be built into continued everyday practice at home (Nieuwboer, 2007). "Big step" training is aimed at the tendency of people with Parkinson's disease to make movements smaller without realising it (hypokinesia). The Berlin BIG randomised controlled trial (n=60) confirmed that large-amplitude movement training (LSVT BIG) improved motor symptoms more than ordinary walking or unsupervised home exercise(UPDRS motor score −5.05, against +0.58 / +1.68 in the control groups, p<0.001), and performance on the TUG and the 10-metre walk test was also better (Ebersbach, 2010).
As for dual-task training, the traditional view is that people with Parkinson's disease "cannot do two things at once and must not be distracted when walking". The more recent DUALITY randomised controlled trial overturned this over-cautious idea: dual-task training guided by a therapist does not increase the risk of falling(p=0.84), and keeps improving walking speed under dual-task conditions (an increase of +7.75–13.44%, still kept at the 12-week follow-up), and the benefit also extends to tasks that were not trained (Strouwen, 2017). It can be seen that having Mr Chan "walk while doing a mental task" is a safe arrangement with evidence behind it.
Please note: the RESCUE, BIG and DUALITY figures above are all research data(the average results of the whole group of participants), used to explain the scientific basis of these treatment methods. Mr Chan's actual progress varies from person to person, and these figures are not a guarantee of effect.
Case 2: middle stage (H&Y 3). Mrs Lee's freezing of gait and fall-prevention training
Patient background
Basic details
- Name: Mrs Lee (pseudonym)
- Age: 75
- Diagnosis: Parkinson's disease (Hoehn & Yahr stage 3)
- Duration: diagnosed 7 years ago
- Medication: levodopa + a dopamine receptor agonist
Main problems
- A marked "on-off phenomenon" in the effect of the medication
- Cannot walk at all in the "off" period when the medication wears off
- Severe freezing of gait
- Fell 5 times in the past 3 months
- Hip pain
Timing of treatment: to fit Mrs Lee's medication times, home visits are specially arranged for 1 hour after she takes her medication (that is, the "on" period when the medication works best), so that she can practise in the best possible state.
Treatment plan
Why treatment is given in the "on" period, and the medical evidence for fall-prevention training
Mrs Lee's "on-off phenomenon" makes her mobility swing sharply within a single day. In the "off" period she can hardly move, but at the "on" peak about an hour after taking medication she is clearly more agile. Arranging training in this golden window gives the patient enough mobility to learn and practise movements, and the process is also safer. For freezing of gait, using external cues (including the rhythmic auditory stimulation of a metronome, the visual target given by a laser cane, and the attention-shifting technique of "stop, breathe, restart") is supported by the results of the RESCUE trial. That study confirmed that cueing training at home reduces the severity of freezing, but the benefit fades over time, so practice has to continue (Nieuwboer, 2007).
For reactive and anticipatory balance training, the HiBalance randomised controlled trial (n=100) pointed out that highly challenging balance training helps to improve balance (Mini-BESTest), walking speed and dual-task gait(Conradsson, 2015), which matches the weight-shift and reactive balance training that Mrs Lee received. In summary, strategies for freezing, fall-prevention training and the involvement of carers are all core elements of comprehensive care throughout Parkinson's disease (Bloem, 2015).
How is freezing of gait assessed in the clinic? Healthcare staff usually use the "New Freezing of Gait Questionnaire (NFOG-Q)" to record how often freezing happens and how severe it is, and the reliability of this questionnaire has been verified by research (Nieuwboer, 2009). Note, however, that this is only a questionnaire for assessing the situation, and is not evidence that treatment works. To learn whether "treatment can reduce freezing of gait", efficacy studies such as RESCUE need to be consulted. An assessment tool and a treatment effect are two different things.
Case 3: late stage (H&Y 4). Mr Wong's functional maintenance and carer training
Patient background
Basic details
- Name: Mr Wong (pseudonym)
- Age: 82
- Diagnosis: Parkinson's disease (Hoehn & Yahr stage 4)
- Duration: diagnosed 12 years ago
- Living situation: lives with a domestic helper
Main problems
- Uses a wheelchair to get around most of the time
- Needs to be lifted with great effort by other people to move from bed to chair
- Marked forward lean of the trunk
- Has difficulty swallowing and has had pneumonia
- Mild cognitive impairment
Treatment goal: the focus of treatment in late-stage Parkinson's disease is to maintain existing physical function, prevent complications and improve quality of life, and it does not require full recovery of physical function.
Treatment plan
Why late-stage treatment aims at "maintaining function", and the medical basis
When the illness reaches H&Y stage 4, the disease has already caused marked functional limits, and rehabilitation training alone can hardly "reverse" the course. But this by no means means that physiotherapy has no use. Non-drug treatment (including physiotherapy) remains at the core of comprehensive care throughout Parkinson's disease, covering preventing falls, strategies for freezing, and maintaining function and preventing complications in the late stage(Bloem, 2015). For Mr Wong, keeping joint range of movement and basic mobility, preventing complications such as pressure sores and pneumonia, and easing the carer's burden are in themselves treatment goals with evidence behind them. Moreover, the functional benefit of targeted exercise and physiotherapy should be kept up in the long term (Mak, 2017). Exercise in bed, transfer training, adjustment of wheelchair positioning, and teaching carers body mechanics are exactly how the goal of "maintaining function" is put into everyday life at home.
"Dad has been ill for so many years, and we know he cannot get better. But with a physiotherapist visiting regularly and teaching the helper how to look after him, Dad is much more comfortable and we feel more at ease. Best of all, Dad is very happy every time he sees the therapist, and his spirits are better."
A frank note: the family's account above reflects the real feelings of Mr Wong's family, and shows that Mr Wong is more comfortable and the carer more confident, but this is not a reversal of the illness. Physiotherapy cannot stop late-stage Parkinson's disease from progressing, and the aim at this stage is to maintain the current state and ease physical discomfort.
Principles shared by the three cases
Looking at the three cases together, two main lines of physiotherapy for Parkinson's disease emerge. First, the treatment plan must be adjusted by stage of illness: the early stage focuses on improving gait and large-amplitude movement, the middle stage on freezing of gait and fall prevention, and the late stage on maintaining function and supporting carers. Second, home practice and the involvement of carers run through the whole rehabilitation process. Because the benefit of external cueing fades with time (Nieuwboer, 2007), and the benefits of training such as progressive resistance take time to build up (a 2-year RCT showed an extra 7.3-point improvement in UPDRS-III in the medication-off state; Corcos, 2013), home practice and help from carers between treatment sessions become the key. As for which case an older adult at home resembles most, families often find it hard to judge accurately alone, and it is generally advised to have a first assessment through a physiotherapist visiting the home, to clarify the actual needs.