Parkinson Disease — A Guide for Physical Therapists

Publication Date: December 28, 2021



Aerobic Exercise

Recommendation: Moderate- to high-intensity aerobic exercise improves oxygen consumption (VO2), reduces motor disease severity, and improves functional outcomes. (S)
Benefits: Start aerobic exercise on a treadmill or stationary bike early in disease for maximal benefit; perform 3×/wk for 30–40’.
Risks: Choose mode to ensure safety and gradually progress to reduce risk of musculoskeletal injury.
Exclusions: Screen to ensure no other conditions exist that preclude moderate–high intensity aerobic exercise.

Resistance Training

Recommendation: Strength, power, non-motor symptoms, motor disease severity, functional outcomes, and quality of life are all improved by resistance training. (S)
Benefits: Benefits observed when done alone or part of multi-modal program. May reduce fall rate. Optimal dosing has not been determined. Perform 1–2×/wk for 30–60’ at 80% repetition maximum (RM) for strength; 40% RM for endurance.
Risks: Muscle or joint pain.
Exclusions: Individuals with cognitive impairment or advanced.

Balance Training

Recommendation: Balance-training programs improve postural control, balance and gait outcomes, mobility, balance confidence, and quality of life. (S)
Benefits: Multi-system balance training 2–3×/wk may improve motor symptoms such as postural control and mobility as well as quality of life.
Risks: Falls.

External Cueing

Recommendation: External cueing reduces motor disease severity and freezing of gait and improves overall gait in individuals with Parkinson disease (PD). (S)
Benefits: Cueing included rhythmic auditory, visual, verbal, and attentional cues. No type of cue was superior. Cost of equipment should be considered.
Exclusions: None.

Flexibility Exercises

Recommendation: Flexibility exercises improve range of motion (ROM). (W)
Benefits: Addresses the impact of rigidity on ROM.

Community-Based Exercise

Recommendation: Community-based exercise reduces motor disease severity, and improves non-motor symptoms, functional outcomes, and quality of life in individuals with PD. (S)
Benefits: No one mode of community exercise program is superior to another. There may be improved adherence with community over individual exercise.
Exclusions: Most studies included individuals with mild to moderate PD with no cognitive impairment.

Integrated Care

Recommendation: For individuals with PD, integrating care with other health professionals can reduce motor disease severity and improve quality of life. (S)
Benefits: Receiving care from an integrated multi-disciplinary medical team (including physical therapists [PTs]) may improve motor and non-motor symptoms.
Exclusions: Studies limited to Hoehn and Yahr scale (H&Y) I–III without cognitive impairment.


Recommendation: Physical therapy services may be delivered via telerehabilitation to improve balance in individuals with PD. (W)
Benefits: Balance may improve with telerehabilitation. May remove patient barriers to therapy.
Risks: Some may need safety assistance from a caregiver for remote monitoring.
Exclusions: Studies limited to H&Y I–III without cognitive impairment who have access to technology.

Gait Training

Recommendation: To reduce motor disease severity and improve stride length, gait speed, mobility, gait training and balance should be included in any treatment plan for individuals with PD. (S)
Benefits: Appears to work best when provided 20–60 minutes, 3–5 days per week, for 4–12 weeks. Studies show a decline over time indicating gait training may need to be continued to prevent decline.
Exclusions: Studies did not include individuals in middle to late disease stages. A harness should be used for individuals at high risk of falls.

Task-Specific Training

Recommendation: Task-specific training improves task-specific impairment levels and functional outcomes. (S)
Benefits: Improves the task that was specifically trained and works in upper and lower extremity as well as bladder function.
Exclusions: Individuals in late middle and late stage and those with cognitive impairment were not included in any studies.

Behavior Change Approach

Recommendation: Behavior change approaches augment improvement in physical activity and quality of life. (M)
Benefits: Improved participation, activities, body structure, and function.
Exclusions: Additional training of physical therapists may be necessary to optimize behavior change approaches.

Recommendation Category — PD EDGE Suggested Measures to Assess Change

Recommendation Category PD EDGE Suggested Measures to Assess Change
Aerobic Exercise Movement Disorders Society Unified Parkinson’s Disease Rating Scale (Part III; Motor Exam) (MDS-UPDRS III), Six Minute Walk Test (6MWT)
Resistance Training Montreal Cognitive Assessment, 10 Meter Walk Test (10MWT), Mini Balance Evaluation Systems Test (Mini-BESTest)
Balance Training Mini-BESTest, Functional Gait Assessment (FGA), Freezing of Gait Questionnaire (FOG-Q), Parkinson’s Disease Questionnaire-39 (PDQ-39), Activities-Specific Balance Confidence Scale (ABC)
External Cueing 10MWT, Dual Task Timed Up and Go (TUG), Mini-BESTest, 6MWT, FOG-Q
Community-Based Exercise MDS-UPDRS III, Montreal Cognitive Assessment, PDQ-39 and-8
Gait Training MDS-UPDRS III, 6MWT, ABC, FGA, Mini-BESTest
Task Specific Training 6MWT, ABC, Mini-BESTest, Dual Task TUG, FGA, 10MWT, 9 Hole peg test, FOG-Q, MDS-UPDRS III
Behavior-Change Approach MDS-UPDRS III, 6MWT, PDQ-39
Integrated Care MDS-UPDRS III, PDQ-39
Telerehabilitation 6MWT, PDQ-39