Q&A: Physiotherapy and Parkinson's

Fiona Lindop is a physiotherapist who specialises in Parkinson's. On 18 May 2010 she joined our discussion forum for a Question and Answers (Q&A) session to answer questions on all aspects of physiotherapy. People also sent in questions through the website.

Transcript of the event

Fiona:  Hello, I'm Fiona Lindop. For over 10 years I've been working as a physiotherapist with people with Parkinson's, and am currently working as part of an NHS team in the Midlands that were awarded "Centre of Excellence" status by the American National Parkinson's Foundation.

I have many years experience helping people with Parkinson's overcome some of the problems they encounter as well as teaching physiotherapists and other professionals how to offer the best standard of care to people with Parkinson's. I'm looking forward to taking your questions and I hope I can pass along some useful information over the next week. I'll be checking the questions throughout the week and posting my answers from midday 18 May. And I'll do my best to get through as many as I can.

Questions and answers

JoyceBH: My PD nurse says she will refer me to a neuro physiotherapist. What's that and how is it different to the regular physio I had when I injured my shoulder?

Fiona: A “neuro physio” is a physiotherapist who specialises in disorders of the nervous system (neurology) such as Parkinson’s disease.

Anon via website: Can physio help with headaches?

Fiona: Headaches can have a number of different causes and physiotherapy can be helpful for those which are associated with problems in the neck and shoulders. Stress, rigidity (stiffness) and poor posture can cause tension in these areas which can lead to headaches. A physiotherapist can provide assessment, advice and exercises to help in such cases.

Anon via website: At the latter stages if the person lives alone how will you involve others to be part of the treatment programme?

Fiona: Physiotherapy for Parkinson’s disease is best provided as part of a multi-disciplinary team (including Parkinson’s nurses) who are able to provide appropriate support, equipment, therapy management and referral to other agencies (eg social services for home carers) when the need arises. Community physiotherapy and occupational therapy can be also be arranged when necessary.

Carole via website: How can I help my Mum (76) at home? I`m disabled myself and my elderly Dad has to do most things. I want to help too. So what can I do for my Mum as far as exercise? We can do it together!

Fiona: If your mum is struggling with some aspects of her PD and has not already had an assessment by a physiotherapist, then she could ask her GP, PD nurse or consultant to refer her so that an appropriate therapy/exercise programme can be planned. Ask your mum what she perceives as her biggest problem and look at whether you could agree on an achievable goal. You can encourage your mum to exercise and as you suggest, do it with her. There are lots of exercises that can be done sitting down and exercise has many benefits. The physiotherapist might suggest a specific exercise programme and may also teach cues to help with mobility. You could be involved in helping your mum carry out the exercises and in her use of the appropriate cues eg.reminding her to take “Big Steps” if she is shuffling or freezing, or reminding her about her posture.

Anon via the website: Dear Fiona, I am not currently doing any exercising at present. What do you recommend for walking as I occasionally trip over and have painful neck and shoulders all across the top of my back? Any information on exercises recommended to help me with Parkinson's would be much appreciated.

Fiona: Exercise is really important for people with PD and there is growing evidence that it can bring many benefits. Exercise doesn’t necessarily mean having to go to the gym - you can do exercises at home, and can even do them sitting down. Fitting some form of exercise into your daily routine is most beneficial. The Parkinson’s UK publication Keeping Moving provides an exercise programme that you could follow or a physiotherapist could help you work out your own home exercises.

Occasional trips can be caused by a number of things eg shorter stride length, freezing, poor balance, poor posture etc. Some falls can be caused by dual-tasking ie walking and talking at the same time, or walking and carrying something. It is important to identify the reason for your instability and address that as well as finding an appropriate exercise programme that you can carry out safely. Rigidity (stiffness) and poor posture can contribute to neck, shoulder and upper back pain in PD and a personalised exercise programme could help with this. I would advise you to see a physiotherapist (your GP or consultant can refer you) as they can carry out a full assessment and treatment/exercise and falls prevention programme.

Titan: I have been seeing a physiotherapist at my local hospital, and received a series of exercises to be used as treatment for a frozen/painful left shoulder. The pain in my shoulder is apparent when reaching upwards, to the side, or backwards.Is not to bad when stationery or within normal range. The exercises made it worse, indeed it also triggered my other shoulder off again having had trouble with that 2 years ago. So I have had to stop. They know I have Parkinson's and are at a loss as what to do, but have suggested acupuncture if i get the okay of my neurologist (which i have done). My neurologist says acupuncture can give pain relief but won't cure the shoulder problems. I know shoulder problems can be common in Parkinson's - is it just something i have to accept as part of the condition or is there something I can do without aggravating the shoulder problems? I am about to embark on medication after my recent visit and discussion with my neurologist - maybe this may help my shoulder along with all the usual problems, I don't know. I am 46 years of age diagnosed in November. Any advice would be much appreciated.

Fiona: As your diagnosis is quite recent, it is possible that your frozen shoulder is in fact a symptom of the Parkinson’s disease. Many people are diagnosed with a frozen shoulder before being diagnosed with PD because the rigidity (stiffness) and slowness of movement can make it both difficult and painful to move your shoulder. This may explain why you have had no improvement in these symptoms.

As you are about to start medication you may find that your symptoms improve because the rigidity and slowness of movement can reduce as a result of appropriate drug therapy. It is important to keep the shoulder moving so that the joint does not become stiff, but you should not push through the pain. Hydrotherapy is an option that you could consider – exercising in warm water can enable you to strengthen muscles and maintain joint movement without pain. You could ask the physiotherapists if there is a hydrotherapy pool in your area.

Patann: I was diagnosed with Parkinson's in February 2008. I have not responded to the drugs and a second opinion in March this year diagnosed MSA. I have been to an assessment and they will take me into rehab for 2 weeks. At the moment my left leg is very painful and stiff. My goal is to be more fit and mobile and be able to walk 9 holes of golf. Is this realistic?

Fiona: Multiple System Atrophy (MSA) is a progressive neurological condition with some features in common with Parkinson’s such as stiffness and slow movements. People with MSA can also find their coordination is affected and they can experience problems with automatic body functions eg blood pressure (low).

Falls, particularly backwards, can be a common symptom. Having 2 weeks intensive rehabilitation should give you a good opportunity to strengthen your legs and hopefully reduce your pain. It is important to maintain your mobility and muscle length and strength, and the physiotherapist will be able to devise an appropriate exercise programme for you.

It is important to bear in mind that if your blood pressure is low, and also drops when you stand up, it is better not to exercise first thing in the morning, but to wait until the later part of the morning or afternoon so that the exercises do not make this worse. Without knowing what your current level of mobility is, I am unable to comment on whether your goal of being able to walk around the 9-hole golf course is realistic. This is something you will be able to discuss with the team when you have your rehabilitation.

Anon via website: My mum has had Parkinson's for 20 years. I would assume that someone should be giving my parents advice on good positioning and maintaining good posture, and exercises for day time activities. Since a falls clinic pre 2004 mum appears to have had no input. Is this something we should expect or should physio be providing ongoing episodes of care?

Fiona:  I would certainly advise that your mother should have an assessment to highlight any problems she might be having so that these can be addressed. Advice is vital to prevent problems and it’s much easier to avoid a problem than to deal with it once it has become a major hurdle. Exercise is also a very important factor in maintaining mobility and avoiding falls. In most areas of the country you may be able to access a physiotherapist for a number of sessions before being discharged (hopefully having attained agreed goals) and would then need re-referral for future intervention as required. The recommendations from NICE and the National Service Framework for Long Term Conditions (of which PD is one) is that physiotherapy should be available for people with PD.

Anon via website: I work for myself and have been told I have PD. I started taking tablets and feel ok as I was before but I can't lose my drivers licence as I work for myself and don't want to tell the DVLA as this would just mess my life up. I need to drive and have no problems driving. This is doing my head in.

Fiona: I am glad your PD medication is being effective. It is a legal requirement to inform the DVLA about your diagnosis otherwise your insurance could be invalidated, but it does not mean that they will remove your license - they just need to be informed about your new diagnosis. If you are finding this stressful you could talk to an Occupational Therapist or your PD nurse specialist for advice. Parkinson’s UK has produced a very helpful booklet on driving which you might find useful.

Dilip via website: Is massage an option worth considering to help ease the pain factor and maybe improve circulation?

Fiona: Massage can help ease the pain caused by rigidity (stiffness) in the muscles, particularly in the upper back and shoulder region. It can also help someone to relax which can help reduce anxiety and fatigue.

Bob via website: I find myself bitting my tongue a lot lately. Is this an advanced sign or just something else to deal with?

Fiona: As far as I am aware, biting your tongue is not a common feature of PD but some people find they have a “bulky” tongue which could lead to biting your tongue more often. Once you have bitten your tongue it will swell a little from the injury, which it turn makes it more likely that you could bite it again. I would advise that you ask for a referral to a speech therapist to assess the problem

Passeggiata via website: Could you please suggest exercises that will help with the daily bouts I get of dystonia in my abdominal muscles. When I get them my abdominal wall muscles contract tightly and painfully (as though I was preparing myself for someone throwing a punch), and I can hardly move, and even talking or sitting in a chair are difficult. The dystonia usually occurs when my PD medication is wearing off, or can be started by just bending over to pick up something, or, for example, bending over the sink to clean my teeth. I would like to know whether there are exercises I can do on a regular basis to avert the dystonia, and whether there is an exercise or posture I could use to reduce the severity of a bout when it does occur.

Fiona: Dystonia can be relieved by stretching the affected part for 2 minutes. You could lie down and stretch both arms above your head with both legs straight, pointing your toes away from you (but if you have pain in the lower back you will need a pillow under your knees). Hold this position for 2 minutes then relax. You can repeat this exercise a couple more times if the dystonia is still present. If it is not possible to lie down (perhaps if you are out), then stand with your back against a wall and stretch both arms above your head and hold this position. If the dystonia is too severe to allow this position, then only stretch as far you are able.

When you need to pick something up off the floor, try to bend your knees, keeping your back straight rather than bending at the hips, as this might prevent the dystonia occurring. Sitting on a stool to brush your teeth rather than standing might also help. You could discuss your medication with the PD nurse or consultant if your PD medication is wearing off frequently as this could alleviate the problem

Moderator: Members of the forum have been discussing cramping in the feet lately. Is there anything that physiotherapy can do to alleviate this?

Fiona: Foot cramps are likely to be dystonia which, like cramp, is painful and can put the ankle/foot and toes into unusual positions. It is important to consider why you may be experiencing dystonia at night – it may be related to your PD medication. Keep a diary of the frequency and timing of your symptoms and discuss this with your PD nurse or consultant so that any medication changes necessary can be made. This may resolve your problem in the long term. Something that can help short term is to apply prolonged stretches of the affected part for 2 minutes. Hold your foot, ankle or toes (whichever is most affected), in the neutral (how it would be if it were relaxed) position and then apply a stretch. Hold this position and the stretch for 2 minutes then relax. You can repeat this process if necessary.

Bridge: I'm thinking of learning the Alexander Technique. Do you think this will be helpful managing pain and improving my posture?

Fiona: There is evidence (NICE – National Institute for Health and Clinical Excellence) to suggest that the Alexander Technique can help people with Parkinson’s in terms of helping them to adjust their lifestyle and thinking as well as aiming for physical improvement. A physiotherapist could also teach you other exercises and techniques to both manage your pain and improve your posture.

SF: Please could you suggest what help can be offered by a physiotherapist to someone with early more subtle physical and internalised symptoms?

Fiona: A physiotherapist would be able to offer you a full assessment to identify both motor and non-motor symptoms (non-motor symptoms are often both subtle and internalised). The physiotherapist could offer advice on managing your symptoms and help in identifying what might be being caused by Parkinson’s and what might have other causes.

SF: Please could you tell me if there is there any long term help that can be offered for upper back and shoulder fatigue possibly caused by stooping?

Fiona: Exercise and advice are absolutely vital to improve and maintain posture and also to maintain neck and shoulder range of movement and strength. A physiotherapist could help devise an appropriate exercise programme. If you adhere to your exercise plan you should find your posture improves and your fatigue reduces.

Moderator: Thanks to Fiona Lindop for her very helpful answers and to forum members and to website visitors for their questions.

If you feel you would like to speak with a physiotherapist, ask your Parkinson’s nurse, GP or specialist. As always you can contact our confidential helpline on 0808 800 0303 for more information.

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About Fiona Lindop

Fiona has been working with people with Parkinson's for over 10 years. She designed a physiotherapy-specific assessment scale for Parkinson's - the Lindop Parkinson's Assessment Scale - which is being used by many physiotherapists around the country.

Fiona is part of a multidisciplinary NHS team in the Midlands that was awarded "Centre of Excellence" status by the American National Parkinson's Foundation.

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