INTRODUCTION — Parkinson disease (PD) is a chronic disorder that requires broad-based management including patient and family education, support group services, general wellness maintenance, exercise, and nutrition. Treatment of PD can be divided into nonpharmacologic, pharmacologic, and surgical therapy. A useful algorithm for the management of PD has been published by the American Academy of Neurology (AAN) [1].
This topic will review the nonpharmacologic management of PD. The pharmacologic treatment of PD and the treatment of comorbid problems associated with it are discussed separately. (See "Initial pharmacologic treatment of Parkinson disease" and "Management of nonmotor symptoms in Parkinson disease".)
EDUCATION — The prospect of having a chronic and progressive neurologic disease is frightening. Many individuals are familiar with PD and may even have had first-hand acquaintance with its disabling effects in an affected family member or friend. Education is essential in order to provide the patient and family with some understanding and control over the disorder. Education can combat the stigma and misinformation that often surround the disorder [2-4].
However, caution should be exercised in newly diagnosed patients with mild symptoms and an uncertain future with regard to progression; early overexposure to potentially disturbing material may be counterproductive. Focused education surrounding particular symptoms may be more effective and is available through books and other materials (see 'Information for patients' below) written for the lay audience, through national and regional PD organizations (table 1), which publish educational pamphlets and organize symposia for patients and families, and through the internet.
SUPPORT — The emotional and psychologic needs of the patient with PD and family should be addressed. Normal reactions of anger, depression, anxiety, and social and economic concerns often begin with the onset of the disease and evolve as it progresses. Support for the care partner is particularly important as he or she learns to cope with the increasing needs of the spouse or parent, or more rarely, a son or daughter [5]. Support groups are especially valuable for allowing interactions with other patients or families with similar experiences and for providing access to useful educational information [6].
For patients with early PD, referral to another affected patient or family may be less overwhelming than a large support group composed of patients with advanced disease. Patients and care partners can enroll in the online Parkinson's Buddy Network to connect with other individuals affected by PD. Early-onset PD groups also have been formed in some locales, and an early-onset PD handbook is available [7]. There are also some national support organizations, several of which have local chapters (table 1).
Referral of the patient and/or family to a psychologist or psychiatric social worker experienced in dealing with chronic illness may be appropriate in some cases. For many patients, disclosing the diagnosis is a source of concern, particularly among younger patients, employed patients, and those with younger children [8]. Social workers, psychologists, and other trained therapists can offer support and resources to aid in these challenging discussions. There are books available to help children of different ages understand the diagnosis of PD in a loved one, written by individuals with PD and by care partners [9-11]. In other instances, referral for legal, financial, or occupational counseling is indicated.
Social isolation — Patients with PD and their care partners are at risk for social isolation, particularly during later stages of disease or periods of home confinement. In a study conducted prior to the coronavirus disease 2019 (COVID-19) pandemic, researchers found that individuals with PD who reported having many friends had 21 percent fewer PD symptoms than those with few or no friends, and individuals identifying as lonely had a 55 percent higher PD symptom severity score than those denying loneliness [12]. Pandemic-imposed isolation has been associated with decreased quality of life, increased risk for mood disorders, decreased mobility, and worsening of motor function and symptom burden [13-17].
Social prescribing refers to connecting patients and care partners to sources of support within their own community, whether geographic, online, or related to a particular disease or even health system. Many social prescribing initiatives have been launched through the United Kingdom's National Health Service, the United States Department of Veterans Affairs, and individual health care institutions [18-21], including one PD-specific program launched during the COVID-19 pandemic [22]. Social prescribing may include lifestyle modifications such as diet and exercise, with connection to specific community resources, or may consist of referrals to support groups, self-management classes, volunteer opportunities, and community activities.
EXERCISE AND PHYSICAL THERAPY — Regular exercise promotes a feeling of physical and mental wellbeing; it is especially valuable due to the chronic nature of PD and its associated progressive motor limitations. In patients with PD, exercise may help to slow motor progression, improve nonmotor symptoms, and alleviate some secondary orthopedic effects of rigidity and flexed posture such as shoulder, hip, and back pain [23-28].
The available evidence suggests that regular aerobic exercise has a small positive impact on PD [25,29-34]. As an example, a randomized trial in patients with mild PD within five years of diagnosis assigned participants to high-intensity exercise, moderate-intensity exercise, or a waitlist control. High- and moderate-intensity participants engaged in four days per week of treadmill exercise for six months, achieving 80 to 85 or 60 to 65 percent of their maximum heart rate, respectively, compared with waitlist controls. The intervention met its feasibility goals, and after six months, there was a small but statistically significant difference in the change in Unified Parkinson's Disease Rating Scale motor score in the high-intensity group compared with controls [35].
Multiple studies also support tai chi as a beneficial form of exercise in patients with PD [36-39]. A randomized controlled trial of 195 subjects with mild to moderate PD found that a six-month program of twice-weekly tai chi training was superior to resistance training and stretching for improvement in measurements of postural stability, stride length, and functional reach [36]. There were fewer self-reported falls at six months for the tai chi group compared with the resistance training and stretching groups (62 versus 133 versus 186), and the difference was statistically significant for the comparison with the stretching group. In a meta-analysis that included 21 studies of individuals with PD, 15 of which were randomized trials (n = 735), tai chi/qigong was associated with small to medium improvements in most studied motor outcomes including the Unified Parkinson's Disease Rating Scale III, balance, Timed Up and Go testing, six-minute walk, and falls [37]. A subsequent randomized controlled trial compared the effects of an eight-week mindfulness yoga program to a stretching and resistance training program in individuals with mild to moderate PD [40]. Both yoga and stretching/resistance training demonstrated similar improvements in mobility and motor dysfunction, and yoga yielded additional benefits in anxiety, depression, and health-related quality of life.
Thus, exercises to improve balance, flexibility, and strength should be emphasized. Brisk walks, tai chi, swimming, and water aerobic exercises may be particularly useful, although available studies comparing the effectiveness of different interventions are not definitive [41,42]. Other modalities that may improve functional outcome for patients with PD include the following [24]:
●Multidisciplinary rehabilitation with standard physical and occupational therapy components [43,44]
●Use of compensation strategies to facilitate gait (eg, external auditory, proprioceptive, or visual cuing) [45,46]
●Treadmill training [35,47-49]
●Balance training and high-intensity resistance training [50,51]
●High-intensity agility training [52]
●Cued exercises with visual (mirror), auditory (metronome), and tactile feedback [53]
●Active music therapy [54]
●Dance therapy [55,56]
●Lee Silverman Voice Treatment physical therapy program (LSVT-BIG) [57]
Many patients engaged in physical therapy gain lasting confidence and a sense of control over one aspect of the disease, especially if they have never engaged in physical activity in the past. Parkinson-specific exercise programs may also provide social support and camaraderie, separate from and complementary to the support options above [58,59]. Referral to a physical therapist or exercise group is a good way to get patients started in such activities.
SPEECH THERAPY — Dysarthria and hypophonia are common manifestations of PD, and small randomized trials support speech therapy as an intervention to improve speech volume [24,60-64].
Several techniques have been shown to be more effective than no treatment in small, nonblinded randomized trials in patients with PD. One technique employs speech therapy emphasizing prosodic features of pitch and volume reinforced with visual feedback [60], while another aims to maximize phonatory effort and loudness (the Lee Silverman Voice Treatment [LSVT-LOUD]) [61,63]. Patients should be directed to therapists trained in PD-specific methods for optimal benefit.
In practice, many individuals find improvements in their speech volume and prosody immediately after completing therapy; however, nonadherence to vocal exercises at home may lead to attrition of the initial benefits. As with physical and occupational therapy, patients should be encouraged to continue their speech therapy exercises at home to maintain their level of function and may benefit from periodic re-evaluations and refresher courses of these targeted and effective therapies.
OCCUPATIONAL THERAPY — As PD progresses, impairments in dexterity commonly affect a patient's ability to complete activities of daily living. Occupational therapists can work with patients to adapt certain activities, introduce assistive devices, and change the environment to foster safety and continued engagement in the activities a person enjoys. Most occupational therapy trials have been small; however, one randomized trial of 191 patients found a benefit in self-perceived performance of daily activities after three months [65].
MINDFULNESS AND MEDITATION — Various approaches aimed at cultivating or enhancing mindfulness, often incorporating meditation and/or yoga, have been studied in patients with PD [40,66-68]. This is an area of great interest among patients and care partners and of continued study among researchers, given the relative lack of side effects and potential benefits in self-efficacy, function, and social relationships. Mindfulness-based group therapy, delivered virtually, is both feasible and acceptable to patients with PD, and efficacy testing is underway [40,69].
NUTRITION — Older adults with chronic illness are at risk for poor nutrition, weight loss, bone loss, and decreased muscle mass. Patients with PD are specifically at increased risk of malnutrition and weight loss due to increased metabolic demands, anosmia and hypogeusia, dysphagia, and constipation [70]. These changes are associated with significant alterations in the gut microbiome in patients with PD [71].
Oropharyngeal dysphagia is prevalent in patients with PD, particularly at advanced stages. Swallowing problems impact nutrition and increase the risk of aspiration. Strategies to identify and treat dysphagia in patients with PD are reviewed separately. (See "Swallowing disorders and aspiration in palliative care: Definition, pathophysiology, etiology, and consequences" and "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management".)
Healthy dietary habits over a longer period of time may help to prevent or slow progression of PD. One large cross-sectional study detected a difference in age of PD onset of up to 17 years among the highest adherers to the MIND diet (Mediterranean-DASH Intervention for Neurodegenerative Delay) [72]. Earlier studies have also reported delayed progression of parkinsonism and a reduced incidence of cognitive impairment and Alzheimer disease associated with the MIND diet [73-75].
An analysis of the Nurses' Health Study and the Health Professionals Follow-Up Study among nearly 48,000 participants found that adherers to a healthy dietary pattern, including a Mediterranean-type diet, had a lower likelihood of reporting prodromal PD symptoms over time, such as depression, excessive daytime sleepiness, and constipation [76]. In this cohort and others, high adherers also had improved longevity after a diagnosis of PD [77].
While there are no consensus guidelines on a specific PD diet, certain recommendations can be made [78].
●A high-fiber diet, adequate hydration, and regular exercise help manage the constipation of PD.
●Large, high-fat meals that slow gastric emptying and interfere with medication absorption should be avoided.
●The MIND diet may delay the onset and reduce the incidence and progression of parkinsonism.
●Dietary protein restriction is not necessary except in some patients with advanced disease and motor fluctuations in whom competition with other amino acids interferes with L-dopa absorption. (See "Medical management of motor fluctuations and dyskinesia in Parkinson disease", section on 'Unpredictable "off" periods' and "Medical management of motor fluctuations and dyskinesia in Parkinson disease", section on 'Failure of "on" response'.)
There is no evidence at this time that large doses of vitamin E or other antioxidants are useful in PD [24].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Parkinson disease".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Parkinson disease (The Basics)")
●Beyond the Basics topics (see "Patient education: Parkinson disease treatment options — education, support, and therapy (Beyond the Basics)")
PATIENT PERSPECTIVE TOPIC — Patient perspectives are provided for selected disorders to help clinicians better understand the patient experience and patient concerns. These narratives may offer insights into patient values and preferences not included in other UpToDate topics. (See "Patient perspective: Parkinson disease".)
SUMMARY
●Education – Education is essential in order to provide the patient with Parkinson disease (PD) and family with some understanding and control over the disorder. In addition, the emotional and psychologic needs of the patient and family should be addressed. Support groups are a valuable resource (table 1). (See 'Education' above and 'Support' above.)
●Social prescribing – Social isolation is associated with greater motor and nonmotor severity and poorer quality of life in PD. Referring individuals to community resources to promote social engagement and lifestyle modifications may be beneficial. (See 'Support' above.)
●Exercise – Regular exercise and various physical therapy modalities appear to offer some benefit for improving function in patients with PD. (See 'Exercise and physical therapy' above.)
●Speech therapy – Dysarthria and hypophonia are common manifestations of PD. Speech therapy may be helpful in improving speech volume and maintaining voice quality. (See 'Speech therapy' above.)
●Nutrition – No specific diet influences the course of PD, but a high-fiber diet, adequate hydration, and regular exercise can help to reduce constipation associated with PD. Emerging evidence suggests the MIND diet may be associated with a lower risk of cognitive impairment. Large, high-fat meals that slow gastric emptying and interfere with medication absorption should be avoided. (See 'Nutrition' above.)
