Exercise and physiotherapy in Parkinson's disease: what the guidance recommends

Parkinson's disease slows and shrinks movement, affects posture and balance and can cause freezing, where the feet feel stuck. Medicines help the motor symptoms, yet rehabilitation teaches strategies, strengthens muscles and maintains fitness. Parkinson's UK states that physical activity has both physical and mental benefits and can be as important as getting the right dose of medication.

A physiotherapist who specialises in the condition can spot small changes in the way a person moves, sometimes before the person is aware of them, and give advice before problems become harder to manage. They normally work with a Parkinson's nurse and an occupational therapist in a multidisciplinary team.

NICE guideline NG71 sets out a layered approach, with early information then targeted therapy when problems appear.

• Consider early referral to a Parkinson's physiotherapist for assessment, education and advice, including information about physical activity.

• Offer Parkinson's-specific physiotherapy to anyone with balance or motor function problems.

• Consider the Alexander technique for balance or motor function problems.

• Consider early referral to a Parkinson's occupational therapist, and offer specific occupational therapy for difficulties with activities of daily living.

• Consider early referral to a speech and language therapist, and offer therapy for communication, swallowing or saliva problems.

• Consider dietitian advice, and advise people not to reduce total daily protein or to take over-the-counter supplements without checking with a pharmacist or clinician.

Parkinson's UK lists several areas. Independence work covers walking, turning in bed and getting in and out of chairs, along with advice on aids and home adjustments, with occupational therapists consulted before equipment is bought because needs differ. Falls prevention uses strength and balance training, especially for turning, and teaches ways of overcoming freezing and of getting down to the floor and up again safely.

Pain is addressed too. Stiffness can produce aching in the neck and back, while dystonia can cause severe pain from involuntary muscle contractions. Physiotherapists assess the cause and use manual therapy, stretching and heat or cold, remembering that not all pain is due to Parkinson's. Breathing work matters because stiff, weaker chest muscles can lead to shallow breathing and chest infections, and posture and breathing exercises help clear phlegm.

Parkinson's UK says the right activity differs between people, but is most effective when you push yourself, whether that means an hour of tennis, a long walk with the dog or practising everyday movements such as climbing stairs. Its guidance spans low-intensity options such as chair-based workouts to high-intensity sessions, and it lists partners offering classes, including non-contact boxing, walking football, cycling, Nordic walking, tennis, table tennis, yoga, netball and gym access.

NICE guidance on neurological rehabilitation adds that an exercise programme should take account of executive function, fatigue and pain, consider risks, agree a clinically relevant dose of frequency, duration and intensity, and be overseen by a registered practitioner such as a physiotherapist or occupational therapist. Behaviour-change strategies, including motivational interviewing, are suggested to help people keep going.

Freezing can last seconds or minutes and raises the risk of falling. Physiotherapists teach cueing strategies, such as rhythmic counting, stepping over lines or changing the movement plan, and they practise turning in wider arcs. Adjusting environments is part of the work: removing rugs, improving lighting and arranging furniture so that routes avoid tight turns. Occupational therapists often join the physiotherapist to identify tripping hazards at home.

Strength training for the legs and trunk, and balance training under supervision, are core parts of falls prevention. NICE suggests that vitamin D supplements be advised for people with Parkinson's, referring to its falls and osteoporosis guidance.

Speech and language therapists work on voice volume and clarity using approaches such as attention-to-effort therapy, and on swallowing safety with strategies including expiratory muscle strength training. Alternative communication equipment can be considered as the condition progresses. Occupational therapists look at tasks such as dressing, cooking, handwriting and work, suggesting adaptations and energy-saving methods that fit the person's pattern of medication on and off periods.

NICE says people with Parkinson's disease should have regular access to clinical monitoring, a continuing point of contact and a reliable source of information, which may be a Parkinson's disease nurse specialist. Referral to physiotherapy and occupational therapy is usually made through the nurse specialist, neurologist, geriatrician or GP, and some areas allow self-referral. Parkinson's UK recommends seeing a Parkinson's physiotherapist as early as possible after diagnosis and whenever balance or movement problems arise.