CRITICAL REVIEW
Is Physical Exercise Beneficial for Persons
with Parkinsons Disease?
Alexander Michael Crizzle, MPH* and Ian J. Newhouse, PhD
Objective: To review existing studies evaluating the effectiveness of
physical exercise on mortality, strength, balance, mobility, and
activities of daily living (ADL) for sufferers of Parkinsons disease
(PD).
Data Sources: The following databases were searched (1)
Cochrane Database of Systematic Reviews, (2) Cumulative Index
to Nursing and Allied Health Literature (CINAHL), (3) PubMed and
(4) Medline/NARIC (National Rehabilitation Information Center)
using combinations of key words Parkinsons disease and physical
exercise. Only articles written in English were included. References
cited were also examined.
Study Selection: Studies were eligible if (1) only patients with PD
were included in the intervention study (there were many studies that
evaluated the benefits of exercise after stroke, cardiac arrest, sports
injuries, surgery, and arthritis, but only a few for patients with PD),
(2) the intervention included some form of physical or therapeutic
exercise, (3) the effects of the physical exercise were evaluated, and
(4) the studies were published in a refereed journal. Because few
studies were found that dealt with PD patients exclusively, all studies
that evaluated the effectiveness of physical exercise for only PD
patients were included. Seven studies met our criteria and were
selected. Three of the selected studies were randomized controlled
studies, 1 was an open trial, and the other 3 relied on patients own
assessments.
Data Synthesis: Outcomes in the studies were measured in terms of
physical improvements in patients with PD, such as improved axial
rotation, functional reach, flexibility, balance, muscle strength, short-
step gait, and mobility. All studies reviewed show that exercise
improves overall performance in PD patients. Improvements were
measured using standardized tests and other measurement scales.
Conclusions: The results of the present research synthesis support
the hypothesis that patients with PD improve their physical
performance and activities of daily living through exercise. Future
studies should include the development of standardized exercise
programs specific for problems associated with PD as well as
standardized testing methods for measuring improvements in PD
patients. There is also a need for longer term studies (over 1 year) to
Submitted for publication July 25, 2006; Accepted August 10, 2006.
From the *Department of Public Health, Lakehead University, Thunder Bay,
Ontario, Canada.
Reprints: Alex Crizzle, MPH, 31 Lyncroft Drive, Scarborough, Ontario,
Canada M1E 1X6.
Copyright 2006 by Lippincott Williams & Wilkins
422
assess if improvements achieved during the intervention stage are
retained long term.
Key Words: Parkinsons disease, physical exercise, exercise,
Parkinson disease
(Clin J Sport Med 2006;16:422425)
INTRODUCTION
Parkinsons disease (PD) is a progressive neuromuscular
disorder that eventually leads to institutionalization. There is
no known cure. The question is whether physical exercise
helps maintain the PD patients cardiorespiratory fitness, trunk
muscle strength, spinal mobility, balance, and flexibility to
allow the patient to continue living independently and thus
delay the need for institutionalization?
Symptoms and Cause of PD
PD can strike at any time, but it is usually associated
with older people. It may take some time to diagnose because
some of its symptoms are also symptoms of aging. PDs
cardinal symptoms include difficulty in initiating movements
(akinesia) and slowness and difficulty in maintaining move-
ments (bradykinesia). Bradykinesia, while most commonly
affecting movement, also affects speech and makes swallow-
ing difficult. Other symptoms are postural instability which
includes lack of balance, a stooped posture, and muscle trem-
ors. PD patients are susceptible to falling, and many suffer
from hip fractures. Treatment for PD usually involves the use
of drugs; however, even with prescribed drugs, PD patients
will continue to deteriorate. At this time, no treatment has been
effective in stopping the progression of the disease.
PD is due to the lack of the neurotransmitter dopamine,
which regulates the substantia nigra and the striatum. The
pigmented cells in the substantia nigra synapse with other cells
located in the striatum, which is responsible for movement,
balance, and walking. Messages between the substantia nigra
and the striatum are transmitted by dopamine.
Goals of Physical Exercise
There is considerable literature that physical exercise of
moderate intensity leads to an increase in the level of
dopamine, which suggests that an exercise program for PD
patients would be beneficial.1 One experiment determined
levels of epinephrine, norepinephrine, and dopamine in 0.1-
mL plasma samples using a sensitive enzymatic isotope
derivative. Standing trials showed little changes in the levels of
Clin J Sport Med  Volume 16, Number 5, September 2006
Clin J Sport Med  Volume 16, Number 5, September 2006
these molecules; however, epiniphrine, norepiniphrine, and
dopamine activity increased exponentially with the work load
during exercise.2 Nevertheless, more thorough testing in-
volving dopamine regulation and exercise is needed to verify
the underlying factor in reducing symptoms of PD. Re-
habilitation programs increase longevity of muscles and
attempt to postpone the inevitable physical decline that results
from PD. Programs often focus on neurological symptoms of
PD, functional limitations (walking, stair climbing, reaching,
grasping), and disabilities (hobbies and social activities).
Physiotherapy programs for PD aim to maximize functional
ability and to minimize secondary complications through
movement rehabilitation.3 Common exercises conducted in
physical therapy include gait training, training of daily
activities, relaxation therapy, and breathing exercises. The
main deficit underlying bradykinesia and akinesia is the
inability to direct motor output internally. Physiotherapy
methods aim to compensate for this loss of internal motor
generation by substituting external reference points. Therapy
in a group setting may also help in relieving some psycho-
social fears for the patient and family as well as providing
a supportive setting for educational programs about PD. In
general, studies of physical therapies have found significant
and stable improvements in stride length, walking speed and
ability, and activities of daily living (ADL).1,4 Furthermore,
adding physiotherapy treatments for patients with PD with the
resulting improvements in functional abilities raises the
possibility of delaying increases in medication doses, thus
reducing for a longer time the risk of unfavorable side effects.5
One gap in the current literature is the lack of follow-up studies
to at least 1 year after the end of the intervention to gauge
whether improvements obtained during the exercise period
remain long-term. There is also scarce literature on predicting
the effect of rehabilitation in PD. We have no clear idea which
patients would gain the most from therapeutic interventions.6
SEARCH METHODOLOGY
We were looking for studies that included some form of
physical exercise involving only patients with PD. We
searched four databases: The Cochrane Database of System-
atic Reviews, the Cumulative Index to Nursing and Allied
Health Literature, PubMed and MEDLINE/NARIC (National
Rehabilitation Information Centre). The most hits were pro-
duced by PubMed, but only 2 studies met our criteria. The least
hits were produced by CINAHL, but 4 studies met our criteria.
Studies that involved both healthy people as well as patients
with PD were not chosen, nor did we choose studies that
involved the administration of drugs in combination with exer-
cise. Patients had to be tested before and after the intervention
to measure any differences in performance. The effects of the
exercise had to be evaluated, and the studies had to be pub-
lished in a refereed journal. Our search terms included a
combination of the words Parkinsons disease, Parkinson
disease, exercise, physical exercise. Seven studies met our
criteria and were selected (Table 1). The quality of the
description of the interventions was an important criteria used
to assess the methodological quality of the studies. The goals
of the interventions had to be stipulated, such as improved
q 2006 Lippincott Williams & Wilkins
Physical Exercise Beneficial for Persons with Parkinsons Disease
TABLE 1. Literature Search
Time No. No. of Studies Key Words
Database Frame of Hits Selected MeSH Words
CDSR None 18cefg 4 Parkinsons Disease;
Exercise
CINAHL None 8bcdg 4 Parkinsons Disease;
Physical Exercise
PubMed None 42ac 2 Parkinsons Disease;
Physical Exercise
MEDLINE/NAIRC None 24dfg 3 Parkinsons Disease;
Exercise
CDSR, Chochrane Database Systematic Reviews; CINAHL, Cumulative Index to
Nursing and Allied Health Literature; NARIC, National Rehabilitation Information
Center. aKurodo et al, 1992; bReuter et al, 1997; cSchenkman et al, 1998; dBaatile et al,
2000; eNieuwboer et al, 2001; fMiyai et al, 2002; gHirsch et al, 2003.
strength, balance, or flexibility. There were methodological
shortcomings, including patient selection criteria (heteroge-
neity and within-patient variability are an inherent problem in
the PD population), training designs (sometimes had to be
adapted to each individuals need), and the measurement tools
used in the experiments (various, not all standardized). Some
trials were small. One of the reasons not much research has
been done with PD patients is that PD is an unpredictable
disease, with patients experiencing on-off periods and freezing
that may interfere with a regular physical exercise program. It
is not easy to recruit large numbers of PD patients who would
qualify for a research trial and who are willing to invest the
time and effort for testing and interventions.
RESULTS
Study Design
As noted in Table 2, rehabilitation methods in the 7
selected studies varied from physical exercise, balance, and
resistance training to pole striding and body weightsupported
treadmill training (BWSTT). All participants were in the early
or middle stages of PD. Three of the seven trials were
randomized controlled trials, one was an open trial, and the
other three relied on patients own feedback. The number of
participants in the trials ranged from 6 to 46, apart from one
study on mortality,7 which included 438 participants. The
length of the interventions ranged from 4 to 14 weeks, apart
from the mortality study, which lasted 4.1 years. One of the
studies was interesting in as much as it looked at the trans-
ferability of functional improvement training from one setting
to another.7 None of the studies included any long-term
follow-up (.1 year) to assess whether the improvements
obtained remained long-term, although the improvements
obtained with the BWSTT were still in effect when measured
after 6 months.
Positive Results
There were numerous methodological issues with these
studies. Nevertheless, if taken at face value, the results would
suggest that physical exercise is beneficial for PD patients. As
shown in Table 2, all trials reported positive results for the
423
Crizzle and Newhouse Clin J Sport Med  Volume 16, Number 5, September 2006

TABLE 2. Characteristics of Studies Reviewed

Reference Patient Selection Training Design Measurement Results Comments
Hirsch et al, 2003 15 participants; 2 groups: 1 group Computerized Combined training Randomized
subjects had never balance and dynamic had superior and controlled trial
exercised before resistance training; posturography; longer lasting between the 2
being pre-tested 1 group only sensory orientation results; reduced No. groups, but no
balance training; test; muscle of falls in subjects control group
exercised thrice strength test
weekly for
10 weeks
Miyai et al, 2002 24 participants; 2 groups: BWSTT UPDRS; ambulation BWSTT was superior Randomized
12 men & 12 45 min/3 days/wk speed; No. of steps to conventional PT, controlled trial
women; all subjects for 1 month; PT in a 10-min walk; especially on
2.5 or 3 on 45 min/3 days/wk stride length short step gait
Hoehn-Yahr scale for 1 month; both
groups O/T
Schenkman et al, 1998 46 participants; 2 groups: 1 doing Functional axial Significant Randomized
34 men and 12 individual physical rotation; functional improvement in controlled trial
women; between exercise thrice reach; time supine axial rotation and
ages 55 and 84 weekly (45 to to standing functional reach;
years; stages 2 or 60 min) for 10 not significant in
higher on the weeks; 1 control supine to sit time
Hoehn-Yahr group no
intervention
Baatile et al, 2000 6 male participants; Pole striding for 8 UPDRS; PDQ-39 All subjects improved Small sample size
mean age = 72.7 6 weeks; up to 1 hour mobility and ADLs; (n = 6); subjects
3.7 years; 3 subjects thrice weekly 3 had lower served as own
stage 2; 1 subject cognition & control
stage 2.5; 2 subjects well-being
stage 3
Nieuwboer et al, 2001 33 participants; 2 groups: 1 group UPDRS; gait velocity; Significant Within subject
21 men & 12 physiotherapy at stride length; improvements in controlled design
women; 15 subjects home; 1 group in cadence home care setting,
stage 2.5; 16 stage hospital setting; some in hospital
3 on Hoehn-Yahr thrice weekly for setting
scale 6 weeks
Kuroda et al, 1992 438 subjects; 3 groups: 1 exercising Ratio: observed to Mortality rates much Relied on patients
178 men, 260 group, 1 expected deaths; lower in exercising questionnaire to
women; mean intermediate, 1 Coxs proportional patients; hazard rate level of
age = 58.9; stages neglecting group; hazard model ratio was 1.83 exercise
3 or higher on duration 4.1 years
Hoehn-Yahr
Reuter et al, 1997 16 participants Standardized sport UPDRS; CURS; Physical and mental Open trial
without cardio activities; exercised BMT; MMS; imp; MMS: no
vascular diseases; twice weekly for SIP; AMQZ change; imp evident
Exclusion of PD 1 hour; weekly in 6 wks after trial
patients unable to water, weekly ended
walk or stand in gym
without help
AMQZ, Adjective Mood Questionnaire of Zeersen; BMT, Basic Motor Test; BWSTT, body weight-supported treadmill training; CURS, Columbia University Rating Scale; MMS,
Mini Mental State; OT, occupational therapy; imp, improvements; PDQ-39, Parkinsons Disease questionnaire; PT, physiotherapy; SIP, Sickness Impact Profile; UPDRS, Unified
Parkinsons Disease Rating Scale.

groups that received the intervention, such as improvement in
walking speed, increased spinal flexibility, better functional
reach, improved axial mobility, improved motor ability, in-
creased muscle strength, and reduction in number of falls. These
improvements are important for daily activities such as turning
over, moving in bed, standing from a sitting position, reaching
forward while sitting or standing, turning while standing, and
walking. As specific measurements were used to measure
specific functional improvements depending on the physical
exercises employed, it is difficult to compare whether any one
particular exercise regime is superior to another. In the 7
reviewed studies, all exercise modes resulted in improvements,
although the BWSTT was found to be superior to regular
physiotherapy, especially as far as short step gait is concerned.
Key Findings
The study on transferability of functional improvement8
concluded that the improvement is most noticeable in the
setting in which the training is received. This would imply that
a patient still living in his/her own home should best receive
rehabilitation training in the home rather than at a clinic or
other location.

424 q 2006 Lippincott Williams & Wilkins

Clin J Sport Med  Volume 16, Number 5, September 2006
DISCUSSION
Need for Clear and Accurate Information
In order for rehabilitation professionals to provide
appropriate services to functionally impaired individuals with
PD, they need to have clear and accurate information. Reha-
bilitation for PD patients is relatively new and lacking em-
pirical evidence for the support of specific exercise programs
in alleviating PD symptoms and improving lifestyle factors.
Only now are there more studies conducted on various types of
exercises that can improve physical and cognitive impairments
associated with PD. However, although there is a general lack
of empirical evidence, there is a general consensus that
physical rehabilitation exercises are beneficial to PD patients.
Timing of Interventions and Predictors
of Success
There is a growing body of evidence that early
intervention is beneficial in preserving or improving physical
performance of people who are in relatively early stages of
PD.9,10 These improvements could be instrumental in pre-
serving independence. Physical interventions that enhance
balance and muscle strength and reduce falls are relatively
inexpensive interventions that help prevent dysfunction and
dependence in persons with PD.11 The physical exercise
programs would probably have to be continuous to remain
effective. There is a lack of studies that address the problem of
predicting the effect of rehabilitation in PD so as to determine
which patients would be most likely to benefit from reha-
bilitation intervention. The 1 study conducted by Nieuwboer
et al6 found that disease severity was the most important
predictor of whether patients will benefit from physiotherapy
treatment based on cueing and teaching conscious motor
control. The intervention lasted for 6 weeks with a follow-up
of 12 weeks. They found that both younger and older patients
benefited from physiotherapy, although older patients and the
cognitively less able were more likely to lose their functional
gains after 3 months without physiotherapy. However, the
improvements were sufficient to suggest that both younger and
older patients should be referred to physiotherapy.
Interplay of Neurological and
Musculoskeletal Impairments
Exercises should be designed in such a way as to
acknowledge the connection between the neurological impair-
ments that relate directly to PD (such as rigidity, tremor, motor
planning) and the musculoskeletal impairments that follow
(such as stooped flexed posture, loss of extremity, and spine
flexibility). It has been suggested that rigidity in combination
with bradykinesia contributes to loss of axial mobility,
resulting in the stooped posture of people with PD. Loss of
spinal flexibility contributes to impaired balance. Such an
interplay would suggest that exercises designed to improve
spinal flexibility should also improve balance and function
despite rigidity, bradykinesia, and motor planning deficit.12
Ancillary Benefits
Other benefits, besides the physical improvements, also
need to be taken into account. A person with PD undergoing
q 2006 Lippincott Williams & Wilkins
Physical Exercise Beneficial for Persons with Parkinsons Disease
a rehabilitation program who may not show significant im-
provements in ADL, may still obtain an improved quality of
life based on the perceived improvements made during the
rehabilitation program. These beneficial cognitive effects may
improve mood changes or prevent PD patients from becoming
depressed.
CONCLUSION
Despite the many findings that suggest that an exercise
program is beneficial to PD patients, this area still lacks
validity. More work and research is needed to develop a
standardized approach to aid patients with PD through
exercise training.
We do know that in the absence of regular physical
activity, balance, and muscle strength deteriorate in persons
with PD.
The current, although somewhat limited, evidence
suggests that exercise training is beneficial to patients with
PD, especially in the early stages.
Doctors should encourage their patients to join a physical
exercise program. Early referral to an exercise program may
prevent, or at least delay, secondary complications.
REFERENCES
1. Baatile J, Langbein WE, Weaver F, Maloney C, Jost MB. Effect of exercise
on perceived quality of life of individuals with Parkinsons disease.
J Rehabil Res Dev. 2000;37:529534.
2. Koch G, Johansson U, Arvidsson, E. Radioenzymatic determination of
epinephrine, norepinephrine and dopamine in 0.1 mL plasma samples:
plasma catecholamine response to submaximal and near maximal
exercise. J Clin Chem Clin Biochem. 1980;18:367372.
3. Deane KHO, Jones D, Playford ED, Ben-Shlomo Y, Clarke CE.
Physiotherapy versus placebo or no intervention in Parkinsons disease.
Cochrane Database Syst Rev. 2004;4:ID#CD002817.
4. De Goede CJT, Keus SHJ, Kwakkel G, Wagenaar RC. The effects of
physical therapy in Parkinsons disease: a research synthesis. Arch Phys
Med Rehabil. 2001;82:509515.
5. Miyai I, et al. Long-term effect of body weight-supported treadmill
training in Parkinsons disease: a randomized controlled trial. Arch Phys
Med Rehabil. 2002;83:13701373.
6. Nieuwboer A, De Weerdt W, Dom R, Bogaerts K. Prediction of outcome
of physiotherapy in advanced Parkinsons disease. Clin Rehabil. 2002;16:
886-893.
7. Kuroda K, Tatara K, Takatorige T, Shinsho F. Effect of physical exercise
on mortality in patients with Parkinsons Disease. Acta Neurol Scan. 1992;
86:5559.
8. Nieuwboer A, De Weerdt W, Dom R, Truyen M, Janssens L, Kamsma Y.
The effect of a home physiotherapy program for persons with Parkinsons
disease. J Rehabil Med. 2001;33:266272.
9. Plant RD, Jones DC, Hutchinson A, et al. Physiotherapy in Parkinson
disease referral, contact and discharge patterns (abstr). Mov Disord.
2000;15:71.
10. Bridgewater KJ, Sharpe MH. Trunk muscle training and early Parkinsons
Disease. Physiother Theory Prac. 1997;13:139153.
11. Hirsch MA, Toole T, Maitland CG, Rider RA. The effects of
balance training and high-intensity resistance training on persons with
idiopathic Parkinsons disease. Arch Phys Med Rehabil. 2003;84:1109
1117.
12. Schenkman M, Cutson TM, Kuchibhatla M, et al. Exercise to
improve spinal flexibility and function for people with Parkinsons
disease: a randomized, controlled trial. J Am Geriatr Soc. 1998;46:1207
1219.
425