This presentation contains brief description about parkinsons disease , its medical management and physiotherapy management ( aims of rehabilitation and exercise training for parkinsons disease patient)

1. PARKINSONꞌS DISEASES MEDICAL TREATMENT AND
PHYSIOTHERAPY MANAGEMENT:
PRESENTED BY: SRINITHA BUSAM
INTRODUCTION:
Parkinsonꞌs disease was first described as “ shaking palsy” by James Parkinson in 1817
Parkinson disease is divided in to two sub clinical sub groups:
Dominant symptoms Non dominant symptoms
Postural instability Tremor
Gait disturbances Bradykinesia
Genetic form is about 10% of all cases
In small no. of. Families, several gene mutations have been identified ( PARK 1, PINK 2) etc..,
Genes are classified in to two :
Casual genes Associated genes
Produces the disease Do not cause the disease but increase the risk of
developing it.
DEFINITION:
Parkinsonꞌs disease is a progressive disorder of central nervous system with motor & non motor
symptoms.
4 cardinal features of Parkinsonꞌs disease are
1) Brady kinesia
2) Rigidity
3) Postural instability
4) Tremor
INCIDENCE”:
Estimated that 7-10 million people worldwide are suffering with parkinsons disease
Age of onset is 50-60 yrs
Men are affected 1.2-1.5 times more frequently than women.
Causes :

2. Parkinsonism is a generic term used to describe a group of disorders with primary disturbances in the
dopamine systems of basal ganglia.
Genetic and environmental influences
Idiopathic type is affecting 78% of individuals
Secondary parkinsonism is caused by
Viruses( encephalitis lethargica)
Toxins (carbon monoxide, manganese, MPTP)
Drugs ( Phenothiazines, reserpine, metoclopromide ,butyrophenones)
Tumours of basal ganglia.
Metabolic causes: Wilsonꞌs disease,
Hypo& hyper parathyroidism
Hepato cerebral degeneration
Drug induced parkinsonism:
A variety of drugs can produce extrapyramidal dysfunction that mimics with parkinsons disease .
These drugs are thought to interfere with dopaminergic mechanism pre synaptically/ post synaptically.
Drugs include:
Neuroleptic drugs: chlorpromazine
Haloperidol
Thiothixene
Anti depressant drugs: Amoxapine
Trazodone
Anti hypertensive drugs: Methyl dopa
Reserpine
High doses of this medication are problematic in elderly people.
STAGES OF PD:
STAGES LESION IS FOUND IN
1 medulla oblongata
2 Caudal nuclei, giganto cellular reticular nuclei
Coerulus and subcoerulus complex
3 Nigrostriatal system
4 Cotex
5 Involves sensory association areas of neo cortex

3. & pre frontal neo cortex
6 Involves sensory association areas of neo cortex
& pre motor areas
CARDINAL FEATURES AND CLINICAL MANIFESTATIONS OF PD:
Cardinal features 1) Rigidity
2) Brady kinesia
3) Postural instability
4) Tremor
Motor performance 1) Fatigue
2) Contractures and deformity
Motor planning 1) Start hesitation
2) Freezing episodes
3) Poverty of movement
4) Masked face
5) Micrographia
Motor relearning 1) Procedural learning deficits for complex
& sequential tasks
Gait 1) Reduced speed of walking
2) Increased step to step variability
3) Cadence( steps/min) typically intact
may be reduced in advanced
parkinsons
4) Increased time: double limb support
5) Insufficient hip, knee, ankle flexion:
shuffling steps
6) Reduced trunk rotation/ reduced arm
swing
7) Festinant gait
8) Freezing of gait
9) Difficulty in turning - increased steps
per turn
10) Difficulty with dual tasks
11) Difficulty with attentional demands of
complex environments
Posture 1) kyphosis with forward head
2) leaning to one side with tonal
asymmetries
3) increased fall risk
Sensations 1) Parasthesias
2) Pain
3) Akathisia – a sense of inner restlessness &
need to move ( 25% of patients experience
this)
Speech , voice, swallowing disorders 1) Hypokinetic dysarthria
2) Dysphagia
Cognition function 1) Dementia
2) Bradyphrenia
3) Visuospatial deficits
4) Depression
5) Dysophoric mood
Autonomic nervous system 1) Excessive sweating

4. 2) Abnormal sensations of heat & cold
3) Seborrhoea
4) Seborrheic dermatitis
5) Gastro intestinal dysfunctions include
▪ Poor motility
▪ Sialorrhea & weight loss
▪ constipation
6) Urinary bladder dysfunction
Cardio pulmonary function 1) Low resting blood pressure
2) Compromised cardio vascular response to
exercise
3) Impaired respiratory function
4) Light headed ness &blurred vision with
position changes ( supine to sit / sit to stand)
MEDICAL MANAGEMENT:
As we all know that Parkisonꞌs disease has no cure. Medical management is directed at slowing of
progression & symptomatic treatment.
Anti – parkinsonian medications:
Became available in 1960ꞌs
Neuroprotective therapy:
Monoamine oxidase inhibitors ( MAOꞌs)—To improve the metabolism of intra cerebral dopamine (
eg: selegiline)
ADVERSE EFFECTS:
An increase in dyskinesias & orthostatic hypotension may be seen when selegiline is combined with
levodopa therapy.
SYMPTOMATIC THERAPY:
Levodopa ( L-dopa)
- Introduced in1961 as an experimental drug & came in to widespread clinical use by 1967.
- Metabolic precursor of dopamine i.e. is able to cross the blood brain barrier & raise the level
of strital dopamine in the basal ganglia→ this attempts to correct the neuro chemical balance.
- L – DOPA is administered with carbidopa which allows a higher % of L-dopa to enter the
CNS.
- Benefit of this is alleviating with less effect on tremor
- The initial functional improvement is often dramatic referred to as honey moon period
ADVERSE EFFECTS:
a) Gastrointestinal disturbances( anorexia, nausea, vomiting, constipation)
b) Cardiovascular ( hypotension & arrhythmias)
c) Cognitive ( confusion & hallucinations )
d) Genitourinary ( Dysuria)

5. e) Neuromuscular ( motor fluctuations & dyskinesias)
f) Sleep disturbances ( insomnia, sleep fragmentation)
Random fluctuations in motor performances termed as on- off phenomenon occur in 50% of
cases treated more than 2 years and can be very disabling.
Deprenyl can be administered with L-dopa to control mild wearing “off” phenomena.
Sudden discontinuation of L-dopa is life threatening.
DOPAMINE AGONISTS:
Acts directly on post synaptic dopamine receptors, can be administered with L-dopa ( i.e. L-
dopa spraying therapy)
Dopamine agonists drugs such as bromocriptine
Ropinirole →→ these 3 reduces rigidity, bradykinesias, &
Pramipexole also reduces motor fluctuations.
ADVERSE EFFECTS:
Nervousness
Dyskinesias
Nausea
Headache
Cramps
Pulmonary / peritoneal fibrosis
Dizziness
Fatigue
ANTI CHOLINERGIC DRUGS :
Trihexophenidyl : 2mg thrice a day
Bentropin : 1mg twice a day
ADVERSE EFFECTS :
Blurred vision
Dry mouth

6. Dizziness
Tachycardia
Nausea
Vomiting
Confusion
SURGICAL MANAGEMENT :
Surgery is an accepted treatment for patients with advanced parkinsons disease/ who
experience complications related to pharmacotherapy.
Three main surgical approaches are:
1) Ablative surgery
2) Deep brain stimulation
3) Neural transplantation
ABLATIVE SURGERY :
Stereo tactic surgery:
The surgical lesioning of the brain & is in current renewed use owing to the increased
accuracy of imaging & surgical equipment
Pallidotomy :
Involves producing a destructive lesion in the sensorimotor portion of the globus pallidus
internus.
The lesion reduces excessive globus pallidus internus inhibitory activity i.e. results in
thalamic hypoactivity. Benefits appear for long lasting.
Thalamotomy :
Involves producing destructive lesion within the ventral intermediate nucleus of the thalamus
Bilateral surgical lesion are usually not recommended because of higher rate of motor
complications.
DEEP BRAIN STIMULATION:
Implantation of electrodes in to brain where the block nerve signals that cause symptoms.
Stimulation of ventral intermediate nucleus of thalamus is commonly done with severe &
uncontrolled upper extremity tremors, that are unresponsive to medication.

7. A pace maker is implanted to chest, with a thin wire that goes under the skin to the brain
electrodes. The patient can control the pacemakers on-off switch while the physician
determines the amount of stimulation it delivers, tailoring it to individual needs.
Total suppression of tremor is observed in 1/3 rd – 1 ½ of patients.
NEURAL TRANSPLANTATION:
It is still under research. Transplantation of cells capable of surviving & delivering dopamine
These modifications in the striatum of patients with advanced PD is an experimental study.
NUTRITONAL MANAGEMENT
A high-protein diet can block the effectiveness of L-dopa. The dietary amino acids in protein
compete
with L-dopa absorption. his is particularly problematic in patients with chronic disease who
exhibit fluctuations in motor performance. Thus, patients are generally advised to follow a
high-calorie, low-protein diet.
Generally no more than 15% of calories should come from protein. Dietary recommendations
may also include shifting the intake of daily protein to the evening meal when patients are
less active. These modifications minimize motor fluctuations and maximize responsiveness
to L-dopa therapy. The patient is encouraged to eat a variety of foods and may be advised to
take dietary supplements to ensure adequate intake of vitamins and minerals. Patients are also
advised to increase their daily intake of water and dietary fiber to help control problems
of constipation.76 Rigidity and bradykinesia can limit upright posture and UE feeding
movements. Learned motor plans, for example, using a cup or eating utensils, may also be
difficult.
Occupational therapy intervention to improve feeding and recommend adaptive eating
devices is of considerable importance in helping to maintain nutritionand general health
status. The speech-language pathologist also has an important role in the evaluation
of dysphagia and the recommendation of strategies to assist with swallowing dysfunction.
Patient, family, and caregiver education should focus on the importance of maintaining good
nutritional intake.
Percutaneous endoscopic gastrostomy (PEG) is reserved for advanced disease when all other
strategies for dysphagia fail.
PHYSIOTHERAPIST APPROACH TO PARKINSONS PATIENT:
AIMS OF P.T TREATMENT:
To decrease pain
To decrease tone
To improve the cardiopulmonary endurance
To improve fatigue
To improve ROM (range of motion)
To correct posture ( deformity correction )

8. Management of tremor
Management of dysphagia
Management of incontinence
To improve balance, gait& locomotion
Functional retraining
To improve the ADL
To improve strength, power and endurance
Patient , his family and care giver education
EXERCISE TRAINING FOR PARKINSON PATIENT:
BASIC EXERCISE PATTERN FOR THE PD PATIENT:
- Toes tip should be used in every step the patient takes and should never make a move
with out `lifting toes.
- The space should be about 10 inches when walking / turning to provide wide
BOS(base of support ) a better stance & prevent falling.
- Patient should practice walking in to tight corners of a room, to overcome fear of
close places.
- Patient should practice rapid curls of body backward, forward to left & right for 5
minutes several times a day to insure balance.
RELAXATION EXERCISES:
Exercise should initially be performed in fully supported positions:
- Supine lying – slow side to side head rotations
- Supine lying- bilateral symmetrical proprioceptive neuromuscular facilitation (PNF)
- A) D2 flexion pattern ( flexion, abduction, external rotation)
- B) D2 extension pattern ( extension, adduction, internal rotation)
- Hook lying – lower trunk rotations
- Side lying – upper and lower trunk rotations
Side lying trunk rotations are combined with scapular patterns; shoulder protraction with
elevation & retraction with depression.
Jacobsonꞌs relaxation technique – shawasana/still pose
YOGA SEQUENCE FOR EARLY/MILD PARKINSON’S DISEASE:

9. Marjaryasana (Cat Pose)-
1. Start on your hands and knees. Tabletop
position.
2. As you exhale round your spine toward the
ceiling. Hold for 5 seconds
Bitilasana (Cow Pose)-
1. As you inhale lift your sitting bones and chest towards ceiling. Hold for 5 second
Bhujanga (Cobra Pose)
Adho Mukha Svanasana (Downward-Facing Dog)
1. Start in the tabletop position.
2. As you exhale lift your knees and torso from
the ground forming an inverted “V.”
3. Push your shoulder blades against your
back and heels to the ground.
4. Hold for 5 seconds
Bhujanga asana ( cobra pose)
1. Lie on your stomach with your hands under
your shoulders.
2. As you inhale press the shoulders and torso
off the mat and look up. Hold for 5 seconds.
Anjaneyasana (Low Lunge)
1. Step your right foot forward and maintain
your left knee on the ground.
2. As you inhale raise your arms to the sky and
stretch your torso forward.
Virabhadrasana II (Warrior II pose).
1. Rise up from low lunge maintaining the
right knee bent and the left knee straight.
2. Right foot should be straight ahead and the
left foot should be turned out 90 degrees.
3. Ensure that outside border of the left foot
stays on the ground.
4. With the right arm straight forward and the
left arm straight back sink into the pose
looking over the fingers of your right hand.
YOGA SEQUENCE FOR LATE PARKINSON’S DISEASE
Marjaryasana (Chair Cat Pose)
1). Start perch sitting (body at front of chair),

10. sitting tall and hands on the side of your
head.
2. As you exhale round your spine toward the
back of the chair, bring your shoulders and
head forward while bringing your elbows
together. Hold for 5 seconds.
Bitilasana (Chair Cow Pose)
1. As you inhale arch your back and look up to the sky. Open your chest and spread your
elbows wide. Hold for 5 seconds
Parighasana (Chair Gate Pose)
1. Start sitting tall with your right hand on the
chair and left arm raised to the sky palm
facing in.
2. Inhale deeply.
3. As you exhale side bend your torso to the
right and look up to your left hand. Hold for
5 seconds.
4. Repeat on the opposite side
Ardha Matsyendrasana (Chair
Spinal Twist)
1. Start sitting tall with your hands on the side
of your head.
2. Inhale deeply.
3. As you exhale rotate to one side. Hold for
5 seconds.
4. Repeat on the opposite side
Eka Pada Rajakapotasana (Chair
Pigeon Pose)
1. Start sitting tall with your legs crossed, right
ankle on top of left knee.
2. As you exhale lean forward from the hips
keeping your spine long. Hold for 5 seconds.
3. Repeat on the opposite side.
Anjaneyasana (Modified Low
Lunge)
Variation A (Advanced)
Variation A:
1. Stand holding onto a stable surface for stability.
2. Left foot supported on chair behind you.
3. With a tall upright spine exhale, and bend
the right knee while moving the pelvis forward.
Hold for 5 seconds.
4. Repeat on the opposite side

11. Variation B (Beginner)
1. Stand holding onto a stable surface for stability.
Left foot forward and right foot back.
2. With a tall upright spine exhale while bending
the left knee and maintaining the right
leg straight. Hold for 5 seconds.
3. Repeat on the opposite side.
Utthita Parsvakonasana (Modified
1. Hold on to a stable surface with your right
hand, left foot forward and right foot back.
2. While maintaining a long spine bend the
left knee moving the pelvis forward and
side keeping the right knee straight.
3. As you exhale raise the left arm to the sky
and turn your head to the left looking up
to your left hand. Hold for 5 seconds.
4. Repeat on the opposite side.
FLEXIBILITY EXERCISES:
-Both AROM and PROM exercises are used to improve flexibility.
-ROM exercise in physiological patterns of motion are recommended as these patients have a
minimum energy to expand & multiple clinical problems eg: PNF PATTERNS
-ROM Exercises are performed two to three times a day.
-Active muscle inhibition techniques eg: hold relax, contract relax techniques
- Gentle stretching of flexors for about 15-30 seconds
- Grades of mobilization are improving ROM & grades of mobilization 1,2 are used in
decreasing pain.
- Mechanical low load stretching exercises are performed
MOBILITY EXERCISES :
Trunk mobilization exercises :
- Prone on elbows and prone extension activities can be used to improve thoracic and
neck extension. Standing with elbows extended & hands weight bearing on a wall can
be used to promote upper trunk extension.eg: standing push ups.
- Sitting to standing exercises:
Sitting control can be facilitated first through exercises designed to improve pelvic
mobility. SWISS ball provides an excellent tool to facilitate these motions.
- Progression to the weight shifting & reaching activities. Static control can be achieved
by PNF patterns.
PROGRESSION IS FROM SUPPORTED STANDING TO UNSUPPORTED
STANDING:
Tactile cueing / light resistance to hip extensors on the anterior pelvis can be used to
promote full extension in standing.
- Reciprocal arm swinging / reaching movements can be used to promote trunk
rotation.
WEIGHT SHIFTING AND STEPPING MOVEMENTS:

12. - Should be incorporated to promote pelvic motion. Lateral side step/ step-ups using a
low platform step can be used to improve abductor function.
- As the patient experiences a high no.of. falls ,should be taught how to get up after a
fall.
- Quadruped creeping should be practice so patient is able to move to anear by stable
chair / couch at home.
- The patient should practice transitions moving from quadruped to kneeling to half
kneeling & finally to standing using upper extremity support.
FOR GETTING IN & OUT OF CHAIR:
- The head end of the bed should be raised as it would be easier to sit up& swing the
legs off the bed.
- A knotted rope is tied to the foot of the bed can help the patient to pull himself up
- MOBILIZATION OF FACIAL MUSCLE WEAKNESS:
- It is important goal of exercise as the patient will have limited social interaction &
poor feeding skills.
- Use of massage, stretch, manual contacts, & verbal commands can be used to enhance
facial movements.
- Reciprocal motions should be stressed.
- Visual feed back.
- Opening and closing of the mouth combined with neck stabilization in a neutral
position. Verbal skills should be practiced in association with breath control.
BALANCE ACTIVITIES:
- For better balance
- Should stand with hands on hips, feet spread apart & practice marching in place
- Practice raising leg straight out to the roof, practice raising leg straight outside.
- Practice drawing circle with legs
- Should stand with hands at side, feet spread a part& lean forward and backward
Lean to both sides .lean in a circular motion and reverse it
-
- KITCHENSINK EXERCISES TO IMPROVE BALANCE:
- Reaching activities
- Climbing stairs
- Standing with heels off and toes off the ground
- Side kickings
- Sitting on a swiss ball and maintaining the position & moving, bending, in all
directions
- Wall squats
- BREATHING EXERCISES :
- Respiratory dysfunction is linked to morbidity and mortality in patients with
Parkinsonꞌs disease. Both obstructive and restrictive ventilator deficits are common
- A comprehensive pulmonary rehabilitation should be advised:
- Any pooling of secretions in lungs then following techniques are done 1) vibration
2) shaking/rib springing 3)percussion
- BREATHING EXERCISE : 1) Diaphragmatic breathing exercises
- 2) Segmental breathing exercises which include Apical,
Lateral costal and posterior basal breathing exercises.
- 3) pursued lip breathing exercises
- Chest wall mobility can be increased by using PNF patterns of upper extremity
bilateral symmetrical D2 flexion and extension pattern.D2 flexion includes shoulder

13. flexion, abduction, external rotation, fore arm supination, wrist radial deviation ,
fingers extension.
- D2 extension pattern includes shoulder extension, adduction, internal rotation, fore
arm pronation, wrist ulnar deviation, fingers flexion.
- All these techniques would result in improved upper extremity endurance and
pulmonary function.
- AEROBIC CONDITIONING:
- Deconditioning and decreased endurance are evident in individuals with PD.
- Training modes can include upper & lower extremity ergonomics and walking.
- Postural instability & increased risks of falls will require use of a stationary/seated
ergometer .
- Regular walking is recommended.
- Swimming- should not be done without supervision because it may be too risky for
the patient with moderate disease who experiences episodes of freezing.
GROUP THERAPY:
Patients benefit from positive support,& communication
The patient can begin in sitting position & progressed to standing position using light
touch down support of the back of the chair
- Warm up activities
- Progression to combined activities
- The group can then practice walking with an emphasis on taking large high steps.
- Music is used to provide necessary stimulation to movement and movement pacing.
- Exercise stations eg: stationary bicycles, mats, pulleys etc..,
- Exercise done by whole group to gether should focus on important exercise goals (
improving ROM & MOBILITY)
- TO improve ROM all the free exercises are trained to patient
- IMPROVE DYSPHAGIA( DIFFICULTY IN SWALLOWING):
- Exercises for the muscles of oral cavity ( chewing, ballooning, gritting of teeth,
whistling.)
Electrical stimulation
Soft tissue manipulation
Apply pressure on gums; tongue, with gloved hands.
Swallowing of ice cubes followed by liquids followed by semisolids followed by
solids
Swallowing of lemon drops ( acidic in nature and acts as a stimulant)
Resisted straw sucking ( as a progression exercise)
Pharyngeal electrical stimulation
MANAGEMENT OF INCONTINENCE:
Pelvic floor muscle strengthening ( kegelꞌs exercises)
Electro modalities ( IFT( inter ferential therapy),ELECTRICALSTIMULATIONS)
Swiss ball exercises
Kegels exercises are done in three position 1) lying 2)sitting 3) standing
In lying : crook lying
- Pelvic bridging( contract pelvic floor muscles for 2-3 seconds )
- Crook lying with ball between two knees
- Single leg raise with ball between two knees
- Walking – toes moving up on the wall
- SITTING:
- Raise the leg from chair
- Draw a line move toes forward by contracting the pelvic muscles

14. - Knee raising
- Forward toe walking
- Sideway toe walking
- STANDING:
- Erect posture/position of patient & ask him/her to do mini squats
- Squatting hold 3-5 seconds with contraction & relaxation
- Stride standing & squatting – hips are slightly abducted, arms are slightly abducted
with pelvic floor muscle contraction & stride standing with ball between two knees.
- HOME ADVICE:
- Relaxation exercises
- Flexibility exercises
- Strengthening exercises
- Cardio respiratory endurance
- Prolonged periods of inactivity should be avoided
- Wall pulleys
- Hanging from an overhead bar.
- Walking on treadmill.
■ PATIENT, FAMILY, AND
CAREGIVER EDUCATION
The interdisciplinary team provides information abouta variety of topics related to living
with PD. Interventions can take the formof direct one-on-one instruction, group sessions,
printed materials, and video or computer presentations. The therapist’s overall approach
needs to be positive andsupportive.
Community support groups are available for patientsand their families. They disseminate
information and offer a chance to discuss common issues, problems, and management tips.
They also can provide a stabilizing influence,assisting patients and families to focus on
healthy behaviors, coping skills, and effective self-management.
For some patients in the early stages of the disease,participation in a support group may
increase levels of anxiety as they observe more disabled patients. Groups particularly targeted
to patients with early-stage disease and similar ages may be more helpful.
Elements of a Patient, Family,and Caregiver EducationProgram:
• Parkinson’s disease: clinical presentation, strategies to
manage symptoms
• Medications: purpose, dosage, possible adverse side
effects, signs of either overmedication or undermedication
• Preventative measures to minimize the secondary complications
and impairments
• Impact of PD on movement and effective strategies to
manage movement problems
• Barriers to exercise and effective solutions to regular
exercise participation
• Impact of PD on function and effective strategies to
maintain independent function in home, community,
or work environments
• Strategies for energy conservation and activity pacing
• Strategies for ensuring activity participation in valued
leisure and family activities
• Community resources for patients: support groups,

15. in-home interventions, community training programs,
day programs
• Community resources for caregivers: counseling, support
groups, exercise programs, respite care.
MANAGEMENT OF FATIGUE:
Activity pacing –rest intervals
-split the exercises
-simple to complex activities
Avoid excessive consumption of energy
MANAGEMENT OF TREMOR:
Weight bearing on hands, start with activity hold something in hands.
CORRECTION OF POSTURE:
Spinal orthotic devices are used
Stretching of tissues
PNF patterns
Locomotor Training
Locomotor training goals focus on reducing primary gait impairments, which typically
include slowed speed, decreased stride length, lack of a heel-toe sequence with forward
progression characterized by a shuffling (festinating)gait pattern, diminished contralateral
trunk movement and arm swing, and an overall attitude of flexion while walking. Goals also
focus on increasing the patient’s ability to safely perform functional mobility activities and
prevent falls.216 Effective strategies for improving upright alignment and safety include
having the patient walk with vertical poles (pole walking) Strategies to enhance posture, step
length, velocity, and arm swing include the use of verbal instructional sets (e.g., “Walk tall,”
“Walk fast,” “Take large steps,” “Swing both arms”). Behrman et al217 found that
commands for large step and arm swing were more effective instructional strategies than the
command to walkfast. As previously discussed, visual and auditory cues arealso effective in
improving gait speed and step length.Transverse visual–spatial cues (across the gait path)
were more beneficial than parallel visual cues (alongside thegait path) in improving gait
velocity, stride length, and percentage of leg stance time. Strategies to improvefoot
placement can include use of floor markers or footprints on the floor. Strategies to improve
step height include practice marching in place progressing to walking using an exaggerated
high stepping pattern.Brisk marching music can be used to enhance pace.Sidestepping and
crossed-step walking can be practiced. The PNF activity of braiding, which combines
side-stepping with alternate crossed-stepping, is an ideal training activity for the patient with
early PD because it emphasizes lower trunk rotation with stepping and side-stepping
movements.