Intervention should be goal-oriented (i.e. preventing loss of function is the desired outcome) and individually tailored, based on the stage the patient is in. Relaxation exercises may be useful to reduce rigidity and there is some support for the idea that strengthening exercises may help to prevent falling. However, patient adherence to exercise programs is an important issue (Pickering et al., 2013). Stretching and active range of motion (ROM) exercises are vital, and the patient should be provided with a home program to facilitate improvement in functional postural alignment. Breathing and endurance exercises can help to maintain vital and aerobic capacities. They are important, as PD patients have a high incidence of pulmonary complications such as pneumonia. Balance, transfer and gait activities (including weight shifting) are also recommended.

Balance training should include repetitive training of compensatory steps (Jobges et al., 2004), and practice at varied speeds as well as self-induced and external displacements. Self-induced displacements are necessary to help the patient in tasks such as leaning, reaching and dressing. Displacements of an external origin may be expected if a patient is walking in crowds or attempting to negotiate uneven or unfamiliar terrain. External displacements may be simulated by the use of gradual resistance via rhythmic stabilization. Neurofeedback (Rossi-Izquierdo et al., 2013) and tai chi (Tsang, 2013) have been shown to improve balance in patients with PD.

Transfer training should focus on those activities reasonably expected of the patient. At a minimum, bed mobility and transfers, and chair and commode transfers should be considered. Limitations in active trunk and pelvic rotation may impair a PD patient’s mobility in bed. Satin sheets or a bed cradle may reduce resistance to movement from friction. An electric mattress warmer may ease mobility by reducing the need for and thus the weight of covers. If the PD patient cannot be taught to perform a transfer independently, accommodations should he considered. Examples include bed rails or a trapeze, a lift chair and a commode with arms.

Specific training may enhance a PD patient’s ability to perform some transfers such as sit to stand. Evidence indicates that strategies designed to facilitate tibialis anterior activation may improve sit to stand performance (Bishop et al., 2005). Mak and Hui-Chan (2008) reported that cued task-specific training was better than exercise in improving sit to stand in patients with PD. More recently, Mak et al. (2011) noted that limb support and ill-timed peak forward center of mass velocity, rather than dynamic stability, play dominant roles in determining successful sit to stand performance in patients with PD.

Gait training should focus on musculoskeletal limitations that can be quantified. PD patients tend to have limitations in ankle dorsiflexion, knee flexion/extension, stride length, hip extension and hip rotations. Joint mobilization and soft-tissue stretching can be effective to increase ROM and improve gait. It is important to include trunk mobility (rotation) and upper extremity ROM (large, reciprocal arm swings) in a comprehensive gait training program for PD patients. Ebersbach et al. (2010) reported that high amplitude movements were an effective technique to improve motor performance in patients with PD.

Rhythm or music may facilitate movement, but the use of assistive devices such as canes and walkers is not always appropriate for PD patients. At times, the use of an assistive device increases a festinating gait or aggravates problems with balance or coordination. Care should be taken to avoid excessive musculoskeletal stress and falls. Conditions such as osteoporosis may predispose a patient to injury.

For PD patients, a primary problem is difficulty in motor planning. Complex tasks such as transferring out of bed and walking to the bathroom have to be broken down into simple components (Bakker et al., 2004). It is important for patients and caregivers to remember that verbal and physical cuing (and other forms of assistance) should be oriented toward completion of a number of simple tasks in order to accomplish the overall goals of maintaining function and mobility. It has been noted that stress, fatigue, anxiety, or need to hurry imposed by the caregiver may exacerbate the freezing associated with PD. Further, Schenkman et al. (2011) stated that functional loss occurs at different points in the disease process, depending on the task under consideration.

When examining and planning interventions for a PD patient, common age-related changes must be considered. For instance, older individuals are more sensitive to glare and benefit from contrasting colors when determining depth. These facts are especially evident when working in some environments during activities such as gait training on steps. Further, some signs and symptoms of PD have been confused with changes associated with aging. PD patients may present with a reduced or lost sense of smell, handwriting that is difficult or impossible to read, and changes in sleep patterns.

Specific nonpharmacological interventions include biofeedback, proprioceptive neuromuscular facilitation, Feldenkrais and the Alexander Technique (Stallibrass, 2002). In addition, treadmill training, spinal flexibility training, Qigong and tango dancing appear to be of some benefit for people with PD (Morris et al., 2010). Technology can also play a role in helping patients with PD: Ledger et al. (2008) reported that auditory cueing devices can improve walking speed, stride length and freezing.

Stretching, active ROM and strengthening exercises should emphasize safety: patients should be placed in a fully supported position initially and progressed to unsupported positions. In addition, spinal mobility must be oriented toward complete full normal rotation, including elongation of trunk musculature. A loss of pelvic motion occurs and can be addressed by means of lateral and anterior/posterior tilts; for instance, the functional task of standing from a seated position can incorporate anterior pelvic tilts. Mobility in bed, such as rolling over, can include trunk rotation. To improve postural (i.e. balance) responses, a variety of balance activities has been recommended (Hirsch et al., 2003). It is noted, however, that a variety of tasks should be practiced, as skills tend to be task-specific (de Lima-Pardini et al., 2012). Examples of some of the mobility skills are shown in Figures 30.1, 30.2 and 30.3.