The Keeping Moving Parkinsons Exercise Programme:

A rationale for physiotherapists and other health and

social care professionals

In 2003, the Parkinsons Disease Society produced Keeping Moving, an

exercise programme for people with Parkinsons disease, devised by Bhanu
Ramaswamy MCSP and Richard Webber MCSP, two senior physiotherapists
in Sheffield. This information sheet explains the rationale behind the
programme. Although aimed mainly at physiotherapists, it may also be of
interest to other health and social care professionals working with people
with Parkinsons.

The evidence for physiotherapy intervention in Parkinsons

The evidence available to practitioners with regard to appropriate physiotherapy
intervention for people with Parkinsons up until the recent Rescue Project
randomised control trial has either been of poor quality or absent. Physiotherapy
has therefore had to rely on unsubstantiated anecdotal reports from professionals,
people with Parkinsons or carers regarding the effectiveness of input.
An effectiveness bulletin on neurological conditions (Chartered Society of
Physiotherapy 2001) concluded that many areas of physiotherapy had yet to be
sufficiently evaluated. This was a reflection obtained from several reviews
comparing two or more therapeutic interventions or placebos with a treatment
intervention, such as the two Cochrane systematic reviews (Deane et al, 2001 a
and b) and that of Reuter & Engelhardt (2002). These reviews cannot be read to
imply lack of effect, as all were inconclusive regarding the effectiveness of
physiotherapy interventions with no clear statistical or clinical evidence to prove the
benefit from training.
The papers critiqued in this information sheet and other books read in the course of
its development continue to theorise improvements expected from physical
interventions, despite the lack of supporting evidence.
Another issue that becomes apparent in the papers reviewed is the lack of
agreement about what is a standard form of physiotherapy or what might
constitute best practice. Deane et al (2001 a and b) suggest that the capability
of standard physiotherapy should be proven first before examining variations
in physiotherapeutic methods.
Clinical symptoms of Parkinsons that may be influenced by physical therapies
Considering the World Health Organizations classification of consequences of
disease (1980), physiotherapy has most effect on the management of disabilities
(abilities), impairment (participation) and health of someone with Parkinsons
compared with anti-Parkinsons medications that influence the disability.
Physiotherapy is therefore advocated in combination with optimal timing of the
effect of medications (Morris et al, 1998).
During the development of the Keeping Moving programme, articles on other
styles of exercise (anecdotally recognised as having a positive effect on
Parkinsons) were sought for review. These included the Alexander technique
(Stallibrass, 1997), Pilates (Reyneke, 1993), conductive education (Kinsman,
1986, Kinsman et al, 1988; Brown, 2000) and tai chi (Li et al, 2001; Jancewicz,
2001; Lan et al, 2000; Hong et al, 2000) although not all looked specifically at
Parkinsons. Underlying themes common to them all seemed to be the use of
cognition to promote posture and body awareness or control of movement with
emphasis on slow, flowing movements. All were timed with breathing to induce
relaxation. These core principles follow a rationale put forward by both Morris
(2000) and Schenkman et al (1998) that suggest focusing on postural control
during movement.

Original plan for the exercise programme

The Keeping Moving programme was originally designed as an exercise class. As
well as improving/maintaining physical function (Ward, 1992), the aims of group
therapy should be to lessen the social impact of impaired communication; increase
confidence; improve motivation to communicate; restore a sense of control and
provide a supportive framework for the participants over a period of months or
years. A person can also do these exercises in their own home on an individual
basis if a class is not available, which is why we have produced a DVD and booklet
containing the programme.
It is recommended that people should do 30 minutes of moderate exercise at least
five times a week, if not on a daily basis (American Council on Exercise, 2000). As
gait pattern and disability levels in Parkinsons subjects were shown to remain
stable over a one-week period with optimal medication (Urquhart et al, 1999) we
proposed that there would remain sufficient benefit from some of the exercises
even if a person with Parkinsons only did this regime once a week.
Following this point, exercising routinely can be an issue (Bassett & Petrie,
1999; Crook et al, 1998; Williams and Lord, 1995). These studies concluded
that compliance is increased if the participants self-referred (as was the case
for the participants in the class and those obtaining the DVD themselves) and if
there was an emphasis on social interaction.
Finally, best practice would dictate a holistic exercise regime. As Sheffield has a
good speech and language service for those who require work on facial muscle
tone and voice production/amplification, the content of the proposed class could
concentrate on a more defined aspect of postural control.
Specialist physiotherapists from four centres in Bath, Newcastle, South Shields
and Southampton (recognised nationally by others in their profession for their
interest and research in Parkinsons and with experience of running exercise
classes for people with Parkinsons) were contacted during the course of
preparing our routine. All programmes included:
work on postural awareness
techniques to correct poor posture
control of movement, including the trunk and limbs
exercises for weight transference and balance, requiring that people with
Parkinsons exercise at a cognitive level
The therapists who ran the classes reported that they had based the sessions on
their clinical expertise and current knowledge of evidence of best practice.

The exercise regime

The Keeping Moving programme has been based on this concept of action
systems of motor control described above and three therapeutic models outlined as
follows:
1. The Movement Enablement Through Exercise Regimes and Strategies
(METERS) advocates the promotion, maintenance and use of quality
functional performance by focusing on four core areas of physiotherapy
practice gait, balance, posture and transfers outlined in Plant et al (2000)
and detailed further in the Guidelines for Physiotherapy Practice in
Parkinsons Disease (Plant et al, 2001).
2. A model put forward by Morris (2000) for physical therapists promotes
a task-specific approach to training in the context of functional tasks.
3. A rationale for the management of individuals with Parkinsons by
Schenkman et al (1989 and 1998), uses a systematic approach to evaluate,
interpret and treat people with Parkinsons.
The Keeping Moving programme emphasises minimising musculoskeletal
limitations and postural deformities in order to preserve the individuals capability for
independent function as long as possible. Clinically, the authors have found rotation
useful in inducing relaxation and decreasing rigidity. It is also a necessary part of
balance reactions and functional activities.
The programme makes practical use of activity from two separate motor control
systems: the medial system (concerned primarily with axial musculature contraction
and extensor innervation) necessary for postural and anti-gravity work; and the
lateral system (concerned with distal limb movements and flexion innervation)
which is necessary for speed and agility in movement (Buchwald, 1967; Kuypers,
1964). Recruitment of individual muscles and synergies of movement according to
this theory can be seen in the clinical context in the work done on functional stability
in movement (Comerford & Mottram, 2001a and b)
It is hypothesised, therefore, that the effects of following this system of
relaxation, breathing control and slow, controlled movement at a conscious
level should be twofold in physical terms, there could be benefits from better
posture (and therefore balance and respiratory status) as well as control of
movement (with subsequent influence on delayed progress from poverty of
movement on physical function e.g. transfers, gait). In psychosocial terms, the
group intervention will have a positive effect on aspects of the disease, for
example health and social participation, while better physical ability will lead to
improvements in confidence and independence.
The exercises progress through postural sets of lying, sitting and standing. Work on
core stability and single limb range of movement in lying progresses to more
complex sequences involving bilateral or diagonal limb movements where the base
of support is progressively decreased and the complexity of the movements
increased. Elements of strengthening, balance, co-ordination of movements and
flexibility are incorporated into the exercises and most of the exercises are
synchronised with breathing. All are done at a cognitive level and with auditory cues
(Morris et al, 1999; Chartered Society of Physiotherapists, 2001; Plant et al, 2001).
Morris (2000) points out that there is little use in working on individual
symptoms if the training does not relate to functions such as standing and
walking, so the final exercises concentrate on aspects of stepping and sit-to-
stand control, hopefully resulting in modified or use of skills to gait and
transfers. The table at the end of this information sheet summarises the
exercises recommended and the aims behind the movement.
No specific bed mobility or floor transfer exercises are done, as the task of
getting on to and off the floor to perform the lying exercises requires similar
skills. The therapist assists and instructs the person in how to get on or off the
floor as necessary.
All the exercises can be modified should the person with Parkinsons
experience difficulty in any one postural set. Some of the standing exercises
are done with arm support if the person is very unstable, or sitting where their
bottom becomes the base of support.
Throughout the sitting and standing exercises, maintenance of best postural
alignment
is stressed.
Obtaining the programme/further information
The Keeping Moving programme is available to order, free of charge, from:
Sharward Services Ltd
Westerfield Business Centre
Main Road
Westerfield
Ipswich IP6 9AB
Tel: 01473 212115
Email: pds@sharward.co.uk
The booklet is also available to download on the PDS website at
www.parkinsons.org.uk

References and bibliography

American Council on Exercise (2000) ACSMs guidelines for exercise testing
and prescription (6th ed) Lippincott, Williams and Wilkins, Philadelphia
Bassett S & Petrie K (1999) The effects of treatment goals on patient
compliance with physiotherapy exercise programmes Physiotherapy 85(3)130
137
Behrman A et al (1998) Verbal instructional sets to normalise the temporal and
spatial gait variables in Parkinsons disease J Neurol Neurosurg Psychiatry 65,
58082
Buchwald J (1967) A functional concept of motor learning American Journal of
Physical Medicine 46(1)141150
Charlett A et al (1998) Breadth of base whilst walking: Effect of ageing and
Parkinsonism Age and Ageing 27, 4954
Chartered Society of Physiotherapy (2001) Effectiveness bulletin: Neurology:
Parkinsons disease, Multiple Sclerosis and severe traumatic brain injury
Effectiveness Bulletin Evidence-based Practice Vol 3, Issue 2, pp13
Comerford M & Mottram S (2001a) Functional stability retraining: Principles and
strategies for managing mechanical dysfunction. Manual Therapy; 6(1);314
Comerford M & Mottram S (2001b) Movement and stability dysfunction
contemporary developments Manual Therapy; 6(1);1526
Crook P et al (1998) Adherence to group exercise: Physiotherapy-led
experimental programmes Physiotherapy 84(4)366372

Daleiden S (1990) Weight shifting as a treatment for balance deficits: A

literature review Physiotherapy Canada 42(2)8186
Deane KH et al (2001) Physiotherapy for Parkinsons disease: A comparison of
techniques (Cochrane Review) The Cochrane Library, Issue 2, Oxford:
Updated software
Deane KH et al (2001) Physiotherapy versus placebo or no intervention in
Parkinsons disease (Cochrane Review) The Cochrane Library, Issue 3,
Oxford: Updated software
Di Fabio R & Emasithi A (1997) Ageing and the mechanisms underlying head
and postural control during voluntary motion Physical Therapy 77(5)45875
Franklyn S (1986) An introduction to physiotherapy for Parkinsons disease
Physiotherapy 72(8)379380
Hodges P et al (2000) Three dimensional preparatory trunk motion precedes
asymmetrical upper limb movement
Gait and Posture 11,92101
Hodges P & Richardson C (1997) Contraction of the abdominal muscles
associated with movement of the lower limb Physical Therapy 77(2)132144
Hong Y et al (2000) Balance control, flexibility and cardiorespiratory fitness
among older Tai Chi practitioners Br J Sports Med. 34,2934
Horak F et al (1992) Postural inflexibility in Parkinsonian subjects J of the
Neurological Sciences 111,4658
Jancewicz A (2001) Tai Chi Chuans role in maintaining independence in
ageing people with chronic disease Journal of Bodywork and Movement
Therapies 5(1)7077
Kinsman R (1986) Conductive education for the patient with Parkinsons
disease Physiotherapy 72(8)385
Kinsman R et al (1988) A conductive education approach for adults with
neurological dysfunction Physiotherapy 74(5)227230
Kuypers HG The descending pathways to the spinal cord, their anatomy and
function In Eccles JC and Schad JP (Eds) (1964) Progress in brain research
Volume II; The organization of the spinal cord. Elsevier, Amsterdam
Lan C et al (2000) Tai Chi Chuan to improve muscular strength and endurance
in elderly individuals: A pilot study. Arch Phys Med Rehab 81, 604-607
Li JX et al (2001) Tai Chi: physiological characteristics and beneficial effects on
health Br J Sports Med 35,148156
Manchester D et al (1989) Visual, vestibular and somatosensory contributions
to balance control in the older adult J of Gerontology Medical Sciences
44(4)M118127
McNiven D (1986) Rotational impairment of movement in the Parkinsonian
patient Physiotherapy 72(8)381382
Morris M (2000) Movement disorders in people with Parkinsons disease: A
model for physical therapy Physical Therapy 80(6),578597
Morris M et al (1999) Strategies to prevent falls in people with Parkinsons
disease Physiotherapy Singapore 2,135141
Morris M et al (1998) The role of the physiotherapist in quantifying movement
fluctuations in Parkinsons disease Australian Physiotherapy 44,105114

Murray M et al (1978) Walking patterns of men with Parkinsonism American

Journal of Physical Medicine 57(6)278294
Norris C (1995) Spinal stabilisation 1. Active lumbar stabilisation concepts
Physiotherapy 81(2)6164
Norris C (1995) Spinal stabilisation 4. Muscle imbalance and the lower back
Physiotherapy 81(3)127137
Plant R & Jones D (2001) Guidelines for physiotherapy with Parkinsons
disease. London: Institute of Rehabilitation, University of Northumbria
Plant R (2000) Physiotherapy for people with Parkinsons disease: UK best
practice short report, Institute of Rehabilitiation, University of Northumbria,
Newcastle upon Tyne.
Rescue Project
www.rescueproject.org/overview/welcome.htm
Reuter I & Engelhardt M (2002) Exercise, training and Parkinsons disease:
Placebo or essential treatment? The Physician and Sportsmedicine 30(3)43
50
Reyneke D (1993) The Pilates method of exercise and rehabilitation
Physiotherapy
in sport XVIII (3),19
Schenkman M et al (1998) Exercises to improve spinal flexibility and function
for people with Parkinsons disease: A randomised controlled trial JAGS 46,
120716
Schenkman M et al (1989) Management of individuals with Parkinsons
disease: Rationale and case study Physical Therapy
69(11),944955
Stallibrass C (1997) An evaluation of the Alexander technique for the
management of disability in Parkinsons disease a preliminary study Clinical
Rehabilitation 11,812
Stockmeyer S (2002) Course notes from
MSc module.
Urquhart D et al (1999) Gait consistency over a seven-day interval in people
with Parkinsons disease Arch Phys Med Rehab 80,696701
Ward C (1992) Rehabilitation in Parkinsons disease. In: Reviews in Clinical
Gerontology: 2,254268. London: Edward Arnold Publishers
Weinrich M et al (1988) Axial versus distal motor impairment in Parkinsons
disease Neurology 38,540545
Williams P & Lord, S (1995) Predictors of adherence to a structured exercise
programme for older women, Psychology and Aging 10(4),617624
Woolacott M & Shumway-Cook A (1990) Changes in posture control across the
life span A systems approach Physical Therapy 70(12)799807
World Health Organisation (1980) The international classification of
impairments, disabilities and handicaps A manual of classification relating to
the consequences of disease. Geneva; WHO
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Parkinsons Disease Society
215 Vauxhall Bridge Road, London SW1V 1EJ, UK
Tel: 020 7931 8080 Fax: 020 7233 9908
Helpline: 0808 800 0303. (The Helpline is a confidential service.
Calls are free from UK landlines and some mobile networks)
Email: enquiries@parkinsons.org.uk Website: www.parkinsons.org.uk

Parkinsons Disease Society of the United Kingdom (2008)

Charity registered in England and Wales No. 258197 and in Scotland No. SC037554.
A company limited by guarantee. Registered No. 948776 (London)
Registered office: 215 Vauxhall Bridge Road, London SW1V 1EJ

Revised October 2008

To obtain any PDS resource, please go online to www.parkinsons.org.uk or contact

Sharward Services Ltd, the appointed PDS Distribution House, at Westerfield
Business Centre, Main Road, Westerfield, Ipswich, Suffolk IP6 9AB
tel: 01473 212115, fax: 01473 212114,
email: pds@sharward.co.uk
Code FS79
A summary of the exercises in the proposed class, their aims and
source
Exercise Aim Literature
Relaxation Reduces daily tensions Franklyn 1986,
prior to exercising, Schenkman et al 1998,
heightens awareness of Morris et al 1999, Body
the different parts of their control pilates
body and starts to
decrease rigidity to allow
increased flexibility

Breathing exercises Further reduces tension Schenkman et al 1998

and increases vital
capacityof
the lungs

Exercises in lying
Neck rolling To increase range and Weinrich et al 1988,
freedom of movement of Schenkman et al 1998,
head on trunk to aid Di Fabio 1997
increased visual input and
balance (anticipatory and
reactionary strategies).
Encourages
posture/positioning of the
head.

Pelvic tilt To improve range and Norris 1995

smoothness of movement
in pelvis for activities of
weight transference eg sit to
stand, walking. Strengthens
axial muscles used for core
stability

Knee opening Core (axial) stability whilst Norris 1995, Hodges et al

controlling movement and 1997 & 2000
range of a single limb also
stabilises the pelvis in
transverse plane.

Knee lifts Progression of knee Norris 1995, Hodges et al

opening still with single 1997 & 2000
 limb action, but in a
different plane of
movement, pelvis
stabilisation in sagittal
plane.

Leg stretch Progression of the knee Norris 1995, Hodges et al

lift but increasing core 1997 & 2000
stability control as
controlling a fully
lengthened limb (long
lever). Pelvic stabilisation

Arm reaching Single limb arm stretch for Norris 1995, Hodges et
range to arm, shoulder al 1997 & 2000
girdle complex (including
the scapula) and thoracic
spine

Arm and leg stretch Increased complexity with Norris 1995, Hodges et
dual tasks to control al 1997 & 2000
opposing limbs for core
stability and diagonal limb
range

Knee rolling Increase range and McNiven 1986,

freedom of trunk rotation Schenkman
et al 1998
Exercises in sitting
Sitting posture Posture maintenance with Franklyn 1986
mental rehearsal of good
alignment for sitting and
standing tasks

Sitting pelvic tilt Progression of pelvic tilt Norris 1995

exercise in lying with
maintenance of upright
posture

Trunk rotations Improve range and McNiven 1986, Schenkman

freedom of trunk rotation to et al 1998
separate upper trunk from
lower trunk for
counterbalance in walking
and to maintain balance in
tasks involving reaching
or twisting

Exercises in standing
Rocking on feet: Forwards Forwards and backwards Horak et al 1992,
and backwards sway to increase balance Woollacott & Shumway -
within cone of stability in Cook 1990, Daleiden 1989
one plane, and then
reduce rocking movement
until standing with weight
evenly at best point of
balance. For weight
transference for sit to
stand, walking etc and
input to ankle strategy for
balance. Also improves
postural control and
increases confidence for
tasks in steady standing

Rocking on feet: Side to Repetition of the above Horak et al 1992,

side exercise in the coronal Woollacott & Shumway-
plane Cook 1990, Daleiden 1990,
Manchester
et al 1989
Circling on feet Combination of above two Horak et al 1992,
exercises circling in one Woollacott & Shumway-
direction, and then the next Cook 1990, Daleiden 1990,
to combine hip and ankle Manchester et al 1989
balance strategies plus
weight transference in all
directions

Sideways arm stretch Complex co-ordination of

bilateral out of phase arm
control in two planes with
neck rotation

Rotation in standing Progression of rotation Schenkman et al 1998,

exercise in sitting, with Morris et al 1999
maintenance of upright
posture

Rotation with stepping Progression of the above Schenkman et al 1998,

exercise but inclusion of a Morris et al 1999
step to the side rotation
increases need for control
of weight transference and
smooth stepping skills

Stepping forwards Exercise to practice length Murray et al 1978,

and quality of stepping Behrman et al 1998 with
action, to aid balance, verbal instructions Franklyn
initiation problems, co- 1986, Daleiden 1990,
ordination of aspects of a Charlett et al 1998
step forwards in
preparation for controlled
walking

Stepping backwards Repeat of the above Daleiden 1990, Charlett

exercise but backwards to et al 1998
increase hip and trunk
extensor control in
preparation for walking
Standing bend and stretch Full body stretch with arms
with knee flexion up to the ceiling combined
with deep breath in and
slow, controlled knee and
hip flexion to touch floor on
the breath out. Multi-
tasking with sequences of
movements whilst
maintaining body control
from extension through
flexion and postural
adjustments. Useful for
balance, flexibility of spine,
limb range of movement
and sit-stand tasks

Standing bend and stretch Full body stretch with arms

with knees straight up to the ceiling combined
with deep breath in, and
slow, controlled hip flexion
to touch floor on the breath
out. Further challenges
balance as the reach to the
floor demands greater
control as there is no knee
flexion to counter forward
movement.

Loosening twist End of the programme

with free action rotation
from side to side, allowing
arms to swing freely aiding
momentum of twisting
action. To relax body in the
standing position, but also
a challenge to standing
balance in the face of
maintenance of good
posture and speed of
movement