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Tags >> PD Rehabilitation

Dr. Kelvin Chou, MD, Associate Clinical Professor of Neurology, Director, Deep Brain Stimulation Clinic and Co-Director, Movement Disorder Clinic, University of Michigan Medical Center; and Member, MPF Professional Advisory Board. Anonymous Family. Deborah M. Orloff, MPH, BSN, RN, Chief Executive Officer, Michigan Parkinson Foundation.

Over the years, one of the major concerns we at the Michigan Parkinson Foundation continue to hear is the fear people with Parkinson's have regarding hospitalization. A traumatic experience in itself, the inability of those hospitalized to receive Parkinson medications as prescribed makes this experience even more difficult. We have read articles in other newsletters about difficulties encountered and even the need to avoid emergency rooms. Others, on a more positive note, focus on how to handle the hospital situation.

Dr. Kelvin Chou (University of Michigan), and his colleagues wrote an article which was featured in NPF's Parkinson's Report as well as the Messenger, (Fall 2008, pp. 6-8), answering 5 frequent questions about hospitalization. Since then, the Michigan Parkinson Foundation's Professional Advisory Board sanctioned a 4- page form created by the Parkinson's Resources of Oregon and Oregon Health & Sciences University ("Critical Information for Caring for the Parkinson's Patient") which we are encouraging people to complete prior to their hospitalization so they can explain to hospital staff what their needs are. Yet, the problem continues.

The National Parkinson Foundation commissioned neurologists at their Centers of Excellence to review articles and studies relating to the effect of hospitalization on people with PD. Dr. Chou was part of this effort and the results were published in the journal, Parkinsonism and Related Disorders (Aminoff, et. al, Management of the hospitalized patient with Parkinson's disease: Current state of the field and need for guidelines. 2011, pp. 139-145). A White Paper was written, focusing on the need for education of hospital staff about the care of the person with PD while hospitalized.

In this article, we report the success of one family in working with hospital staff to care for the hospitalized person with PD. As the story unfolds, Dr. Chou comments on each aspect, from preparation for the emergency room to what happens during the hospitalization. It is the intent of the Michigan Parkinson Foundation to work towards furthering the knowledge base of health professionals to enable the person with Parkinson's to receive optimal care, regardless of the setting.

Mr. and Mrs. X were very satisfied with their care during a brief hospital stay at a local hospital. It could have turned into a discouraging situation had they not been able to work out a compromise with health professionals with whom they dealt.

Mrs. X has had PD for over 20 years and is, as she puts it, very meticulous about her medication schedule. She needs to maintain a very strict every 3-hour schedule while awake, or else she goes into an "off period" (becomes very slow and rigid) and consequently she has carefully constructed a comprehensive method of insuring that she takes her medication on time.

During the summer, she was treated on an outpatient basis for a bladder infection. Despite treatment, symptoms persisted and were severe enough to result in her having to go to the emergency room. Her husband accompanied her. What is very striking is their preparation to go to the ER. The system she has developed helps her to feel a measure of control over managing her condition which at times can be overwhelming.

    1. Mrs. X has a form on her computer where she enters all of the pertinent information about her medications and conditions that are important. She carries a copy of this in her wallet and also places it in a small "cosmetic bag." At right (next page) is what her record looks like. Note that there are additional instructions at the bottom.

    2. In this cosmetic bag, she also has a 2-day supply of all of her medications, plus one extra dose. Because she needs to take her medications frequently, she uses a pill container that is actually intended to hold a week's supply, but she places one dose in each compartment for the entire day. There is an extra compartment where she places a back-up dose - just in case. Her pill containers are filled every other week, allowing her to have a 2-week supply. Mrs. X carries a 2 day supply with her at all times.

    3. In order for her to ensure she takes her medication on time, she uses a watch with an alarm which she sets to go off every 3 hours. Just in case, she sets it 10 minutes early to allow for a window. In her cosmetic bag, she also has a form that she checks off each time she takes her medications.

Commentary: The preparation of Mrs. X is to be commended. Such preparation is important not only for the emergency room, but for clinic visits as well. Being organized helps the physician focus on the patient and the patient's complaints, rather than spending time figuring out which medications the patient takes. Knowing your medications or having a current list also decreases the likelihood of mistakes.

Once at the ER, her husband explained to the staff that she needed to take her medications on time, showing them her medication system. The staff allowed him to help administer the pills to her. Mrs. X had various tests and it was determined that she needed to be hospitalized for IV therapy treatment.

Commentary: Based on the review of the medical literature, it is clear that patients with PD are admitted more often to hospitals and frequently have longer hospital stays than the general population. However, what is most interesting is that PD symptoms by themselves are not common reasons for hospitalization. In fact, the most common reasons for hospital admission among PD patients are pneumonia or other infections (such as urinary tract infections), elective procedures (such as a knee replacement or hip replacement), cardiac problems (such as heart attacks), gastrointestinal disorders (such as nausea, vomiting and diarrhea), and lightheadedness with standing causing fainting spells, strokes, and changes in thinking and memory. PD is often treated by a neurologist in the clinic, so hospital staff are often unfamiliar with PD symptoms and PD medications. You will be surprised how much more you know about your disease than the people you interact with in the hospital. Be prepared to re-educate the staff as you are transferred from the emergency room to your hospital room.


Once admitted to her hospital room, accompanied by her husband, Mrs. X was interviewed by a nurse. The couple explained that she had a strict schedule of several medications which had to be taken at specific times, and described the timing of the medications. They found out that one of the medications was not on the formulary, and the hospital couldn't provide it. Additionally, the nurse informed them that, because of staffing, it would be difficult to maintain such a strict administration schedule.

Commentary: These are common problems encountered in the hospital. Often, PD medication schedules may be changed to match that of other required medications (such as antibiotics) or to better accommodate a nursing schedule. This is often because nurses have to take care of many patients, and making medication times similar between patients allows for more efficient administration. There is also often a one hour window before and after a scheduled timing of medication that is allowed in hospitals. This flexibility is there just in case there is an emergency that the nurse or hospital staff has to address. Finally, hospitals may not stock your brand of medications. All of these changes may result in greater risk for wearing off for the PD patient. If you need a strict administration schedule or if you need your own brand of medication, some hospitals may allow you to keep your own medications at the bedside as long as it is drawn exactly from what was written on the bottle.


Anxious about the whole process, Mr. and Mrs. X asked if it would be allowable for her to keep her own medications at the bedside. This was not allowed. Again, they stressed that Mrs. X had to take her medications precisely, explaining the anxiety this caused and the consequences of on-off symptoms.

The nurse called in her supervisor, who said she understood what they were saying, "but the rules won't allow for us to deliver your medications as precisely as you want." However, she did call in the Pharmacy supervisor. Again, Mr. & Mrs. X discussed the dilemma.

After some discussion, the staff nurse made a suggestion that solved the problem. Mrs. X's medications would be brought in and stored by the staff. The nursing staff brought Mrs. X each dose one hour before the medications were due. Mrs. X could see the medications and this allayed any anxiety she had. She took her medications at the precise time she needed them, with help from her husband if necessary, and informed nurse when she had taken the pills.

This strategy gave both the X's and the hospital staff a zone of comfort. Mr. X concluded that any person with PD admitted to a hospital needs another person to advocate for him/her and who understands the fear of being without timely medications.

Commentary: Although the hospital would not let Mrs. X keep her own medications at the bedside, she did not give up and continued to try and find a solution that would work for her and the hospital staff. The lesson here is Hard work now = Less work later. The person with PD knows when medications wear out and often becomes compulsive about taking medication. Hospital staff, on the other hand, do not realize that many people with PD fear that they will never get out of the "off" time. Putting in the effort initially to educate staff and get what you want (Hard work now) will result in a less anxious stay with little off time (Less work later). Convince nurses that giving medications to you on a strict schedule (Hard work now for them) will result in fewer calls for assistance because of immobility or anxiety later (Less work later for them). Persevere and find a compromise. This allows everyone to win. Try to apply the Hard work now = Less work later principle the next time you need to be hospitalized and hopefully you too will have a successful outcome.



By: Kelvin L. Chou, M.D., Michael S.Okun, M.D., Hubert H. Fernandez, M.D., Diane Breslow, MSW, LCSW, Joseph H. Friedman, M.D.

Most people with Parkinson's disease will need to be hospitalized at some time. Hospitalization can be stressful for various reasons. The neurologist who takes care of you and manages your Parkinson's disease medications may not have privileges at the hospital where you are admitted. The hospital physicians and nursing staff may not know a lot about PD. If you undergo surgery or other invasive medical procedures, you may not be able to take any medications until the surgery or procedure is complete.

It is important for the patient and the caregiver to plan and anticipate what is likely to happen. This article will answer five of the most frequently asked questions about hospitalization for people with Parkinson's disease.

1) When I am in the hospital, why don't I always get my medications on time?

Hospitals and hospital pharmacies have their own dosing schedules. A medication written for "TID (three times a day)" may be given at 7 AM - 3 PM - 11 PM or some other standard schedule. Many hospitals may have a policy that permits nurses to give medications at times different (generally, one hour before or after) from the scheduled time. This policy is a practical compromise because nursing staffs are busy and each nurse cares for multiple patients. Such a policy provides nurses time to complete their scheduled duties and allows flexibility in case of emergencies on the ward. As a result, it may seem that patients with Parkinson's disease receive their medications at random times.

How can such a situation be remedied? First, make sure that the drug schedule, with specific times, is written into the doctor's orders. Check that the physician knows when it should be given. Bring with you the complete list of your medications with the correct dosage. Talk with your nurse about the importance of receiving your medications on time. Explain that, without the medications, you can be immobile or uncomfortable and that the medications allow you to move around independently. You may know more about Parkinson disease than the doctor and the staff, so it is your responsibility to help them understand your situation. While you will still need to be somewhat flexible, sharing your knowledge can alleviate many problems. The staff wants patients to be well cared for during their stay.

2) Why can't I take my own medications in the hospital? Why do they substitute some medications for me?

The nursing staff must have control of your medications. This is a safety issue and is standard hospital policy.

Some patients may be taking medications that are not stocked in that hospital's pharmacy. In such situations, the hospital physician may have to prescribe substitute medications. If you want to take your own medications, bring them from home in their original bottles and give them to the nurses, who will dispense your medications. In some hospitals and outpatient surgical facilities, the doctor can write an order for patients to take their own medicines under supervision.

3) My mother has Parkinson's disease and was recently hospitalized. However, she seems to be moving much worse in the hospital than at home. Why is that?

Several explanations are possible. When patients with PD are hospitalized with an infection of some kind, whether it is the common cold, pneumonia, or a urinary tract infection, they often feel their PD symptoms are worse. Increased tremor or more difficulty walking may be noted. When the infection is treated, their symptoms generally improve.

Patients with PD who have an infection can experience more difficulty with swallowing, so that food goes down into the lungs, causing an "aspiration pneumonia," which may further impair swallowing ability. A speech pathology consultation can be useful to formally assess swallowing and make dietary recommendations. Additionally, a respiratory therapist consultation for "chest PT" may help patients mobilize the sputum and make it easier to cough.

Another possible cause of worsening symptoms is the addition of new medications. Common offenders include certain antipsychotic drugs or antinausea drugs commonly prescribed in hospital settings. Other medication may be substituted.

All patients with PD should be as active as possible in hospital. Moving around not only tones muscle, it allows faster recovery and prevents decomposition of the skin from staying in one position for too long. You may have no choice if your doctor orders you to bed rest; then, physical therapy should be ordered. Some patients may also need rehabilitation at a rehabilitation hospital or a nursing facility before being discharged home.

4) My husband has Parkinson's disease and became confused in the hospital last time he was there. How can I prevent this?

Any infection in a patient with PD can tip a patient "over the edge" mentally, or adversely affect motor function. New medications, especially for pain, frequently result in disorientation and memory problems. Lack of sleep, IV machine alarms and hallway lights can also contribute to a confusional state. Nurses regularly enter the room overnight to take vital signs, give medications, or check on a patient. For some, especially the elderly with intermittent confusion at home, being in a different and unfamiliar environment may tip them into a delirious state. The combined effects of anesthesia and medications to treat incision pain following surgery also can cause confusion.

Confusion often disappears once the underlying cause is treated, whether it is the infection or problems with medications. Frequent reassurance, support and comfort may be all that is needed. Confusion can sometimes lead to aggression, refusal to take pills, hallucinations or delusions. Physical restraints may be necessary to prevent self-injury. Some hospitals have bed or wheelchair alarms to alert nurses when patients wander; other facilities may use a sitter. If there are psychotic symptoms such as visual hallucinations, clozapine (Clozaril) and quetiapine (Seroquel) are the only antipsychotics to be used for most patients with PD.

In very severe cases of confusion with hallucinations and behavioral changes, physicians may temporarily discontinue dopamine agonists, MAO inhibitors, amantadine, benzodiazepines and pain medications. Treatment with carbidopa/levodopa and either clozapine or quetiapine will usually result in improvement. Later, patients may slowly be titrated back onto previous doses.

5) I had deep brain stimulators (DBS) placed two years ago. I now need to have knee replacement surgery. Will the doctors know how to take care of me?

Many medical professionals and hospitals still may not be familiar with this treatment. There are a few things you and your doctors should be aware of. First, if you have had DBS surgery, you can only get a MRI of the brain, and it must be done with something called a head-receive coil. You cannot get a MRI of any other part of the body, because the DBS device can become heated and damage the brain tissue during MRI. Radiologists performing a brain MRI can learn of certain precautions from the FDA. Additionally, your stimulator's voltage should be turned down to 0 before the MRI. Only a programmer experienced with MRI should supervise the procedure.

An electrocardiogram (EKG) may be important if you happen to have cardiac problems before, during or after surgery. But the stimulators may interfere with the EKG. Bring your portable Medtronic Access Device or Access Review Device (or a magnet that comes with the device) to turn off your stimulator in the hospital. Know how to turn your stimulators on and off before going to the hospital, or having any type of surgery. Similarly, if you need a brain wave test - an electroencephalogram (EEG) - or will simply be monitored during an inpatient or outpatient procedure, know how to turn that device off.

Most anesthetics are safe for individuals who've had DBS. However, some precautions need to be taken when using electrocautery, which stops bleeding during surgery and could potentially reset your stimulator to its factory settings. Only bipolar electrocautery is recommended (with grounding placed below the level of the device). If your neurologist is on staff at the hospital where you are getting surgery, ask him or her to confirm that your stimulator is on and that the correct settings are reset following surgery. Otherwise, schedule a follow-up appointment with your neurologist to recheck your settings soon after discharge from the hospital.

The above tips and scenarios should help aid minimize problems for patients with PD who are hospitalized. Some symptoms do worsen following general or local anesthesia. There are patients who have reported feeling as if they never return to their baseline. Generally, local anesthesia is thought to be safer than general anesthesia. If you have problems with thinking and memory, have them evaluated prior to surgery as they may deteriorate.

Finally, it is important to discuss with close family members what you would like done in case of a life-threatening emergency. They and the medical staff should know your medical wishes. You should choose an advocate who can ask questions and act as your spokesperson. If you have a living will or a durable health care power of attorney, those documents should be brought to the hospital and placed in the medical chart.

The checklists below are useful tools to take with you to the hospital: one for you and one for your doctor/nurse.You can assist them with lessening some of the stress of your hospital stay; this, in turn, can help other patients with PD later on.


Information Checklist for Hospital Stays

General Points to be Aware of When Entering the Hospital

  • Provide a list of your medications with exact times, frequencies and dosages. Share your knowledge about PD, including on-off fluctuations and the importance of taking medications at specific time intervals.
  • Bring medication in original bottles.
  • Know which drugs can worsen the symptoms of PD
  • Research study participants should provide information about experimental drugs. Inform the study coordinators that you are in the hospital.
  • Speak up when medications are wearing off.
  • Do not take medication on your own. Unless you have prearranged permission, the staff should administer all medication.
  • Tell the staff if you have a (DBS) implant. Bring the access review or magnet device to turn the stimulator on and off.
  • Inform your neurologist that you are in the hospital. Provide your neurologist's phone number of your neurologist to your hospital doctor.
  • Be mobile, especially during prolonged stays! Walk around as much as possible. Inquire about physical therapy or occupational therapy.

If you have difficulty swallowing:

  • Sit up while eating.
  • Ask for a speech-swallowing therapist.
  • Alert staff that your medications may need to be crushed and administered through a tube. Make sure medications are administered one hour prior to meals or feedings, especially if medications are crushed.
  • There is a dissolvable form of carbidopa/levodopa called Parcopa® that can be given by placing on the tongue.

Factors that may make your symptoms worse:

  • Failure to get medications at specific times and coordinated with meals.
  • Certain dopamine blocking drugs can worsen symptoms. If absolutely necessary because of hallucinations or behavior, only quetiapine (Seroquel) or clozapine (Clozaril) should be used.
  • Anxiety, stress, and sleep deprivation
  • Urinary tract, lung, or other infections (and antibiotics)
  • Provide Advance Directives: Power of attorney for health care and living will. Choose an advocate who can ask questions and act as your spokesperson. Make sure this person is aware of your medical wishes so he or she can assist in speaking for you if needed.


Information Checklist for Your Nurse and Doctor When You Enter the Hospital


  • Name of your Parkinson's disease (PD) neurologist.
  • Phone Number of your PD neurologist.

The following are some suggestions to make the hospitalization of this person with PD smoother:

  • Parkinson's disease medications often need to be given at specific times of the day. When writing medications in the orders, please use specific times (e.g. 8AM, 11AM, etc.).
  • Patients with PD should resume medications immediately following procedures, unless vomiting or severely incapacitated.
  • If there is confusion, consider urinary or lung infections.  Also, pain medications or benzodiazepines may be potential causes.



By Susan R. Vergilio, OTR

It has been said that the "horse symbolizes the drive for freedom shared by people of all nations" (author unknown) and that "in riding a horse, we borrow freedom" (Pam Brown). All who come in contact with these beautiful animals, especially those patients receiving hippotherapy, can confirm these quotes. Hippotherapy is a treatment tool used by a specially trained occupational, physical, or speech therapist to treat patients with neurological problems. By using the specific movement of the horse, the therapist can influence the patient's nervous system and ability to plan their movement. Why the horse? The horse's movement is rhythmic and repetitive, and with the right horse, it is symmetrical. The horse's stride also simulates human walking in terms of the influence of movement on the hips of its rider. It also encourages motor learning, a treatment principle that therapists use in treatment, so the movement of the horse creates responses that are essential for walking and other activities, which can be carried over off of the horse. The horse acts as a three-dimensional mobile mat from which therapy can occur. As therapists, we are continuously trying to teach "normal" movement to our clients with neurological problems, and the horse can naturally assist us with this. The movement of the horse can improve balance, strength, tone, timing, coordination, and postural control, which can all lead to improved functional ability of the person with Parkinson's disease. In addition to the natural influence of the horse's movement, there is added benefit from the natural animal-human bond that occurs throughout the sessions. Animals are extremely motivating and can inspire us and touch us in ways that the traditional setting for therapy cannot. This is especially important because therapy is a participatory program. Your therapist can't just do therapy to you; you have to participate and be engaged in the activities in order for them to be effective. Let's face it, when you have been involved in the same traditional treatment activities for a long time, they become a bit repetitious. This leads to decreased patient motivation and participation and therefore decreased improvements in treatment. This is why hippotherapy opens up a whole new opportunity for patients.

Tim is a 47 year old man with Parkinson's. He receives hippotherapy treatments once a week. Tim was in his 30's when diagnosed with Parkinson's disease. In the past, he has been involved in traditional therapy and recently started hippotherapy. He, as well as his family, feel that the hippotherapy has improved his function at home as well as improved his mobility overall. He had developed the very classic signs associated with Parkinson's disease, including a flexed posture, decreased coordination, increased rigidity, as well as "scissoring" in both of his legs. He was wheelchair-dependent prior to starting his hippotherapy sessions. He is now able to walk short distances, with improved control and coordination. He is noted to have a visible change in control over his legs, with less "scissoring" immediately following his session. Tim says he feels he hasgreater self- esteem, and feels the sessions are "good for the soul," not to mention feeling less rigidity through out his body following his hippotherapy sessions.

Hippotherapy is not for everyone. All patients must be carefully screened. Typical hippotherapy sessions are 1-2x/week, 30-60 minutes in duration, and are used in addition to traditional therapy techniques. Treatment can only be effective if the therapist has been specially trained to utilize the proper movements of the horse from an accredited program. For more information regarding hippotherapy or if you interested in receiving hippotherapy services please contact Sue Vergilio, OTR at Stable Possibilities LLC, at 586-292-8472.



by Michelle Elmo, Physical Therapist

Good posture is important for everyone. In the general population, many back and neck problems stem from poor posture. In addition to this, poor posture decreases a person's ability to weight shift appropriately to maintain balance. Patients with Parkinson's disease are often already set forward due to poor posture and have minimal ability get to neutral let alone shift weight backward without falling. Therefore it is even more important that these patients be diligent about fighting bad posture. So how do you do that?

First, by stretching tight muscles: Pectoral muscles (the front of the chest) Ilipsoas muscle (front of the hip) Hamstrings (back of the upper leg) Gastrocnemius and Soleus (back of the lower leg)

Second, by strengthening the muscles that tend to get weak: Gluteus maximus- buttocks Erector spinae- on either side of the vertebrae of the back Posterior scapular retractors-between the shoulder blades Cervical extensors- in the neck and keep the head from falling forward.

Thirdly, correct positioning at all times: Get rid of extra pillows, only use one pillow to support the small of the neck when you sleep. Sit back against the chair and pull head back- "chin tucks". Walk tall- always think shoulders back, head up, chest out and lead with your heels.

We know exercise works! Many research articles document improvement in balance, confidence, quality of life and reduced fall rates with persons with Parkinson's disease when they are participating in an exercise program. Studies have looked at community verses home based programs and have found improvement with either. Improvement is usually noted in first 3-4 weeks of exercise, with exercise occurring 3-5 times per week. Exercise needs to be a lifelong habit and the benefit fades if exercise stops.

There are many publications with exercises especially for persons with Parkinson's. Many persons not familiar with exercise or anatomy of muscles may have a hard time simply following written instructions for exercises. Don't be overwhelmed! Please ask your physician for a physical therapy referral so that you can be confident and performing exercises that will benefit you maximally. If you are able to safely leave home you can go to an outpatient clinic. If you are rarely and not routinely leaving home you may receive services in your home.

Michelle Elmo is a Physical Therapist, graduate of Grand Valley State with a Masters in the Science of Physical Therapy. She currently works at Gentiva Home Health in Jackson. This article is a portion of her presentation to the Jackson Parkinson Support Group.




The Messenger - Fall 2010 Issue. Comments by Brian Cooper, OTR, Residential Home Health, Member, MPF Professional Advisory Board.

Preliminary studies show that patients with Parkinson's disease who regularly do certain exaggerated movement exercises are seeing reductions in their symptoms. In an article published in MedPage Today,, the senior editor reported on a study of 20 patients who underwent a supervised program called LSVT BIG for eight weeks and then worked with the Nintendo Wii video gaming system in the final four weeks.

The patients participated in a supervised open-floor series of exercises, which stresses large extensions and movements of the arms and legs. The Wii activities encouraged patients to swing their arms and move vigorously. At the end of the study, all patients showed measurable improvements.

Locally, Brian Cooper, an occupational therapist with Residential Home Health, explained that BIG is based on a successful speech therapy program for PD patients, called LSVT (Lee Silverman Voice Treatment). That therapy helps participants enhance sound and articulation by speaking at an exaggerated volume.

"LSVT BIG teaches patients how to move better, focusing on high amplitude movements to overcome perceptual deficits," said Cooper. "It shows patients, through modeling, how to make bigger movements, then reinforces through practice how to perform high intensity, high amplitude exercises."

Cooper said that patients are taught to take "great big" steps with arms extended and swinging forcefully. They are encouraged to overcome the typical shuffling steps of PD. The concept behind the program is to increase awareness of how movements are made and, by exaggerating the way they are performed, learn more effective techniques. In addition to improving walking, BIG therapy sessions can help patients work on other daily functions such as dressing.

In Michigan, certain physical and occupational therapists have been trained in BIG therapy. Typically, the therapy is conducted in one-hour sessions four times a week on an outpa¬tient basis and is customized when appropriate. After about three or four weeks, patients can practice on their own. Contact your physician for a referral. For more information, call your physician, or (866)902-4000.



by John Argue

A proactive Parkinson's Support Group in the Detroit Metro area contacted us for our professional input on the book titled Parkinson's Disease and the Art of Moving, written by John Argue. We also reviewed the companion videos that incorporate the theories found in this text, which assists in the performance of the exercise program.

John Argue is a gifted teacher with a movement/theatre/ drama therapy background who really understands the various challenges of the Parkinson's patient. Most recently, he has focused his talents toward teaching movement and voice classes for people with Parkinson's disease. I was impressed by the book and videos for many reasons. I appreciated the team approach between the family/ caregiver/client with his instructions and insights. Safety is encouraged with step-by-step exercises to be mastered before continuing to the more progressive advanced standing and floor work. The exercises begin with seated warmup activities and progress to motor planning, coordination, functional weight shift, body awareness and mobility training.

The book is helpful not only for caregivers and clients, but also for any therapist working with clients with Parkinson's disease and/or movement challenges. I particularly appreciate the yoga and Tai Chi influence within the program, which stress quality of movement, grace, and promotion of improved quality of life, an increased sense of well being, alignment, and relaxation. His emphasis on timing and rhythm also assists quite well with ambulation. I am now utilizing many of his techniques with my current patients with increased success.

People at all levels can perform many of these exercises. He also encourages caregivers to care for themselves and stay physically fit. This is a great place to begin an exercise program and I highly recommend using the book and/or video in a safe and supervised (if needed) environment. Remember to do something everyday for your health and fitness...and never give up!

The website for these resources and to learn more about John Argue is:, or phone 510-985-2645. The book is also available locally at Borders Booksellers.

Note: St. John Health System, in Detroit, recently started a weekly exercise program, in which we are also utilizing his philosophy. It meets every Tuesday at 3:00pm. Feel free to contact us if you have questions or are interested in participating in this exercise group at 313-343-3744. At home, the equipment is minimal to start. All you need is a chair with arms and a tennis ball.




Symptoms of Parkinson's Disease (PD) may interfere with people's ability to function effectively on a daily basis. Occupational Therapy, Physical Therapy, and Speech and Language Pathology are health disciplines that help people to prevent problems from occurring and to treat difficulties people are having. They can offer you strategies to improve your function or adapt to changes that are imposed by Parkinson's symptoms. Family members can also be involved in learning techniques to make life easier. Typically, a referral by a physician is needed in order to have these services covered by health insurance. It is also necessary to see under what circumstances your health plan provides coverage.

Communication Impairment in PD: Speech and Language Pathology

Speech, language, voice and swallowing disorders are common problems in patient's with moderate to significant PD. Very often the first sign of significant PD is reduced voice power and increased rate of utterance. As the duration of PD increases communication impairment also becomes more complex. Additional communication problems may include poor precision and strength of speech sound pronunciation and reductions in expressive language complexity. Further some patients will experience slowing of mental functioning and memory loss that will also impact language formulation and expression. If these communication impairments become dominant in everyday activities then the patient will begin to withdraw from necessary daily communication activities . Patients may decide to refrain from answering the phone or initiating telephone calls or maintaining conversations. This communication disability can seriously isolate patients and make it difficult for them to function in their families and with caregivers.

The speech and voice communication impairment symptoms in PD are identified by speech-language pathologists as a stereotypic cluster identified as "hypokinetic dysarthria". In general, PD patients will eventually exhibit:

  • Weak and diminishing voice power.
  • Sudden increased rate of utterance.
  • Reduced range of motion of the speech gesture.
  • Monotone and monoloud speech intonation.
  • Poor initiation in speech utterance.
  • Stuttering-like fluency symptoms.

These symptoms of communication impairment can be treated by speech-language pathologists to provide exercises that will allow the patient to reduce the negative effects on overall speech intelligibility. PD patients can improve their communication with treatment, practice and a willingness to work hard to compensate for the neuromuscular impairment in PD.

Swallowing disorders in PD can be significant and should also be evaluated and treated by speech-language pathologists. Because the neuromuscular deficits in PD also affect the muscles of swallowing, patient precautions, x-ray evaluation procedures and treatment may be necessary. Patients may experience difficulty in chewing certain foods sufficiently, choking on liquids or poor passage of food into the esophagus. These swallowing difficulties can also be remedied with exercises and diet recommendations provided by the speech-language pathologist.

Finally, the possible reduction in mental functioning in PD patients has become an increasing concern. These cognitive difficulties include slowing of mental response, short-term memory limitations, slowing word retrieval, time and space disorientation, reductions in expressive language complexity and length, and diminished emotional affect. These problems should also be addressed by the speech-language pathologist in concert with social workers and caregivers.

Evaluating and treating the communication impairment of PD patients while complex, it is rewarding, because improved functioning is possible with speech-voice-language and cognitive rehabilitation.

Contributed by Richard Merson, Ph.D., Speech and Language Pathologist, Beaumont Hospital, Royal Oak Michigan
Chairman, MPF Professional Advisory Board, Member MPF Board of Directors

Occupational Therapy

Occupational therapists (OT) - Occupational therapy is a health care/rehabilitation profession. OT's work with people of all ages, who are experiencing difficulties with leading independent, productive, and satisfying lives. The goal of an occupational therapist is to assist individuals with performing their activities of daily living. People with Parkinson's Disease may need the help of an occupational therapist for many different reasons. While one person may need help learning various strategies to manage their tremors, another may need help with feeding skills, and yet another may need to learn various coordination exercises to maintain functional use of their hands, and someone else may need a home evaluation so the therapist can make recommendations on equipment needs and home safety, the list is endless. The treatment is individualized to your needs which is based on your goals for therapy as well as the therapists evaluation. If you have lost some independence due to your Parkinson's Disease consult your physician regarding occupational therapy.

Contributed by:
Sue Vergilio, O.T.R., St. John Macomb Hospital
Past Member, MPF Professional Advisory Board

Physical Therapy

Some symptoms of Parkinson's disease may include tremors, rigidity or muscular stiffness, and bradykinesia or slowness of movement. These symptoms can cause you pain, a decrease in range of motion in your joints, neck and back, a change in your posture and difficulty moving.

When you experience these problems, your balance and mobility may be affected. You may have difficulty walking and may even start to fall. If any of these occur, you may benefit from visiting a physical therapist. First you need to see your physician for a referral.

When you see a physical therapist, you will have a thorough evaluation. The P.T. will examine your range of motion, strength, coordination, balance, posture, functional mobility skills and your gait, or ability to walk.

One the evaluation is completed, recommendations may include assistive devices such as a cane or walker and a comprehensive exercise program designed especially for your needs. You will also be instructed on the importance of daily exercise or activity to help maintain or improve your quality of life.

Contributed by: Stacey Turner, R.P.T., St. John Macomb Hospital, Warren, MI
Past Member, MPF Professional Advisory Board

Mental Health Issues

The recognition and management of mental health issues is an important part of maintaining a high quality of life for all people. Common issues experience by people with Parkinson's and their families include depression, anxiety, acute confusional states, and dementia. Depression may cause sadness, loss of interest, guilt, lack of energy, insomnia and the inability to experience pleasure. Anxiety may be due to medical problems, pain, or be an understandable reaction to life's circumstances. Medical illness and medications are common causes of acute confusion. Finally, chronic confusion (or dementia) can be seen in some people with later stage Parkinson's Disease. Proper diagnosis of each of these conditions is important because treatment will improve the quality of life.

If you are experiencing any difficulties such as a change in mood or thinking, or anxiety, please discuss this with your physician. It is possible that medications prescribed for P.D. or other illnesses can cause some of these symptoms. You may need to have your medications adjusted. After exploring if there are any physical issues or medications that contribute to your mental health changes, you may receive a referral for further consultation.

Contributed by:

Mark Ensberg, M.D., Michigan State University School of Human Medicine, East Lansing, MI
Member, MPF Professional Advisory Board