Clinical Rehabilitation 2005; 19: 870 Á/877Effects of home exercises on motor performance inpatients with Parkinson’s diseaseAT Caglar Istanbul University, Neurology Department, Cerrahpasa School of Medicine, HN Gurses Istanbul University,Cardiopulmonary Department, Institute of Cardiology, FK Mutluay Istanbul University, Neurology Department, CerrahpasaSchool of Medicine and G Kiziltan Istanbul University, Neurology Department, Cerrahpasa School of Medicine, TurkeyReceived 31st January 2004; accepted 21st April 2005.Objective: To investigate the effect of home exercises on the motor performance ofpatients with Parkinson’s disease.Design: A prospective blinded study with allocation of patients into their groups byalternate weeks.Setting: A University Hospital neurology and physiotherapy department.Subjects: Recruited from a movement disorders outpatient clinic of CerrahpasaSchool of Medicine diagnosed with Parkinson’s disease, classified as Hoehn and YahrGrades I, II and III.Interventions: Patients who fulfilled the inclusion criteria were recruited to thestudy. Each patient was evaluated at the end of first and second month after thebaseline evaluation. Patients were divided into two groups. Those in the first andthird week were put in the exercise group and second and fourth week in the controlgroup. Patients in the exercise group (n 0/15) were given a schedule of exercises toundertake at home; the others (n 0/15) did not receive this instruction.Measures: Ten- and 20-m walking test, first pace length, pace number in 10 m,walking around a chair, Nine Hole Peg Board (NHPB) test.Results: Following the home exercise programme, patients in the exercise groupshowed improvement in walking 10 and 20 m, time elapsed to complete walkingaround a chair and length of the first pace length, and in the motor performance ofboth hands (p B/0.001).Conclusions: A home-based rehabilitation programme for patients with Parkinson’sdisease helped to improve motor performance compared to patients who did nottake advantage of a regular, professionally designed exercise programme.Introduction tional activity disorders may arise due to loss of trunk mobility and postural reflex, which mayParkinson’s disease (PD) is a neurological disorder also result in dependency in activities requiringcausing loss of functional abilities and progressive manipulation and skill, especially in the earlyloss of independence despite medical treatment.1 Á 3 stages.4 Á 7 Progressive bradykinesia and hypokine-Depending on the severity of the disease, func- sia result in difficulty in performing daily activities. Akinesia may hinder initiation of activity byAddress for correspondence: Professor H Nilgun Gurses, seconds or even minutes. Although levodopaPhysiotherapist, Prof. B. Tarcan, sok. Meric Konak 4 ap./ 4Gayrettepe, 80290 Á/ Istanbul, Turkey. decreases the bradykinesia, it alone would not bee-mail: email@example.com effective in increasing movement, and therefore# 2005 Edward Arnold (Publishers) Ltd 10.1191/0269215505cr924oa
Home exercise for Parkinson’s disease patients 871aggressive intervention in the early stages is Patients were evaluated by the same phy-necessary.8 siotherapist (FKM) at baseline, first month and In general, the combination of pharmacother- second month a total of three times, at the sameapy with rehabilitation is the optimal treatment time post dose. Patients and relatives were ques-strategy for symptom control.2 Patients with tioned whether medication was taken or not.milder disase severity have a better potential of Following the assessments, patient allocation toimprovement, hence commencing physiotherapy the exercise or control group was done by aand rehabilitation programmes at an early stage research physiotherapist, who was also the co-can be beneficial.9 In addition, patients at the ordinator of the study (HNG). Patients recruited inchronic stage who are independent at home and in the first and third week were included in thethe community are known to benefit from a home exercise group and patients recruited in the secondprogramme.9 Á 12 Despite the data obtained from and fourth week were included in the controlthese trials, there is still insufficient evidence to group. The appointments for assessments andsupport the efficacy of physiotherapy on motor exercise instructions were made for a day bestperformance in Parkinson’s disease as there are few suited for the patients. The home exercise pro-controlled studies to date.13 gramme was given to the exercise group by another The aim of this study was to evaluate the effects physiotherapist (ATC).of a suitable home exercise programme on motor Both the neurologist and physiotherapist whotests evaluating walking and hand skills in did the assessments and the patients werepatients diagnosed with Parkinson’s disease seen blinded to the study grouping and they did notas outpatients and who had not previously been know which treatment was to be given in a certaininvolved in a physiotherapy and rehabilitation week.programme. Patients’ inclusion criteria: . Patients had been diagnosed Parkinson’s disease by a neurologist. . Patients had to be at grade I, II and IIIPatients and methods according to Hoehn and Yahr Scale.14 . Patients had to be on a stable drug regime.Patients with Parkinson’s disease referred to the . Patients could walk independently with noMovement Disorders Outpatient Clinic at Istanbul assistance or walking aid.University Cerrahpasa School of Medicine from . Patients had no orthopaedic problems thatthe Neurology Department of the same university would affect mobility and had no systemic andwere included in the study. We used a prospective, metabolic disease.blinded and controlled design and the selection of . Patients could come to the hospital three timespatients for the groups were done by an alternate for the physiotherapy assessments.week method. Disease stage of the patients was . Patients had not been previously involved in adetermined by one of the neurologists of the physiotherapy and rehabilitation programme.Movement Disorders Outpatient Clinic (GK),and the eligible patients who fulfilled the inclusion The following assessments were performed oncriteria for the study and who agreed to participate patients; 10-m walking time (s), 20-m walking timewhen they were informed about the study were sent (s), first pace length (cm), pace number at a 10-mto the physiotherapist (FKM) for other assess- distance, time to walk around a chair (s) and Ninements (Figure 1). Each week six referred patients Hole Peg Board test.14 The 10-m timed walkwere evaluated by our neurologist. The range of involves asking the patient to walk over a seteligible patients for the study per week was 0 Á/2 distance of 10 m (with no turn component) and apatients according to our patient inclusion criteria. 20 m walk (10 m, return, 10 m) at their ownAll eligible patients who fulfilled the selection preferred speed. The second one is the time testcriteria were actually included. Selection of pa- often used with patients with Parkinson’s diseasetients for the study lasted for eight months. but, since two tests were used in different studies,
872 AT Caglar et al. Neurology Department (Patient (Pt) Reference) Movement Disorders Outpatient Clinic Neurologist Neurologist Neurologist (GK) (Pt Selection) Physical Therapist (FKM) (Assessment) 1st & 2nd Month 1st & 2nd Month Assessments Assessments Physical Therapist (HNG) (Group Selection & Coordination) Exercise Group Control Group Physical Therapist (ATC) (Exercise Training)Figure 1 Design of the study.we decided to use both of them in order to be able hands. Lowest time taken to complete the testto compare our results with the others. Time to was recorded by a chronometer.walk around a chair (s) was assessed independently Home exercises were given to the patients in thefrom 20-m walking time (s). exercise group at hospital and after the initial First pace length was determined after the training the patients were instructed to continuepatient walked on a slightly wet floor and the the exercise programme at home. Patients weredistance was measured between the fronts of instructed to carry out each of the exercisesthe first and second footprints. In order to avoid 10 times, three times a day for a period ofpatient awareness, the patient was not informed of two months. Home exercise training period wassuch a measurement. In the 10-m walking time 1 h and the primary goals were to improve rangetest, steps taken by both feet were noted. The peg of motion and functional activity, balance andboard test (which evaluates hand co-ordination) gait, and ultimately fine motor dexterity. A book-was performed while the patient was sitting. The let outlining the movements from which thepatient was requested to place the nine pegs from exercises were selected according to the needs ofthe table into the board, and then to take the pegs the patients were also given to them, aiming toout one by one and place them on the table as assist the patients visually in performing theirquickly as possible. Test was started with the exercises. The booklet included the followingdominant hand and repeated twice with both exercises:
Home exercise for Parkinson’s disease patients 8731) Relaxation and stretching exercises such as Results bending and turning of trunk.2) Exercises to ease breathing and facial muscle During the eight months, of the patients who were exercises to stress the mimic expressions and referred to the Movement Disorders Outpatient to enhance oral motor function. Clinic from the Neurology Department, only 303) Exercises to increase movement of head, neck, fulfilled the inclusion criteria and registered to the shoulder, elbow and hand, besides leg, knee study. Difficulties with transport, severity of the and feet and alternative exercise of the four illness (at grade IV or over) and having systemic limbs in supine position for recovery of and metabolic disease were the main reasons for muscular co-ordination. withdrawal from the study. Some patients had4) Exercises to assist improving body move- already had physiotherapy, so they were not ments; exercises to get in and out of bed and allocated to the study. There was no loss in either also exercises to ease standing up and sitting the exercise group or the control group in all down on a chair and turning around in the assessments, since the patients who already agreed chair. to come to hospital for three times were recruited5) Exercises done while standing up to improve to the study. The baseline characteristics of the balance and finally walking exercises were patients in exercise and control groups are shown given. in Table 1. The control and exercise groups were compar-These programmes were not recommended to the able with respect to age, sex, stage and duration ofcontrol group and they continued with their the disease with no statistically significant differ-routine activities. In order to track the compliance ences.of the exercise group, a daily follow-up diary was The assessment results of the parameters in thegiven to be completed by the patient or his or her first and second months in both groups and therelative. At the second and third visit after the comparison of these parameters in the exercise andassessments, the exercise group was referred to control groups at baseline, first month and secondphysiotherapist (ATC) again in order to check the month evaluation are shown in Table 2.diary and exercise compliance. At the end of the All variables were significantly improved in thesecond month final evaluations were carried out, exercise group, from baseline to second month,exercises were instructed and an individualized whereas there was a significant impairment in theexercise booklet was given to the control group. control group in 10-m and 20-m walking times. The exercise group consisted of 15 patients The two groups were similar on all variables at(mean age 679/5 years) and the control group baseline with no statistically significant differences.consisted of 15 patients (mean age 649/3 years). Comparison of groups showed significant changesThere was no loss in either group in all assess-ments. A patient’s treatment regimen remained constant Table 1 Comparison of patient characteristics (n 0/30)throughout this study. Except for two in the Control group Exercise group p-valuecontrol and one in the exercise group takingselegiline, all patients were on L-dopa and a Age (years) 64.3 (9/12.3) 67.4 (9/5.04) 0.325a Sex (male/female) 10 M/5 F 11 M/4 F 0.5bdopamine agonist. Statistical analysis of the data was carried out Hoehn and Yahr Stage I 1 2using the Kruskal Á/Wallis test for evaluating each Stage II 11 10group and the Mann Á/Whitney U -test and Stu- Stage III 3 3dent’s t-test in comparing the two groups. Non- 0.827c Duration of 5.2 (9/2.7) 5.5 (9/2.7) 0.79dparametric statistics chi-squared test was used to disease (years)analyse the proportion of disease stage and Fish-er’s exact test for the distribution of male and a Mann Á/Whitney U-test; bFisher exact; cChi-squared; dStu-female subjects in the two groups. dent’s t.
874 AT Caglar et al.Table 2 Improvement of motor tests and the comparison between groups Assessment time Control group Exercise group p-value Mean (SD) Mean (SD) (DBG)10-m walking time (s) Baseline 14.3 (7.7) 13.6 (5.3) !/0.762 1st month 16.2 (9.1) 10.3 (4.2) B/0.029 2nd month 15.3 (8.7) 9.46 (3.9) B/0.01p-value (DEG) B/0.03 B/0.00120-m walking time (s) Baseline 29.7 (15.8) 28.2 (12.4) !/0.779 1st month 33.2 (18.9) 22.2 (8.9) B/0.045 2nd month 33.9 (20.5) 19.3 (8.3) B/0.009p-value (DEG) B/0.013 B/0.001First pace length (cm) Baseline 50.7 (18.1) 45.1 (17.3) !/0.467 1st month 50.8 (16.4) 54.6 (14.3) !/0.515 2nd month 52 (17.8) 63.1 (13.2) !/0.056p-value (DEG) !/0.1546 B/0.001Pace number in 10 m Baseline 19.6 (8.8) 21.2 (9.9) !/0.644 1st month 20.2 (8.1) 17.2 (4.1) !/0.199 2nd month 20.2 (8.9) 15.8 (3.1) !/0.512p-value (DEG) !/0.6376 B/0.001Time taken to turn around Baseline 10.3 (8.7) 8.53 (4.1) !/0.472 a chair (s) 1st month 12.2 (9.3) 7 (3.4) B/0.05 2nd month 12.6 (10.2) 5.53 (2.27) B/0.004p-value !/0.0661 B/0.001Nine Hole Peg Board test Baseline 44.6 (16.6) 42.8 (16.7) !/0.761 left (s) 1st month 45.4 (16.4) 36.5 (11.9) !/0.101 2nd month 45.1 (15.6) 33.8 (11.1) B/0.03p-value (DEG) !/0.8899 B/0.001Nine Hole Peg Board test Baseline 37.6 (13.4) 39.1 (10.6) !/0.742 right (s) 1st month 37.9 (13.4) 33 (9.1) !/0.254 2nd month 37.6 (12.1) 30 (8.3) B/0.053p-value (DEG) !/0.9355 B/0.001DBG, Difference between groups (Mann Á/Whitney U ); DEG, difference in each group (Kruskal Á/Wallis).in 10-m (p B/0.029), 20-m walking time (p B/0.045) The differences were not statistically significant inand time taken to turn around a chair (p B/0.05) at the second month when compared with the firstfirst month assessment. When the results of the month but were still significant when comparedsecond month assessments of the two group were with baseline (p B/0.0020 and p B/0.0028, respec-compared, there were significant changes in all tively).parameters except pace number in 10 m. Comparison of the groups showed that the The difference seen in the parameters in two changes in IÁ/II, II Á/III and IÁ/III were significantmonths were compared in the groups and the in first pace length (cm) (p B/0.0017, p B/0.0002comparison of results of baseline to first month and p B/0.0000, respectively) and pace number in(I Á/II), first month to second month (II Á/III) and 10 m (p B/0.0552, p B/0.0474, and p B/0.0331,baseline to second month (I Á/III) evaluations are respectively).shown in Table 3. Comparison of the groups showed that the Comparison of the groups showed that the changes in II Á/III and IÁ/III were significant inchanges were significant in 10-m (p B/0.0053) and time taken to turn around a chair (p B/0.0344 and20-m walking time (p B/0.0159) in the first month. p B/0.0110, respectively).
Home exercise for Parkinson’s disease patients 875Table 3 Comparison of differences between assessments in two groups Difference between Control group Exercise group p-valuea assessments Mean (SD) Mean (SD)10-m walking time (s) I Á/II (/1.93 (2.49) 3.27 (3.31) B/0.0053 II Á/III 0.93 (1.94) 0.87 (1.46) !/0.9162 I Á/III (/1 (2.77) 4.13 (3.70) B/0.002020-m walking time (s) I Á/II (/3.53 (4.12) 6.00 (7.80) B/0.0159 II Á/III 1.33 (4.27) 2.93 (3.20) !/0.2563 I Á/III (/2.2 (5.59) 8.93 (8.68) B/0.0028First pace length (cm) I Á/II (/0.12 (3.82) (/8.62 (8.31) B/0.0017 II Á/III (/1.12 (4.94) (/8.92 (6.19) B/0.0002 I Á/III (/1.24 (7.01) (/17.5 (8.68) B/0.0001Pace number in 10 m I Á/II (/0.67 (2.06) 4.00 (7.16) !/0.0552 II Á/III 0.07 (1.87) 1.40 (1.64) B/0.0474 I Á/III (/0.60 (2.38) 5.40 (7.44) B/0.0331Time taken to turn around I Á/II (/1.53 (3.07) 1.53 (2.03) !/0.1201 a chair (s) II Á/III (/0.40 (2.10) 1.47 (1.41) B/0.0344 I Á/III (/1.93 (3.45) 3 (2.42) B/0.0110Nine Hole Peg Board test I Á/II (/0.73 (4.37) 6.27 (7.54) B/0.0111 left (s) II Á/III 0.27 (2.79) 2.73 (2.58) B/0.0181 I Á/III (/0.47 (5.05) 9 (7.86) B/0.0011Nine Hole Peg Board test I Á/II (/0.27 (4.61) 6.07 (7.27) B/0.0119 right (s) II Á/III 0.27 (4.95) 3.07 (3.33) !/0.0815 I Á/III 0 (4.22) 9.133 (6.59) B/0.0002aStudent’s t-test. Comparison of the groups showed that the programmes carried out in conjunction with drugchanges in I Á/II, II Á/III and I Á/III were signifi- therapy.1,15cant in the Nine Hole Peg Board test left (s) Recently, a randomized and controlled study(p B/0.0111, p B/0.0181 and p B/0.0011, respec- showed that multidisciplinary rehabilitation fortively) and in I Á/II and IÁ/III in the Nine Hole patients with Parkinson’s disease may improvePeg Board test right (s) (p B/0.0119 and p B/0.0002, mobility, and follow-up treatments may be neededrespectively). to maintain beneficial effects.18 Compliance was very high and patients dis- Some articles stated the benefits of short-termplayed great care and attention in keeping the applied physiotherapy. In one, patients were in-diary. They put ticks for every day for every structed by a physiotherapist at home, but it wassession. not a controlled study and the physiotherapy only lasted a short time.10 In a second study, patients were instructed by nursing students and the investigators were mainly interested in nursingDiscussion parameters.12 More recent articles in the literature have alsoThe effects of physiotherapy and rehabilitation on described the use of home treatment for patientspatients with Parkinson’s disease have been re- with advanced Parkinson’s disease.9,11 Investiga-searched by many investigators in the past.1,15 Á 17 tors stated that physiotherapy aimed at improvingThe findings of these studies have showed the function in Parkinson’s disease is best provided inbenefits of physiotherapy and rehabilitation the home situation.11
876 AT Caglar et al. The results of our present study suggest that if Significant improvement was found in walkingpatients with Parkinson’s disease are taught in a controlled clinical trial done by Formisonoindividualized and detailed home exercises by a et al. ,19 but the time taken to walk around a chairphysiotherapist, there is a statistically significant and Nine Hole Peg Board test completion time didclinical improvement in their motor performance not change. In our trial we observed a highlyover an eight-week period. The benefits of a significant decrease (p B/0.01) in the time to walksimilar programme have also been shown in two around a chair, however there was an increase inweeks in Parkinson’s disease as an outcome of an this time test in the control group. We think thatuncontrolled study in which home exercise was the main reason for this difference in patients ininstructed at home.10 However, our study showed the exercise group is that they had to walk aroundthat the improvement associated with physiother- the chair as a part of their home exercise pro-apy continued for longer than two weeks and the gramme.patients who were not referred to the exercise There was a significant decrease (p B/0.001) ingroup for home exercise could not benefit from it. both left and right hand Nine Hole Peg Board testIndeed, walking had deteriorated in control group completion times in the exercise group, whichpatients over two months. Instructing exercise at reflects distal motor performance. The improve-home may be feasible for patients, but it is not ment in the exercise group was due to the easilyfeasible for the hospital staff if they do not have a performed hand exercises performed frequently byspecial home therapy visiting team. This was why the patients.we chose patients (grade I, II and III) who had Although the present study was based on ano problems in transport, and we assessed and home programme, we believe the success in com-instructed the patients at hospital. Since the pliance was primarily due to the motivationalpatients agreed to come to hospital for three factor from the daily diary provided for comple-visits at the beginning of the study, we did not tion by patients or relatives. Secondly, frequentsuffer from loss of patients. Patients in the visits to hospital and being assessed in detailexercise and control groups had never been to a increased their interest in their treatment.physiotherapist before. Our results showed that Another interesting finding was that the im-patients who had difficulty in walking around a provement in most parameters was higher in thechair also took longer for the 20-m walk test. We first month, but all continued to improve in theconcluded that these two parameters may be second month also. Some outcomes such as firstdependent to each other, since 20-m walking pace length and time taken to turn around a chairtime also has a ‘turn’ component. A highly improved similarly in the first and second months.significant improvement was observed in the 10- These findings show the importance of follow-upand 20-m walking time and time taken to turn visits to hospital by patients or to home byaround a chair for the patients in the exercise hospital staff in maintaining the useful outcomesgroup. of physiotherapy. As a result of their review, Deane et al. 13 Our study is a blinded and controlled study butconcluded that although 10 of the trials claimed our limitation is that group selection was donea positive effect from physiotherapy, few outcomes with alternation of weeks. It is not a randomizedmeasured were statistically significant. Walking study.velocity and stride length were the two parameters In addition, although it is a prospective andincreased significantly in two trials. Our present time-consuming study including training facilitiesstudy also confirms that these parameters are and three assessments in two months, the numberaffected by physiotherapy and is valuable in of patients was rather small and it would have beenshowing the outcomes of motor performance. First better if we had reached a higher number ofpace length showed a significant improvement patients. On the other hand, the strength of the(p B/0.001) and pace number in the 10-m walk study is that the doctor and physiotherapisttest decreased significantly (p B/0.001) in the assessing the patients were blind to the patientexercise group. This provided an increase in the group selection, as well as the patients themselveswalking speed of these patients. being blind to selection of groups.
Home exercise for Parkinson’s disease patients 877 5 Weiner WJ, Singer C. Parkinson’s disease and Clinical messages nonpharmacological treatment programs. J Am Geriatr Soc 1989; 37: 359 Á/63. . Individualized home exercises have positive 6 Schenkman M, Donovan J, Tsuboto J. Management effect on the motor performance in patients of individuals with Parkinson’s disease: rationale with Parkinson’s disease. and case studies. Phys Ther 1989; 69: 944 Á/55. . The home exercise programme is easy for the 7 Sudesh SJ, Francisco GE. Parkinson’s disease and patients. other movement disorders. In: De Lisa JA ed. . Further investigation is required to examine Rehabilitation medicine Á/ principles and practice. Philadelphia: Lippincott-Raven, 1998: 1035 Á/57. the optimal training period that causes a 8 Melnick ME. Bazal ganglia disorders. In: Umphred significant improvement and how long the DA ed. Neurological rehabilitation , third edition. St. outcomes are sustained after the programme Louis: Mosby, 1995: 621. is finished. 9 Nieuwboer A, De Weerdt W, Dom R et al. Prediction of outcome of physiotherapy in advanced Parkinson’s disease. Clin Rehabil 2002; To conclude, the benefits of the home pro- 16: 886 Á/93.gramme are measurable and three sessions of 10 Banks MA. Physiotherapy beneﬁts patients withphysical therapy training per patient is efficient. Parkinson’s disease. Clin Rehabil 1989; 3: 11 Á/16.Our results are consistent with previous studies 11 Nieuwboer A, De Weerdt W, Dom R et al. Theand suggest the usefulness of physical therapy as a effect of a home physiotherapy program for persons with Parkinson’s disease. J Rehabil Med 2001; 33:home exercise programme done at home for 266 Á/72.patients with Parkinson’s disease. The benefits of 12 Hurwitz A. The beneﬁt of a home program exercisephysiotherapy can be demonstrated at an earlier regimen for ambulatory Parkinson’s diseasestage of disability and should therefore be part of patients. J Neurosci Nurs 1989; 21: 180.management of the disease. Regular visits and a 13 Deane KH, Jones D, Playford ED et al.daily dairy would be useful in enhancing compli- Physiotherapy for patients with Parkinson’s disease:ance to do exercises. It will be interesting to know, a comparison of techniques. Cochrane Databasein the long-term follow-up, how many patients Syst Rev 2001: (3):CD002817.continue their home exercise and to what extent 14 Wade DT. Measurement in neurologicalthe improvements are maintained by the patients. rehabilitation . Oxford: Oxford University Press, 1992: 118, 171, 324 Á/25. 15 Comella CL, Stebbins GT, Goetz CG. Physical therapy and Parkinson’s diseases: a controlledReferences clinical trial. Neurology 1994; 44: 376 Á/78. 16 Palmer SS, Mortier JA, Webster DD. Exercise 1 Viliani T, Pasquetti P, Magnolﬁ S. Effects of therapy for Parkinson’s disease. Arch Phys Med physical training on straightening-up processes in Rehabil 1986; 67: 741 Á/45. patients with Parkinson’s disease. Disabil Rehabil 17 Szekely BC, Kosanovich NN, Sheppard W. 1999; 21: 68 Á/73. 2 Abrams GM. Rehabilitation and neurological Adjunctive treatment in Parkinson’s disease: disorders. In: Aminoff MJ ed. Neurology and physical therapy and compherensive group therapy. general medicine, third edition. New York: Rehabil Lit 1982; 43: 72 Á/76. Churchill Livingstone, 2001: 953. 18 Wade DT, Gage H, Owen C et al. Multidisciplinary 3 Caird FI. Non-drug therapy of Parkinson’s disease. rehabilitation for people with Parkinson’s disease: a Scott Med J 1986; 31: 129 Á/32. randomised controlled study. J Neurol Neurosurg 4 Gauthier L, Dalziel S, Gauther S. The beneﬁts of Psychiatry 2003; 74: 158 Á/62. group occupational therapy for patients with 19 Formisono R, Pratesti L, Modarelli FT. Parkinson’s disease. Am J Occup Ther 1987; 41: Rehabilitation and Parkinson’s disease. Scand J 360 Á/65. Rehabil Med 1992; 24: 157 Á/51.