Ask an Expert: Shelly Yu Discusses the Role of Physiotherapy in Parkinson’s Disease Management

Shelly Yu is a neuro physiotherapist based in Vancouver. She began working with the Parkinson’s community in the UK at the National Hospital of Neurology and Neurosurgery. Shelly has worked in spasticity and dystonia, facial rehab, hand and vestibular rehab, and movement disorder clinics, with the latter leading her to become trained in PD Warrior and Dance for PD. You may recognize Shelly from some of Parkinson Society British Columbia’s exercise programs! Alongside her work at the Society, she is the lead physiotherapist at a private neurology clinic in the Lower Mainland. Shelly is also the Advocacy Officer at the Global Health Division of the Canadian Physiotherapy Association, working on health equity issues within Canada – specifically, access to care. Outside of her clinical practice, she is a dancer in a modern dance company and an amateur knitter!

What are some of the most common concerns you see from clients with Parkinson’s disease?

Falling, and the fear of falls, is a very common concern I see in Parkinson’s. There are various reasons why someone may fall or feel unstable, including: freezing, poor eyesight, dystonia and pain (especially in the feet and toes), slow movement, rigidity, and stiffness. Falls can happen anywhere, and it can cause a great deal of anxiety to feel at risk of falling. Dexterity issues (including difficulties with handwriting and opening jars), difficulty getting in and out of chairs, lack of confidence when walking, and fear of the future and loss of independence, are all factors that may further contribute to worsening this anxiety as well.

How do physiotherapists evaluate their clients? What do you look for?

We usually start with the person’s main concerns, and build a picture of their general wellbeing and health condition from there. I start by asking questions about their independence to do certain activities of daily living, and their ability to participate in hobbies and maintain social circles. For the physical assessment, we usually look at posture, walking pattern (gait), ability to pick up and manipulate small objects with hands, ability to weight-shift in different directions, ability to turn or change directions, ability to step over objects, ability to catch self when perturbed in different directions, ability to get on and off the floor, ability to get in and out of a chair, and ability to multitask.

What are some of the ways you work with clients to meet their goals?

I like to focus on educating people about the importance of exercise and self-management to maintain overall health and wellbeing. Depending on what the person’s main issues are (according to what they think their issues are, and also what we find in the assessment), the exercises given will differ. For example, if someone’s main issue is their bradykinesia (slowness of movement), then the exercises we tend to give are focused on big amplitude (large, wide, and sweeping movements). For tremor, the exercises are usually high-effort based, to challenge their strength and mobility. When agility and balance are the primary concern, then the exercises we give tend to be more weight-shifting and direction-change type activities, for stability and controlled movement.

Progressive goal setting is also key: if you have a goal of being able to walk 5km, we don’t just start walking 5km right away. We start small and work on taking big steps, and clearing your feet off the floor so you don’t trip. Then, gradually, we work on walking 1 block, 2 blocks, 3 blocks, and so on, to build your stamina and strength until you are able to reach your ultimate goal. What we do largely depends on what the person with Parkinson’s wants to achieve, and what is important to them in their lives, in addition to some things that we would like to work on for safety reasons.

What are some self-management strategies for motor symptoms in Parkinson’s?

The main self-management strategy I advocate for is to find an exercise program you enjoy, and stick to it. Exercise is so important for living well with Parkinson’s. Having a consistent routine is going to make all the difference.

Other self-management strategies will depend on the type of issues you are having. If you generally feel stiff and rigid, then doing a stretching program every few hours or so will help. Since stretching will only temporarily relieve you of stiffness, doing it once a day will not be enough. Building the stretching program into your daily routine will be a good way to make sure you stick with it. For example, try doing the stretching program after every meal, or every time you return from the bathroom.

If your issue is freezing, then finding a cue (visual, auditory, tactile, or imagery) that works for you will be important to prevent you from falling as a result of an episode. For example, you can sing a song in your head with a steady beat, and then try to step forward in time with the beat. Using visual cues on the floor to unfreeze your feet, you can step over lines such as the border between a carpet and the floor beneath to get walking again. However, before trying any cueing strategies, it is important to reset your mind: Stop trying to move and plant your feet firmly onto the floor. Take 3 deep breaths, then start again.

If your issue is dystonia in the foot and toes, then finding a way to stretch them during an episode may help alleviate the pain. Then, in between your dystonic episodes, you can try to strengthen the muscles in the foot and toes to help make them easier to control. Ultimately, for dystonia, medication would be the most valuable.

Always try to move bigger than you think you can. Step out farther, lift your feet higher off the ground, stretch your arms further, and exaggerate the swing of your arms when you walk. All of this will not only help with your walking pattern and prevent you from tripping over your feet, but you will also be working on your amplitude exercises at the same time.

What are the best forms of exercise for Parkinson’s disease?

A mix of aerobic, strength, stretch, and balance training tend to be the most beneficial for Parkinson’s. You ultimately need to challenge yourself and be as versatile as possible, so doing the same low-intensity routine over and over again may not be enough. You always want to work up a sweat and feel like you are exerting 70-80% of your maximum effort (of course, being wary of any health conditions that may impede your ability to exercise). A good way to test your exertion level is by feeling your heart rate increase, feeling breathless or sweaty, or feeling tired, but still be able to talk in full sentences.

Having a healthy, consistent relationship with exercise is the best way to live well with Parkinson’s. If you would like to read further about exercising with Parkinson’s, the Society will be publishing an exercise booklet shortly, so keep your eye out for that!

What is your advice to people with Parkinson’s looking to maintain a regular exercise routine?

Don’t be afraid of exercise! Tremors tend to get worse temporarily when doing intensive exercise, and this sometimes throws people off. In reality, it is a very normal sign of a good exercise program, and once the fatigue wears off, the tremor will go back to baseline again.

Keeping yourself motivated is also the best way to make sure you stick with your exercise routine. You can do this by having an exercise buddy that can join you and keep you accountable. This also makes the exercise routine more fun and sociable. Keeping an exercise diary or journal is another good way to track how often and how consistently you are exercising, and also serves as a motivator to remind you of why you started exercising in the first place. Our upcoming exercise booklet will feature all the tools you need to get started.

How can physiotherapists help people with Parkinson’s get the most out of their exercise?

The best way we can help is by supporting goal setting and ensuring exercises are at the right level for you, in terms of intensity, impact, and how they help with your goals. The exercises a physiotherapist gives you should not feel easy – they should be challenging, but not impossible to do.

We can also help with identifying the underlying issues you don’t see and explore the root problem. We can also cue you to move bigger, stretch further, or think of your movement in a different way so you can activate the right muscles. For example, when standing up from squats, you can think “push the floor away from you” rather than simply straightening your knees and standing tall.

The Society has various exercise classes, recordings, and helpsheets available online at www.parkinson.bc.ca.

What is your best advice to carepartners?

Be patient. It may be tempting to do everything for your loved one, like pulling them up out of bed, helping them walk, or finishing tasks they would otherwise do too slowly. Although some movements may be slow, it’s a good idea to let your loved one finish the task themselves wherever possible. Only help if the person is unable to finish the task, and has asked for help. The more they are able to do on their own, however slow, the better!

If you are helping to transfer or mobilize someone, always use your legs and never lift with just the arms or your back, because you are likely to injure yourself.

This content was published in the Fall 2021 edition of our quarterly magazine, Viewpoints. The content was accurate as of this publication date.