Version July 2025
INTRODUCTION —
Parkinson disease (PD) is a chronic disorder that requires broad-based management including patient and family education, support group services, general wellness maintenance, exercise, and nutrition. These aspects of care span the disease course and supplement medications, surgical and device-based therapies, and supportive and palliative care.
This topic will review the nonpharmacologic management of PD. The pharmacologic treatment of PD and the treatment of comorbid problems associated with it are discussed separately. (See "Initial pharmacologic treatment of Parkinson disease" and "Management of nonmotor symptoms in Parkinson disease" and "Palliative approach to Parkinson disease and parkinsonian disorders".)
EDUCATION AND COMMUNICATION —
The prospect of having a chronic and progressive neurologic disease is frightening. Many individuals are familiar with PD and may even have had first-hand acquaintance with its disabling effects in an affected family member or friend. Education is essential to provide patients, families, and caregivers with some understanding and control over the disorder. Education can combat the stigma and misinformation that often surround the disorder [1-3].
Disclosing the diagnosis — Offering a diagnosis of any neurologic condition can be life-changing; given the stigma and misconceptions surrounding PD, we advise a careful approach to the conversation. It can be helpful to use the "ask-tell-ask" framework for difficult conversations [4]. Before discussing the diagnosis, remember to ask if the person would like anyone else with them in the clinic room or by phone, since family members and caregivers often have questions and can be helpful in remembering details of the conversation.
Begin by asking for the individual's understanding of their symptoms and if there are any diagnoses about which they are specifically concerned. If so, exploring the reasons for this and any knowledge or preconceptions about those diagnoses can provide a window into the individual's awareness or anticipation of PD.
Next, share the diagnosis in straightforward language. It can be useful to first point out the pertinent history and examination findings in lay terms that, taken together, suggest a diagnosis of PD. The clinician may offer a brief description of the diagnosis. As an example, "Parkinson disease is a neurologic condition where certain brain cells start to die off before they should. These cells produce dopamine, which helps with movement, and other neurotransmitters, or chemical messengers, like norepinephrine and serotonin, which regulate mood and anxiety. Parkinson disease is more common than you might think, and while we do not have a cure, we have many treatments (both medication and nonmedication) that can help manage your symptoms, function, and quality of life."
After providing a brief description, pause to allow the individual and any care partners present to absorb the information and ask questions. If no questions are asked, ask the individual to share their understanding of the diagnosis to confirm understanding or correct misunderstandings before moving on to discussions of treatment and exercise recommendations, support groups, or other offerings. In some clinics, a PD nurse or other team member may be utilized to answer additional questions and offer support and resources if the clinician's time is limited.
In some cases, care partners and family members may want more information about their loved one's diagnosis, management, and/or prognosis than the individual with PD, or vice versa. When possible, providing time and space to address such concerns separately is recommended and may require an earlier follow-up visit or telehealth appointment.
Early phase of disease — Education at the time of diagnosis should be approached thoughtfully and be individualized to the patient and their circumstances. Caution should be exercised in newly diagnosed patients with mild symptoms and an uncertain future regarding progression; early overexposure to potentially disturbing material may be counterproductive.
Focused education surrounding particular symptoms may be more effective in this phase and is available through books, interactive webinars, and other materials written for the lay audience; through national and regional PD organizations (table 1), which publish educational pamphlets and organize symposia for patients and families; and through the internet.
Workbooks designed by and for recently diagnosed individuals, with an emphasis on how to live well with PD, can be particularly helpful in both educating individuals and families about the condition and combating stigma and fatalism. One resource the author finds particularly helpful in this stage is the Every Victory Counts manual available through the Davis Phinney Foundation. A patient perspective on early PD symptoms and diagnosis is provided separately. (See "Patient perspective: Parkinson disease".)
Culturally relevant care — With increasing recognition of disparities in access to PD care and limited representation of communities of color in public-facing materials, provision of culturally relevant and linguistically appropriate materials is critical [5-12].
Community-based participatory research performed as part of the PD Care Gap project exemplifies a holistic approach to improving care for underserved and historically marginalized populations [6]. A storybook compiled by the project is an excellent resource, particularly for Black and African American people with PD [8].
Spanish-language resources for patient and family/caregiver education are available at the following sites [9-12]:
●American Parkinson Disease Association
●The Michael J. Fox Foundation
SOCIAL AND EMOTIONAL SUPPORT —
Clinicians and care teams should assess and support the emotional and psychological needs of patients and families with PD. Normal reactions of anger, depression, anxiety, and social and economic concerns often begin with the onset of the disease and evolve as the disease progresses.
Support groups and peer mentoring — For patients with early PD, referral to another affected patient or family may be less overwhelming than a large support group composed of patients with advanced disease. Patients and care partners can enroll in the online Parkinson's Buddy Network to connect with other individuals affected by PD. Early-onset PD groups also have been formed in some locales, and an early-onset PD handbook is available [13]. There are also some national support organizations, several of which have local chapters (table 1).
Support for care partners is particularly important as they learn to cope with the increasing needs of the spouse, parent, or, more rarely, son or daughter [14]. Support groups are especially valuable for allowing interactions with other patients or families with similar experiences and for providing access to useful educational information [15].
Social work and psychology referral — Referral of the patient and/or family to a psychologist or psychiatric social worker experienced in dealing with chronic illness may be appropriate in some cases. For many patients, disclosing the diagnosis is a source of concern, particularly among younger patients, employed patients, and those with younger children [16].
Social workers, psychologists, and other trained therapists can offer support and resources to aid in these challenging discussions. There are books available to help children of different ages understand the diagnosis of PD in a loved one, written by individuals with PD and by care partners [17-20]. In other instances, referral for legal, financial, or occupational counseling is indicated.
Social isolation and social prescribing — Patients with PD and their care partners are at risk for social isolation, particularly during later stages of disease or periods of home confinement. In a study conducted prior to the coronavirus disease 2019 (COVID-19) pandemic, researchers found that individuals with PD who reported having many friends had 21 percent fewer PD symptoms than those with few or no friends, and individuals identifying as lonely had a 55 percent higher PD symptom severity score than those denying loneliness [21]. Pandemic-imposed isolation has been associated with decreased quality of life, increased risk for mood disorders, decreased mobility, and worsening of motor function and symptom burden [22-26].
Social prescribing refers to connecting patients and care partners to sources of support within their own community, whether geographic, online, or related to a particular disease or even health system. Many social prescribing initiatives have been launched through the United Kingdom's National Health Service, the United States Department of Veterans Affairs, and individual health care institutions [27-30], including one PD-specific program launched during the COVID-19 pandemic [31]. Social prescribing may include lifestyle modifications such as diet and exercise, with connection to specific community resources, or may consist of referrals to support groups, self-management classes, volunteer opportunities, and community activities.
Mindfulness and meditation — Various approaches aimed at cultivating or enhancing mindfulness, often incorporating meditation and/or yoga, have been studied in patients with PD [32-35]. Mindfulness refers to an awareness of one's internal states and surroundings. Mindfulness approaches aim to help individuals learn to observe their thoughts, emotions, and other present-moment experiences without judging or reacting to them [36].
This is an area of great interest among patients and care partners and of continued study among researchers, given the relative lack of side effects and potential benefits in self-efficacy, function, and social relationships. Mindfulness-based group therapy, delivered virtually, is both feasible and acceptable to patients with PD, and efficacy testing is underway [35,37].
REHABILITATION THERAPIES
Exercise and physical therapy — We encourage all patients with PD to engage in regular exercise, aiming for at least 150 minutes per week of moderate-intensity aerobic exercise. The type of exercise is less important than the consistency, and patients should choose activities that are interesting and enjoyable to them to promote long-term engagement [38].
Physical therapy offers many benefits to people with PD, including providing a starting point for less active individuals to evaluate and match their capabilities and interests with an appropriate exercise program. Many patients engaged in physical therapy gain lasting confidence and a sense of control over one aspect of the disease, especially if they have never engaged in physical activity in the past. Parkinson-specific exercise programs may also provide social support and camaraderie, separate from and complementary to other support options [39,40]. Referral to a physical therapist or exercise group is a good way to get patients started in such activities.
A large body of evidence supports the value of exercise in patients with PD to help slow motor progression, improve nonmotor symptoms and quality of life, and alleviate some secondary orthopedic effects of rigidity and flexed posture such as shoulder, hip, and back pain [35,41-58]. A 2023 meta-analysis of physical exercise in patients with PD identified 156 randomized trials in nearly 8000 individuals, largely with mild to moderate PD without significant cognitive impairment [59]. Moderate beneficial effects on motor signs were seen with the following interventions, ranked in descending order of effect size:
●Dance (five trials, 169 participants, mean improvement of 10.3 points on the motor portion of the Unified Parkinson's Disease Rating Scale [UPDRS])
●Aqua-based exercise (two trials, 30 participants, mean improvement of 7.8 points)
●Gait/balance/functional training (three trials, 137 participants, mean improvement of 7.4 points)
●Multidomain training (seven trials, 271 participants, mean improvement of 7.0 points)
●Strength/resistance training (two trials, 52 participants, mean improvement of 7.0 points)
Mind-body training (eg, tai chi, yoga) and endurance training had smaller beneficial effects on motor symptoms [59]. Aqua-based therapies had the greatest beneficial effect on quality of life (mean improvement of 15 points on the Parkinson's Disease Questionnaire 39), with more moderate benefits seen with endurance training and multidomain training. Although numerous exercise modalities were included and compared, the authors concluded that most types of physical exercise are safe and yield benefits in PD, with minimal differences among interventions.
Speech therapy — Dysarthria and hypophonia are common manifestations of PD, and small randomized trials support speech therapy as an intervention to improve speech volume [42,60-64].
Several techniques have been shown to be more effective than no treatment in small, nonblinded randomized trials in patients with PD. One technique employs speech therapy emphasizing prosodic features of pitch and volume reinforced with visual feedback [60], while another aims to maximize phonatory effort and loudness (the Lee Silverman Voice Treatment [LSVT-LOUD]) [61,63,65]. Patients should be directed to therapists trained in PD-specific methods for optimal benefit.
In practice, many individuals find improvements in their speech volume and prosody immediately after completing therapy; however, nonadherence to vocal exercises at home may lead to attrition of the initial benefits. As with physical and occupational therapy, patients should be encouraged to continue their speech therapy exercises at home to maintain their level of function and may benefit from periodic re-evaluations and refresher courses of these targeted and effective therapies.
As an alternative or adjunctive strategy to traditional speech therapy, group singing interventions for PD, variably led by music therapists or speech language pathologists, have demonstrated improvements in phonation and vocal intensity [66].
Occupational therapy — As PD progresses, impairments in dexterity commonly affect a patient's ability to complete activities of daily living. Occupational therapists can work with patients to adapt certain activities, introduce assistive devices, and change the environment to foster safety and continued engagement in the activities a person enjoys.
Most occupational therapy trials have been small; however, one randomized trial of 191 patients found a benefit in self-perceived performance of daily activities after three months [67]. Evidence-based practice guidelines recommend that occupational therapists incorporate self-management, cognitive-behavioral, coaching, and compensatory strategies into individualized, multicomponent treatment plans for individuals with PD [68].
NUTRITION
Vulnerabilities in patients with PD — Older adults with chronic illness are at risk for poor nutrition, weight loss, bone loss, and decreased muscle mass. Patients with PD are specifically at increased risk of malnutrition and weight loss due to increased metabolic demands, anosmia and hypogeusia, dysphagia, and constipation [69]. These changes are associated with significant alterations in the gut microbiome in patients with PD [70].
Additionally, poor oral health has also been reported in individuals with PD, leading to higher rates of gingivitis, dental caries, and oral pain, all of which may impact dietary habits and overall nutrition [71].
Healthy dietary habits — Healthy dietary habits over a longer period of time may help to prevent or slow progression of PD. One large cross-sectional study detected a difference in age of PD onset of up to 17 years among the highest adherers to the MIND diet (Mediterranean-DASH [Dietary Approaches to Stop Hypertension] Intervention for Neurodegenerative Delay) [72]. Earlier studies have also reported delayed progression of parkinsonism and a reduced incidence of cognitive impairment and Alzheimer disease associated with the MIND diet [73-75].
An analysis of the Nurses' Health Study and the Health Professionals Follow-Up Study among nearly 48,000 participants found that adherers to a healthy dietary pattern, including a Mediterranean-type diet, had a lower likelihood of reporting prodromal PD symptoms over time, such as depression, excessive daytime sleepiness, and constipation [76]. In this cohort and others, high adherers also had improved longevity after a diagnosis of PD [77].
While there are no consensus guidelines on a specific PD diet and while randomized trials are needed to confirm a causal relationship between diet and improved outcomes, certain recommendations can be made [78].
●A high-fiber diet, adequate hydration, and regular exercise help manage the constipation of PD.
●Large, high-fat meals that slow gastric emptying and interfere with medication absorption should be avoided.
●The MIND diet may delay the onset and reduce the incidence and progression of parkinsonism.
●Dietary protein restriction is not necessary except in some patients with advanced disease and motor fluctuations in whom competition with other amino acids interferes with levodopa absorption. (See "Medical management of motor fluctuations and dyskinesia in Parkinson disease", section on 'Unpredictable "off" periods' and "Medical management of motor fluctuations and dyskinesia in Parkinson disease", section on 'Failure of "on" response'.)
There is no evidence at this time that large doses of vitamin E, coenzyme Q10 (CoQ10), or other antioxidants are useful in PD [42].
Oropharyngeal dysphagia — Oropharyngeal dysphagia is prevalent in patients with PD, particularly at advanced stages. Swallowing problems impact nutrition and increase the risk of aspiration. Strategies to identify and treat dysphagia in patients with PD are reviewed separately. (See "Swallowing disorders and aspiration in palliative care: Definition, pathophysiology, etiology, and consequences" and "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management".)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Parkinson disease".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Parkinson disease (The Basics)")
●Beyond the Basics topics (see "Patient education: Parkinson disease treatment options — education, support, and therapy (Beyond the Basics)")
PATIENT PERSPECTIVE TOPIC —
Patient perspectives are provided for selected disorders to help clinicians better understand the patient experience and patient concerns. These narratives may offer insights into patient values and preferences not included in other UpToDate topics. (See "Patient perspective: Parkinson disease".)
SUMMARY AND RECOMMENDATIONS
●Education – Education is essential to provide patients with Parkinson disease (PD) and their families and caregivers with some understanding and control over the disorder. Education and effective communication can combat the stigma and misinformation that often surround PD. (See 'Disclosing the diagnosis' above and 'Early phase of disease' above.)
Culturally and linguistically relevant resources should be provided, when possible. (See 'Culturally relevant care' above.)
●Social and emotional support – Clinicians and care teams should assess and support the emotional and psychological needs of patients and families with PD. Support groups and peer mentors from within the PD community are a valuable resource (table 1). (See 'Social and emotional support' above.)
Social workers, psychologists, and other trained therapists can offer support and resources to aid in challenging discussions; disclosing the diagnosis of PD to others is a common source of concern, particularly among younger patients. (See 'Social work and psychology referral' above.)
Social isolation is associated with greater motor and nonmotor severity and poorer quality of life in PD. Referring individuals to community resources to promote social engagement and lifestyle modifications may be beneficial. (See 'Social isolation and social prescribing' above.)
●Rehabilitation therapies
•Exercise and physical therapy – We encourage all patients with PD to engage in regular exercise and/or physical therapy, aiming for at least 150 minutes per week of moderate-intensity aerobic exercise. The type of exercise is less important than the consistency, and patients should choose activities that are interesting and enjoyable to them to promote long-term engagement. (See 'Exercise and physical therapy' above.)
•Speech therapy – Dysarthria and hypophonia are common manifestations of PD. Speech therapy may be helpful in improving speech volume and maintaining voice quality. (See 'Speech therapy' above.)
•Occupational therapy – Impairments in dexterity commonly affect the ability to complete activities of daily living as PD progresses. Occupational therapists can work with patients to adapt certain activities, introduce assistive devices, and change the environment to foster safety and continued engagement in the activities a person enjoys. (See 'Occupational therapy' above.)
●Nutrition – Patients with PD are at risk for poor nutrition and its consequences (eg, weight loss, bone loss, decreased muscle mass). (See 'Vulnerabilities in patients with PD' above.)
We encourage patients to eat a high-fiber diet, maintain adequate hydration, and perform regular exercise. Such habits can reduce constipation and mitigate slowed gastric emptying, both of which are common in PD and interfere with medication absorption and appetite. (See 'Healthy dietary habits' above.)
Oropharyngeal dysphagia is prevalent in patients with PD, particularly at advanced stages, and may impact nutrition and increase the risk of aspiration. Strategies to identify and treat dysphagia in patients with PD are reviewed separately. (See "Swallowing disorders and aspiration in palliative care: Definition, pathophysiology, etiology, and consequences" and "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management".)
ACKNOWLEDGMENT —
The UpToDate editorial staff acknowledges Daniel Tarsy, MD, who contributed to earlier versions of this topic review.
