Takeaway: Numerous studies support massage therapy for improving sleep quality, reducing constipation, improving self-reported quality of life, maintaining flexibility, and other benefits that speak to the varied experiences of people with Parkinson’s disease. 

In 1817, a renowned English surgeon, paleontologist, apothecary, and political activist (yes, all the same person), published “An Essay on the Shaking Palsy,” in which he described some of his patients, along with some other people he had observed, who shared similar signs of stiffness combined with uncontrollable tremors. He named this condition paralysis agitans.  

The doctor was James Parkinson. Sixty years later, a noted pioneer in neurological diseases, Jean-Marie Charcot, promoted changing the label paralysis agitans to la maladie de Parkinson, or Parkinson’s disease.  

In 1886, another pioneer in medicine, Sir William Gowers (the same doctor who identified what we now call fibromyalgia as fibrositis), sketched a man with Parkinson’s disease. His illustration captures many of the physical characteristics we look for today: a mask-like face, stooped posture, shuffling gait, and a suggestion of tremor in the arms. 

Parkinson’s disease (PD) is now recognized as the second most common neurodegenerative disease in the world (after Alzheimer’s disease). At this time, about 1 million people in the US live with PD, and about 90,000 new diagnoses are made each year. Men have PD more often than women, at a ratio of about 1.5:1.¹ 

PD is usually found in people over 65 years old, but about 4 percent of cases are found before age 50.² A small percentage of cases are related to an identifiable genetic anomaly, but for most people, this disease is probably the result of a combination of genetics and other factors. Some contributors include exposure to pollution, tainted well water, or agricultural chemicals; mitochondrial damage and oxidative stress; long-term, low-grade inflammation; and a history of head trauma. 

PD Pathophysiology: New Discoveries 

It would be possible to devote an entire column to the current understanding of all the underpinnings of PD, but we will limit this discussion to a brief overview. New discoveries about PD pathophysiology are coming frequently, and within a few years, the way this disease is described may be substantially different. Two main issues are at the forefront of our understanding of PD today: low dopamine production in the basal ganglia, and Lewy body deposition. 

Dopamine Production 

Dopamine is a multifunction neurotransmitter. When it stimulates certain neurons in the limbic system, we call it our reward system. Too much of it in the frontal lobe can cause psychosis. But just the right amount of it, in the correct locations, allows us to have smooth, coordinated, voluntary muscle contractions. Lift your water bottle gently toward your mouth. Take a sip, then gently put it back down. This action, performed without shaking, spilling, or dropping your bottle, relies on perfect dopamine production that allows a series of neurons to communicate and control voluntary muscles. This dopamine is produced by cells deep in a structure called the pars compacta, which is part of the basal ganglia, located near the bottom of the cerebral cortex. The dopaminergic cells in the pars compacta form left and right dark lines called the substantia nigra (“black stuff”). PD is the result of the death of the substantia nigra. Motor symptoms emerge when 60–80 percent of the cells are destroyed. 

Without sufficient dopamine, our ability to achieve smooth movement with the correct interplay of flexors and extensors is lost. One result is tremor: oscillating movement from flexion to extension in a single plane. Another result is progressive tightening of some muscles, especially flexors. This shows as stiffness or rigidity in the torso and face. Additionally, it becomes increasingly difficult to initiate movement. 

Lewy Body Deposition

But loss of substantia nigra cells is not the only problem with PD. The deposition of misfolded proteins that make up fibrous structures called Lewy bodies is another factor. These proteins, called α-synuclein, accumulate in various locations in the brain, and the Lewy bodies they create interfere with important synaptic connections. They can restrict dopamine activity, but they also affect the secretion of acetylcholine, norepinephrine, serotonin, glutamate, and more. This is thought to create many of the nonmotor signs and symptoms of PD like fatigue, fluctuating blood pressure, slowed digestion, and so on.  

Signs and Symptoms 

PD can present very differently from one person to another. Specialists have developed various ways to categorize its signs and symptoms, but for our purposes, describing them as motor issues and nonmotor issues is the most useful. 

Motor Signs 

The motor symptoms of PD often vary in onset and relative severity from one patient to another, but three are considered the hallmarks of this disease: resting tremor, progressive rigidity, and bradykinesia. These occur bilaterally but asymmetrically: one side is typically worse than the other.   

The resting tremor associated with PD usually begins in the arms, but it may also involve the neck, jaw, or legs.  

Rigidity refers to the tightening of certain muscles, especially trunk flexors and facial muscles. This increased tone leads to the characteristic stooped posture and “mask-like” appearance of people with PD. It can also contribute to problems with speech and swallowing, because facial, jaw, and neck muscles become increasingly hard to move. And if it affects the extremities, it impacts both gait and handwriting; people with PD often develop micrographia: their handwriting gets progressively smaller.  

Bradykinesia (brady for slow, kinesia for movement) suggests slow movement. But in this context, it refers to the feeling of being stuck—it is especially difficult for people with PD to initiate movement. Bradykinesia has big implications for gait and fall risks. It takes so much effort to start walking, that it’s easy to lose one’s balance. Combine this with a stooped posture and a changing center of gravity, and it’s easy to see how bradykinesia plus rigidity can contribute to postural instability and the risk of serious injuries. 

Nonmotor Signs and Symptoms 

The nonmotor effects of PD include a loss of the sense of smell (anosmia), urinary incontinence, constipation, dysautonomia with orthostatic hypotension, fatigue, sleep disorders (especially with the lack of REM sleep), anxiety, and depression. These arise slowly and often predate a PD diagnosis by several years, so some experts call these signs and symptoms a Parkinson’s prodrome stage.  

In later stages, people with PD may experience personality changes, cognitive decline, and dementia. These last can be made worse with typical PD medications, so such signs must influence treatment strategies. 

Chronic and unexplained pain is another common nonmotor symptom for many people with PD. This is not well understood, and it is often under-recognized and undertreated. 

The nonmotor signs of PD can destroy a person’s quality of life and often prompt a person’s transition into an assisted-living facility or nursing home.   

Treatment: Some Surprises 

Parkinson’s disease has no cure, and every patient requires individually calibrated combinations of pharmaceuticals along with physical, occupational, speech, and other therapies. These treatments work to preserve function as long as possible, and they are often successful: The life expectancy of a person with PD is within the same range as a person without it. But ultimately this disease raises the risk of falling with serious injury and aspiration pneumonia if the swallowing reflex is impaired; many patients with PD succumb to these complications.  

As the disease progresses, it is increasingly important to maintain physical activity. This is challenging when postural stability isn’t strong, so interventions that promote good balance and confidence while walking can be very helpful. Massage therapy has a possible role here—more on that in the “Implications for Massage Therapy Practice” section. One especially uplifting option for people with PD is dance therapy. It’s been found that various kinds of dance, including ballet, the Argentine tango, waltzing, and even Irish step dancing can help with a variety of motor and nonmotor symptoms. All forms of dance have been seen to improve gait, balance, joint mobility, muscle strength, mood, and cognition. The added benefits of having partners and weekly classes help patients feel stronger, more connected to others, and more confident overall. Yoga and tai chi are similarly helpful.  

If medications and physical activity are not sufficient to manage PD symptoms, then deep brain stimulation (DBS) might be an option. This is a procedure that implants electrodes into key areas of the brain to send a low-grade impulse. They connect to a pulse generator that is inserted near the clavicle. DBS can help with intractable tremors and is used for several other conditions in addition to PD. 

As function continues to decline, many patients need speech therapy to help with speaking and swallowing. Occupational therapists can suggest changes in the tools it takes to live independently and provide strategies for self-care. Not surprisingly, massage therapy is a popular choice for pain relief, improved sleep, and other benefits.

Medications: A Moving Target 

One of the great challenges of living with PD is finding the right combinations and doses of medications as the disease progresses. The drugs that treat PD work to lessen the worst of the motor symptoms, but they often create additional side effects and complications. In fact, advancing dementia with hallucinations, paranoia, and confusion in PD patients is sometimes attributed less to the disease and more to the side effects of the medications. Patients often find that they need to adjust their medications or try new combinations of treatments to maintain the best possible function—any single protocol tends to lose effectiveness over time. 

A typical pharmaceutical approach is a combination of two drugs called levodopa and carbidopa. Levodopa, or L-dopa, is an amino acid that can cross the blood-brain barrier. It is converted into dopamine in the brain, which helps to compensate for the loss of the substantia nigra cells. And carbidopa works to keep levodopa active for as long as possible. These drugs are usually administered in short-acting or long-acting pill form, but other routes of administration are being explored so that their levels can be more even. This will help prevent swings between the improved function and loss of function many patients struggle with.  

These interventions come at a price, however. The side effects of the L-dopa/carbidopa combination include dyskinesia—uncontrolled movements—along with possible hallucinations, confusion, and impulsive behaviors (some patients have developed gambling problems, for instance). These go alongside more typical drug side effects like nausea, sleepiness, and lightheadedness. And after prolonged use, many patients develop severe motor fluctuations: marked periods of high function (“on” time) followed by periods of severely limited function (“off” time). 

But restoring proper levels of dopamine is only one strategy for PD treatment. The discovery of the role of α-synuclein as a factor has raised interest in treatments that may neutralize the negative effects of these mutated proteins and slow the progress of the disease. This strategy is still in development, but it holds promise for patients with PD.  

Along with these medications, several others might be used to help with additional symptoms: other dopamine agonists, drugs to help with tremor, rigidity and dyskinesia, NSAIDs and opioid pain relievers, and medications that work to prolong the positive effects of L-dopa.  

Implications for Massage Therapy Practice 

Massage therapists who specialize in working with people aged 60 and older are likely to have some clients who live with PD, and a significant body of evidence points to several benefits our work could offer this large group of people who live with a diverse set of challenges. 

While massage therapy does not restore lost neurons, fix dopamine secretion, or eliminate abnormal α-synuclein proteins, a large, systematic review of a variety of techniques suggests that our work can induce relaxation and reduce anxiety and pain for this population. This allows us to have a positive impact on motor symptoms like rigidity, difficulties with movement, and balance and nonmotor symptoms like sleep disturbance, fatigue, and depression.³  

Another large-scale systematic review that included nearly 400 participants found that traditional massage was more effective than the control (that is, treatment as usual) for motor symptoms, although scores for activities of daily living were not significantly different.⁴ 

One frequently cited case report found that massage therapy treatment had a positive effect on resting and postural tremor, as well as short-term benefits for rigidity.⁵ 

Because balance becomes a challenge, and fear of falling may negatively impact the quality of life of a person with PD, findings like those in the article “Massage and Mobilization of the Feet and Ankles in Elderly Adults: Effect on Clinical Balance Performance” may become relevant. This study found that even a single session of massage and mobilization of the feet and ankles of adults 65–95 years old led to significant improvements in timed up-and-go (how long it takes to come from sitting to standing) and one-leg balance tests.⁶  

Numerous studies also support massage therapy for improving sleep quality, reducing constipation, improving self-reported quality of life, maintaining flexibility, and other benefits that speak to the varied experiences of people with Parkinson’s disease. 

That said, this population also presents with some cautions for massage therapy. Diseases rarely occur one at a time, especially in older people. So those with PD may also be living with a variety of comorbidities, including osteoporosis, Alzheimer’s disease, complicated surgical histories, and many other factors that must influence our choices for massage. The medications that help manage PD also carry significant side effects—like nausea, low blood pressure, lightheadedness, and excessive daytime sleepiness—that might also influence decisions.

Because PD presents extremely differently from one patient to another, it’s impossible to make a comprehensive list of the most appropriate client accommodations. However, we can predict that clients with PD might derive the best benefits from massage when their medication is most active, as opposed to approaching the end of their dose-cycle when their function diminishes and rigidity and tremors worsen. Clients with PD may also have difficulty getting on and off the table, and their tremor or muscular “freezing” may require some in-the-moment adjustments and experimentation to find what techniques they respond to best.  

Some massage therapists have sent me their best tips for working with clients who have PD. These include working with fully clothed clients using floor mats—this reduces the risk of falling, but it may add new challenges in helping the client get down and then up. Another therapist found that their clients had better responses to short, frequent sessions (i.e., 20 minutes three times a week) than less-frequent, longer sessions; this seemed to be especially helpful for improved sleep.  

Massage therapy and other non-drug therapies are popular among people with PD, and for good reason: Our work can add substantially to a client’s quality of life. Because clients with PD are likely to be challenged in many ways, it is especially important to work in conjunction with their health-care team so our goals are in alignment with theirs and to consult over any questions about physical or mental health. People with PD are at risk for chronic pain, anxiety, depression, injury, falls, and much more. While massage therapy won’t solve this problem, our work can certainly help to deal with the consequences of this common and sometimes devastating disease. 

Notes 

1. Parkinson’s Foundation, “Statistics,” www.parkinson.org/understanding-parkinsons/statistics.  

2. Parkinson’s Foundation, “Statistics.”  

3. Efthalia Angelopoulou et al., “Massage Therapy as a Complementary Treatment for Parkinson’s Disease: A Systematic Literature Review,” Complementary Therapies in Medicine 49 (March 2020): 102340, https://doi.org/10.1016/j.ctim.2020.102340. 

4. Zhiran Kang et al., “Effectiveness of Therapeutic Massage for Improving Motor Symptoms in Parkinson’s Disease: A Systematic Review and Meta-Analysis,” Frontiers in Neurology 13 (September 2022), https://doi.org/10.3389/fneur.2022.915232. 

5. Yolanda Casciaro, “Massage Therapy Treatment and Outcomes for a Patient with Parkinson’s Disease: a Case Report,” International Journal of Therapeutic Massage & Bodywork 9, no. 1 (March 2016): 11–8, www.ncbi.nlm.nih.gov/pmc/articles/PMC4771486/. 

6. Jacques Vaillant et al., “Massage and Mobilization of the Feet and Ankles in Elderly Adults: Effect on Clinical Balance Performance,” Manual Therapy 14, no. 6 (December 2009): 661–4, https://doi.org/10.1016/j.math.2009.03.004. 

Resources

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Chute, B. The Michael J. Fox Foundation. “Breaking News: Parkinson’s Disease Biomarker Found.” April 13, 2023. www.michaeljfox.org/news/breaking-news-parkinsons-disease-biomarker-found. 

Cleveland Clinic. “Deep Brain Stimulation.” Last modified May 23, 2022. https://my.clevelandclinic.org/health/treatments/21088-deep-brain-stimulation.  

Fields, C. R., N. Bengoa-Vergniory, and R. Wade-Martins. “Targeting Alpha-Synuclein as a Therapy for Parkinson’s Disease.” Frontiers in Molecular Neuroscience 12 (2019). www.frontiersin.org/articles/10.3389/fnmol.2019.00299.  

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Healthline. “Ways to Cope with the Side Effects of Parkinson’s Drugs.” Last modified May 14, 2021. www.healthline.com/health/parkinsons-disease/cope-with-side-effects. 

Kouli, A., K. M. Torsney, and W. L. Kuan. “Parkinson’s Disease: Etiology, Neuropathology, and Pathogenesis.” Parkinson’s Disease: Pathogenesis and Clinical Aspects (December 21, 2018). https://exonpublications.com/index.php/exon/article/view/186. 

MedicalNewsToday. “Parkinson’s Disease Early Signs and Causes.” Last modified April 4, 2023. www.medicalnewstoday.com/articles/323396.  

Medline Plus. “Levodopa and Carbidopa.” Last modified January 15, 2022. https://medlineplus.gov/druginfo/meds/a601068.html.  

Parkinson’s Foundation. “Caregiver Corner: Lewy What? Explaining Lewy Body Dementia.” January 9, 2015. www.parkinson.org/blog/care/lewy-body-dementia.  

Parkinson’s Foundation. “Motor Fluctuations.” Accessed May 11, 2023. www.parkinson.org/library/fact-sheets/motor-fluctuations.  

Parkinson’s Foundation. “Pain in Parkinson’s Disease.” Accessed May 11, 2023. www.parkinson.org/library/fact-sheets/pain.  

Parkinson’s Foundation. “Statistics.” www.parkinson.org/understanding-parkinsons/statistics.  

Physiopedia. “Parkinson’s and Dance.” Accessed May 10, 2023. www.physio-pedia.com/Parkinson%27s_and_Dance.