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Exercise Treatments for Patients with Parkinson’s Disease

Parkinson’s disease is a neurodegenerative disorder characterized by erosion of dopaminergic neurons in the substantia nigra coupled with the accumulation of abnormal protein deposits called Lewy bodies. Researchers have been unable to determine the underlying cause of Parkinson’s: exposure to certain toxic chemicals (pesticides, herbicides, etc.) is thought to play a role, along with genetic predisposition in about 5-10% of patients (Olanow & Tatton, 1999). Onset is typically during the fifth and sixth decades of life, although some individuals develop symptoms as early as their 30s (Doidge, 2015).

Early symptoms may include a slight tremor in one hand, loss of smell, constipation, bladder problems or sleep disturbance (Doidge, 2015): things that most individuals would write off as part of the aging process. Patients may also develop micrographia: a stiffening in the hands and wrist. This causes a distinct change in handwriting. The patient’s writing becomes much smaller and more condensed, sometimes making it difficult to decipher (Kandel et al., 2013).

As the disease progresses, patients develop the following cardinal symptoms:

1. A stooped, flexed posture with bradykinesia (slow movement).
2. Akinesia manifested as decreased arm swing when walking.
3. Resting tremor of 4-5 seconds, often involving the hands with the forefinger rubbing against the thumb producing a pill rolling gesture. (Kandel et al., 2013).
4. Loss of autonomic movement, which causes patients to develop a characteristic mask-like expression and can eventually lead to hesitation and slurred speech (mayoclinic.org., 2020).
5. Unsteady balance, leading to the characteristic shuffling gait. (Kandel et al., 2013).

In later stages, affected individuals will often “freeze” mid-gait. As the process continues, many patients lose the ability to walk completely. Other late stage complications include chewing and swallowing problems, hypertension, fatigue, pain and cognitive impairment (mayoclinic.org., 2020).

Treatment

Parkinson’s disease is not curable, but it is treatable. Traditional pharmacotherapy consists of dopaminergic agents (e.g. levodopa), or dopamine agonists (ropinirole, etc.) that have recently received FDA approval for treatment (American Parkinson Disease Association, 2020). There are two surgical options: Deep Brain Stimulation (DBS), and a procedure to insert a tube in the small intestine that delivers a gel formulation of carbidopa/levodopa. (Parkinson’s Foundation, 2020).

All medications have side effects. Common side effects of levodopa include: dizziness, weakness, headache, confusion, nightmares, change in taste, loss of appetite, etc. (medlineplus.gov., 2020). In addition, patients typically develop a tolerance over time, meaning they need to consume higher doses of the medication(s) to achieve the same effect.

Exercise as Medicine

An increasing body of evidence supports use of exercise to attenuate PD symptoms and slow disease progression. In his book, The Brain’s Way of Healing, Dr. Norman Doidge describes his experiences with a “walking companion” named John Pepper, who had used a vigorous physical activity program and cognitive restructuring to reverse his PD symptoms (Doidge, 2015).

“Pepper moves too quickly for a Parkinson’s patient,” says Doidge. “He has none of the slowed movements that are the hallmark of Parkinson’s. He hasn’t been on anti-Parkinson’s medication for nine years, since he was sixty-eight years old, yet appears to walk normally. In fact when he gets going at his normal walking speed, I can’t keep up with him.” (Doidge, 2015, p. 33.).

John Pepper is an exceptional case: a very tough man who lived through the Nazi raids in England as a child and pulled himself out of poverty as a successful business man. His mental and physical toughness are atypical of the average individual.

However, validated medical research supports Pepper’s strategy. A recent study conducted by physicians at Katowice Medical University of Silesia, Poland, assessed the effectiveness of a six-week Nordic walking program on functional performance, gait quality and quality of life in 40 PD patients ages 50-75. (Derela et al., 2020).

Researchers found that among those in the intervention group, “Median Unified Parkinson’s Disease Rating Scale part III scores were significantly reduced with NW (nordic walking) by 8.5… with significantly greater improvement with NW than SR (standard rehabilitation).” (Derela et al., 2020).

Physicians in Sweden are currently conducting the EXPANd (EXercise in PArkinson’s disease and Neuroplasticity) trial to assess the effects of exercise in PD patients using a double blinded randomized controlled protocol. The study includes 100 patients with idiopathic PD, Hoehn & Yahr stage 2 or 3, age 60 or older. Patients in the treatment arm participate in the HiBalance exercise training program that targets four main components of balance affected by Parkinson’s: stability limits, anticipatory postural adjustment, motor learning, progressive overload and variation. The program also includes cognitive tasks, so that skills learned translate to activities of daily living. (Franzen et al., 2019).

Researchers explain that: “A growing body of research highlights the role of exercise as an essential part of managing PD, through potential neuroprotective mechanisms. Multiple structural and physiological mechanisms have been suggested to underlie neuroplastic changes due to exercise in PD, such as increased synaptic strength and a preservation of dopamine neurons. Furthermore, exercise can induce general brain health that might also influence structural and functional properties of the brain.” (Franzen et al., 2019).

Resources for PD Patients

There is a wealth of good information on the Internet to help your patients learn about Parkinson’s disease and treatment options. A few are listed below:

American Parkinson Disease Association: www.apdaparkinson.org. A nationwide network of local chapters serves PD patients and their families with education and support. The organization also offers downloadable PDFs, webinars and an “ask a doctor” service.

Michael J. Fox Foundation: www.michaeljfox.org. Supports ongoing research and keeps Parkinson’s disease patients abreast on new findings in diagnosis and treatment.

Parkinson’s Foundation: www.parkinson.org. A not-for-profit organization with a free helpline (1-800-4PD-INFO) and a wealth of information on early signs and symptoms, diagnosis and treatment.

Medline Plus: www.medlineplus.gov. A service of NIH and the US National Library of Medicine, a reliable source of information on FDA-approved prescription medications.

Stanford Medicine Parkinson’s Community Outreach Program: www.parkinsons.stanford.edu. The website provides support for both PD patients (including those recently diagnosed) and their caregivers, and includes an online community forum.

Exercise Programs

The goal of exercise programs is to help patients to be more functionally independent, through improved balance, tasks that mimic activities of daily living and by increasing patients’ ability to combine cognitive processes with movement.

Balance: This should be the foundation of any Parkinson’s movement program. Keeping the exercises simple is important to include persons at all stages of the disease, and also so patients can practice what they learn in the clinic at home. Safety is important. Work with patients to develop ways of performing these exercises independently, by having a nearby support such as a countertop or sturdy chair. Start at the “basement level” with the following procession:

• Standing with two feet shoulder width apart, progressing to feet together, eyes open.
• Semi-tandem stance progressing to tandem stance.
• Single-leg stance supported progressing (if possible) to single leg stance unsupported.
• Rising from a chair using a walker or cane, to rising using the chair’s arms, and finally rising with the patient’s arms crossed across his/her chest. Perform a similar sequence for moving from standing to seated positions.

Mid-level exercises would include:

• The clock: Have the patient pretend he/she is in the middle of a giant clock. Call out a time and have the patient indicate the time by positioning where his/her foot would be if it was the clock arm. This exercise helps patients to connect cognitive and movement processes.
• Square dance: The patient moves each foot in “square dance” positions: straight out in front, front diagonal, to one side, to the back and then back to the start position.

High-level exercises: All of the following exercises should begin supported and progress to unsupported according to the patient’s skill level.

• Unstable surfaces: Begin with a foam pad.
• Progress to a Bosu ball.
• Progress to a vibration board.

Stair climbing and descending: These exercises help patients to more confidently step up and down off of curbs, climb and descend stairs.

• Basement level: Using an aerobic platform on the floor (2” height), have the patient perform simple step up and step down exercises using a railing for support. Progress to stepping up and over, then to performing the exercise without support.
• Mid-level: Raise the platform 2” and have the patient repeat the basement level exercises.
• High-level: Combine stair climbing and descending with functional hand movements, such as carrying a light weight, similar to carrying items around the house or groceries to the car. Begin with one hand weight and progress to a weight in each hand. Focus on having the patient use mind-body connection to remember these complex movements.

Twisting:

• Basement level: Seated on a chair, the patient holds a light ball or weight in his/her hands and twists back and forth. Progress to shaking a TheraBand Flexbar while seated.
• Mid-level: The patient performs basement level twisting exercises while seated on an exercise ball. Always spot the patient on the ball when first transitioning to this stage.
• High-level: Door frame touch. The patient stands in a door frame using a semi-tandem stance. He/she reaches for the door frame with the opposite hand (e.g. reaching for the right side with the left hand and vice versa). Aim for ten door frame touches on each side.

Manual dexterity:

• Have a hand exercise ball or putty available for patients to use for developing grip strength. A finger web helps patients to develop extensor muscles and also work on articulation.
• Have the patient practice touching the second, third, fourth, and small fingers to the tip of the thumb. Progress to using the index finger to making small circles on the table surface.
• Stacking coins is a good way to practice fine motor movement.
• Have the patient practice rolling a pen in between his/her thumb and index finger. Control is more important than speed.
• “Playing scales” on an invisible piano combines dexterity and fine motor movement skills.

Flexibility: Because muscle stiffness is a hallmark symptom of Parkinson’s, stress the importance of flexibility exercises several times per week.

• Seated reach: From a seated position, the patient leans over and moves the hand down an extended leg.
• Stretch out the shoulder capsule by having the patient grasp his/her hands behind the back.
• Overhead reach.
• Head and neck roll.

Freezing: Patients with advanced Parkinson’s symptoms may have problems with freezing, in other words, not being able to initiate movement. This can be very frustrating and humiliating. To assist the patient, have him/her rock back and forth gently until the feet begin to move again.

Aerobic activity: Aerobic exercise is particularly important for Parkinson’s patients to maintain strength and endurance. The goal should be to accumulate 30 minutes of moderate-intensity activity using ratings of perceived exertion five days per week. Many patients may not be able to complete 30 minutes of continuous activity. Stress that small bouts of activity throughout the day are a good alternative. Using a 1-10 scale for perceived exertion, 6 represents moderate intensity activity.

Although walking is the ideal form of aerobic activity, some patients may be concerned about falling. There are two options here:

• An exercise partner who can accompany the patient on daily walks. Having a friend along should also improve patient compliance with the exercise prescription.
• A Nordic track walker combines upper and lower body movements and has the advantage of handles that the patient can grab onto for balance.

Alternative forms of activity such as stationary cycling appeal to patients concerned about their ability to walk. Some patients may have difficulty keeping their feet on the bike pedals. A quick fix is using velcro straps across the forefoot in an X-pattern to steady the feet on the bike pedals. Multiple 10-minute bouts of peddling during the day are a good starting point.

A hand ergometer (available at most fitness facilities) will help patients with limited lower extremity mobility to maintain aerobic fitness.

The Schwinn Airdyne combines upper and lower body ergometer in a single machine, enabling patients to build full-body strength while safely seated.

References

Dix, R. (2017). 10 Organizations that Support Parkinson’s Patients and Their Families. Parkinson’s News Today. www.parkinsonsnewstoday.com.

Doidge, N. (2015). The Brain’s Way of Healing: Remarkable Discoveries from the Frontiers of Neuroplasticity. Penguin books. pp. 33-100.

Franzen, E. et al. (2019). The EXPANd trial: effects of exercise and exploring neuroplastic changes in people with Parkinson’s disease: a study protocol for a double-blinded randomized controlled trial. BMC Neurology. Open access. https://doi.org/10.1186/s12883-019-1520-2. pp. 1-10.

Kandel, E., Schwartz, J., Jessell, T., Siegelbaum, S. & Hudspeth, A. (2013). Principles of Neural Science. Fifth Edition. p. 1544.

MedlinePlus. (2020). Levodopa and Carbidopa. www.medlineplus.gov/druginfo/meds.

Olenow & Tatton (1999). Etiology and Pathogenesis of Parkinson’s Disease. Annual Reviews in Neuroscience. Vol. 22. pp. 123-144.

Parkinson’s Foundation (2020). 10 Early Signs of Parkinson’s Disease. www.parkinson.org.

Parkinson’s Foundation (2020). Surgical Treatments. www.parkinson.org.

Szefler-Derela, J. et al. (2020). Effectiveness of 6-Week Nordic Walking Training on Functional Performance, Gait Quality, and Quality of Life in Parkinson’s Disease. Medicina. Vol. 56. www.mdpi.com/journal/medicina. pp. 1-10.