Expert exercises for Parkinson’s disease

By Melita Petrossian, M.D. - Medical Director for Movement Disorders Center at Providence Saint John’s Health Center

In the past two decades, scientific studies have shown again, and again that exercise and physical activity can have dramatic impacts on the outcome and well-being in Parkinson’s disease (PD). The benefits of exercise are so widespread, as listed below, that exercise should be thought of as medicine, but with almost no side effects. I have many PD patients who are so dedicated to improving their neurological health with an exercise regimen that they become more physically fit than before they were diagnosed with PD. These patients often report, anecdotally, that they feel worse regarding their PD when they don’t have the opportunity to exercise consistently.

Benefits of exercise include:

• Improved gait and balance / reduced freezing of gait / reduced risk of falls
• Improved flexibility / reduced rigidity / reduced risk of contractures
• Improved endurance / energy
• Improved ability to complete activities of daily living / improved sense of well-being / improved quality of life
• Improved working memory and decision making
• Improved attention and concentration
• Improved mood / reduced depression and anxiety
• Improved quality of sleep

Direct effects of exercise include:

• More efficient use of dopamine by brain cells (neurons) (making medications more effective)
• Growth of blood vessels, improving blood flow
• Helps neurons make new connections (synapses) by releasing brain growth factors
• Improves neuroplasticity (teaching the brain a new pattern of thinking / functioning)
• Improves cardiovascular health / improves brain metabolism
• Supports the functioning of the immune system / reduces inflammation

Regarding types of exercise, the good news is that almost every kind of activity has been shown to have benefit for PD. To create a PD-appropriate exercise regimen, it’s helpful to know that there are five major aspects of exercise / physical activity that are beneficial for Parkinson's disease.

1. Cardiovascular activity

This refers to activity that increases the heart rate (provided your general doctor and/or cardiologist have not advised against this). The heart rate should be increased by 50 percent for 20-25 minutes, 3-4 times per week. This means if your resting heart rate is 60, you should aim for a heart rate goal of 90 beats per minute during the activity.

Please keep in mind that if you have a heart condition, have a pacemaker, or are taking heart medications such as beta-blockers (propranolol, metoprolol, atenolol) your heart rate may not increase and therefore the heart rate should not be used as a target.

Low-impact cardio includes stationary bike (recumbent bikes are most comfortable typically), elliptical machines, water aerobics and swimming, among other options. I don’t recommend treadmill use for patients who have slowness or balance issues because of the risk of falls. Some patients like to use conventional bikes or go hiking, and the outdoor environment can certainly provide benefit, provided that the balance has not been affected.

Cardiovascular activity releases brain chemicals that help clear out toxic proteins in the brain and can be helpful in preventing memory loss, so what’s good for the body is good for the mind as well.

2. Strength training

This includes using weights (free or machine) and resistance bands. Resistance bands tend to be the easiest since they can be easily moved around, are inexpensive, and can be used in the home. Resistance bands come in different strengths, like increasing the number of pounds in a weight.

Some people prefer going to a gym, using exercise equipment, and/or working with a personal trainer. Strength exercises may include:

• chest press
• lateral pull down
• reverse fly's
• double leg press
• biceps curl
• shoulder press
• triceps extension
• back extension
• knee extension
• hip extension
• knee flexion
• calf raises

Start with a low weight or degree of resistance and slowly do 10 repetitions of each exercise. Very gradually increase the weights or repetitions by no more than 5 percent per week.

There was a clinical trial comparing progressive resistance exercise (increasing weight or repetitions) to more typical Parkinson's activity, and the progressive resistance exercise group not only did better than the control group, but they improved beyond their own baseline after two years. The average patient in this group had had Parkinson's for seven years, so these were not necessarily patients in very mild stages.

Skeptics who hear that people with PD who exercise do better may argue that those who can exercise may have a milder form of PD to begin with, but this study shows that physical activity is beneficial regardless of the underlying severity of PD. The study also suggests that aggressive physical activity can slow down the progression of the disease!

There are DVD/Blu-Ray sets that show how to use resistance bands to create an exercise program helpful for seniors; some come with the resistance band. These can typically be found at online retailers such as Amazon.com or at local fitness stores.

3. Stretching

This should be done after a warmup period (low-intensity walking for example) or after exercising: do not stretch "cold" muscles. The stretch should feel like a gentle pull: do not stretch to the point of pain. Hold the stretch for at least 30 seconds; use a kitchen timer or stopwatch if necessary. Avoid bouncing, which can cause small tears in muscles, causing reduced flexibility in the long run. Make sure to breathe deeply through your nose, activating the diaphragm (you should see your stomach expand) and breathe out through the mouth. Remember to stretch both sides of the body equally.

Here are some stretches that can be useful for PD patients:

• Chest stretch
  Face a corner, placing forearms and hands on each wall; lean forward into the corner, keeping the head up and feet flat on the floor.
• Backstretch
  Stand with feet hip-width apart, placing palms on low back; gently lean trunk and neck back.
• Shoulder stretch
  Stand with feet hip-width apart, clasping hands behind back; gently lift arms up and away from the back, keeping the head up.
• Hamstring stretch
  Sit tall in a chair, placing one leg straight out onto another chair; gently reach for toes, keeping toes up, knees flat and back straight.
• Ankle circles
  Move foot in slow, complete circles, repeat in both directions.
• Overhead stretch
  Sit tall in a chair, interlocking fingers together; turn palms facing out and slowly lift arms overhead, stretching backward; gently extend the neck until you are looking at your hands.

Repeat the entire stretch routine at least once; this should take about 10 minutes total. Stretch at least 3 times per week, preferably every day.

4. Balance/walking

As we age, often times our ability to balance becomes more difficult, but consistent practice we can maintain or regain our ability to balance. Walking helps prevent falls and maintain mobility. Go for a walk for 15 minutes 3-4 times per week to maintain your maximum rate with focus on arm swing, posture and picking up your feet as you go.

Balance Classes are available at the YMCA and other local centers such as Cypress PT and Top Floor Fitness. Senior yoga and Tai chi classes are great for balance training. Avoid chair yoga and advanced pretzel-twisty yoga. Avoid Bikram (hot temperature) yoga to avoid the risk of passing out.

Or you can spend 2-3 minutes per day at home working on your balance with the following exercises:

• Tandem stance:
  Stand near something sturdy (e.g. a sink or table)
  Stand with 1 foot in front of the other (heel touching the toe). This is called tandem stance. Try to let go of the counter/sink for 30 seconds.
  Switch feet and do the same.
  After you feel you have mastered standing in tandem stance, see if you can do so with eyes closed for 5-10 seconds.
• Single-leg balance:
  Standing next to something sturdy, lift one leg up and try to let go of the for up to 10 seconds. Switch feet and do the same.
• Tandem gait:
  Walk in a straight line with 1 foot touching the other. It helps to put your hands on your hips, focus on a spot further away, and move relatively quickly (not too slowly). Try this in a hallway where you can hold on to something if you feel you are losing your balance.

For all three exercises, you may not be able to any of the poses initially but with daily practice you will improve.

Coordination

Exercise the brain by adding in the component of alternating movements or doing a different movement with the arms with the legs. For example, while seated, you could raise the right leg up and down (straighten and bend the knee) while moving the left arm front to side. This cross-body movement does more for strengthening your motor circuits than doing the movements in isolation. Another trick is to bounce a ball while walking or count backward while walking. This brings in the component of skill-based exercise to improve motor function.

Putting it all together

It can be overwhelming to think about adding all of these exercises to your daily or weekly routine. Consider a phased approach, where you'll work in one element every week or every other week. If you try to take on too much out of the gate you could hurt yourself, especially if you are starting from a relatively sedentary lifestyle.

In addition, "weekend warrior" athletics (fairly sedentary during the week, then hard and fast on weekends) can you put you at risk of injury. Start small and steady and gradually increase the number of days per week that you are exercising. The goal is to exercise at least 2.5 hours per week (30 minutes five days per week) but many patients find further benefit from more frequent and longer duration exercise (60 minutes seven days per week).

There are various types of activities that will incorporate a few or all of the exercises mentioned above. Examples include dance, boxing and other Parkinson's-specific classes. I recommend that patients change it up to avoid boredom. The muscles will get bored of the same exercises over and over and they stop responding to exercise. The brain gets bored as well - it needs a challenge! And of course, psychologically it becomes a chore to do the same exercises over and over. For example, some patients will do cardiovascular three days per week, work on machines three days per week, stretch for 10 minutes daily, and do tai chi on the seventh day.

One of the most importance aspects of exercise is mindfulness. This means being aware of what your body is doing at all times. This increases the utility of the exercise (and helps avoid injury). In PD, the strength is there in the muscles! It's just the subconscious brain that's not signaling the movements with the same speed and smoothness as before.

By focusing the conscious mind on the movements, the speed and smoothness will improve. Exercising mindlessly (while watching TV or reading, for example) will not get you far as the body slips back into the small, slow, stiff movements of PD. Therefore, classes such as boxing and dance have been so successful - it's hard to do these activities mindlessly. If you're not interested in going to a class, consider doing a video at home. The other benefit of these types of classes is that they are skill-based (as opposed to purely aerobic) and studies in PD patients have shown that skill-based exercise that is challenging and enjoyable leads to benefits in motor function.

Keep in mind that it's never too late to start! The clinical trial comparing progressive resistance exercises to milder exercise enrolled patients who had had PD for seven years and weren't particularly active at baseline. Many of my patients tell me that after diagnosis, the commitment to physical fitness and exercise made them in better shape than before their diagnosis.

Also remember that it's OK if you used to be active and "life got in the way" … you can always get back on track! Don't get discouraged if you don't see changes right away as some improvements may take time to develop. The body is always able to adapt and there can be improvements in quality of life at any stage.