Exercise and Parkinson’s disease

by Michael Kleinman, D.O.

The treatment of Parkinson’s disease (PD) is often thought of as just medications, or in advanced cases, surgical treatment. There are in fact many non-medication treatments for PD, and exercise is one of them. Exercise has been shown in studies to improve not only the movement related symptoms, but also many non-motor symptoms of Parkinson’s. Starting an exercise regimen may not seem to be as important when one initially receives a diagnosis of PD as the symptoms are often no more than a minor nuisance at that point. However, getting started early is vital, as it becomes harder to commit to making exercise a routine part of life as one’s condition progresses. Participating in regular exercise can seem daunting to someone who has lived with PD for years. There are many different ways to go about getting exercise and these can be tailored to an individual’s needs and abilities.

Getting Started
Exercise and physical activity are vital to an early treatment regimen in PD. By participating in exercise, one takes an active role in the fight against the disease. It can also give a person with PD a sense of empowerment over the course of their condition. In early stage PD, it is most important to choose an exercise regimen or activity that one will have a high probability of participating in regularly, rather than choosing one specific exercise over another. The ideal regimen will include activities that are enjoyable, and that also help control PD symptoms.

Identifying and addressing barriers to exercise will help overcome the daunting nature of beginning a new fitness regimen. In later stages of PD, one of these major barriers is apathy. Apathy is a troublesome non-motor symptom of PD that involves a lack of motivation and reduction of emotional expression, and can be difficult to treat. In my experience, starting an exercise regimen before apathy becomes problematic may even prevent this symptom from becoming a factor in reducing one’s quality of life.

A referral to a physical therapist experienced with PD is often helpful in getting started with an exercise regimen. Periodically revisiting courses of physical therapy as PD progresses is important in order to customize and adjust one’s exercise program to fit one’s needs and capabilities. Home-based physical therapy programs are also an option for those who have a difficult time adhering to outpatient therapy programs. Exercise classes can be a good way of building social interactions both within and outside the PD community. The care partner also plays a vital role in providing motivation to stay active. Exercising with a family member can have a positive effect on relationships.

Exercise as a Symptomatic Treatment
Numerous research studies have found that various exercise regimens improve many bothersome symptoms of PD, including reducing stiffness, increasing strength, and improving balance, gait and mobility. Research on exercises aimed at improving gait and balance have shown a consistent improvement in balance with a reduction in the number of falls. Exercise has also been shown to improve overall quality of life.

What Types of Exercises are Good for PD?
Although there have been many studies which have demonstrated the positive effects of exercise, there is little data to say that one exercise program is superior to another. In general, a physical activity program that incorporates a variety of movements involving a large range of motion are preferred over performance of a single repetitive exercise. Ideally, an exercise routine would include lighter intensity activities focusing on stretching and balance, as well as higher intensity activities. Some specific examples of exercises for PD include:

• Brisk walking
• Aerobics classes
• Resistance exercises (light weight)
• Participation in sports
• Biking
• Dancing
• Yoga
• Tai Chi

Many patients have been referred to participate in the LSVT-BIG program for physical therapy through local outpatient rehabilitation centers. This is an intensive program focusing on promoting high amplitude movements. LSVT-BIG has been shown to improve motor functioning in PD, as well as increase walking speed. We are now fortunate to have practitioners experienced in this program at several different locations throughout Maine. It is very important to remember that performance of the exercises at home after the completion of the course will maximize the likelihood of experiencing a sustained benefit.

The Effects of Exercise on the Non-Motor Aspects of PD
For many patients with PD, the most troublesome symptoms are related to the non-motor aspects of PD. These may include problems with fatigue, constipation, insomnia, anxiety, depression, and cognitive dysfunction. In many cases, medications to address these symptoms are of limited effectiveness, but exercise can help. In one series, patients who started exercise early rather
than later in their illness were found to have fewer symptoms of depression.

Cognitive symptoms, problematic in PD, include slowed processing speed, difficulties with multi-tasking, and impaired decision-making skills. These cognitive domains are referred to as frontal executive functions, impairment of which is seen in a significant number of people with PD, even relatively early on the course of the condition. Research on exercise in PD has shown an improvement in executive function skills, with the effects noted up to six months into treatment.

The Effects of Exercise on the Brain in PD
It is known that the movement symptoms of PD relate to a loss of the dopamine producing cells in a structure called the midbrain. Research has been performed on the effects of exercise on mice treated with a substance that mimics the effects of PD on the human brain. The mice that performed treadmill exercise were found to have lost fewer dopamine producing cells, when compared with the mice that did not perform any exercise. The exact mechanism for this protection of dopamine producing cells is unclear, but is thought to be due to a reduction of inflammation in the brain.

Mice with Parkinsonism were also found to have increased connections with other cells within the movement center of the brain, the basal ganglia, after being exposed to an exercise program. This suggests that exercise can enhance neuroplasticity, the brain’s ability to form new connections and pathways. Studies of the levels of certain substances that are thought to promote neuroplasticity have found an increase in the level of these substances in humans with PD after the completion of exercise.

Structural imaging studies of the brain have also demonstrated positive changes after exercise in people with PD, with increased volumes of certain parts of the brain noted. Similar effects on brain volume have also been seen outside of the PD population in older patients, underscoring the importance of physical activity for overall brain health as we age.

How Much Exercise Should One be Doing?
There is no single number to describe the frequency and duration of exercise that applies to every person with PD. If you are not initially an active person, or you have physical limitations, then it is advised that you start with a shorter duration of exercise and gradually increase with time. Those who are younger or are in the mild stage of PD should be able to tolerate longer durations of exercise and perform higher intensity exercises. For most people with PD, a goal of 30 minutes of exercise 3-4 times a week is achievable. Many experts believe that more intensive programs may confer a higher degree of benefit.

In conclusion, exercise plays a vital role in maximizing one’s functional abilities and quality of life across the spectrum of PD, should be incorporated into the treatment plan at the time of diagnosis, and continued throughout the course of the condition.

REFERENCES

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