How Do I Know If I’m Doing the Right Thing When I Exercise?

Parkinson's Physical TherapistPosting for Dr. Hackney this month is Tricia Creel, DPT, NCS, an outpatient physical therapist and the co-founder–along with Dr. Hackney and Doherty Riebesell, DPT, GCS–of MDT Educations Solutions, the mission of which is to equip health and fitness professionals, care partners, caregivers and people with PD with the knowledge and resources to form and participate in community-based exercise programs. Tricia specializes in the treatment of neurologic disorders, with an emphasis on Parkinson’s disease. She is a member of the American Physical Therapy Association Neurology Section and the Physical Therapy Association of Georgia and is a Board Certified Neurologic Specialist. She has written articles for the American Parkinson Disease Association on physical therapy, as well as presented at multiple patient/family seminars on Parkinson’s disease. Tricia is a certified LSVT® BIG therapist and is certified in vestibular rehabilitation. She is also a trained PWR! clinician and is a member of the Board of Directors of PD Gladiators.

Recent literature strongly suggests that exercise has a therapeutic benefit for people with Parkinson’s disease. But for exercise to be effectively prescribed as a first line therapy alongside pharmacologic agents, we must understand the optimal type, intensity level and duration. Madeleine E. Hackney, PhD The Exercise Files blog Numerous studies provide evidence that many types of exercise have positive effects on strength, walking, range of motion, balance, and cardiovascular fitness in people with Parkinson disease (PD). There is evidence of benefits from such varied types of exercise as Tai Chi, treadmill training, boxing, progressive resistance training and adapted tango (1-12). It can be confusing to understand which type of exercise is optimal for you and how often you need to be exercising.

In addition to deciding which type of exercise is appropriate, you may also be wondering how intense your workout should be. There is growing evidence that vigorous exercise may have a neuroprotective effect for people with PD. Both research in animals with PD and clinical studies with humans suggest that high intensity exercise may be important in promoting activity-dependent neuroplasticity. This means that there are positive changes within your central nervous system in response to physical activity (13).  It may help to know that the terms “intense” and “vigorous” can apply to a number of aspects of exercise, including high repetition, velocity, complexity, and cardiovascular response.

In the last several years, there has been an increasing number of studies looking at the effect of treadmill training on the symptoms of PD. Woman on Treadmill Treadmill training offers multiple factors that might drive neuroplasticity.  It can provide a cardiovascular challenge if you walk at a fast pace and provide high repetition if you walk long enough.  It can also be complex.  You may be simultaneously listening to music, adjusting your pace, monitoring your arm swing, talking to someone, etc.  Walking on the treadmill is also functionally meaningful since it is very close to over ground walking. In 2008, Beth Fisher, Ph.D., P.T., at USC, conducted a study with people who had been diagnosed with PD for less than three years.  The participants were divided into three groups to compare the effects of different levels of exercise.  People in the high-intensity group exercised three times a week for 60 minutes on a treadmill.  People in the low-intensity group participated in balance and stretching exercises.  A zero intensity group received education only. The study found that the high-intensity group demonstrated increased walking speed, increased step length, improved balance during sit to stand transitions, and more consistency in stepping patterns. They also found that the only the high-intensity group showed improvements in brain function as assessed by duration of cortical silent periods during transcranial magnetic stimulation (13).

Studies indicate that coordination of steps while moving is significantly worse in people with PD who freeze compared to non-freezers and people without PD.  More complex movements, such as turning and backward walking, tend to result in worse coordination compared with forward walking. In addition, worsening coordination seems to be correlated with more severe freezing (14). Even in people with PD who do not experience freezing, coordination is often affected. A 2015 study showed that people with PD have reduced hand velocity and difficulty modifying movement strategies during cued reaching tasks (15). Complex exercise that addresses coordination has been shown to improve the symptoms of PD.  A 2012 study on the effects of an adapted tango program showed significant improvements in motor scores, decreased freezing, improved walking speed both forward and backwards, and improved upper extremity coordination. In addition to coordination, adapted tango addresses cognition, balance, walking, and turning (16).

So, at what intensity should you be exercising? What type of exercise should you be doing? The research hasn’t yet given us exact answers. We still need large, well-designed, randomized controlled trials to establish the impact of different doses of exercise of different types on the long-term impairments of individuals with PD. But here is what you can take away from the research that has already been completed:

  1. People with PD have a wide variety of symptoms, differing rates of disease progression, and different mobility levels. As a result, exercise programs should be tailored to the individual. A physical therapist can help you design a tailored exercise program.
  2. People with PD need to develop long-term, sustainable exercise habits. Even the most advantageous exercise program is helpful only if you stick with it. Find something you enjoy!
  3. Try to participate in a variety of exercises. Group classes, especially those designed specifically for people with PD, can help you achieve this.
  4. Challenge yourself to perform complex (multi-step or multi-task) exercises. For example, both boxing and dance-based exercise require coordination, concentration, and balance.
  5. Include exercise that provides a cardiovascular challenge. On a scale of 0-10, try to reach an exertion level of 5-7.
  6. If there is something specific that you are having trouble doing, such as turns or rolling in bed, find an exercise that mimics that activity as closely as possible. Specificity of training matters!

It’s always a good idea to consult with your physician before starting a new exercise program. And remember to keep moving!

CLICK HERE to View Citations to Studies Referenced in this Post

Dr. Madeleine E. Hackney, Ph.D, is a Research Health Scientist at the Atlanta VA Center for Visual and Neurocognitive Rehabilitation and an Assistant professor of Medicine in the division of General Medicine and Geriatrics at the Emory School of Medicine. She holds a Ph.D. in Movement Science from Washington University and a BFA in Dance from NYU, Tisch School of the Arts and has also been an American Council on Exercise certified personal trainer since 2000. Dr. Hackney’s extensive research interests include inquiry into challenging exercise programs–traditional exercise, Tai Chi and partnered tango classes–designed to improve physical function and quality of life in people with PD, older adults and those with serious mental illness. In 2014, she co-founded MDT Education Solutions, which has trained almost 60 fitness and allied health professionals how to develop and lead safe, evidence-based exercise programs for people with PD at all stages of the disease, including almost all instructors in the PD Gladiators Metro Atlanta Fitness Network (including the YMCA of Metro Atlanta).

4 responses on How Do I Know If I’m Doing the Right Thing When I Exercise?

  1. I was recently diagnosed with PD. I am certified to teach Russian Kettlebell lifting through the Russian Kettlebell Challenge (RKC). http://www.dragondoor.com/instructor/Marc_Fine/ I use them extensively in addition to just starting boxing and doing yoga. I would like to discuss the idea of creating a program for Parkinson’s patients to use kettlebells as I am convinced that they are helping me slow the progressiion via different resistance movements with varying wieght as well as ballsitic movements that require using the body for stabilzation. In addition, they are excellent tools for facilitating building muscle and fat loss. Thank you for your consideration.

    Marc Fine

  2. Moderate intensity exercise is adequate to produce a neuroplasticity effect, which is brain reorganization and repair. Qi Gong and Tai Chi are Chinese exercises which are documented therapeutic activity for people with Parkinson disease. Full range of motion exercise, that is full movement around a joint or body part may be integrated in daily activity. Focusing on exercise while participating provides a synergistic effect on the body and brain. The most effective exercise is exercise you participate in regularly. Dr. Sheree Loftus, PhD, is a Nurse Scientist in New York City at Mount Sinai Beth Israel Neurology. She holds a PhD in Nursing research and her doctoral work was on Qi Gong to Prevent Parkinson Falls. She is also certified in Physical Medicine and Rehabilitation Nursing. She has facilitated Parkinson support groups for over 25 years. She continues her research on neuroplasticity, mobility and aging with disability.

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