Expert Voices: Effective, Safe Exercise for People With Parkinson’s Disease
In this installment of our “Expert Voices” series, Parkinson’s News Today asked Becky Farley, PhD, to answer some of your questions about exercise.
Farley is the chief scientific officer and founder of Parkinson Wellness Recovery (PWR!). She received a PhD in neuroscience from the University of Arizona, a master of science in physical therapy from the University of North Carolina, and a bachelor of physical therapy from the University of Oklahoma. She is a published author on exercise for people with Parkinson’s disease (PD) and gives public and medical seminars worldwide.
Since her pioneering research on the importance of training amplitude as a singular focus to target bradykinesia, she has been changing the lives of those living with PD. Locally, she established a model community facility in Arizona for implementing ongoing access to cutting-edge rehabilitation, group exercise, and wellness programming. Globally, she has trained more than 7,000 physical and occupational therapists and exercise professionals to work together to implement programming similar to the PWR!Gym in Arizona in their local regions.
What types of exercises are recommended for people with Parkinson’s and how do they find an effective and safe class?
To adhere to a lifelong exercise program, you need an exercise professional who collaborates with healthcare professionals, has specialized knowledge of PD, and knows how to design and implement safe and effective classes that address PD-specific fitness and mobility problems across disease severity. To help PWP [people with Parkinson’s] find these types of exercise professionals, ones that are similar to those used in research trials, the Parkinson’s Foundation (PF) in collaboration with the American College of Sports Medicine recently brought together multiple organizations and thought leaders in the field of exercise and education to review existing guidelines, PD-specific research, and offer expert opinions in order to develop consensus on new Parkinson’s disease exercise guidelines.
These new exercise guidelines recommend that exercise programs should include the standard health-related physical fitness components (aerobics, strength, balance, flexibility). But they also include other more complex fitness components like agility (quick changes in direction or position) and dual task training to target more PD-specific mobility training. For each component, the guidelines provide a recommended dosage and highlight PD-related motor and nonmotor considerations that may require special modifications.
When you add up the dosage requirements for each fitness component, you would need to spend one to two hours per day, five to six days a week, at moderate- to high-intensity levels to meet the weekly requirements! Unless you are already an athlete or habitual exerciser, that dosage may sound intimidating! But research shows that even sedentary PWP can get more fit and show the same positive changes in their symptoms and brain (i.e., dopamine circuits become more robust) as habitual exercisers. You just need an exercise prescription that is right for you! I would recommend that you start with a multi-modal exercise program. This type of program mixes up the fitness components into an hour or hour-and-a-half exercise class that you can do three to four times a week! If that still sounds too overwhelming, or you prefer to spend your time doing other types of nonexercise physical activity, don’t worry!
Guidelines alone are not useful if you don’t have educational programs that can train competent exercise professionals. That is why the PF also developed competencies that describe the knowledge and skills that are necessary for exercise professionals to design and implement exercise programs for PWP that are effective and safe for people of varying levels of fitness and mobility. There are now several PF Pilot-Accredited Educational Programs that are using those competencies to educate and train exercise professionals, and then certifying them in particular exercise programs. To find these PD-specialized PWR!Moves Certified exercise professionals, visit the directory on our website.
Do you have a favored exercise program or regimen for people with Parkinson’s?
Generally, people with PD do get better at what they practice, so I am hesitant to recommend one type of exercise program. Also, choice and variety matters when you need to exercise for a lifetime! However, when you read the research on exercise in humans and animals with PD, there are a two things that the most effective studies have in common.
Aerobics: My first recommendation to PWP is that they need to see a physical therapist to establish a progressive aerobic training program at diagnosis. The research is robust that aerobic exercise not only improves cardiovascular function, but it improves cognition, mood, and motor function in PWP. While aerobic exercise is good for the brain for all of us, when you are living with a degenerative disease, it is even more essential. Many of the physiological benefits triggered by aerobic exercise may be protective, helping our brain fight against stress, environmental toxins, and other degenerative processes.
In addition to brain health, habitual exercisers at diagnosis have a more robust dopamine system and reduced motor symptoms compared to sedentary PWP. The good news is when they exercised sedentary PWP, they see that these people experience those same positive changes after a three-month bout of progressive aerobics exercise on a treadmill! Most recently, aerobics in sedentary PWP for six months at home on a stationary bike with “exercise gaming” features stabilized disease progression by normalizing connectivity in the dopamine circuits and enhanced cognitive performance. In fact, in another study, when aerobics was paired with skill training, the aerobic-related physiological changes enhance skill training (e.g., walking on a treadmill). The problem is that most of these research participants did not do it alone! Even the habitual exercisers received coaching or immediate feedback for weeks and intermittently throughout the protocol to assure compliance. You need a coach!
Skill training: First you need to identify the aim or focus of your training. What problem is interfering with something you want to do better? In sports science and motor learning research, they call this specificity of training. For PWP, motor and cognitive deterioration underlies the loss of complex everyday movement. So, can we design a PD-specific exercise program that focuses on retraining complex everyday movement? If so, where do you start?
In thinking about these questions, I recalled that children are in skill training mode 24/7. They are rehearsing fundamental skills and putting them together into meaningful and salient sequences to accomplish goals. Through variable and complex practice conditions while exploring their environment, complex familiar movements gradually become automatic and children then begin to attempt dual tasks (carrying a bottle, picking up or playing with toys in multiple positions). When I began doing research with PWP, I had one of those ah-ha moments when I realized that PWP were experiencing development in reverse … their automaticity was deteriorating, they were doing less dual-tasking and focusing all their attentional resources on voluntarily performed simple movement sequences. So, it occurred to me that we needed to go back to the basics and retrain the building blocks of function, then put them back together into familiar sequences, while simultaneously increasing the variability and complexity of practice to mimic everyday movements.
We are now training physical therapists and occupational therapists in how to retrain complex everyday movements (i.e., functional mobility) in therapy for accomplishing personalized goals (i.e., posture) or tasks (i.e., getting in/out of bed, opening the refrigerator). Exercise professionals use the same curriculum but integrate these functional movement sequences into fitness goals and activities.
Where should a person with Parkinson’s start when trying to get started in exercising?
Everyone with PD (sedentary or habitual exercisers, newly or later diagnosed) needs to get to know the rehabilitation members of your care team. Traditional rehabilitation team members include physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP). Strong evidence supports referrals to each of these disciplines for PWP for education, assessment, and implementing research-informed interventions at any stage of the disease, early to advanced. They specialize in the most difficult aspects of everyday life for PWP (e.g., functional mobility, self-care, communication, swallowing). They can educate you on the benefits of exercise and show you how to integrate more physical activity into your daily life! Not everyone is an exerciser — but most people enjoy integrating more physical activity doing the things they love. Therapy is not a one-time event; these professionals should be committed to your success for life, so pick them well! If your physician doesn’t refer you to PD-specialized PTs, OTs, or SLPs early after diagnosis, ask anyway, or find someone who will. Take advantage of all your resources, build your team!
Members of your rehab and community exercise team need to be working together to make sure you adhere to exercise, are appropriately challenged physically and cognitively, and that you are proactive after any change of health status (i.e., injury, illness, planned surgery, pain, mood, motivation). For example, if you are new to exercise, use members of your healthcare team to “prepare” you for structured exercise programs of moderate to high intensity. This may involve developing a personalized conditioning program, consultations on solutions for fatigue, pain, or self-management, or working on therapy goals to decrease fall risk or improve automaticity so you can participate and be challenged more in a community setting. You should also consider observing a class before starting so you know what to expect or ask to do some 1:1 sessions with the instructor to practice the class activities.
If you are already fit, learn to focus your efforts on highly complex and skilled PD-specific motor and cognitive challenges, stress reduction techniques, hand dexterity, or proactive postural exercises. Even after you get started in community exercise, you may need to come in to rehab periodically (every three to six months) to work on problem areas or activities before they interfere with quality of practice or safety. This is the time to be empowered, set new exercise goals, and to update the exercise prescription to get more out of your time and effort.
What recommendations might you have for a person who finds they’re exhausted for days after exercise sessions?
First, let your instructor know how you are feeling and see if they can offer you a lower intensity exercise class or suggest other forms of activity like meditation, qi gong, tai chi, yoga, or table tennis. They can also measure your heart rate, blood pressure, and perceived exertion during a 1:1 session to screen for other causes or medical conditions, and to identify a better dosage of practice.
If nothing is working or you can’t get a 1:1 session with your instructor, contact your physical and occupational therapist so they can reassess the situation, determine triggers, teach you different ways of coping, or refer you for additional health screening. In most cases, titrating the right dosage of physical activity or exercise throughout your day can decease fatigue.
Remember, all forms of physical activity count as exercise. For example, spending more hours/day doing nonexercise-related activities like recreational sports, yard work, cleaning, home repair, meal preparation, and activities of daily living (e.g., dressing, personal hygiene, transferring and overground mobility) have been shown to reduce bradykinesia. So, pacing yourself with “short bouts” of appropriate intensity and increasing your daily participation in complex movements is one way to decrease your symptoms without reaching exhaustion.
Is yoga safe and effective for people with Parkinson’s?
Yoga is one of my top recommended community programs for PWP, and that choice is supported by several good quality studies. You don’t have to be a lifelong “yogi” to experience the PD-benefits. First, it is important for controlling stress — which has been shown to negate the positive benefits of exercise in PWP. Second, don’t underestimate rigidity, it is insidious and will cause stooped posture and loss of shoulder, thoracic spine and neck mobility changes. You won’t even be aware of those changes until you start to fall or stumble, experience pain, and struggle with mobility, dressing, and transfers. Yoga will help strengthen the “anti-gravity extensors” for good posture and stretch the overactive flexors that pull you forward, reducing your base of support and interfering with shoulder and hip mobility. Third, yoga trains attentional focus and sensorimotor awareness and whole-body dynamic movements to decrease bradykinesia. These techniques will also help you balance and correct your posture. Fourth, yoga is empowering, and can help you turn off those negative thoughts that contribute to anxiety and fear and loss of self-efficacy!
If you have never done yoga, you can get started by working with your physical therapist to identify the most helpful poses during a class and how to adapt poses for pain, joint problems, or weakness. Therapists can use videos, apps, and pictures in therapy to educate you about what to pay attention to during your yoga practice. They can also work on task-specific practice in therapy to improve your posture and teach you how to do it at home. Start with beginner level yoga classes and slower paced types of classes (Yin, Restorative). If you have always been a yogi, keep doing the classes you love but don’t hesitate to adapt your movements or try other types of classes so that you can target movements and postures that are most helpful for PD (Power, Ashtanga, Iyengar). To learn more about the different types of yoga click on the link.
With a progressive disease, it’s hard to find reason to exercise when one feels they can never reach their goals. Do you have advice for them?
Everyone can reach their goals, but you have to take incremental steps! Really, there is always something you can get better at. You wouldn’t expect to achieve the goal of running a marathon overnight or in six months, would you? Start with something reasonable and achievable in a short period of time. Don’t blame yourself, realize that goals can change as you change or as your interests or situations change. Let it go, set a new goal.
Reach out to your physical or occupational therapist to help you set more realistic and meaningful goals. At the same time, take advantage of consults and intensive bouts of therapy to target mobility problems that may be keeping you from enjoying group exercise or achieving your goals. Seek more personalized feedback from your class instructor or your rehab team. You can’t get as much specific feedback in a group class as you can in a 1:1 session. Athletes may be involved in team sports, but they seek individualized consults of multiple coaches!
Finally, realize that not everyone is an exerciser — but most people enjoy nonexercise physical activity doing the things they love. And that counts! So allow yourself to set goals about doing more nonexercise activities. People with PD who do more in their daily life experience less severe symptoms. That is because everyday movements (e.g., dressing, cooking, shopping, sports, hobbies) are difficult physically and cognitively and count as exercise!
Here are a few more tips to staying motivated and positive:
- Get involved in fun and creative activities you like to do or have never done! These type of activities challenge you cognitively and increase motivation.
- Try a buddy system so that you have someone who will hold you accountable and be working on their own goals as well.
- Try a support group virtual or live or just go have coffee with some of your exercise buddies; make it a routine.
- Reward yourself with something special; just because!
- Do something for someone else.
- Join the PD-SELF program to change how you motivate yourself and meet challenges. This is a link to a virtual program for persons with newly diagnosed PD.
Expert Voices is a monthly series involving a Q&A with an expert in the Parkinson’s space about a specific topic. These topics and questions are curated from a survey in which we ask readers what they want to learn more about from experts. If you’d like to submit topics or questions for consideration in a future installment of the series, click here to take the survey.
Parkinson’s News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.