Exercise and Neurological Disorders
Parkinson's Disease
“I've said Parkinson's is a gift. It's the gift that keeps on taking, but it has changed
my life in so many positive ways.” - Michael J. Fox.
What is Parkinson’s Disease?
Parkinson’s disease (PD) is a progressive neurological disorder caused by the loss of dopaminergic neurones in an area of the brain known as the substantia nigra. This reduction in dopamine production is responsible for reduced control of body movements, but may also lead to: muscular rigidity, a tremor, poor posture, gait deficits and pain. Some individuals may also develop depression, anxiety, dementia, and hallucinations. These symptoms may not present until half of the dopaminergic neurones have been lost. In many cases, this degeneration may even be symptomless for up to 6 years. Once symptoms occur, PD progression may continue for up to another 10-13 years before death.
What causes PD?
At present, it is estimated that there is no known cause in over 90% of all PD cases. There is speculation that two factors may play a role in the development of PD:
Genetic factors
Some rare genes, such as: autosomal dominant SNCA and LRRK2, and autosomal recessive PARK7, PRKN, and PINK1 may be associated with elevated PD risk, but further research is needed.
Environmental factors
Certain environmental toxins have caused PD-like symptoms in other animals. The herbicide Paraquat, as well as the pesticide, Rotenone, have been associated with the development of parkinsonian symptoms.
Symptom incidence and diagnosis
According to the UK Brain Bank, inclusion criteria for a diagnosis of PD include bradykinesia (slowness of voluntary movements) AS WELL AS muscular rigidity, a 4-6Hz resting tremor, or postural instability not caused by visual, vestibular, cerebellar, or proprioceptive dysfunction.
For a definitive diagnosis, three or more of the following symptoms are required:
• Unilateral onset
• Rest tremor present
• Progressive disorder
• Persistent asymmetry affecting side of onset most
• Excellent response (70-100%) to levodopa
• Severe levodopa-induced chorea
• Levodopa response for 5 years or more
• Clinical course of ten years or more
Many secondary symptoms may also exist in those with PD, including: Fatigue, softness of voice, drooling, dystonia, stooped posture, bladder issues, and restlessness.
Exercise prescription for individuals with PD
Exercise is a vital intervention for those with PD. It may serve to delay disability, improve quality of life, and maintain balance, co-ordination, strength and mobility. Due to the symptoms of PD, many will experience a more sedentary lifestyle as the disease progresses. This can lead to poorer cardiorespiratory fitness, flexibility, mobility, strength and metabolic health. Perhaps surprisingly, the exercise recommendations for PD are not dissimilar to healthy adult populations, although certain adjustments may need to be made on an individual basis – for example, the treadmill may not be suitable for some, and a bicycle may be a sensible alternative. Any PD exercise plan should contain elements of training which focus on: Strength, cardiorespiratory fitness, flexibility, and balance, agility and co-ordination.
Exercise and PD: Considerations
Since PD is associated with autonomic dysfunction, it is worth considering that orthostatic hypotension may be of particular danger to these populations. This sudden drop in blood pressure when going from sitting to standing may be problematic for two reasons: The initial dizziness that accompanies this postural change may increase the risk of losing balance, whilst the impaired cognitive function, strength and functional capacity of the individual may mean that, in the event of a fall, the individual is unable to catch themselves.
It is also worth considering that certain individuals with significant cognitive impairment may struggle to talk whilst exercising. It may be sensible to allow them to focus purely on the exercise task at hand whilst giving feedback at the end of a bout.
Cardiorespiratory exercise
As mentioned previously, the exercise recommendations for PD do not differ significantly from the healthy adult population. Therefore, those with PD should aim to accumulate 30 minutes of aerobic activity on 3 days each week, where possible. This would total 90 minutes of moderate intensity (RPE 11-13 on a 6-20 Borg scale) activity per week, as opposed to 150 for the healthy population. Where sensible, this should be performed as walking, to help maintain economy of gait and weight transfer, as well as balance. However, if this is not a suitable option, then cycle ergometers may provide a better solution. If possible and safe to do so, increasing cadence, velocity or the intensity of the cardiorespiratory exercise may appear to increase neuroplasticity in the brain and reverse some of the degeneration caused by PD. 1
Side Note: From experience, if the cycle ergometer has foot/pedal straps, it may be awkward for those with dystonia or moderate-to-advanced symptoms of PD, such as significant loss of flexibility, to place their foot in the strapping, and therefore an ‘open’ pedal may be preferable, even if it results in more awkward pedal action at first.
Resistance exercise
Resistance training is vital for PD as it improves muscular strength and endurance, aiding with activities of daily living (ADLs). In particular, strengthening muscles in the posterior chain may help to maintain correct posture as the PD progresses. These exercise sessions should occur on 3 days each week, leaving at least one day between for rest and recovery. Intensity can be as low as 40% 1RM for 1-3 sets of 10-15 reps in exercise novices, up to 70% 1RM for 1-3 sets of 8-12 reps in more advanced exercisers. These 1RM data can be obtained using conversion tables for a 5-10RM. It is vital to ensure that correct posture and form is maintained throughout the sets, and sensible adjustments should be made as necessary. For example, seated dumbbell shoulder press as opposed to standing dumbbell shoulder press. A variety of equipment may be used, including, but not limited to: resistance bands, dumbbells and kettlebells, machines and Bosu balls.
Range of motion exercise
Daily stretching, when possible, is recommended as this will maintain flexibility and mobility. In particular, slow, controlled static stretches, held for up to 30s at the point of slight discomfort are recommended. Extra emphasis should be placed on the neck muscles to counteract the rigidity which often comes with PD. Once more confident and able, these stretches can be progressed to dynamic concurrent strengthening and stretching in the form of yoga or Pilates (see below).
Training for agility, balance, co-ordination (multi-tasking)
This is where, as practitioners, we may need to get creative. I myself have been very lucky recently, as I have access to a Batak board (image below). This device illuminates a series of lights which only turn off when the user has tapped the correct button. It is a simple but effective way of training proprioception, agility, reaction speed, balance and agility. Overall, this is a great method for training for multi-tasking, and so long as the practitioner is able to supervise sensibly, is incredibly low risk.
For those without access to a Batak board, activities such as Tai Chi, yoga or dance, or even low-intensity boxercise may be of benefit. These activities require constant shifting of weight, as well as testing co-ordination. If these activities are unavailable, simple alternatives such as throwing and catching certain colour coded balloons or beanbags may be just as effective. This should be performed on 2-3 days each week, with small bouts of daily integration when possible.
Three things to remember
Every intervention must be individualised. No two cases of PD are identical.
Loss of balance is common in those with PD, so be vigilant when supervising a session.
Make it as fun as possible! This will increase the likelihood of maintaining good exercise habits.
Before you go…
If you found this article interesting, please do feel free to share with anyone else who may benefit. You can share by clicking the button below, and you can find me on my other socials such as Instagram or my website. I look forward to speaking to you soon!
1 de Laat, B., Hoye, J., Stanley, G. et al. Intense exercise increases dopamine transporter and neuromelanin concentrations in the substantia nigra in Parkinson’s disease. npj Parkinsons Dis. 10, 34 (2024). https://doi.org/10.1038/s41531-024-00641-1
Thanks Ben, it’s always fun to read your posts!!