Progress and Prospects in Parkinson's Research/Therapy/Exercise

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Exercise: assured limited neuroprotection

Front line defences in Parkinson’s disease therapy have traditionally been pharmacological. The realisation that the disease is more widespread in terms of pathology than was initially realised and the recognition that pharmacology has some serious limitations has, however, led to renewed interest in non-pharmacological approaches. Exercise is one of the subjects receiving more attention and the successes achieved using exercise in animal trials have been exceptionally encouraging. While exercise is indisputably beneficial for healthy people, it is only in relatively recent times that the idea that exercise might also be beneficial for those suffering from an illness has become more widely accepted.

What type of exercise
Having accepted that exercise is a good thing, the question immediately arises, what type of exercise should a PD patient be doing? how often should the exercise be done? how long and how intense should each session be? Given the broad spread of capabilities or as the case may be, restrictions in movement capability, together with the diversity of possible exercise spanning jogging, cycling, swimming, gymnastics and a host of others, it is not readily obvious at first which direction to take. Many forms of exercise overlap in terms of their effects so a degree of substitution is possible, bearing in mind that the physical activity limitations will vary considerably from one PD patient to the next.

Jogging/walking, either indoor or outdoors, features prominently in practically all exercise regimes so the focus will be in that area.

Before going on to look at what elements any particular exercise should include, it is useful to classify the various types pf exercise.

Exercise can be divided roughly into three types, all of which differ one from another, with different objectives and outcomes.

Exercise classification

 * resistive or strength exercises, including weight lifting, use of Thera bands
 * aerobic or cardio exercises, usually involving walking, running
 * stretching or flexibility exercises

All three should ideally be included in an exercise routine.

Having classified exercise broadly by type, the next thing to look at is how and when to use it. A possible starting point is http://www.pateintslikeme.com a website describing up to 150 different types of exercise, categorised into disease conditions including, of course, PD. The site is easy to navigate. In forum postings, it is possible to pick up a considerable amount to information on what has been found to be beneficial, drawing on the experience of others.

The following elements have to be taken into account:


 * Duration/Frequency
 * Intensity
 * Complexity

The first element needs little comment. Duration along with frequency is one of the fundamental pillars of exercise. Values cited by experts vary considerably, with a minimum duration of 20-30 minutes, 2-3 times per week, regarded as being at the lower end of the scale. Recommended levels converge towards 30-60 minutes, 4-5 times per week. The LSVT/BIG therapy program that is currently attracting attention, lays emphasis on a daily routine. This particular program is focused on voice training coupled with large amplitude movements.

Intensity is somewhat more difficult to define and is usually related to heart rate. There are different definitions of heart rates, resting heart rate, maximum heart rate (MHR), (defined as 220 minus age), target heart rate, usually 50-70% of MHR, heart rate reserve (HRR) obtained by deducting resting heart rate from MHR.

Exercise intensity

Occasionally the term VO2 max, determining oxygen consumption, is used as a measure of intensity. Though usually measured in a laboratory setting, it can also be calculated as follows: This parameter is of interest mainly for trained athletes and need not concern us further.
 * Run all-out for 15 mins
 * round off the distance covered to the nearest 25 m
 * divide by 15
 * subtract 133
 * multiply by 0.172
 * and finally add 33.3

Complexity refers to the extent to which a multiplicity of systems, including neurological feed-back loops, are involved in carrying out the exercise. A repetitive movement, with little or no variability in feedback, involving a limited involvement of neuro-muscular systems, is not as beneficial as one where a diversity of coordinated inputs and outputs arise. Skipping, for all its benefits, is repetitive whereas walking over rough ground involves interactive signal processing, with a degree of diversity, thus is beneficial in a broader context.

Baltimore trial
Many Parkinson patients ask themselves what is the best type of exercise for me? The answer could be any type of exercise is beneficial but some exercise regimes are better suited for PD patients than others. In this context, a considerable amount of information is available from a recent study which relates directly to PD patients. The study, carried out in the USA by a group headed by Dr .M Schulman at the University of Maryland School of Medicine, Baltimore, compared three types of exercises to determine which was best suited to patients having light to moderate PD with walking difficulties.

67 patients participated. One third used a treadmill at high intensity, (15 min per session to start, increasing to 30 min at 70 to 80% HRR). One third also used a treadmill but at lower intensity (start at 15 min per session, walking at a self-determined comfortable pace, increasing to 50 min at 40-50 % HRR). One third did stretching and resistance exercises directed at the lower body, followed by stretching of the upper and lower body.

All three groups trained for 3 months, three times a week. Before and after the trial, participants were subjected to various tests to evaluate the effect of training, general fitness and an evaluation of Parkinson symptoms.

The results showed that the low intensity treadmill group and the stretching and resistance training group had significant improvement in terms of gait and mobility, measured by the distance walked in 6 minutes. The high intensity group showed only a trend towards improvement that did not reach significance.

Cardiovascular fitness showed significant improvements in peak VO2 in both treadmill groups but no change in the stretching group, PD measured by UPDRS, both total and motor and Schwab & England ADL outcomes however improved only by stretching and power exercises and that only in the UPDRS motor score. The success of the program in alleviating symptoms and disability were measured in the UPDRS motor and overall scales as well as the Schwab and England ADL scale. Only stretching and resistance training had an effect and that only on the UPDRS motor score.

Other non-motor symptoms were also evaluated but no appreciable changes took place with regard to e.g. depression, fatigue quality of life etc. The overall result indicates that a combination of low intensity exercise, combined with stretching and power exercises, gives the best outcome. The first of its kind, the trial is an important one in that it provides an indication of the intensity, frequency and duration required to achieve specific results. Furthermore it underlines the importance of whole body exercise, including upper body strength.

Equipment
Exercise equipment can begin with such inexpensive items as a Thera band (Body Band) and skipping ropes (suitable mainly for those who can tolerate high impact exercise) and progress through an almost endless variety of devices such as  ergometers, ( safe to use but  effects confined to leg muscles) rowing machines, steppers,  treadmills, cross trainers  weights etc

Most investigations relating to exercise involve treadmills rather than cross-trainers. This may be related to the fact that cross- trainers have been on the market only since 1995. While treadmills may be superior to cross-trainers in some respects (cross- trainers have relatively low complexity), they have serious drawbacks, especially for seriously handicapped or elderly users. The danger of falling is much greater, a foot “land” outside the belt area can occur easily and can have serious consequences. Furthermore impact shock loading on joints is an order of magnitude higher with treadmills so that use of cross-trainers should be considered.

Mental exercise
Up to now, most interest has focussed on physical exercise. Only in recent times has attention been given to mental exercise. This switch of emphasis is based on the premise that the brain has a degree of plasticity that can be utilised to maintain or even improve memory, concentration, cognitive abilities and multitasking when provided with an appropriate stimulus. . A number of companies have entered the market offering mind training. The programs offered are in the region of Pds.100 and upwards. One of the better known examples is a US company, Lumosity, with the logo ‘reclaim your brain’. The company offers a number of program modules with automatic degree of difficulty adjustment. Other mental activities such as arise in playing bridge, solving sudoku puzzles and the like are all regarded as being able to contribute to brain fitness, even if the activities themselves may be uni-dimensional.

A word of caution:
When beginning to exercise for the first time or after a long lay-off, it is essential to get a professional assessment of state of health, particularly in regard to the cardio-vascular system. Over-exertion can lead to serious complications, it is important to begin slowly and build up gradually. On the other hand, getting optimum benefits from the time spent calls for an appropriate level of exertion so striking a balance is important.

Finally
It goes without saying that even the most elaborate machine is useless or the best designed program is ineffective if it is not used regularly. Motivation and discipline are important factors in making a decision to commit to an exercise program. It is a life-long undertaking. The rewards come in the form of improved well-being and a sense of control resulting from adopting an active role in managing the disease. The results obtained by the Schulman group, though modest in some respects, speak for themselves.

Coming together in a group can provide an enjoyable experience that helps to persist with an exercise schedule which would otherwise be regarded as a chore