The exercise type and dose for Parkinson's treatment? An interview with an expert
Best Exercises, Recommendations on Dose and Why Parkinson’s Exercise is so important!
Questions about exercise tend to dominate every group I speak to around the world. In this blog Indu Subramanian and I sit down with a guru to pick her brain about the most important questions about exercise and Parkinson’s disease.
Who is the author Julie Hershberg PT, DPT, NCS and what is her connection to exercise and Parkinson’s disease?
Dr. Julie Hershberg is a physical therapist with board certification as a neurologic clinical specialist. Julie received her Doctor of Physical Therapy degree in 2002 from Slippery Rock University in Pennsylvania and then completed her neurologic physical therapy residency at the University of Southern California (USC) and Rancho Los Amigos National Rehabilitation Center. Julie continues to teach Neuropathology at USC and mentor residents and students in neurology. In addition, she collaborates and mentors therapists across the globe through re+active education, an online therapy education community. A passionate neuro PT, she started re+active physical therapy and wellness in 2012 as a specialty neurology physical/occupational therapy and fitness practice. Re+active now has two studios in the Los Angeles area, serving thousands of people every year with neurologic disorders through physical therapy, occupational therapy, personal training, yoga and group exercise classes. The team at re+active has collaborated on several research studies to investigate the different types and parameters of exercise that can best help people with PD. Julie is most passionate about exercise as a lifelong habit to promote potential neuroplasticity and health in people with chronic disease.
Indu Subramanian, M.D.
Co-author of this blog post and the frequent host of the Parkinson’s and Movement Disorders Alliance webcast series.
Many people have heard that exercise for PD is helpful. What type of exercise do you recommend? And at what intensity?
The short answer is—anything that is FUN and will keep you engaged in exercise for a lifetime. But we do know that certain types of exercise potentially promote neuroplasticity and may possibly slow down disease progression in PD. Skill training and aerobic exercise are two types of neuroplasticity inducing exercise that I will touch on here.
Skill training includes any type of activity where the focus is on a goal and includes learning, having success and getting feedback. It often involves coordinated movement with speed, power and large amplitude. Great examples of skilled training include dancing, following an exercise routine that becomes progressively difficult, and incorporating doing two tasks at once while you are moving. Skill training is at the heart of most physical and occupational therapy practices, personal training and group exercise for PwP. One of my favorite activities that we do in our exercise classes and therapy sessions is to add boxing sequences with a secondary cognitive instruction. For example, we call out a sequence of a jab and hook with right and left fists and then ask a person to use their right hand when we say left and vice versa. This cognitive practice of inhibition requires intense concentration and leads to a lot of laughter initially; but ultimately success, fun and a lot of neuroplasticity!
Aerobic exercise is activity where the person pushes the cardiovascular system to raise the heart rate and breathe harder. Aerobic exercise contributes to neuroplasticity by improving brain blood flow and general brain health. Examples of aerobic exercise include running, walking, swimming, biking and high intensity interval training. But aerobic exercise doesn’t require a gym or special equipment, you can even increase your heart rate with an intense sitting exercise routine.
You can turn any activity into an aerobic exercise by ramping up the intensity to where your heart rate rises to a moderate level. A simple formula for checking your target heart rate zone is to calculate your maximal heart rate (max HR). Max HR = 220-age. To find your moderate intensity aerobic zone, you would take 50-75% of your max HR. For example, if you are 50 years old, your max heart rate is 170 and your target moderate aerobic zone is 85-127 beats per minute. I love using a simple Polar HR monitor, Apple watch or Fitbit to monitor heart rate while exercising. Without a heart rate monitor, you can also use a rate of perceived exertion scale and aim to exercise in the 5-7 zone.
Now, incorporate both aerobic and skilled exercise into your routine and you have hit the jackpot! One way that people combine skill and aerobic training is through cycling at a forced pace on a stationary bike. Cycling at a high cadence (80-90 RPMs is the recommendation in PD) is a skill because it is goal oriented (i.e.--keep up your speed!), that often has the added benefit of aerobic exercise. You can also get the combination by dancing at a high intensity while learning and remembering the dance steps and routine. In many of our classes, we combine skill and aerobic training by doing high intensity intervals that are progressively more difficult and involve a secondary cognitive task or sequence. Another simple suggestion for home is to try setting your walking, running or other exercise to music that changes rhythm. One of the most important qualities of your routine to promote neuroplasticity is to keep your routine challenging and progressive.
You talk about exercise as medicine and a lifelong habit, how long should people exercise and how can people keep exercise sustainable?
Exercise is medicine, but unfortunately it is not a magic one-time pill. It does take commitment and effort to see results. We recommend exercising 30-60 minutes for at least 3x/week to see the neuroplastic benefits. In the studies of exercise in PwP, people experience greater benefit with increased time exercising. We see this in our exercise class participants. The more hours and different types of exercise they participate in, the better their mobility and symptoms. However, if you have not been exercising at all, don’t be disheartened. It is huge to take that first step. Start with 5 minutes per day and slowly build up. And if you have other health conditions, especially heart disease, check in with your doctor first to ensure that challenging exercise is safe for you.
One of the most challenging parts of exercise as medicine, is making it a sustainable, lifelong habit. I already mentioned that number one key to sustainable practice--keep it fun!
Are you laughing, smiling, and joking during your routine? Another way to help keep it sustainable is to have accountability. Do you have an exercise partner like I do- that person texts me every Saturday night to confirm my Sunday run? I would rarely wake up early on Sunday for a run if I did not have a friend waiting for me. Sometimes people need a personal trainer who can not only keep them accountable, but provide the coaching, encouragement and feedback to drive a progressively difficult program. I also highly recommend partnering with a physical therapist to design a program that not only drives neuroplasticity but is safe and targets areas of difficulty specific to you. To quote one of our exercise class participants: “Exercise, and neuro-PT specifically, re-defined my anger/loss of having PD for a number of reasons. Of most importance, it made me realize that exercise/PT gives you agency--the disease doesn't dictate everything in your life, and your efforts matter again. “
In this time of COVID, what are your recommendations for staying active at home?
This pandemic has definitely brought challenges for people who previously had a great routine out of the house with classes, the gym or even getting out in nature. With many of these options closed, the need to stay active at home and in your own neighborhood has become more important.
One of the silver linings of the COVID pandemic is that many PD exercise experts have made services available online. PwP who previously did not have access to an expert, can now find one and work with them from the comfort of their home. In many areas of the country you will find your local boxing classes, exercise classes and personal training now available online. If you have been uncertain about an online led class, trainer or therapy session before, I highly recommend trying it. We have had many people surprised at the benefit (and how much easier the technology has gotten!). Some PwP are exercising even more now because they have set up space at home with their equipment ready to go all of the time. In addition, people who have built successful exercise habits at home during the pandemic have scheduled their exercise and activity as a daily appointment.
I have found that PwP are exercising in new ways including attending a live online class or watching a recorded class. My first recommendation is to attend a live online class because you reap the benefit of the social interaction, support and feedback from the group and the instructor. It also keeps you accountable! However, watching exercise videos and completing them on your own time is convenient if live classes don’t fit your schedule.
Safety can be a concern for people exercising at home. I recommend working with a physical therapist in person or via telehealth to evaluate and make recommendations for safe ways for you to exercise at home. A physical therapist may have you monitor your blood pressure and heart rate and provide guidelines for safety and to move without pain. If you have had falls in the past, we may also recommend areas to perform exercise safely like near your bed or couch, while holding onto furniture or a walker for support, or with a family member or care partner present.
Do I need special equipment to exercise?
Definitely not! During the pandemic, people have learned that exercise can be challenging and engaging at home with little to no equipment. Both aerobic and skilled training can be done without equipment. However, if you want to add variation and progressive challenge into your routine, there are a few low-cost items that can enhance your exercise routine.
● To add resistance to your routine: try using cans, water bottles, or low-cost resistance bands.
● For larger movements and goal orientation for skill training: try stickers on the wall for targets, pool noodles in your hands to extend your reach, and beach balls or tennis balls to toss as a dual task.
For increased aerobic training and fun with walking: try trekking poles. I love using poles for walking, hiking, and doing a full body warm up routine. Here is a link to a simple routine. https://youtu.be/rR4wlWZThf8
For a dual task and cognitive challenge with skill training try using music, a metronome app, or one of my favorites, the clock yourself app https://www.clockyourself.com.au
Yoga for added physical healing and emotional grounding!
What do you think about yoga for PwP?
Bias alert--I LOVE yoga! I have been doing yoga for over 15 years and found immense physical healing and emotional grounding through yoga practices. One of the first classes that we started at re+active was a yoga class for people with neurological disorders. In particular for PwP, yoga is a wonderful part of an overall exercise program for different reasons than the skill training and aerobic exercise (although yoga can be both). Yoga can benefit PwP through building strength, balance and flexibility. The nervous system regulation that occurs with the grounding practices and focus on the breath in yoga is also helpful for feelings of anxiety and restlessness.
Dr. Michael Okun
To read more books and articles by Michael S. Okun MD check Twitter @MichaelOkun and these websites with blogs and information on his books and http://parkinsonsecrets.com/ #EndingPD #ParkinsonPACT #Parkinsonsecrets and https://www.tourettetreatment.com/
References
Ahlskog JE. Does vigorous exercise have a neuroprotective effect in Parkinson’s disease? Neurology 2011;77:288-294
Alberts JL, Linder SM, Penko AL, Lowe MJ, Phillips M. It is not about the bike, it is about the pedaling: Forced exercise and Parkinson’s disease. Exerc Sport Sci Rev 2011;39(4):177-186
Petzinger GM, Fisher BE, McEwen S, Beeler JA, Walsh JP, Jakowec MW. Exercise-enhanced neuroplasticity targeting motor and cognitive circuitry in Parkinson’s disease. Lanc Neuro 2013;12:716-726