7 Strategies to Deal with the Excuses and Barriers Limiting Exercise in Parkinson's Disease
Who is Alison Kraus? Alison is a PT, DPT, NCS and is a board certified neurologic physical therapist specializing in Parkinson’s disease and vestibular dysfunction. She received a doctorate in Physical Therapy from Ithaca College, and a BS in clinical health studies. She currently works at the University of Florida Norman Fixel Institute for Neurological Diseases (UF Health Rehab). She is a member of the interdisciplinary teams for patients seeking deep brain stimulation surgery, patients with atypical parkinsonism and she is also a vestibular therapist for the Traumatic Brain Injury team. She works to coordinate care with local and non-local physical therapists to promote wellness in patients with Parkinson disease; Alison also works as an adjunct faculty member for University of Florida Department of Physical Therapy. She assists with lecturing, and hands on laboratory sessions, for their neurological rehabilitation curriculum. She works to teach future physical therapists the many ways they can be vital team members in the care of people with PD.
We sat down with Ali to pick her brain on strategies to deal with the excuses and barriers limiting exercise in Parkinson’s disease.
From the time you are diagnosed with Parkinson’s disease, you are more than likely provided with medication and only casually encouraged to exercise. Dr. Becky Farley has previously blogged about the myths in exercise with Parkinson Disease, and the benefits of consulting with a neurologic physical therapist from the onset of the diagnosis. She discussed how physical therapists play a key role in personalizing your fitness plan to help you throughout the disease course.
The next step towards continued success will be to address the potential barriers that lead to inactivity vs fighting for continued independence. Exercise may look different compared to when you were 20 years old, however there are numerous options to manage symptoms. You have the power to choose the best exercise regimen for you and your lifestyle. This blog post will discuss non-medicinal ways to manage symptoms that repeatedly prevent people with PD from consistently exercising. The current recommendations for exercise in PD are to engage in aerobic exercise or “cardio”, for at least 30 minutes 3-4x/week at a moderate-vigorous intensity level. It is also recommended to engage in progressive strength training 2-3x/week. For some people, that seems achievable, and here are some ways to address potential symptoms that may be preventing you from reaching your exercise goals.
By Jonny Acheson
Stiffness – “My hips, shoulders, neck, and
back are so stiff… my legs feel heavy when I
move them.”
We know rigidity is one of the four cardinal symptoms of PD. Early on in the disease, you may notice one side, or one limb tighter than the other, and as the disease progresses the stiffness sensation may become more widespread. The stiffness lends to a feeling like moving is more difficult, however, prolonged lack of movement can increase your rigidity— causing more difficulty with functional mobility. To manage this symptom think: STRETCHING & TIMING.
Stretch first. Ensure you are getting a good stretching warm-up prior to initiating exercise. Stretching with full body/high amplitude movements (i.e. floor to ceiling reaching, trunk rotations) prior to your aerobic or strength workouts prepares your body to counteract rigidity. Discuss with your physical therapist specific exercises to target your body’s rigid muscles and develop a 5-10 minute warm up routine to incorporate in your exercise regimen in order to decrease the feeling of stiffness and heaviness. Time your exercise(s). Make sure you are exercising during the peak of your of medication dose (after it kicks in and not when it is wearing off). Medicine prescribed for your PD is working to decrease the symptoms of stiffness, so planning exercise when your medication is working, will improve the ease of your movements and prevent you from “fighting the rigidity” during your exercise routine.
2. Toe curling or foot Dystonia – “Every time I try to
ride my bike or go for a walk, my toes and feet tighten
up and prevent me from achieving the whole 30
minutes without stopping…frequently.”
Dystonia is a symptom that can affect a person with PD in various parts of their body. Some people endure cervical or trunk dystonia which causes discomfort and impaired posture. Others experience dystonia in their feet or hands causing cramping sensations, that in turn impact exercising. Here are some specific tips for you to perform before or after exercise to assist in the management of foot dystonia. Soak your feet in a warm bath (add Epsom salt for added relaxation). This will work to relax the muscles inside your feet to decrease the cramping. Massage the bottom of your feet. Use your favorite lotion and perform a self-massage of the bottom, or plantar surface of your feet to relax the muscles (if your partner is willing to help, it is an added bonus). Next, move all the joints in your feet, and your toes, to keep them loose. Rolling a golf ball on the bottom of your foot, can be used to mobilize the soft tissue of the foot known as the “plantar fascia.” Ensure you stretch your calf muscles and your plantar fascia as this will also contribute to improve toe and foot mobility. Consider what shoes you are wearing for exercise. Try a shoe with a flexible sole. Sometimes, the stiffer, more built up shoes can limit your foot mobility during activity, thus increasing the dystonia. A shoe with a wider toe box may allow more room for the forefoot and toes to move during exercise thus decreasing the cramped position. Some people perform better with a high top shoe to provide more stability at the ankle if the dystonia is causing the ankle to roll, or turn in. Consult with your physical therapist for the best shoe option to address your foot dystonia during physical exercise and activity.
3. Apathy – “I just don’t have the motivation to start
exercising, I use to enjoy it, but recently I have
trouble getting started.”
Apathy is a lack of motivation to do the things you used to enjoy. It is one of the more difficult, non-motor symptoms that people with PD have to manage. Apathy interferes with exercise, as well as social activities. It is one of the more detrimental symptoms impacting your exercise goals. In addition to discussing this with your neurologist, there are some tips to overcome this barrier. Make a schedule. You will likely be really good about not missing a doctor’s appointment, or even a therapy appointment when they are written in your calendar. Try scheduling your exercise as well. In your weekly calendar, choose which days and what time of day you are going to go for your walk, ride your bike, or turn on your exercise video; make it an appointment you don’t miss. This will allow for you to mentally and physically prepare, and you will be less likely to push it off to a later date. Use the buddy system. Having a friend or partner to go on your walks with you or to perform your exercise routine simultaneously can be motivational. Your “buddy” will increase your accountability to your exercise goals. It tends to be easier to say no to yourself, than to a friend. You can try with a spouse, but maybe it is a good time to socialize while you exercise with a neighbor, a friend, or even a loving dog. If you are having trouble finding a buddy, look into local support group activities (PD Exercise groups) for varying forms of weekly exercise. Try a fitness tracker. A step counter/pedometer, or an activity watch may allow you to set realistic goals and to increase your weekly exercise participation. You can set up small competitions with family members to see who can increase their steps or exercise minutes each week.
4. Balance Changes – “I would love to walk for
exercise but I am too afraid of falling.”
Balance changes can occur with PD and hinder your ability to increase your aerobic exercise intensity. However, if you avoid activity because of fear of falling, your balance can continue to worsen from the lack of movement. Change the type of exercise. If walking outside is challenging, you could try walking on a treadmill where you can hold on to the railings with your hands. Treadmill walking has been proven to be an effective form of exercise with people with PD. Work to increase the speed of walking as well as the incline of the treadmill. If a treadmill isn’t for you, try a stationary bike. They are safe and effective even with balance changes. Just remember to work to increase your heart rate (working at >5/10 on the RPE scale listed above) rather than maintaining a lower intensity workout. Face the balance challenges head on. Find safe exercises to challenge your balance. Tai Chi, yoga, or balance classes can be good ways to diversify your exercise routine while safely challenging your balance. There are always options to have a chair, or your assistive device nearby to grab onto if you need it for support. Another alternative, is to be proactive and request a referral to outpatient PT. If you notice balance changes, attend PT prior to having a fall, rather than waiting for a neurologist to make the recommendation. Incorporate strength training into your regimen. Progressive resistance exercises have been studied in people with PD with potential disease modifying effects. Incorporating strength training using machines, resistive bands or free weights are beneficial for management of the disease. Exercises that are focused on strengthening your legs (i.e. leg press, weighted squats/sit to stands, and hip strengthening) can improve your balance confidence when moving through your daily tasks. Exercises focused on posture (i.e. rowing machine, lat pulldown) can improve your center of mass within your base of support. People with PD often have a crouched/stooped posture causing them to lean forward and feel more off balance. Improving postural awareness, and strengthening posture muscles can improve the ability to stand upright. This, in turn, increases your ability to see and scan the environment, reducing the risk of falling. This will work to help your independence with daily activities as well as your confidence in participating in an exercise routine.
5. Access & Financial limitations- “I was going to the
gym 4x/week but COVID precautions have me at
home more, and I haven’t been exercising as much.”
Exercise groups and gym programs have been vital to a lot of people’s success over the years. However, with recent recommendations secondary to the COVID pandemic, you may need to change up the medium that you are relying on for exercise. Live, Zoom (video) exercise classes. Dancing for PD, or boxing with PD, have been group exercise classes that have been successful in-person. Many exercise instructors and therapists have started live streaming these classes to all patients that are interested. Ask your local groups if they are doing live zoom sessions to allow you to increase social engagement and exercise safely from your home.
Exercise Apps. There are various exercise apps (ranging from free to monthly fees) that can increase the exercise you do at home. Clock Yourself is an exercise app that challenges you physically and mentally from the comfort of your home. General exercise apps like Peloton and Nike Training also provide a wide selection of exercises with varying levels of difficulty to perform on your own time, with little equipment required. YouTube Videos. YouTube is a free website online that provides exercise videos. You can search for specific exercise videos for PD, or a type of exercise that you enjoy the most. Zumba classes, Yoga, Tai Chi, strengthening or mobility exercises are all available to you through online videos. Another option more recently has been videos provided through the Parkinson’s Foundation. They have released over 10 videos since the start of the COVID pandemic for all people with PD to access online. These videos range in difficulty and practice area. It is a good place to start to see your particular interests, and physical level. https://www.parkinson.org/Living-with-Parkinsons/Resources-and-Support/PD-Health-at-Home/Fitness-Fridays
6. Back Pain or Arthritic Changes – “I have had back
pain for a long time and it has prevented me from
exercising, I know exercise is good for Parkinson
Disease but I have a hard time finding something to
do that doesn’t irritate my back.”
Parkinson Disease generally impacts an aging population, therefore many people with PD have diagnoses in addition to PD and these diagnoses can hinder exercise. Chronic low back pain and arthritic changes (i.e. degenerative disc disease, osteoarthritis) are the more common diagnoses that effect exercise. The good news is that a lot of the exercises recommended to manage arthritis coincide with exercises prescribed for patients with PD.
Strength Training: Progressive resistive exercises have been recommended in the exercise prescription for arthritis and are also recommended for people with PD. Therefore, if you are someone who suffers from both, strengthening the muscles surrounding your arthritic areas may improve your exercise tolerance. If the low back is your problem area, try incorporating core exercises (planks, modified plank, quadruped exercises). In contrast, if you are noticing arthritic changes in your knees or hips, try leg strengthening (modified squats, leg press, heel raises). These exercises will improve the strength around your arthritic joints as well as help to maintain bone health. Stretch first thing in the morning: A lot of patients with PD will wake up first thing in the morning with pain. Is it arthritis or is it from rigidity associated with PD? The answer is, probably both. The good news is, both improve with stretching and range of motion exercises to relieve the stiffness. Try to perform full range of motion exercises (i.e. lower trunk rotations, knee to chest) prior to getting out of bed, or before you start an exercise routine. Aquatic Exercise: Low impact exercise is recommended for patients with arthritic changes. In addition to a stationary bike (or walking program as previously discussed), swimming or aquatic exercises are well-tolerated alternatives. The RPE scale previously discussed can be used for your aquatic exercise. Work at an intensity >5/10 (i.e. make it challenging). Swimming strokes can be incorporated into your routine as a combination of aerobic exercise and coordinated movements. If you are not a confident swimmer, incorporating dynamic movements will also increase your heart-rate. Try a combination of water walking, running, lunges, sidestepping, high knees, or butt kicks. You could take a water aerobics class to learn more. It may be the perfect way to change up your exercise routine during the hot summer months.
7. Fatigue – “I am so tired during the day, I can’t get
enough energy to exercise.”
Fatigue impacts people with Parkinson disease physically and mentally. It is multi-factorial and can be influenced by sleep patterns, medication changes, stiffness, slower movements, and possible apathy or depression. Fatigue can limit initiation of fitness programs and cause patients to be more sedentary, influencing quality of life. Use exercise to improve the energy level. It may sound counter intuitive that exercise gives you energy, but aerobic exercise can boost your energy and improve your overall activity tolerance. Try exercising first thing in the morning, or after a mid-day nap to boost your afternoon energy. If aerobic exercise seems too much to start, try a yoga class or full body stretching to wake up your body. Prioritize your exercise and activity. There may be certain times of the day you feel more energetic than others. These times may correlate to timing of your medication. Try to keep track of these times and use them effectively. Plan to go for your walk or ride a bike during your awake times. You can also plan to do your daily activities (i.e. laundry and housework) during these times. Use your more fatigued times to let your body rest rather than fighting through it. Consider a referral for occupational therapy. In addition to reviewing your activities of daily living, an OT is a good resource to discuss energy conservation and sleep hygiene. A neurological occupational therapist can assist with reviewing your daily activities and your sleep habits to maximize your time sleeping as well as maximize your time awake during the day. If you have additional symptoms that are impacting your ability to exercise, ask for a referral to a physical therapist who specializes in Parkinson disease. Your PT can be a critical member of your fitness and wellness when managing many of the symptoms of PD that may hinder your ability to exercise.
This blog is brought to you by Michael S. Okun and Indu Subramanian.
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/
He also serves as the Medical Director for the Parkinson’s Foundation.
To see more on Dr. Indu Subramanian she does live interviews of experts in Parkinson’s for the PMD Alliance
