Episode 129: Using the New Parkinson’s Exercise Recommendations as Part of Your Treatment Plan

Dan Keller 0:02 Welcome to this episode of Substantial Matters: Life and Science of Parkinson's. I'm your host, Dan Keller. At the Parkinson's Foundation. We want all people with Parkinson's and their families to get the care and support they need. Better care starts with better research and leads to better lives. In this podcast series, we highlight the fruits of that research—the treatments and techniques that can help you live a better life now, as well as research that can bring a better tomorrow.

Exercise is one of the most important things a person with Parkinson's can do to improve quality of life in the near term and in the long term, with good evidence that it may slow progression of the disease. Recognizing the importance of regular exercise, the Parkinson's Foundation, in collaboration with the American College of Sports Medicine, developed the Parkinson's Exercise Recommendations Guidelines for people with PD and for exercise professionals. They were developed and reviewed by a panel of exercise and Parkinson's experts, supplemented by physical therapy resources and PD-specific research. The aim was to ensure that people with PD receive safe and effective programs and instruction covering the areas of aerobic activity, strength training, stretching, and balance, agility, and multitasking. The guidelines are specific in recommending the frequency, intensity, time, type, volume, and progression of the exercises.

In this episode, Daniel Corcos of the Feinberg School of Medicine at Northwestern University in Chicago explains the principles, practice, and benefits of endurance exercise. The aim is to raise the heart rate to specific levels for cardiovascular conditioning, which may also have a beneficial effect on the brain. But first, we turn to Lee Dibble, a physical therapist and professor at the University of Utah, who discusses strength training under the new guidelines. He explains that strength training for people with Parkinson's goes beyond just the arms and legs, but should involve respiratory, core, and pelvic muscles as well. I guess the most basic question is, why is exercise important for people with Parkinson's?

Lee Dibble 2:47 It really depends on how you define exercise. Certainly, a person could do aerobic exercise, they could do strengthening exercise, they could do stretching exercise. To answer the question about, "is exercise important," I would say yes, and all of those components or types of exercise have different strengths for a person with Parkinson's disease.

Resistance training or strength training can help muscle force production and allow a person to move more quickly and more easily in situations that might require force, like climbing stairs or standing up from sitting down. Aerobic training works on fatigue, or cardiovascular training works on fatigue and other factors. And then stretching is very good for people that might have rigidity and stiffness that might be limiting their movement.

Dan Keller 3:33 Is strength training important only for the extremities, the arms and legs, or does core strength and other muscles come into play, also?

Lee Dibble 3:43 Yes, strength training is important in the extremities, certainly for movement like walking and upper extremity use, but definitely it's important in the core for balance. People with Parkinson's disease may have some balance problems, so core strength and muscle groups that are right around the hips or the shoulders that can help maintain balance.

In addition, you have skeletal muscles that are responsible for generating a loud voice, adequate swallowing, a strong cough, even helping with urination and bowel movements. You can strengthen even the pelvic floor muscles. There's definitely benefits for strength training throughout the body.

Dan Keller 4:24 Is strength training the same as resistance training? Just to clarify the terms.

Lee Dibble 4:30 That's a great question and clarification. When we use the term strength training, we are using it synonymously with resistance training.

Dan Keller 4:49 And what are people resisting?

Lee Dibble 4:42 That is also a great question. People are resisting, in some cases, gravity. That's probably the most present kind of form of resistance. So your body weight, or the extremities' body weight against gravity, is a great way to try to do some exercises. If we want to move on to try to use equipment, you can use elastic bands, you could use weights or cans of soup. We also have machines that we can strengthen people on that would allow more individualized resistance, but you can be very low-tech and just use gravity or something that you might have in your kitchen.

Dan Keller 5:18 You had mentioned that strength training also applies to muscles of respiration. Increasing cough strength can benefit pelvic floor muscles. How do those get strengthened? You can't actually pull against a training band or lifting a weight with those, can you?

Lee Dibble 5:37 No, you cannot. So, for cough strength and for swallowing, the main way that that's been done has been using what they call an expiratory muscle strength trainer. It's kind of like a high-tech kazoo or a mouthpiece that you put in and the person tries to breathe out, and they have to push enough air out that it opens an aperture and that's when they can expire the air. So it makes the muscles that force air out of your lungs work harder, so they use that with a nose clip on, and they strengthen those muscles. And then when they assess how strong a cough is, those metrics of cough strength have improved, and in some cases the metrics of swallowing skill—kind of being able to swallow fluid or some food down into the stomach rather than going into the trachea—those measures have improved.

In the context of the pelvic floor, oftentimes that's just an isometric type of exercise, like you were trying to stop the flow of urine. Some people may have heard them called like Kegel type exercises, but really they're isometric kind of holding, trying to sustain a contraction of the muscles in and around your pelvis to try to maybe stop the flow of urine, and those type of exercises have been successful in some cases, decreasing incontinence type episodes.

Dan Keller 6:58 There's a chart out by the Parkinson's Foundation of all different kinds of exercise—aerobic, strength, flexibility. Under strength training it mentions reps and it mentions volume of exercise. What do those two things mean?

Lee Dibble 7:14 If you were to think of exercise as kind of a medication dosage, you'd have to kind of manipulate the dosage. So the way we do that for resistance training or strength training is you can look at the amount of repetitions that you do, the number of particular kind of movements that you do. You could actually do 10 repetitions, you could rest and then do another set, so you could add multiple sets of repetitions. You can also increase the intensity of the exercise by adding more resistance. So those factors—number of repetitions, number of sets, intensity of the movement—all kind of combine to make up the dosage of the resistance or strength training that you're doing.

Dan Keller 7:59 This sort of gets into the topic of progressive resistance exercise—adding more weight, adding more reps. Is that also beneficial, or do you get just as much benefit from staying at one level as trying to increase as you get better and stronger?

Lee Dibble 8:17 Your body is very skilled at adapting to the stresses that are placed upon it, so if you were to pick a weight that is challenging for you right now and continue with that weight, it would eventually become easier for you, and you'd get less benefit from the exercise. Your body wouldn't continue to try to increase the size of the muscles or make the brain better at sending signals to the muscles, so the progression of some aspect of dosage is an important factor in continuing to derive benefit from the strength training that you're doing.

Dan Keller 8:52 Besides working on the muscles themselves, does strength training have any effect on the brain, on neurons, on preservation, on progression of the disease?

Lee Dibble 9:03 That is a wonderful question. There is certainly more literature that supports the effects of aerobic exercise on progression of the disease. That being said, the few studies that have looked at the progression of disease severity and resistance training have had positive findings that suggest that it modifies the progression of the disease.

The other way to kind of get a sense of if resistance training is modifying something about the brain is to look at the electrical signals that come from the brain to the muscles and what happens if you do strength training, and you see actually a change and an improvement of the electrical signaling of the central nervous system, the brain and spinal cord. The signals that come to the muscles, those are improved in people with Parkinson's disease after they've participated in resistance training, which suggests that it is modifying some aspect of brain signaling.

Dan Keller 9:56 With all these different exercises to do—strength, flexibility, aerobics—how much time in a day would someone be dedicating to this?

Lee Dibble 10:07 My feeling is that you should try to individualize the exercise to the most specific needs a person might have. We could provide a broad approach and say, okay, you need to do all of these types of exercises, if you have the time to be able to do that, an hour a day would be wonderful to be able to devote to different types of activities like that. But in many cases people have specific needs.

A person that might have more rigidity from their Parkinson's disease might benefit more from the stretching type of exercise than they would some other types. A person that moves slow and has trouble with coming out of the chair and standing up, or walking slowly or climbing stairs, may benefit much more from something like strength training to increase the muscle force, whereas a person that has fatigue problems may benefit from aerobic training. So, helping a person with Parkinson's disease figure out what they might benefit from most may be a good strategy if there's a limited amount of time.

Dan Keller 11:07 What are some recommendations and cautions for people either starting to do exercise or ones who are continuing it?

Lee Dibble 11:18 If you're doing aerobic type of exercise, that is a stress on your heart and your lungs. If a person has a history of problems with their heart, then it is very important that they clear their exercise plan with their primary care doctor or cardiologist to just make sure that they can do it safely. In addition, people with Parkinson's disease may have some difficulty or issues with regulating heart rate and blood pressure, so just being aware of that and considering taking some time for a little bit more prolonged warm up or prolonged cool down. Don't try to rush into activities. That will help kind of a person tolerate the exercises that they're doing. But kind of revisiting what I just said at the start here, we find it very important if we're asking a person to begin a new exercise program to make sure they have medical clearance to participate, that there aren't some heart-related precautions that we need to take.

Dan Keller 12:15 What about timing of exercise, especially in relation to when one takes medication?

Lee Dibble 12:22 Another very good question. The medications, if we're specifically talking about dopamine replacement medications—so medications like Sinemet or Carbidopa/Levodopa—are very effective at improving some aspects of neurologic function. So our experience has been that doing exercises like strength training exercises on medication is much more beneficial because a person can move more vigorously, they can experience the dosage that will stimulate the improvement of muscle size and muscle strength. They can do that more readily when they're on their medication than they can when they're off, so they get more bang for their buck for the exercise that they're doing when they exercise on their medication.

Dan Keller 13:07 Are there some things that people should avoid, like free weights? I mean, they're sometimes hard to control, as opposed to weights that are part of a machine. What if they have balance problems, postural instability?

Lee Dibble 13:21 If a person has balance problems and would like to do strength training types of exercises, we would recommend doing it on a type of machine that would provide some stability, so the person doesn't have to stand up and control weights. The biggest challenge with free weights is the control factor of maybe losing your balance, so you've got momentum with the weight that is a benefit if you have the ability to do it, but it can also be a challenge. So we typically will look at a person's balance abilities and their strength, and then decide if they would be best trying to do a free weight type of activity or a machine type of activity, depending on their level of stability.

Dan Keller 14:04 Would you recommend that people consult with licensed physical therapists who specialize in Parkinson's before they begin? Should they get a pretty good workup before they would initiate the programs?

Lee Dibble 14:18 Being a physical therapist, I feel strongly that a person with Parkinson's disease will derive the maximum benefit from an individualized exercise program by talking to a physical therapist and consulting with a physical therapist that has specialty training in Parkinson's disease. That person is most well suited to understand particular variations of the disease and identify the specific types of exercise that might be most appropriate for an individual to derive the most benefit from their exercise routine.

We also feel like it's critically important that a person accesses that type of advice or feedback from a practitioner early in the process, near diagnosis. Unfortunately, in some cases, people are not referred to a physical therapist until much later in the disease, when they begin to have functional problems, rather than trying to prevent those functional problems from occurring by starting a program early after diagnosis.

Dan Keller 15:18 We now turn to Daniel Corcos to talk about endurance exercise, with his expertise in endurance neurorehabilitation and physical therapeutic interventions for PD. He was an external reviewer of the Parkinson's Foundation's competency framework for exercise professionals and criteria for exercise education programs and continuing education courses. Very briefly, what is the purpose of the initiative? What is it?

Daniel Corcos 15:51 The purpose of the initiative is to spell out general principles for people with Parkinson's disease to exercise using endurance exercise. Endurance exercise is really defined as cardiovascular exercise, and the idea here is to get one's heart rate elevated.

Dan Keller 16:17 So, what is considered first-line therapy for people with Parkinson's disease?

Daniel Corcos 16:23 Currently, first-line therapy is exercise, and so when people see a movement disorders expert, they will often be advised to start an exercise program. The exercise program has really two goals. One is to work on the person's general and overall health. There's no question, the better one's overall health, the easier it is to deal with a particular disease. That's a very general point.

The second point is, there's clear and compelling evidence that exercise helps both the symptoms of Parkinson's disease—that is, the amount of rigidity, tremor, or slowness of the movement a person has. There's also mounting evidence that it may affect the progression of the disease—that is, people who do certain kinds of exercise may have a slower course to their disease.

Dan Keller 17:22 Does endurance exercise benefit only motor symptoms, or can it help things like constipation and cardiovascular effects of the disease?

Daniel Corcos 17:33 Endurance exercise has many, many benefits. Certainly, it's helpful for constipation, which is a main problem for people with Parkinson's disease. It's very, very good for the heart. Certainly, it can lower resting heart rate, which is very good. There's evidence from a wide variety of studies and a wide variety of pathologies that it is helpful for cognition, and so it really has a wide variety of beneficial and therapeutic effects.

Dan Keller 18:08 What constitutes endurance exercise? Types of movements, duration. What would you consider endurance?

Daniel Corcos 18:16 Endurance exercise is really defined as any form of exercise which gets the heart rate elevated, and it needs to be elevated for a reasonable length of time. So, the guidelines from the Centers for Disease Control suggest somewhere up to 150 minutes a week if the exercise is of moderate intensity, and perhaps a little bit less time if it's a bit higher intensity.

For Parkinson's disease, the evidence is quite clear. One prescription is to work out three to four times a week for 30 minutes, and to keep one's heart elevated to perhaps 80 to 85% of one's maximal heart rate. So it's important to find ways to determine one's maximal heart rate, and there are several ways to do this, and then one exercises at 80 to 85% for about four times a week.

Dan Keller 19:13 I think, without doing an actual calculation, in the past I've seen suggestions that if you get your heart rate up to the correct zone, you should be able to talk, but you should still be breathing hard, and things like that. Is that a reasonable way to gauge it, or do you really need to refer to some sort of formula?

Daniel Corcos 19:33 This is a great question. All forms of exercise are good, and certainly, if one goes out for a walk and one can have a conversation whilst one is walking at a conversational pace, that is certainly beneficial for one. But if one's real goal with Parkinson's disease is to maximize the probability that one will slow down the rate at which the disease progresses, then it is important to find a way to measure heart rate and to track heart rate. There are many ways of doing that now; technology has come on a long way.

There are several ways to determine maximum heart rate, and the evidence for this simply comes from a phase two clinical trial, which has shown the benefits of exercising at 80 to 85% heart rate. And so for people who really want to follow the best exercise prescription, then it is important to track one's heart rate and to work out consistently. But for those people who prefer a more moderate form of exercise, it is still very valuable to do, and so it really is a question of deciding what kind of person one is and how much one really wants to work to help one's own health.

Dan Keller 20:55 You were the senior author of a paper looking at the effects of moderate exercise or more intensive endurance exercise, and I think the measure you used was the Unified Parkinson's Disease Rating Scale for motor function. How much should they differ between doing it really intensively and the moderate exercise level?

Daniel Corcos 21:19 Again, that's a very clever question. The way the study was designed was to ask the question: is it worth proceeding to a large phase three clinical trial? And it was only the 80 to 85% group which provided strong enough data to suggest it was worth going to a phase three clinical trial for disease modification, or for basically slowing down the rate at which the disease progresses.

So, if one just looks at the numbers, the group of people who were on a waitlist control, they progressed by about four points over six months. The group in the 60 to 65%, they progressed by about two points, and the group in the 80 to 85% group progressed at only point three. And so there is a difference, probably, but it's not definitive at the moment, and that's the reason that there's currently an ongoing phase three clinical trial to really answer the question: is there a benefit to working out at the higher intensity?

Dan Keller 22:28 Now, you looked at this over six months—the endpoint was at six months. Parkinson's is a chronic, long-term progressive disease. Obviously, wanting to slow progression is a big motivator, but do you see compliance in the long term as being any sort of a problem?

Daniel Corcos 22:46 It's certainly a problem. It's a problem for everybody, whether you have a disease or whether you don't. People find it hard to maintain an exercise program. But as you alluded to, this is really something that people need to build into their lifestyle. The evidence now is so compelling that people who are fit and healthy tend to do better, and they tend to respond to diseases better. So, the likelihood of a person having a disease in their lifetime is quite high.

The clearest evidence of this at the moment is COVID-19. Those people who get COVID-19 who are in very, very good health tend to come out okay. There are exceptions, certainly are exceptions, but people who get COVID-19 who are not in good health, the prognosis is much worse. And so motivation is a big deal. Many people find it hard to motivate themselves to take part in activity. I'm very careful that I use the word "activity"—some people don't like the "E" word—but there are various forms of activity that are very, very beneficial, and I think at the end of the day, if one wants to have a high quality of life, then part of that is keeping oneself in good shape, and the evidence for that is overwhelming.

Dan Keller 24:10 Can medications interfere with endurance exercise, especially in terms of getting your heart rate up? I'm thinking beta-blockers for heart disease—it's probably hard to achieve a higher heart rate—or even medications for Parkinson's disease. So, how do you compensate for those things?

Daniel Corcos 24:28 Again, that's a very good question, and it is very important that if one starts to exercise, especially if one's on a beta-blocker, one discusses this with one's physician. All evidence that I'm aware of shows that it works just as well for people on beta-blockers, so you're absolutely correct. The maximum heart rate that a person can achieve can be 10, 20, 30 beats lower, but then when they're working out, they're still basing their workout on that maximum.

So, another way to look at it is there are scales one can read about. One is called the Borg scale of Rate of Perceived Exertion—it's abbreviated RPE—and if one's working out at about seven to eight, that is a good, vigorous workout. One will certainly be perspiring, and one won't be having the kind of conversation we're having now. That will be quite a hard workout, and regardless of the type of medication one's on, one can then work out with that degree of effort.

The Parkinson's medication is a very interesting topic, and this will depend upon the individual person. There is some benefit to asking oneself: "How do I respond best to medication? How is it affecting me during the day?" And certainly, if one's going to work out quite vigorously, it may be best to time that at a point that the medication's having the maximum effect. Again, there's no one-size-fits-all, but timing one's exercise routine within one's medication regime would be prudent to do.

Dan Keller 26:13 To do the exercises that are considered endurance exercises and that raise heart rate sufficiently, are they safe in terms of cardiovascular health, motor symptoms, your joints, freezing of gait, these sorts of things?

Daniel Corcos 26:29 The quick answer to that is yes, they're safe. The much longer answer is that everybody has to know themselves and be particularly mindful of their own situation. So if one does have freezing of gait, then a treadmill can be quite helpful because it does provide the stimulus to the feet. There's also an auditory stimulus—one can add other auditory stimuli to the treadmill, and all of that helps overcome freezing of gait—but it's then very important that one has handrails, and depending on how bad a person's postural instability is, there are ways to help with that. Some places have harnesses over the treadmill, so as soon as you fall, the harness gets you. Those are not universally accessible, but people do have to be very, very careful.

Now, certainly, if one's on a bike, an indoor bicycle, then the possibility of falling off is significantly less, and so that should be safe. But again, this podcast will be listened to by many, many people with a whole variety of signs and symptoms, and each person needs to be very careful. And if one's disease has progressed quite a bit, then working with a PT or a trainer to get the best possible advice to make sure one has no negative consequences of the exercise is very important.

But the general idea, which one sometimes hears, that "well, if a person has a possibility of falling over, they're best left in a chair, a couch, or a bed" is so bad for people with Parkinson's disease. It's bad for everybody. It's a very outdated idea, and so the idea here is to move, to move as vigorously as one can, but to find an environment that is safe, in which one can either have physical supports or one can have a person supporting one, or both.

The other thing that people can do, which I think is very good, and I see it at my health club all the time, a lot of people benefit from aquatic exercise. So, if one's in the water, then falling over is much less of an issue. It's much easier on the joints, and certainly, if one has arthritis and other ailments as well, one has to adapt one's exercise program. But a really good trainer, a really good physical therapist, will be able to help a person adapt the exercise regimen to be appropriate for the particular person who's exercising.

Dan Keller 29:25 Should everyone who's going to start an exercise program of this sort get clearance from a physician or a physical therapist who's trained in Parkinson's disease or equivalent health professional?

Daniel Corcos 29:37 It's a very blanket statement, "should everyone." Given that I'm doing a podcast here that's published, I think the safe answer is always yes, and certainly, if one gets medical clearance, then that is the safe question. If one's been exercising for a while and if one has no concerns—but I'm a great believer in safety first, and physicians are there to help, and they're very happy to do so.

Dan Keller 30:08 Is there a way to summarize your recommendations in a nutshell to leave people with a thought that they can act on?

Daniel Corcos 30:17 My final recommendation would be for everybody to do as much exercise of the endurance kind that they are able to motivate themselves to do. Even if one goes out for a small walk, it is much better than doing nothing, so any amount of activity is much better than zero activity. And when you look at research studies, you get the biggest benefit from going from nothing to something above nothing.

But if your real goal, and you have Parkinson's disease, is to slow the rate of progression, the evidence currently is quite clear: four times a week, 5 minutes warmup, 30 minutes at 80 to 85% heart rate, 5 minutes cooldown. It's 120 minutes of getting your heart rate high, and that has multiple benefits, because now the blood is pumping through the heart at a much higher rate. The blood is going to the brain. The brain is being oxygenated, and the oxygen is good for neurons, and this is the best way to slow the rate of disease progression.

The other thing is, which is the evidence here is also quite clear, if you don't have a disease, it is protective of getting a disease. So, if you looked after yourself consistently over a period of years, the probability of getting Parkinson's disease is significantly reduced. You can tell yourself, one, "I'm helping my current physical health," and two, "I'm decreasing the likelihood that I will get a future neurodegenerative disease."

Dan Keller 32:04 I really appreciate it. Thank you. More on what we've been talking about today can be found on our website at parkinson.org. Just search on exercise recommendations, you'll find a link to the new recommendations, and on that page is a helpful infographic describing the four exercise domains of aerobic activity, strength training, balance, agility, and multitasking, and stretching. There are also resources for health and exercise professionals, including the exercise guidelines, references, and a video discussion of the guidelines at parkinson.org/exercisepros.

And speaking of exercise professionals, the Parkinson's Foundation recommends people with PD to see a physical therapist specializing in Parkinson's for a full functional evaluation and recommendations before starting a new exercise program. Remember, first be safe, exercise during "on" periods when taking medication, and if you feel it's not safe to exercise on your own, have someone with you.

A couple of past podcasts may help with motivation to exercise. One is called The Benefits of Exercise for People with Parkinson's, and another is Ask the Parkinson's Foundation Helpline: Your Exercise Questions Answered. If you need more motivation to exercise, consider the Exercise is Medicine mantra via our PD Health at Home Fitness Fridays series. You can get moving today with our PD-tailored fitness videos that feature a different focus every week, from balance to coordination and more. Choose the at-home workouts that meet your fitness goals at parkinson.org/pdhealth.

As always, our helpline information specialists are available to answer questions in English or Spanish about today's topic or anything else having to do with Parkinson's. News and updates about future events and resources are available by joining our email list at the bottom of our website's homepage. If you want to leave feedback on this podcast or any other subject, you can do it at parkinson.org/feedback. If you enjoyed this podcast, be sure to subscribe and rate and review the series on Apple Podcasts or wherever you get your podcasts.

At the Parkinson's Foundation, our mission is to help every person diagnosed with Parkinson's live the best possible life today. To that end, we'll be bringing you a new episode in this podcast series every other week. Till next time, for more information and resources, visit parkinson.org or call our toll-free helpline at 1-800-4PD-INFO, that's 1-800-473-4636. Thank you for listening.

Lee Dibble, PT, PhD, ATC is a Professor and the Department Chair of the Department of Physical Therapy and Athletic Training at the University of Utah. He earned a PhD from the University of Utah with a focus on Motor Learning and Motor Control. His research has examined skeletal muscle and functional responses to resistance training, as well and postural and gaze stability in persons with neurologic conditions such as Parkinson’s Disease, Multiple Sclerosis, vestibular hypofunction, and concussion.

Dr. Daniel Corcos, PhD is a tenured Full Professor at Northwestern University. The primary research interests of Dr. Corcos are aimed at helping people with Parkinson’s disease improve their quality of life, improve their mobility and cognition, and slow down the rate at which their disease progresses. Integrating neuroscience and expertise in conducting clinical trials, the Dr. Corcos’s research focuses on interventions (such as resistance exercise and endurance exercise) that aim to reduce the symptoms of the disease and delay the rate at which the disease progresses.