Episode 3: The Benefits of Exercise for People with Parkinson's

Dan Keller – 00:08
Welcome to episode three 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. Today, we're speaking with Professor Bas Bloem, a movement disorder neurologist at the Radboud University Medical Center in Nijmegen, the Netherlands, a Parkinson's Foundation Center of Excellence. We're talking about the value of exercise and some of the barriers that people with Parkinson's face in getting enough exercise. We all know exercise is good for cardiovascular and general health. Dr Bloem says that, besides helping with the motor symptoms of PD, exercise can have a positive effect on non motor symptoms and may even slow down the progression of the disease. We spoke at the World Parkinson's Congress last September. Fill me in on what we know about the value of exercise and how we know it.

Dr Bloem– 01:29
Well, one thing we know for sure is that people with Parkinson's are more prone to lead a sedentary lifestyle. This is partially because elderly people in general tend to move less. But when you've got Parkinson's disease, there are the mobility problems that hamper physical activity. There are the cognitive problems, apathy, depression, pain. So people with Parkinson's have multiple reasons to move less, and at the same time, we know that physical activity is extra important for people with Parkinson's disease. There are the generic benefits of exercise on bone strength, on your heart and lungs. But there are also the effects on Parkinson's itself. There is now good evidence that regular exercise suppresses motor symptoms, so less tremor, less rigidity, like a drug. When you stop the exercise, the symptoms will get back. There is beginning evidence that it also helps the so called non motor symptoms, sleep, maybe cognition, the thinking process. And what we are hoping, and there's exciting work in animals with experimental Parkinson's, is that it could potentially slow down the progression of the disease. That's a hope that's not evidence based medicine yet. I'm definitely a believer that it could potentially slow the progression of Parkinson's.

Dan Keller – 02:41
Does it also have effects on autonomic symptoms, gastrointestinal heat, things like that?

Dr Bloem– 02:47
The autonomic symptoms are a difficult symptom to treat. You're mentioning some of them where it could have a beneficial effect. For example, the gastrointestinal dysfunction, the lazy bowel movements, constipation, there regular exercise is really important. People with orthostatic hypotension, the drop in blood pressure when you rise, may actually have some problems when they exercise, because after exercise, the blood pressure may drop particularly strong, so people can faint after exercise. That's not to say you shouldn't exercise, but that you should take precautions immediately after exercise. Probably consult a physical therapist to guide you in doing the right exercise. For other autonomic symptoms, I would say there is less evidence that exercise helps.

Dan Keller – 03:30
Are there any particular forms of exercise that are better than others, or it's just whatever someone's going to want to do?

Dr Bloem – 03:36
That's a good question. We think it's more important that you do something that you like, and so that you continue to engage in that particular physical activity. We do feel that the so called aerobic component is important, so cranking up your heart rate and making sure that you have a bit of a loss of breath while you're exercising. You should still be able to maintain a conversation. That's sort of a rule of thumb. But whether you exercise by running or cycling or swimming, that really doesn't matter as long as you keep doing it.

Dan Keller – 04:03
I think you alluded to evidence for slowing down the progression of the disease. If there is such evidence, is it animal based, or do you have any human evidence that people do better in the long term?

Dr Bloem– 04:15
The evidence so far for neuroprotective effects is only in animals. So you can make a mouse look like a Parkinsonian patient by giving him a toxin. And when you take like 100 mice and you ask 50 mice to run on a treadmill on a daily basis, and the other mice are just sitting in their cage, two things happen. One is the mice that exercise regularly look much better than the non exercising mice. And when you then kill the mice and look at the brains, you see sprouting of the dopaminergic system. You see increased sensitivity in dopamine receptors. And that is indirect evidence that may hopefully translate into human beings. Proving that any intervention, whether this be exercise or a drug, is modifying Parkinson's is horribly difficult. We're trying this for drugs, and it proves very difficult. I predict it will be even more difficult to prove for exercise in people with Parkinson's.

Dan Keller – 05:08
For people who don't have Parkinson's, but especially people who are at risk, or the general population, is exercise a good way to potentially put it off longer or put it off entirely?

Dr Bloem – 05:23
Yeah, again, that's a very good question. We know it definitely doesn't protect against Parkinson's disease. If you look at the wider population, physical inactivity is a risk factor for a number of conditions, and it could include Parkinson's disease. I recommend regular exercise to anybody. And obviously, we now know that, for example, in families where there's a lot of Parkinson's disease related to genes, people who carry the gene but who are still looking okay, I do think it is important to regularly exercise. You can't say that this will hold off Parkinson's. We hope it might. It's definitely not a guarantee, because I've had marathon runners who developed Parkinson's, for example. So there's some hope.

Dan Keller – 06:00
You see the effects of exercise in your animal models, but do you know the mechanism? Can you tell what it's doing?

Dr Bloem – 06:06
So if you look at the animal work, what you see is a number of mechanisms. One is the dopaminergic system. It shows plastic changes, so it adapts in a beneficial way. And one of them is the dopamine receptors. I always tell my students, dopamine is like a key, and it needs to fit on a lock, and the receptor is like the lock, and the number and the sensitivity of these receptors goes up, so the efficiency of the dopaminergic system goes up. What is also interesting is there are all sorts of mechanisms in the brain that counterbalance each other. So there are also inhibitory mechanisms in the brain that use a neurotransmitter called glutamate, and the glutamatergic system is toned down by exercise, and we feel that they're both beneficial.

Dan Keller – 06:48
Is the glutamatergic system also potentially toxic.

Dr Bloem– 06:52
Glutamate has been implicated in cell death in people with Parkinson's disease, so by toning down the glutamatergic system, there might be an additional reason to suspect why regular exercise could be good for people with Parkinson's.

Dan Keller – 07:06
Anything important on the subject to add or interesting or helpful to patients?

Dr Bloem– 07:11
Yeah, I just came from an exciting session on compliance. So I think an interview like this helps to persuade people that physical activity and exercise is good. The big question is, how do you devise a program that you like and that you adhere to? And there are now many tricks available. Careful planning is one. There are physical activity monitors and apps on the market that can help. Gamification of exercise, we're doing a very exciting study where we have a game that rewards people for engaging in exercise. It rewards people after the exercise, and the exercise itself is also gamified. So for example, people are sitting on a stationary bicycle, and they watch a screen and they play Pac Man, you know, the old computer game, and the harder they cycle, the more monsters they kill. So at the end, the patient thinks he's killed 12 monsters, but in effect, he's exercised for 45 minutes at 70% cardiac output. And I think these game elements can help people with Parkinson's to continue to engage in exercise.

Dan Keller – 08:11
What about using companions or partners? Does it promote adherence better if you're doing it with a friend?

Dr Bloem– 08:17
Absolutely. This was actually in the session that I just came from. There is now evidence based literature that participating in group exercise helps people to motivate and to continue exercising. Dance is a wonderful example in that regard. It's typically done with other people in a group or with a spouse, and that's one example of a good and beneficial way for people to move more.

Dan Keller – 08:39
What about loosening and limbering kinds of exercises? Does that help mobility?

Dr Bloem– 08:44
Stretching alone does not have the aerobic component. The interesting thing is there's been a Tai Chi study published in the New England Journal of Medicine. They had three groups, Tai Chi, which was given people the best result. There was a group just stretching, and there was a control group doing nothing, and the stretch group is actually better than the control group. So we do feel that stretching has something beneficial to offer for people with Parkinson's. I wouldn't say that stretching alone is enough, but it might help to loosen up the limbs.

Dan Keller – 09:21
So there you have it. If you want to find exercise programs and classes near you, call our helpline at 1 800 4PD info, or go to our website at parkinson.org/search. And if you want to leave feedback or comments on this podcast or any other subject, you can do it at parkinson.org/feedback. We will respond to some questions in future episodes. 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 twice a month. Coming up in our next episode, we will continue our conversation with Professor Bloem, when we'll discuss nutrition, a relatively new focus in Parkinson's. Till then, 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.

Dr. Bas Bloem is a consultant neurologist at the Department of Neurology, Radboud University Nijmegen Medical Centre, the Netherlands. He received his MD degree (with honors) at Leiden University Medical Centre in 1993. In 1994, he obtained his PhD degree in Leiden, based on a thesis entitled “Postural reflexes in Parkinson’s disease.” He was trained as a neurologist between 1994‐2000, also at Leiden University Medical Centre. He received additional training as a movement disorders specialist during fellowships at The Parkinson's Institute, Sunnyvale, California (with Dr J.W. Langston), and at the Institute of Neurology, Queen Square, London (with Prof. N.P. Quinn and Prof. J.C. Rothwell).

In 2002, he founded and became Medical Director of the Parkinson Centre Nijmegen (ParC), which was recognized from 2005 onwards as a Parkinson’s Foundation Center of Excellence. Together with Dr. Marten Munneke, he also developed ParkinsonNet, an innovative healthcare concept that now consists of 66 professional networks for Parkinson patients covering all of the Netherlands (www.parkinsonnet.nl). Because of the evidence‐based quality improvement and significant cost reduction, ParkinsonNet has received multiple awards, including the prize “Best Pearl for Healthcare Innovation” in 2011 and “Value Based Health Care” prize in 2015.

In September 2008, Dr. Bloem was appointed as Professor of Neurology, with movement disorders as a special area of interest. He has published over 550 publications, including over 400 peer‐reviewed international papers.