Exercise scientists and neuroscientists are working together to investigate possible neuroprotective, neuroplastic, and neurogenic effects of exercise and how best to incorporate brain training alongside productive physical activities. Aerobic, Think BIG [i, ii], and HELP PD [iii], a novel, sensory-motor, constraint-based agility program, are discussed here. Many of these ideas can be readily incorporated into existing PD exercise programs to improve daily function and quality of life for PD patients.
More than 500,000 Americans are currently diagnosed with Parkinson’s disease (PD) [iv], a chronic, degenerative neurological disorder affecting one in 100 people over age 60 [v]. Individuals with PD suffer progressive and severe loss of balance and mobility, injuries from falls, increased health costs, and decline of quality of life [vi, vii]. Motor symptoms include slowed movement (bradykinesis); the inability to initiate movement (“freezing”); rigidity; poor sensory integration; coordination difficulties; and balance problems (postural instability) [viii, ix]. Cognitive dysfunction (especially reduced executive and visuospatial abilities) also impairs some activities of daily living [x, xi, xii, xiii]. These problems generally are unresponsive to pharmacological and surgical therapies. Consequentially, appropriate exercise therapies may be the most promising modality for treatment and functional improvement for PD. This article introduces three exciting new approaches using exercise as treatment for PD: Aerobic, Think BIG, and HELP PD.
Approach 1: Aerobic Training
Aerobic training offers motor and cognitive benefits to individuals with PD. Treadmill and walking programs have shown improved quality of life as well as improved motor functions, including gait and balance parameters; better ADL performance; greater Levodopa efficacy; and reduced decline in executive and visuospatial abilities [xiv, xv, xvi, xvii, xviii]. Animal studies have shown that neuroprotective effects of exercise lead to improved brain function in Parkinsonian rats. Improved running distance and speed were associated with the preservation of dopaminergic cell bodies and terminals when rats trained on treadmills or running wheels. Conversely, nonuse of a limb (casted limb) resulted in the loss of dopaminergic terminals and increased motor deficits [xix, xx]. By extrapolation, aerobic exercise programs may help delay mobility disability.
Preliminary studies of patients with mild or moderate PD show they tolerate aerobic exercise programs well [xxi] and improve both cardiovascular and motor function [xxii, xxiii]. In addition to PD-specific benefits discussed above and traditional cardiovascular and stamina-related benefits, aerobic training leaves participants feeling less stressed, less fatigued, and refreshed [xxiv].
Almost anyone can train aerobically, as it is easy, inexpensive, and takes little equipment. Aerobic training can be done individually or in social groups, indoors or out, and there are many great community programs available. Walking, trekking, biking, and dancing are examples. Even seated exercises, paced appropriately, can be aerobic. Choose modes your patient or client enjoys and tolerates well. Here are some ideas to make aerobic exercise more specific to PD.
- Emphasize BIG (described below) steps with arm swings. This creates large reciprocal movements that help with weight shifting, rigidity, and coordination. Poles double as a balance aid that can improve arm swing and step length [xxv]. Try Exerstridding with trekking poles.
- Add rhythm or music to aerobic activity. Rhythm, music, poetry, nursery rhymes, and repeating patterns help an individual anticipate and prepare for the next move. Rhythm and music are also helpful for initiation and maintenance of movement, and improves gait symmetry.
- Consider aerobic choices that also require some balance challenge. For example, an elliptical machine requires much more balance and trunk control than a recumbent bike.
- Other kinds of balance challenges can be added to help keep both mind and body more agile. Reading, solving simple math problems, or completing word puzzles while walking requires balance to be more automatic. (Word Winks are really fun.)
- Progress aerobic activity by using novel terrain or include simple obstacle courses that require planning and keep the mind active. Include a variety of surfaces and lighting. Add motor tasks, such as arm swings or reaching, turning, and/or coordinated movement tasks.
- Keep it safe. Add new challenges only when prior tasks have been mastered. Choose what is well tolerated by the individual. Participants should be willing and ready for each new challenge.
Approach 2: Training BIG to Achieve Faster Movements
Think BIG training is about increasing the size, or amplitude, of movement. BIG training can be easily incorporated with aerobic or other kinds of training. Laurie King, PhD, at Oregon Health and Science University offers this explanation for how BIG began and how we can use it for better mobility training for PD patients:
One of the common manifestations of Parkinson’s disease is that people begin to move more slowly and with smaller movements. For example, their steps become shorter and slower as the disease progresses. We know that there is a relationship between speed and size (amplitude) of movements. For instance, if you take a bigger step, it will most likely also be a faster step. Studies show that training larger amplitude movements increase movement speed.
The theory of training amplitude was first applied, over 15 years ago, using the Lee Silverman Voice Training method (LSVT) [xxvi]. This therapy stresses the principles of intensity, complexity, and repetition. LSVT has had great success over the years with voice training and from this, another amplitude training was born, ‘Think BIG,’ which focuses on everyday gross motor skills.
“Training BIG,” aka “Think BIG,” was developed by Becky Farley as a means to reduce bradykinesia. The same LSVT treatment principles are used, and the theory is that training that targets whole-body movements and systematically increases amplitude of movements will carry over to more functional everyday movements. A recent study showed improvements in the length of steps and size of isolated movements after whole-body “Think Big” training [xxvii].
More information on training BIG can be found at http://www.lsvtglobal.com. Principles of Training Big and other whole-body strategies can be incorporated into many modes of training for Parkinson’s disease. Some practical tips are:
- Cue participants to practice “GREAT BIG” steps. They should take steps much larger than they think is “normal” for them. Use cue words such as, “Big right, big left,” “One foot passes the other, each time,” and “Land your feet heel toe.” Be even more PD-productive and along with the BIG steps, cue words such as, “Upright posture. Tall, strong core. Shoulder blades back and down, chest lifted, chin level, head retracted. Walk tall, walk proud, walk BIG.”
- Train participants to use exaggerated arm swings. Use cue words: “MUCH-larger-than-normal” arm swings. “Go BIG or go home!” Light hand weights (half pound or one pound), rolled up magazines, or trekking poles will add momentum to their arm swings and help them initiate and maintain these big arm swings.
- Once participants master the form for BIG walking, add challenges that require changes in tasks, environment, and coordination. Here are a few from HELP PD and ABLE Bodies Balance Training [xxviii]. Cue participants to practice a few head turns while BIG walking. Cue for changes in directions: “Turn right, turn left,” or give them a figure-8 path to follow using chairs or doorways as obstacles. Require random variations in step length: “Big steps, great big steps, little steps, normal steps, pivot turn” and so on). Vary the environment by dimming the room or having them don sunglasses. Walk BIG on carpeted floors, smooth floors, or grass.
Approach 3: HELP PD (constraint-focused agility exercise program)
HELP PD (Home Exercise Program for Parkinson’s Disease) is currently being tested at Oregon Health and Science University (OHSU) by Fay Horak, PhD; Laurie King, PhD; and Jay Nutt, MD [xxix]. It began collaboratively with a brainstorming session led by Horak; more than 15 neuroscientists, researchers, physical therapists, personal trainers, and other experts in PD [xxx] contributed their expertise and suggestions in a weekend mega-session at OHSU’s Neurological Sciences Institute (NSI).
HELP PD is an exciting and novel constraint-focused agility exercise program. Based on a strong scientific framework and neurophysiology, HELP PD targets these six common and debilitating mobility constraints of PD:
- Bradykinesia (slow movement)
- Impaired sequential coordination
- Impaired sensory integration
- Reduced executive function and attention