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Exercise for people with Parkinson’s: a practical approach
  1. Bhanu Ramaswamy1,
  2. Julie Jones2,
  3. Camille Carroll3
  1. 1Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
  2. 2School of Health Sciences, Robert Gordon University, Aberdeen, UK
  3. 3Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
  1. Correspondence to Dr Bhanu Ramaswamy, Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield S10 2BP, UK; b.ramaswamy{at}shu.ac.uk

Abstract

Exercise is key to a healthy and productive life. For people with Parkinson’s, exercise has reported benefits for controlling motor and non-motor symptoms alongside the use of pharmacological intervention. For example, exercise prolongs independent mobility and improves sleep, mood, memory and quality of life, all further enhanced through socialisation and multidisciplinary team support. Recent research suggests that optimally prescribed exercise programmes following diagnosis may alter neurophysiological processes, possibly slowing symptom progression.

Given its benefits, professionals should encourage and motivate people with Parkinson’s to exercise regularly from the time of diagnosis and provide guidance on what exercise to do. We provide examples of how the growing body of evidence on exercise for people with Parkinson’s is revolutionising the services they are provided. We also highlight new resources available to help the wider support network (people such as volunteers, partners and friends of people with Parkinson’s) with an interest in exercise promote a consistent message on the benefits of exercise.

  • Parkinson-s disease
  • exercise

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Introduction

The World Health Organisation (WHO) recommends at least 150 min of moderate-intensity, aerobic physical activity a week.1 Someone doing exercise should have a raised heart and breathing rate, feel warmer and find talking difficult. However, people with Parkinson’s can be 30% less active than age-matched peers,2 3 with some reporting being inactive for 70% of the day.4 Hence, Parkinson’s-specific guidelines endorse early referral to appropriate professionals for an informed discussion about the impact of physical activity and exercise on their lifestyle.5 6

People with Parkinson’s who exercise regularly report that it enables them to stay active and contributes to a sociable, healthy lifestyle and that it provides a means of taking control and fighting back against their condition.7 For those who push exercise to an intensity beyond their previous level, and when still realistically capable of recapturing a prior physical ability, it can mean taking on challenges that they hitherto had believed impossible (see box 1). However, for most people, the practical aim of exercise is to maintain baseline health and fitness levels to stay mobile for as long as possible.

Box 1

Jane’s thoughts about exercise

Exercise has radically improved my life with Parkinson’s. Regular and increasingly intensive exercise has had a significant effect on my symptoms.

Exercise has reduced my adverse motor symptoms. In some ways, more significantly, it has kept me positive emotionally. I feel good about my body again. I believe I am doing something to control my condition. Ten years after diagnosis I can confidently abseil down a waterfall and hike up 3000 feet below Mont Blanc!

I have only needed a small increase in my Madopar dose over the 5 years I have been exercising.

My only regret is that I wish I had started exercising to this level immediately after diagnosis.

For most people, exercise alone cannot sufficiently treat the symptoms of Parkinson’s and is recommended as one part of a multidisciplinary team’s whole approach. Different team members should use their knowledge to communicate and discuss choices of pharmacological and non-pharmacological interventions, for example, diet, exercise and social prescription, to balance management and optimal outcomes.

Evidence around exercise

There is compelling evidence to support the value of exercise in Parkinson’s.8 Its two main aims are to preserve function (which varies over the course of the disease) and to modify disease progression. Different forms of exercise may support these aims. There is research showing improvements in:

  • Motor symptoms using varied exercise styles (figure 1) that generate strength and power through resistance training. These gains are associated with better balance and gait, functional ability and quality of life.6 8–11 There can be further improvement when early rehabilitation combines co-ordination of limb and trunk movements (with or without additional complexity) and increasingly challenging cognitive ability, through dual and multiple tasking exercise routines.12

  • Non-motor symptoms associated with improved sleep, fatigue and mood and with reduced constipation, depression, anxiety and apathy.6 8–11

  • Cognition. Several authors have reported a connection between exercise participation, enhanced memory and associated executive functions.7–14 They noted a positive impact on cognitive abilities, including rational thinking (planning and organising) reading, learning and memory.15 16

  • Secondary complications, such as reducing discomfort from musculoskeletal and central pain, and other medical conditions affecting general health and mobility.6

  • Disease progression, with animal model and clinical studies suggesting a potential neuroprotective role of exercise.17 Higher-intensity activity (increasing to 80% maximal heart rate) appears particularly effective, probably mediated by changes to cerebral blood flow, enhanced turnover of neurotropins (such as brain-derived or glial-derived factors), neurotransmitter modulation and improved cortical plasticity.17–21

Functionally, exercise can help with recalibration of bradykinetic (slow) and hypokinetic (small) movement using complex and large, amplitude-focused exercise.9 11 13 20 This translates into an improved ability for people with Parkinson’s to plan, think, recall facts and learn, all of which have a positive impact on falling (one of the most feared consequences of Parkinson’s and a key barrier to exercise participation).

Figure 1

Types, dose and examples of ideal exercise for people with Parkinson’s.

Barriers to and decisions on when not to exercise

People with Parkinson’s experience both personal and environmental barriers affecting engagement and ongoing participation in exercise.6 22 Frequently reported barriers include:

  • Low expectations of what exercise can achieve.

  • Lack of perceived benefits of exercise.

  • Insufficient time or motivation to exercise.

  • Costs (including transport) or accessibility of classes.

  • Fear of falling and safety considerations (where there is multiple pathology).

  • Lack of available activities to suit personal choice.

Other factors include bad weather, prior experience of exercise, gender and age (older women are generally less likely to take up exercise).

However, there is a clear shift towards people actively wishing to participate in exercise as a way to take control of their condition; this was evidenced in a recent study investigating how people who receive exercise support reconceptualise their physical and cognitive resources,23 plus increasing enquiries from people with Parkinson’s about access to specialist services and education.

Although there is no evidence in research trials of harm from any exercise done correctly, occasionally the specialist nurse’s or consultant’s role is to monitor their patient’s behaviour. For example, introducing a new programme of exercise may lead patients or their carers to have unrealistic expectations; also, some medications can provoke impulsive and excessive responses to exercise. As the condition progresses and people become more at risk of falls and injury, for example from freezing episodes, postural instability or to the effects of ‘off’ periods as medication is wearing off, clinicians must discuss extra safety precautions.

Comorbidity may add to pain or fatigue, both of which might be more acutely felt when ‘off’, or the person may be taking medications such as beta-blockers that affect their ability to raise their heart rate sufficiently to match exercise demands.6

On the whole, to gain the best improvements through exercise, clinicians should suggest patients undertake exercise when their body’s response to medication is optimal, for example, in the first couple of hours after a dose.

In summary, the benefits of participating in exercise, in terms of current symptom management and the potential impact on Parkinson’s progression, highlight the need for clear and effective guidance to improve their physical activity.

Each multidisciplinary team member may have a different role in supporting factors that enable people to exercise, identify and reduce barriers, and to set realistic goals. The main responsibility of neurologists, geriatricians and specialist nurses is in knowing who has expertise in exercise delivery, and to refer the person on to the correct service.6

Parkinson’s Exercise Framework

The Parkinson’s Exercise Framework is part of the eHealth drive, providing a web-based resource (some information as downloadable) to communicate the benefits of exercise to people with Parkinson’s.

The Exercise Framework (figure 2) was developed by a team of experts (underpinned by clinical experience and international evidence) to help answer the question: ‘What exercise is best?’ This model encourages people to engage in exercise and make it part of their daily routine. It also supports decisions about which exercise method or style might help at different times during the disease course. The examples provided in the Exercise Framework are not exhaustive.

Figure 2

Parkinson’s Exercise Framework (for professionals).

The Exercise Framework is principally targeted towards professionals prescribing physical activity but is openly accessible to people with Parkinson’s and their families. Clinicians who are part of the multidisciplinary intervention and who deal with the diagnosis and ongoing review of people with Parkinson’s, for example, neurologists, geriatricians and nurse specialists, should be aware of this online information and recommend individuals explore the resource. It is supported by literature reviews, research evidence and lived experience of people with Parkinson’s, and presented as video cases, animations and suggested exercise types and doses.

People can exercise alone or in company. However, exercising in company increases the positive qualities of socialisation, such as competition and the support of family or peers with or without the disease.23 Parkinson’s UK makes available information about local providers so medical colleagues and specialist nurses can refer people to appropriate services. For those preferring to exercise unsupervised, technology can assist in creating a routine. The Exercise Framework suggests using home-based DVDs, or exergaming, for example, Nintendo Wii or X-Box Kinect.

Examples of models of practice

Box 2

What a neurologist might consider about exercise during a clinic appointment24: an example of how CC approaches the issue during a consultation

  1. Check everyone’s exercise history: What do they do, how often and how intensely? Use the information to determine if it is sufficient to become out of breath and sweaty. Are they meeting WHO guidelines? Is it vigorous enough where appropriate?

  2. Reinforce the positives: keep gardening, doing the housework, walking the dog, looking after the grandchildren—anything associated with increased activity; encourage returning to activities that they previously enjoyed, such as tennis, cycling, golf.

  3. Explore barriers to not exercising sufficiently: pain, comorbidities, confidence, transport difficulties, mobility, motivation.

  4. Explore solutions: for example, physiotherapy referral for targeted advice and confidence building or exercise ‘buddy’; different modalities—static bike, walking, swimming, chair-based groups; talk through specifics (eg, in your 30 min walk, ensure that you are walking sufficiently briskly to become out of breath for at least 10 min of it; try going for two walks a day rather than one; try to pick a route that has a hill, so that you become out of breath; aim for at least 5000 steps per day); set personalised individual goals (eg, walk in your garden with your frame for 5 min twice a day, and then gradually build it to 10 min twice a day, and then 15 min; try doing a sit–stand on your own from your chair, and then every day try and do one more than the day before).

  5. Stress sustainability: it must be something people enjoy so they are motivated to continue; explore the added benefits—social interaction, meeting a personal goal; engage the partner or other friend or family member.

  6. Web resources. Direct them to the Parkinson’s UK exercise website, including the animations and videos (see Resource section); enclose the exercise leaflets and the list of trained providers in the clinic letter; explain current thinking about the benefits of exercise.

  7. Ask again about exercise at next review, and ensure the specialist nurses continue to re-enforce the message between clinic visits.

Consultants who perceive lack of time and limited training as personal barriers to discussing exercise with patients should identify supporting partners within their communities to ensure exercise is explored and followed up.24 25

Models from a northern and southern city in the UK and how they inform practice

Box 3

Sheffield model

Development: Like many of the classes run throughout the UK for Parkinson’s UK local groups, the Sheffield exercise classes were developed by physiotherapists to enable people in the community to maintain, or improve, mobility and physical independence after periods of hospitalisation. The classes promote a long-term supportive and educational environment for participants to exercise and socialise with like-minded people. They are open to the estimated 1000 people in and around Sheffield with Parkinson’s, run independently of intermittent local health service courses.

Links and partnerships: Links with Sheffield Hallam University provide opportunities for health (including medical) and sports science students to observe classes. Some have since volunteered assistance, and others have researched aspects of a class, providing evidence for funding bids, as tutor fees, room rental and equipment are managed through funds raised by Sheffield local group members, donations or grant applications. In return, class participants volunteer their time as models for medical students’ examination and ‘patients as educators’.

The role of consultants and specialist nurses: The support of consultants in adding their names as referees to grant applications has enabled the expansion in class types available to members, and led to partnership provision with the leisure and private sectors. As well as supporting funding opportunities for exercise classes, the consultants and specialist nurses now refer newly diagnosed patients to the classes run by the local group. A volunteer physiotherapist (BR) coordinates the class, which is led by tutors with differing skill sets at facilities across Sheffield. The venues are chosen to enable people across the city to access them through assorted transport, for example, at leisure and sports centres, which host the circuit (figure 3) and boxing training sessions; a dance studio for the seated dance to music, a church hall for the voice class and conductive education classes; a general practitioner practice and private physiotherapy clinic in different areas of the city for posture classes (figure 4); aquarobics and hydrotherapy in a local heated pool (figure 5); monthly walks in four local parks (figure 6); and privately run PD Warrior classes held at the grounds of Sheffield United, one of the city’s local football clubs.

Details of the Sheffield Local Group’s activities and classes can be found online (http://www.parkinsons.org.uk/sheffield).

Figure 4

Posture and balance class.

Figure 5

Aquarobics and hydrotherapy.

Figure 6

Green gym—pre-monthly walk.

Box 4

Plymouth model

Development: A 2016 evaluation of Parkinson’s UK local groups, based in Devon and Cornwall, found that 72% provided exercise classes. Almost all identified barriers to providing frequent classes (more than monthly): these were transport, volunteer capacity, funding, participant motivation and instructor availability. To address these, while increasing exercise opportunities for people with Parkinson’s, we developed a pilot scheme in Plymouth, funded by Active Devon, with support from Parkinson’s UK. The scheme delivered Parkinson’s-specific training to community exercise providers. This helped to provide a range of local community-based exercise to people with Parkinson’s, encompassing a range of activities that they may find enjoyable.

We held the 3-hour pilot course in November 2017, with clear aims and learning outcomes (box 5). The 25 delegates provide a range of exercise types, including dance, spinning, football and circuits. Their initial feedback showed an increased self-perceived knowledge of Parkinson’s, its management and challenges, as well as increased confidence in suggesting exercise to people with the condition. For example, people stated in their feedback:

  • I feel empowered.

  • I enjoyed the course. I began today with no knowledge and now leaving with extensive knowledge. How to help and the importance of exercise.

  • Worthwhile and valuable, providing information about Parkinson’s disease activity and the rationale behind why certain things are important in exercising.

  • Very worthwhile. Great to hear from health professionals and increase understanding of ‘why’. Much clearer now as to how I can work with people with Parkinson’s.

Links and partnerships: The hope is to increase numbers of trained providers within the region with support from Active Devon and community exercise providers (health clubs and gyms). A course will be made available, with supporting documentation, as an ‘Exercise Provider Training Toolkit’ via the UK Parkinson’s Excellence Network.

The Parkinson’s-trained, community exercise providers’ details are accessible to local groups, with opportunities for participants to feed back their experience of classes.

Roles of consultants and specialist nurses: The Plymouth nurse-led pathway now routinely assesses newly diagnosed patients for their attitude to exercise, provides them with resources relating to exercise provision and the list of Parkinson’s-trained providers, and directs them towards a video of a patient’s experience of the benefits of exercise (https://www.youtube.com/watch?v=H997qAklWFM&feature=youtu.be).

We provide the resources with clinic documentation, alongside advice about the minimum level of moderate intensity exercise, and emphasise these during follow-up appointments to patients attending the specialist Parkinson’s neurology service in Plymouth.

Box 5

Pilot course aims and learning outcomes

Aims of the course

  • Increase knowledge and understanding of Parkinson’s.

  • Identify the needs of people with Parkinson’s and the benefits of challenging, higher intensity (vigorous), high-frequency exercise with cognitive load.

  • Give people the ability to identify the challenges associated with the symptoms of Parkinson’s and strategies to help.

  • Explain when vigorous exercise is needed and how gentle exercise is also very beneficial.

Learning outcomes

After taking part in the course, delegates will be able to:

  • Understand the key challenges of living with Parkinson’s.

  • Identify the importance of regular, vigorous exercise in keeping someone with Parkinson’s active.

  • Evaluate their own practice in providing the correct activities for people with Parkinson’s.

The use of the word ‘disease’

There has been a growing and global move away from the negative connotation and stigmatisation from medical labelling of ‘disease’ when referring to advice for, and treatments available to people with Parkinson’s. In response to a membership campaign and wider consultation, Parkinson’s UK changed its name in 2011 from the Parkinson’s Disease Society. Many organisations that advocate on behalf of people with Parkinson’s request that healthcare professionals refer to the condition as ‘Parkinson’s’, unless discussing the condition in its purest pathological sense of a disease process. The neurologists, geriatricians and nurse specialists involved in the UK Parkinson’s Excellence network are gradually introducing such a change in the language used between professionals. We now see this sentiment voiced in the more recent projects such as ‘World Parkinson’s Day’, ‘World Parkinson’s Congress’, ‘Unite for Parkinson’s’ etc. For this reason, the authors of this article chose to refer to the condition as ‘Parkinson’s’ and not as a disease.

Conclusion

Clinicians must address inconsistencies in communication about exercise and sedentary behaviour with people with Parkinson’s. Messages about ‘daily prescribed’ exercise should start from diagnosis, and be delivered with the support of the multidisciplinary team, to complement decisions in the use of pharmacological intervention in various ways that resonate with the individual. Referrals to classes should be supported by health professionals or informed community exercise providers.

Parkinson’s is for life, and the challenges that people face relate to the complexity and changes in motor and non-motor symptoms: a one-size-fits-all exercise approach will not work. A ‘what’, ‘when’ and ‘how to’ exercise framework addresses these issues, encouraging people to exercise regularly, correctly and preferably with others.

Motivation, ability and circumstances vary in people with Parkinson’s, so it is essential to convey the significance of the wide-reaching benefits of exercise in controlling some of their symptoms. Regular and targeted exercise can help people with Parkinson’s to stay well, regain self-restricted mobility, make them more resilient to stress, and help them to remain active and independent for longer.

The role of medical professionals therefore is to support a sustained motivation to exercise, whether providing by referral onwards (to seek web-based information or local classes), or through advice about exercise benefits, and encouragement during clinic appointments.

Resources

  1. The Parkinson’s Exercise Framework:

    Please share the Parkinson’s Exercise Framework with your networks. Available to read and download at https://www.parkinsons.org.uk/professionals/exercise-framework-professionals

  2. Comprehensive patient-facing pages on exercise

  3. A podcast featuring discussion between two UK medical schools and schools of health describing their curriculum approaches for the current students to upskill them to deal with the physical activity issue for tomorrow’s patients at:https://soundcloud.com/bmjpodcasts/physical-activity-in-the-curriculum-impact-in-schools-of-medicine-and-new-healthcare-professionals?in=bmjpodcasts/sets/bjsm-1&utm_source=soundcloud&utm_campaign=share&utm_medium=twitter

  4. The Exercise is medicine resources at:https://www.exerciseismedicine.org/support_page.php/healthcare-providers/

Key points

  • Increasing evidence shows that varied exercise helps people with Parkinson’s to control the challenges of their motor and non-motor symptoms.

  • There is a web-based framework of suggested exercise, although there is no ‘one size fits all’ model.

  • Health professionals must take responsibility for getting out a clear message highlighting the benefits of early, targeted and regular exercise to improve physical health and wellness in people with Parkinson’s.

Acknowledgments

Professor Helen Dawes, for sharing ideas about exercise types and dosage; all participating members of the Parkinson’s Excellence Network Exercise Hub, co-chaired by Beccy Oliver; collaboration with Parkinson’s UK staff to create the Exercise Framework; Amy Noss, Content Editor (Excellence Network and Professionals); Jane Rideout, Regional Lead (and person with Parkinson’s); Val Evans, Education co-ordinator, Peninsula Parkinson’s Excellence Network; and Madeleine Palin (medical student), University of Plymouth Faculty of Medicine and Dentistry.

References

View Abstract

Footnotes

  • Contributors Authorship and contributorship of the three authors is in line with the guideline available online (https://www.bmj.com/about-bmj/resources-authors/article-submission/authorship-contributorship).

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Commissioned; externally peer reviewed by Monica Busse, Cardiff, UK, and Simon Lewis, Sydney, Australia.

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