# Exercise as it relates to Disease/Exercise program prescription for Parkinson's disease
## What is Parkinson’s disease?

Parkinson’s disease (PD) is a progressive pathology that has resulted from death of the dopaminergic neurons located in the brain region known as substantia nigra. Characteristics of PD can include: tremor at rest, bradykinesia (slow movement), hypokinesia (reduction in bodily movement), akinesia (difficulty in initiating movement), hypophonia (weak voice), freezing and drooling.

## PD and Exercise

As PD progresses gait, mobility and balance are altered and thus the risk of injury occurrence increases. Exercise can enhance the synthesis of the remaining dopaminergic neurons to reduce the worsening of symptoms associated with PD and improve balance, gait and functional ability to prevent injuries and assist in maintaining ones quality of life.
A combination of strength, endurance, balance, coordination and flexibility training can have a positive impact on daily living activities (DLA) performed such as movement positions made while sleeping to promote comfort; transitioning from a sitting to standing position and vice versa; reaching forward to grab items while maintaining stability; changing directions when standing; grasping objects without dropping them; walking and climbing stairs.

## Strength Programs for PD

Schilling et al. (2010) conducted a strength program for PD individuals that included: leg press, leg curl and calf raises. Participants demonstrated improvements in relative and absolute leg strength. No upper body strength resistance training were included and there was no improvements in timed up and go's or balance in this study.
Another study by Hass et al. (2012) conducted a strength program on their PD participants that included: seated leg press; knee extension and flexion; abdominal curl; back extension; seated calf raises and seated ankle theraband (dorsiflexion, plantar flexion, inversion and eversion). Participants with PD showed significantly improved stride velocity and length as well as knee flexion and extension. There is risk though of potential bias in this particular study as a ceiling effect is identified where the control group has less chance of improving in the variables measured compared to the exercise group. The study identifies this problem but fails to explain the limitations in the control group.

## Endurance Programs for PD

Active Assisted Cycling with motor speed set at 75rpm has been used in a study by Ridgel et al. (2012) to look at endurance programs for people with PD. Improvements in tremor and bradykinesia of the upper body were noticed in PD participants. Although the sample size was very small consisting of only 10 PD individuals.
Another endurance program by King et al. (2013) involved PD participants walking fast on treadmills. Improvements in PD participants gait and mobility were observed. Participants with PD were quite mobile thus it is unclear how this intervention would impact a person at a more severe stage of the disease.

## Programs Incorporating a Combination of Either Balance, Coordination or Flexibility for PD

This study by Smania et al. (2010) put forward a program for PD participants to engage in balance and coordination activities. The program involved: transferring weight from toes to heels; bouncing ball while alternating hands and walking; maintaining balance on moveable platforms; and walking obstacles while coordinating leg and arm movement. Significant improvements in time taken to transfer body from one position to another, balance control were shown in the PD participants and their risk of falls decreased. There is risk of potential bias in results of this study as the PD exercise group partook in the program already mention but the control group partook in sitting exercises only.
The study conducted by King et al. (2013) explored the effect of balance, coordination and flexibility within those that have PD. This program contained: pre pilates, kayaking, tai chi, boxing, lunges and agility course. Significant improvements in balance, gait, peak arm speed and the trunks range of motion during gait was demonstrated in the PD participants. The PD participants were quite mobile thus again it is unclear how this intervention would impact a person who is at a more severe stage of the disease.

## Recommendations

| Strength | Endurance | Balance, Coordination and Flexibility |
| 3 sets of 5-8 repetitions or 2 sets of 12-20 repetitions At maximal intensity 2-3 times a week | 30–45 minutes cycle or treadmill At high intensities 4+ times a week | Individual exercises should last between 5–10 minutes 2-4 times a week |

## Considerations

* Include a warm up and cool down like any other exercise protocol.
* Promoting adherence to the exercise program as dropout rates can be a common problem.
* Accommodate program for the individual for example some have comorbid disease or other health problems besides PD such as cerebrovascular disease, apathy, fatigue, depression, cognitive implications, muscle cramps and muscle soreness.

## Further reading

* Parkinson's Disease Australian Foundation, http://www.parkinsons.org.au
* Michael J. Fox Parkinson's Foundation, https://www.michaeljfox.org/understanding-parkinsons/resources.html
* Move4Parkinson’s Five Elements Framework, http://wp.move4parkinsons.com/5-elements-guide/

## References

* 1 2 Dauer W, Przedborski S. Parkinson's disease: mechanisms and models. Neuron. 2003 Sep 11;39(6):889-909.
* 1 2 3 4 5 6 7 8 9 10 11 12 King LA, Salarian A, Mancini M, Priest KC, Nutt J, Serdar A, Wilhelm J, Schlimgen J, Smith M, Horak FB. Exploring outcome measures for exercise intervention in people with parkinson’s disease: research article. Epub. 2013 Apr 30; 2013:1-9. doi: 10.1155/2013/572134.
* ↑ Crizzle AM, Newhouse IJ.Is physical exercise beneficial for persons with Parkinson's disease? Clin J Sport Med. 2006 September; 16(5): 422-425.doi: 10.1097/01.jsm.0000244612.55550.7d
* 1 2 3 4 5 6 Schilling BK, Pfeiffer RF, LeDoux MS, Karlage RE, Bloomer RJ, Falvo MJ. Effects of moderate-volume, high-load lower-body resistance training on strength and function in persons with Parkinson's disease: a pilot study. Parkinson's Dis. 2010 Mar 16; 2010:2-7.doi: 10.4061/2010/824734.
* 1 2 3 4 5 Hass CJ, Buckley TA, Pitsikoulis C, Barthelemy EJ. Progressive resistance training improves gait initiation in individuals with Parkinson’s disease. Gaitpost. 2012 Apr; 35(4):669-73. doi: 10.1016/j.
* 1 2 3 4 5 Ridgel AL, Peacock CA, Fickes EJ, Kim CH. Active-assisted cycling improves tremor and bradykinesia in Parkinson's disease. Arch Phys Med Rehabil. 2012 November; 93(11): 2049–2054. doi: 10.1016/j.apmr.2012.05.015
* 1 2 3 4 5 Smania N, Corato E, Tinazzi M, Stanzani C, Fiaschi A, Girardi P, Gandolfi M. Effect of balance training on postural instability in patients with idiopathic Parkinson's disease. Neurorehabil Neural Repair. 2010 Nov-Dec;24(9):826-34. doi: 10.1177/1545968310376057.
* 1 2 3 4 5 6 7 Salgado S, Williams N, Kotian R, Salgado M. An evidence-based exercise regimen for patients with mild to moderate Parkinson’s disease. Brain Sci. 2013 Jan 16; 3(1):87-100.
* 1 2 Allen NE, Sherrington C, Suriyarachchi GD, Paul SS, Song J, Canning CG. Exercise and motor training in people with Parkinson's disease: a systematic review of participant characteristics, intervention delivery, retention rates, adherence, and adverse events in clinical trials. Parkinson's Disease. 2012. 2012:1-15 doi:10.1155/2012/854328
* ↑ Speelman AD, van de Warrenburg BP, van Nimwegen M, Petzinger GM, Munneke M, Bloem BR. How might physical activity benefit patients with Parkinson disease? Nat Rev Neurol. 2011 Jul 12;7(9):528-34. doi: 10.1038/nrneurol.2011.107.