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Exercise as Medicine
Essentials for Parkinson Disease
The WHY and HOW!
Becky Farley, PT, MS, PHD
CEO/Founder
Parkinson Wellness Recovery
Cutting Edge Research in
Exercise and Neuroplasticity
~the motivation~
Exercise is a
physiological tool
that promotes
brain health, repair,
adaptation, and
behavioral recovery
from the INSIDE.
Parkinson Wellness Recovery | PWR!
3
A 501(c)(3) nonprofit founded in 2010 by Dr. Becky Farley
PWR! Vision
Communities where individuals with Parkinson disease
have access to "Exercise as Medicine"
PWR! Mission
To provide individuals with Parkinson disease access to
physiological tools that hold promise to slow disease
progression, put off motor deterioration, improve symptoms,
and increase quality of life.
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Model Community Neurofitness and Wellness Center
for Individuals with Parkinson disease
Tucson, AZ
Specialized in research-based neuroplasticity principled
rehab, fitness and wellness all in one facility.
Validating Model with ResearchDo people get better and stay better with
research-based protocols in a real world setting?
All stages of disease severity;
Group Classes PLUS 1:1 Physical Therapy
1 2 3 4 5
Loss of
postural stability
End
Stage
DXExercise/Therapy
Improve function
CURRENT PARADIGMSreferrals are reduced, infrequent, late
Disease severity – H&Y
Nijkrake MJ, Keus SH, Oostendorp, RA, et al. Allied health
care in Parkinson’s disease: referral, consultation, and
professional expertise. Mov Disord 2009;24:282-286
63% Physical Therapy; 14% Speech Therapy; 9% Occupational Therapy
Barriers to Referral
• Perceived benefit by physicians
• Lack of awareness of supportive data
• Lack of clear indications for non
pharmacological care (nor time to screen for
those referrals)
Nijkrake MJ, Keus SH, Oostendorp, RA, et al. Allied health
care in Parkinson’s disease: referral, consultation, and
professional expertise. Mov Disord 2009;24:282-286
Evidenced Based Resources
• European Federation of Neurological Societies and
Movement Disorder Society (EFS/MDS)
• National Institute for Health and Clinical Excellence
(NICE)
• American Academy of Neurology (AAN)
• Movement Disorder Society (MDS)
• Cochrane Reviews
• Other Systematic Reviews
Josefa Domingos, Miguel Coelho, Joaquim J Ferreira. Referral to rehabilitation in
Parkinson’s disease: who, when and to what end? Arq neuropsiquiatr 2013;71(12):967-972.
Indications/Physical Therapy
• Transfers
• Mobility
• Gait
• Physical Capacity
• Postural Instability/Balance
• Falls and fear of falling
• Freezing
Josefa Domingos, Miguel Coelho, Joaquim J Ferreira
Arq neuropsiquiatr 2013;71(12):967-972
Multiple Level 2-3-4 studies
MedicationDeep Brain
Stimulation
Exercise/Rehab
Legitimate Therapeutic Options TODAYTo provide symptomatic relief and improved function, balance,
gait, strength, physical capacity, fall riskAcademy of Neurology Practice Guidelines – 2006; 2010
Indications/Other• Speech Therapy for Intensity, phonation, dysphagia
• PD Nurse for Counseling and Pallitative Care
• Insufficient
– Occupational Therapy
– Complementary Therapies
– Non Motor
– Advanced/Early Disease
– Cognitive Impairment
– Parkinsonism
– Motor Complication
www.parkinsonnet.info/euguideline
Keus SHJ, Munneke M, Graziano M, et al.
European Physiotherapy Guideline for
parkinson’s disease. 2004; 2014;
KNGF/ParkinsonNet, the Netherlands
www.parkinsonnet.info/euguideline
Neuroprotection
Optimize Brain Health
Aerobic Training
• Start at DX
• Progressive effort beyond self-selected
• Continuous threshold
Neuroplasticity
Optimize Brain Repair and Adaptation
PD-specific Skill Acquisition
• Large amplitude bigger/faster functional movement training
• Multi-modal Approach
• Learning principled practice
Optimize
Physical Capacity
Prevent Inactivity
• Educate/Empower/Coach
• Promote everyday activity and lifestyle
• Address non-motor barriers
• Optimize Medications
• Nutrition
New Indications for Brain Health, Brain Repair, and Function in PWP
EXERCISE AS MEDICINE
for Parkinson Disease???
INDICATIONSESSENTIALS
DOSAGE
BARRIERS
Exercise and Brain Change in Animal Models
15
• NeuroprotectionPreclinical
Phase
• NeurorepairEarly/Moderate
Phase
• AdaptationLate Phase
from the INSIDE!
Brain changes identified vary with disease severity
Bottom LINE:Exercise optimizes brain health and efficiency
1. Preclinical
» Protects/rescues vulnerable neurons
• Sustains/increases DA function
2. Early/Moderate
» Enhances recovery or recruitment of damaged circuits
• DA shunted to active circuits, where needed
• Noisy glutamate circuits are normalized, improved
signal to noise
• DA receptors upregulated
3. Advanced
» Undamaged areas recruited
Evidence for Neuroprotection in People with PD:
Epidemiological, Anecdotal & Experimental
Regular, moderate to vigorous exercise in midlife–lowers
risk for developing PD.
Exercise increases survival rate.
Higher cognitive scores associated with greater physical
fitness
Regular exercise reduces the severity of motor/non-
motor symptoms and improves function with 3-6 month
retention.
Chen et al. 2005; Hale et al. 2008; Gray et al. 2009; Bilowit 1956; Sasco
et al.1992; Palmer et al. 1986; Archer et al. 2011; Reuter et al. 2011
Neurorehab Neural Repair
2012;26(2):132-143
Tango
Ctrl
Tango
Ctrl
19
Treadmill Trainng (Fisher et al. 2013;
Fisher et al. 2004; 2008; Petzinger
et al. 2007; Vuckovic et al. 2010;)
Fontanesi, et al. 2015
Noisy circuits
are silenced.
MORE DA
Receptors.
Triggers
Protective
Factors
Exercise and Brain Changes in People with Early PD
Progressive Treadmill Training
50’, 3x/week; 6 weeks
75-85%
Multidisciplinary Intensive Rehabilitation Training
3 hours/day; 5 days/week; 4 weeks
EXERCISE AS MEDICINE
INDICATIONS
ESSENTIALSDOSAGE
BARRIERS
Ongoing vigorous
exercise and
physical fitness
should be central
place in our
treatment of PD
and highly
encouraged.
Conclusion!
PD physical therapy
programs should
include structured,
graduated fitness
instruction and
guidance for
deconditioned
patients with PD.
Conclusion!
Levodopa and
other forms of
dopamine therapy
should be used to
achieve maximum
capability
and motivation for
patients to maintain
fitness!
Conclusion!
J. Eric Ahlskog, Phd, MD
Neurology 2011;77:288-294
Progressive Aerobic Exercise
Potential motor/nonmotor
targets of aerobic exercise!
• Prevention of cardiovascular complications
• Arrest of osteoporosis
• Improved cognitive function
• Prevention of depression
• Improved sleep
• Decreased constipation
• Decreased fatigue
• Improved functional motor performance
• Improved drug efficacy
• Optimization of the dopaminergic system
Speelman, AD et al. Nature Reviews Clinical Neurology 7, 528-534 (September 2011)
Exercise
benefits multiple
systems
Mov Disord 31(1):23-38.
Neurodegener Dis Manag 2011;Apr1;192):157-170
2
Cortical and motor responses to acute forced exercise in Parkinson’s disease.
Jay L. Alberts, Michael Phllips, Mark J. Lowe, Anneke Frankemolle, Anil Thota, Erik B. Beall,
Mary Feldman, Anwar Ahmed, Angela L. Ridgel. Parkinsonism Rel Disord 2016;24:56-62
PD Brains ON Exercise! Unlocked Potential!
Acute 3-h post
exercise
N=9 averaged
Subcortical
fMRI
activation
during
UE force
tracking task
Aerobics + Skill = helps brain do more with less
-----forced “rate” pedaling on a tandem----
27
How you Practice is Important!
Learning Principles
Optimal Brain
Change
Cognitive Engagement
AttentionalFocus
Emotional Engagement
Physical Effort
Drive motor output
Multiple systems
breathe, hands, voice, eyes
Challenge
attention, self-
monitoringSalient, Fun,
rewarding
Real World Dual Tasks
Boosts!
Motor Learning in PD?
Cognitive-motor fall prevention training
If WHAT and HOW you
practice is important!
Let’s make it PD-specific.
PD-Specific Skill Acquisition
Mechanism:
Enhance Circuitry;
Challenge Dopamine Circuits
Use it and Improve it!
• Target skills that become impaired in PWP!
SKILL Basic4 | PWR!Moves– Antigravity extension PWR! UP
– Weight shifting PWR! ROCK
– Axial mobility PWR! TWIST
– Transitions PWR! STEP
• Amplitude-focused whole body movements
• Functionally based
PD-Specific Target – Bradykinesia
Dopamine loss/disease progression correlates most strongly
with severity of bradykinesia.
Speed/amplitude dysregulation problem
Big movements are slow; Fast movements are small
Scaling amplitude/speed requires the greatest amount of
acceleration/power!
Why Amplitude-Focused
Why Whole Body Focused
Bradykinesia occurs across motor control systems!
(fine motor, respiration, walking, speech, postural control)
To optimize real world carryover. Better quality
practice for better quality everyday movement.
Bradykinesia interferes most with habitual,
(overlearned) everyday movements.
Dressing, walking, in/out bed, sit to stand
GOAL: Habit formation and maintenance!!!
SO…train the skills they need for FUNction
Why FUNctional Skill Training?
37
38
Amplitude
Focused
FUNctional
Skill Training
Agility/
Transfers/Turning
Aerobics
Strength
Flexibility
BalanceADL/Fun
ction
Reach/Grasp
Activities
Gait
Lifestyle
Start with AMPLITUDE and Target Multiple Aspects
of Function and Mobility
Endurance
Activity
Yoga/Chi Qong
Tai Chi
Social,
Sports,
Hobbies,
Recreation
Dance, Boxing
METHODS (cont.)
• The individuals in the Disease-Specific Exercise
Group participated in a PWR!Moves® focused
exercise program consisting of activities that
included high effort, large amplitude functional
movements of rocking, twisting and stepping, in
multiple postures for >3 times per week
• The individuals in the General Exercise Group
completed group exercise sessions, independent
exercises or a combination of both for >3 times per
week
• The primary functional outcome measures included:
• Timed Up and Go at self-selected speed (TUGSS)
• 3-meter backward walk test (3MBWT)
• Self-selected walking speed (SSW)
• After participating in activities that incorporated
aerobic exercise and movements that target the
deficits found in PD, these PWP significantly
outperformed their age-matched norms of those
without PD in measurements of community mobility
in agreement with published literature
• Since PWP have deficits across several domains
such as mobility, cognition and motivation even at
early diagnosis, a disease-specific exercise approach
is necessary for PWP
• PWR!Moves® are a type of exercise that incorporate
movements which target deficits found in PWP such
as bradykinesia, rigidity, coordination and timing of
movement and force production deficits
• It is possible that PWR!Moves® may drive activity-
dependent neuroplasticity in PWP through
mitigating either corticostriatal hyperexcitability or
modulating dopaminergic signaling/glutamatergic
neurotransmission ultimately leading to improved
motor function
• Future studies with large sample size and ‘goal-
based’ exercises (type- frequency-intensity) tailored
specifically to changing clinical presentation and the
capability of PWP are warranted to determine the
exercise induced or disease modifying effect in PDPURPOSE
To compare the physical functional performance of
independent community dwellers with PD who self-
report participation in the PD-specific PWR!Moves®
exercise program to those who self-report
participation in a general exercise program
INTRODUCTION• Persons with Parkinson’s Disease (PWP) often
demonstrate functional deficits such as difficulty
maintaining balance, turning while walking, and gait
with hypokinesia and bradykinesia
• Although PWP are often advised to perform ‘moderate
or intense level’ exercises to help improve their
functional limitations, guidance as to the type of
exercise required is not clear
• A disease-specific approach to exercise in PWP is
necessary to improve and maintain physical functional
performance and safety throughout their life and
across disease severity
• PWR!Moves® are a disease-specific amplitude-
focused functional exercises that target multiple
symptoms of Parkinson’s Disease (PD)
DISCUSSION
CONCLUSION• PWP who exercised with a disease-specific focused
program had significantly better physical functional
performance when compared to PWP who reported
general exercise
• An exercise program that focuses on the disease-
specific movements (PWR!Moves®) is an effective
training modality to improve physical functional
performance for individuals with PD
REFERENCESAvailable upon request
A Disease Specific Exercise Approach in Independent Community Dwellers
with Parkinson’s Disease: A Pilot Study
Alexis M. Okurily, Emily White, Tarang K. Jain, Valerie A. Carter
Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, AZ, USA
METHODS• Cross-sectional study using a convenience sample of
32 independent community dwellers with Parkinson’s
Disease (>3 years, Hoehn & Yahr stages 1-3) who
completed three tests of physical functional
performance on one day
• Subjects were assigned to one of two groups based
upon exercise approach: Disease-Specific Exercise
Group (n=13) and General Exercise Group (n=19)
(Table 1)
RESULTS
• PWP in the Disease-Specific Exercise Group
demonstrated significantly better functional
performance in all of the three outcome measures
(Mann-Whitney test)
• On an average, the individuals in the disease-specific
group were:
• 37% faster during TUGSS (6.73±1.1 vs. 10.6±4.4
sec; Figure 1)
• 34% faster during 3MBWT (3.31±1.1 vs. 5.02±1.5
sec; Figure 2)
• 92% faster during SSW (1.99±0.5 vs. 1.04±0.3 m/s;
Figure 3)
Table 1
General Exercise
Group
Disease-Specific
Exercise Group
Total 19 13
Age (years) 64.7 ± 3.7 71.07 ± 8.2
Gender (M/F) 8/11 10/3
G e n e r a l D is e a s e -S p e c if ic
0
5
1 0
1 5
2 0
T im e d U p a n d G o
F ig u r e - 1
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e (
s)
****
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G e n e r a l D is e a s e -S p e c if ic
0
2
4
6
8
3 -m e te r b a c k w a rd w a lk te s t (3 M B W T )
F ig u r e - 2
Tim
e (
s)
**
p= 0 .0012
G e n e r a l D is e a s e -S p e c if ic
0
1
2
3
G a it S p e e d
F ig u r e - 3
Ga
it S
pe
ed
(m
/s)
****p< 0 .0001
#P24.05
G e n e r a l D is e a s e -S p e c if ic
0
5
1 0
1 5
2 0
T im e d U p a n d G o
F ig u r e - 1
Tim
e (
s)
****
p < 0 .0 0 0 1
G e n e r a l D is e a s e -S p e c if ic
0
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4
6
8
3 -m e te r b a c k w a rd w a lk te s t (3 M B W T )
F ig u r e - 2
Tim
e (
s)
**
p = 0 .0 0 1 2
G e n e r a l D is e a s e -S p e c if ic
0
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it S
pe
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/s)
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General Exercise
Group
Disease-Specific
Exercise Group
Total 19 13
Age (years) 64.7 3.7 71.07 8.2
Gender (M/F) 8/11 10/3
EXERCISE AS MEDICINE
INDICATIONS
ESSENTIALS
DOSAGEBARRIERS
INTENSITY (Aerobics/Function)
• Vigorous/Forced
Exercise is completed at
60-80% Heart Rate Max
• Exercise can also be
measured on the “Rate of
Perceived Exertion
Scale”
– Goal: 6-8/10
Effectiveness of Intensive Inpatient Rehabilitation Treatment on Disease Progression in
Parkinsonian Patients: A Randomized Controlled Trial With 1-Year Follow-up.
Giuseppe Frazzitta, MD et al. Neurorehabi Neural Repair, Aug 15, 2011
Evidence that annual intensive bouts of functional exercise may reduce the need for medication overtime in human PD
Differences statistically different (p < 0.0001)
50*
mg/d
less
30*
mg/d
more
* Time X Group P = 0.004
43
DOSAGE:
3 HOURS/DAY
5 DAYS/WEEK
4 WEEKS =
60 HOURS TOTAL
FREQUENCY/DURATION
• Goal Directed Training – Learning
– Intermittent “intensives – tune-ups” for life
– 3-5 days/week; depends upon duration, disease severity
– i.e., 4 weeks = 4-5 days/week, 6 months = 3 days per week
• Progressive Aerobics
– Goal: 3x/week vigorous 30-45’; 3x/week low/moderate 45-60
minutes;
– Minimum at a time: 10 minute bouts
FREQUENCY/DURATION
• Improvements have been shown to last 1-6
months
• Continuous exercise required to maintain
benefits
– Coaching/Maintenance• Less frequent to monitor, coach, update, coordinate community access,
current needs
• i.e., 1x/week or 1x/month or 3-month update program…..
– Community group exercise programs
MedicationDeep Brain
Stimulation
ExerciseHow, When, What
Legitimate Therapeutic OptionsExercise as Medicine
Multidisciplinary
Rehab
PD-Specific
Functional
Amplitude Training
1:1 Intensive
Physical Therapy
Community: Tango, Irish/Tango Dancing, Tai chi, Yoga,
Qi Gong, Cycling, Boxing, Agility, Pole Walking
Progressive
Aerobics
EXERCISE AS MEDICINE
INDICATIONS
ESSENTIALS
DOSAGE
BARRIERS
Slow motor deterioration
Optimize brain health/brain function
1 2 3 4
Loss of
postural stability
Pre-motor
symptomatic
period
ExerciseDX
1 2 3 4 5
Loss of
postural stability
End
Stage
DXExercise
Improve function
TIME FOR NEW PARADIGMSExercise is Medicine for Parkinson’s
Disease severity – H&Y
Disease severity – H&YDX
Implications for Healthcare
Delivery Paradigms
Physician
Optimize
Medications
PD
specialized
Therapist/Coach
assess/reassess
~3-6 months
1:1 Intense
rehab
Community Centered
Exercise and Wellness
Facility
Community Class
Instructors
A Lifetime of
Optimal Care
50
Collaborations/Networks
51
Empower & Educate – Give Control!
Show people what they CAN do!
Identify what they WANT to do!
Expectations/Placebo enhance (or reduce)
learning in PD. Nature Neuroscience 2014
Stigma
SocialSupport
Pain
Communication
Cognition
ActivitiesofDailyLiving
Mood&Depression
Mobility
paRticipaNts whERE oNE issUE staNds oUt For many people, one
issue stands out as
the most challenging
part of Parkinson’s.
Over half the people
in the study had one
aspect of Parkinson’s
that was much more
troubling than the
others. Everyone’s
journey is different.
What aspect of living with PD is most challenging? Psychological barriers #1 issue to majority of PWP!
Inactivity and PD?
• Inactivity (forced non use OR STRESS)
– worsens symptoms;
– contributes to disease progression;
– is PRO-degenerative
WALKING DISTANCE: 6 MINUTE WALK TEST
HC mean
At DX, PWP are already below norms for HC.
Begin EXERCISE/Physical Therapy AT DX!
Optimal medications + optimal exercise & lifestyle
Non Motor Symptoms • Psychological symptoms (stigma/social network/self-efficacy)
• Emotional symptoms (apathy, anxiety, depression)
• Cognitive symptoms (Reduced awareness and ability to self monitor and correct)
• Autonomic symptoms (pain, sleep, blood pressure,….)
– nutrition, counseling, complementary/alternative referrals, stress management, urologist/pelvic floor specialist
Comorbidities/Exercise HX/Logistics/Motivation
55
Barriers to Optimal Brain Change
PD-Specific Movement Demo
• Functional Skills Targeted
• High Effort
• BIG/FAST Whole Body Movement
(Bradykinesia/Rigidity)
• Learning Principled (Progression)
(Cognitive/Attentional Systems Challenged)
57© 2015 NeuroFit Networks | Parkinson Wellness Recovery
Posture
PWR! Up Focus: Posture/Alignment
Why: Counteract rigidity – stooped
posture, weak extensors, spinal
deformities. Reduce falls,
freezing/hesitation. Improve gait and
ability to step bigger.
58© 2015 NeuroFit Networks |
Parkinson Wellness Recovery
Weight Shift
PWR! Rock Focus: Weight Shifting
Why: Necessary to “get moving”, to
turn, to roll, & retrains better
balance and a wider base of support
59© 2015 NeuroFit Networks | Parkinson Wellness Recovery
Trunk Rotation
PWR! Twist Focus: Trunk Rotation
Why: Reduces rigidity when
practiced rhythmically. Necessary
to “transition” body through
space/postures.
Transition
60© 2015 NeuroFit Networks |
Parkinson Wellness Recovery
Transition
PWR! Step Focus: Transition
Why: To move to a different
location efficiently and effectively.
To catch your balance, to
strengthen muscles.
