How Much Should I Exercise for PD?

At the recent World Parkinson Congress 2016, the main theme that I noticed is that exercise is the best medicine for PD. It may not be as effective at treating PD symptoms as l-dopa, but all the research and anecdotal evidence clearly shows that collectively, those who exercise regularly enjoy a far better quality of life with PD, for a longer period of time, as compared to those who do not. While medical research continues to be important, the best thing that can be done for the growing number of People with Parkinson’s (PwP) today is to encourage exercise.

There is a growing consensus that more exercise is better, and there is concern that many PwP are being given outdated or incomplete exercise recommendations.

propdResults from the Bastyr University Patient-Reported Outcomes in PD (PRO-PD) survey were shared at WPC 2016. The survey asks PwP about their diet, exercise and supplement regimens, and correlates this information with a self-assessment of PD progression.

The survey results indicate that the more days per week that a person exercises (up to and including 7 days per week), for at least 30 minutes, the slower the PD progression.

Before you start a 6 or 7 day per week program, please don’t do the same exercise routine every day. Focus on different muscle groups so that you are not overworking particular muscles, and not neglecting any muscle groups.

In the past, a lot of recommendations for PD exercise have been based on the minimum recommendations published by the USA Centers for Disease Control and Prevention (CDC) and American Heart Association (AHA). In fact, many of the recommendations that I have seen have misunderstood these minimum recommendations, focusing on 30 minutes of moderate intensity exercise 5 days per week, but ignoring the additional recommendation for muscle strengthening activities at least 2 days per week.

These recommendations are not specific to PD, they are for everyone. If you have PD, with no other limiting health conditions, and have consulted your doctor, you should start with the CDC recommendations. These recommendations are outlined below:

Minimum Weekly Exercise For Important Health Benefits
2-1/2 hours (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) OR 1-1/4 hours (75 minutes) of vigorous-intensity aerobic activity (i.e., jogging or running)
AND
2 or more days a week: muscle-strengthening activities that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms)

It is very important to stress that the CDC and other organizations consider these to be minimum recommendations to receive health benefits from exercise.

Most research suggests that more exercise brings even greater benefits. In fact, for greater health benefits, the CDC recommends a target of doubling aerobic activity in the minimum recommendation.

For Even Greater Health Benefits, increase activity to:
5 hours (300 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) OR 2-1/2 hours (150 minutes) of vigorous-intensity aerobic activity (i.e., jogging or running)
AND
2 or more days a week: muscle-strengthening activities that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms)

Note that the recommendation also allows for a mix of moderate and vigorous intensity aerobic activity, where 2 minutes of moderate intensity equals 1 minute of vigorous intensity.

The recommendations don’t stop there. There is no upper limit to the recommendation.

The CDC says More time equals more health benefits:

If you go beyond 300 minutes a week of moderate-intensity activity, or 150 minutes a week of vigorous-intensity activity, you’ll gain even more health benefits.

All of the above recommendations come from the USA CDC, and are for adults 65 and over.  Source: https://www.cdc.gov/physicalactivity/basics/older_adults/index.htm

Under 65 recommendations are similar: https://www.cdc.gov/physicalactivity/basics/adults/index.htm

Of course, it is extremely important to avoid injury.  You should consult with your doctor before beginning an exercise program.  I also highly recommend working with a personal trainer and/or physical therapist, depending on the severity of your PD.

It’s also important to vary your exercise routine and allow rest/recovery for over exerted muscle groups. There is a saying that you should listen to your body.

It is important, of course, to listen to your body. However, as one of my friends with PD recently said to me…“If I listened to my body, PD would have told me not to get out of bed this morning. But, here I am for another boxing class.”

The CDC recommendations are for healthy adults, so you’re probably wondering if they also apply to PD.

The National Parkinson Foundation sums it up well with the following statement(s):

Exercise is an important part of healthy living for everyone. However, for people with PD exercise is not only healthy, but a vital component to maintaining balance, mobility and daily living activities.

Exercise can benefit in two ways:

  1. Symptom management.  …
  2. Possibly slowing disease progression.  …

“One Parkinson’s Outcomes Project” study has proven that people with PD who vigorously exercise for 2.5 hours per week show a slowed decline in quality of life, and the sooner they begin vigorous workouts after diagnosis, the better.

The best way to achieve these benefits is to exercise on a consistent basis. People with Parkinson’s enrolled in exercise programs with durations longer than six months, regardless of exercise intensity, have shown significant gains in functional balance and mobility as compared to programs of only two-week or ten-week durations.

However, when it comes to exercise and PD, greater intensity equals greater benefits. Experts recommend that people with Parkinson’s, particularly young onset or those in the early stages, exercise with intensity for as long as possible as often as possible. Your doctor might recommend an hour a day three or four times a week, but most researchers think that the more you do, the more you benefit.

I strongly recommend that you read the source of the above recommendations: http://www.parkinson.org/understanding-parkinsons/treatment/Exercise/Neuroprotective-Benefits-of-Exercise

How do you know if you’re doing moderate or vigorous aerobic activity?

One of my trainers would definitely say that if you have to ask, you’re not exercising hard enough.

Obviously, everyone has a different level of fitness, so brisk walking may be vigorous intensity for some and moderate for others.

To measure exercise intensity, the CDC uses a self measured rating of perceived exertion, with a 10-point scale, where sitting is 0 and working as hard as you can is 10.

Moderate-intensity aerobic activity is a 5 or 6 on this scale. It will make you breathe harder and your heart beat faster. You’ll also notice that you’ll be able to talk, but not sing the words to your favorite song.

Vigorous-intensity activity is a 7 or 8 on this scale. Your heart rate will increase quite a bit and you’ll be breathing hard enough so that you won’t be able to say more than a few words without stopping to catch your breath.

According to the American Heart Association, for most people, increased heart rate correlates directly with the level of exertion. For this reason, measuring heart rate can be a better measure of intensity. Your maximum heart rate is approximately 220 minus your age. (Some high blood pressure medications affect the maximum heart rate, so if you take such medication, consult your doctor.) Moderate intensity exercise raises the heart rate to approximately 50-69% of your maximum, and vigorous intensity exercise raises the heart rate to roughly 70%-85% of your maximum.

The following table provides rough guidelines:

Age Target HR Moderate Target HR Vigorous Maximum Heart Rate, 100%
20 100-139 bpm 140-170 bpm 200 bpm
25 98-135 bpm 136-166 bpm 195 bpm
30 95-132 bpm 133-162 bpm 190 bpm
35 93-129 bpm 130-157 bpm 185 bpm
40 90-125 bpm 126-153 bpm 180 bpm
45 88-122 bpm 123-149 bpm 175 bpm
50 85-118 bpm 119-145 bpm 170 bpm
55 83-115 bpm 116-140 bpm 165 bpm
60 80-111 bpm 112-136 bpm 160 bpm
65 78-108 bpm 109-132 bpm 155 bpm
70 75-104 bpm 105-128 bpm 150 bpm
75 73-101 bpm 102-123 bpm 145 bpm
80 70-97 bpm 98-119 bpm 140 bpm

If your heart rate is too high, you’re straining. So slow down. If it’s too low, and the intensity feels light or moderate, you may want to try pushing yourself to exercise a little harder.

When starting an exercise program, aim for the lower ranger of your heart rate target zone (50%) and gradually build up to the higher range (85%). After six months or more, you may be able to exercise comfortably at up to 85% of your maximum heart rate.

Everyone’s fitness level is different. This means that walking may feel like a moderately intense activity to you, but for others, it may feel vigorous. It all depends on you – the shape you’re in, what you feel comfortable doing, and your health condition. What’s important is that you do physical activities that are right for you and your abilities.

More information on exercise and target heart rates can be found at the American Heart Association website.

Vigorous Exercise and Parkinson’s Disease

Moderate intensity exercise clearly helps with symptom management of Parkinson’s Disease, fighting rigidity and maintaining muscle to counteract the weakening effects of PD. Numerous studies provide clear evidence that even moderate intensity exercise can improve gait, balance, tremor, flexibility, grip strength and motor coordination.

Additional studies have shown that vigorous exercise can affect not only the symptoms, but can slow down the progression of Parkinson’s Disease.

Vigorous exercise induces and increases the beneficial neurotrophic factors. Studies show an increase in GDNF (glial-derived neurotrophic factor), which reduces the vulnerability of remaining dopamine neurons to damage.

Similarly, exercise increases BDNF (brain-derived neurotrophic factor), which may promote neuroplasticity. Historically, the medical field held the belief that the brain did not make major changes after a certain point in time. However, it is now known that the brain is actually capable of changing and developing throughout a lifetime. The term neuroplasticity is used to describe this tendency for the brain to keep developing, changing, and potentially healing itself. Vigorous exercise is currently considered as the best approach to encourage neuroplasticity.

For people with Parkinson’s, the most common vigorous exercise regimens are:

  1. High intensity interval training, including boxing training programs, which also provides symptomatic benefit.
  2. Bicycling – Based largely on the research of Dr. Jay Alberts, the speed of the cycling may be important, with motor-assisted devices sometimes used to achieve higher speeds. Different studies have had different minimum speed recommendations, varying from 75 to 90 revolutions per minute. (It is likely that the speed/RPM is not as important as getting your heart rate into the vigorous zone.)
  3. Running and/or Brisk Walking – Heart rate monitors are recommended, especially for walkers. If your heart rate is not in the vigorous zone, push yourself harder.

Of course there are many other vigorous exercise activities, such as swimming laps, kayaking, rowing, jump rope, mountain hiking, and sports such as tennis, soccer and basketball, to name a few.

Does vigorous exercise have a neuroprotective effect in Parkinson’s Disease?

Don’t Forget Strength Training

We’ve spent a lot of time focused on aerobic exercise and intensity levels.

Indeed, most people focus on the first part of the exercise recommendation, clocking in their time.  But strength training is equally important.  For example, you might bicycle at 80 to 90 RPM for 60 minute sessions, 3 or more days a week, but that is only exercising a small subset of your body’s muscles.

By contrast, high intensity interval training programs such as Rock Steady Boxing include strength training intervals, and participants may have less need for additional strength training. (They may be better served by adding more vigorous intensity aerobic exercise to their routine.)

PD weakens your muscles, and the symptoms make you use some muscles less. But it is possible to gain strength, and build muscle, even with PD.

If possible, I highly recommend that you see a personal trainer and/or physical therapist, even if they have no experience with PD. They can help ensure that you are strengthening all muscle groups, and avoid injuries that can slow or impede your muscle development.

PD tremors zap arm strength. Fight back with free weights, resistance bands and push ups. Using weight machines is ok (and safer than free weights if you don’t have a spotter), but free weights are better for also helping balance, coordination and grip.

PD wrecks havoc on your balance and increase the risk of falls. Core muscles (ab and lower back) are extremely critical to equilibrium and balance. Sit-ups, crunches, planks, ab rollouts … no one enjoys these exercises … but if they improve your balance, or make it easier to recover your balance, they may be one of the most important categories of exercise for someone with PD.

PD generally effects one side more than the other, leaving an imbalance in leg strength. Walking, biking and jogging will help strengthen some of the muscles in your legs, but your might still have trouble getting out of a chair. Add leg squats to your routine. In my opinion, squats are as important as core exercises for balance.

If you can’t balance well enough to do squats, grab a chair and do repeated sit-stand exercises. As you improve, find a lower chair (or use a weight lifting bench in a gym).

If you’re doing squats without a chair or bench, keep trying to push your rear end lower. Widen your stance. Hold additional weights while you squat. And if you get real good at it, get a BOSU and do squats balanced on top of that.

(And if you have access to gym equipment, weight machines for leg press, leg extension and leg curls can also be helpful.)

To improve strength, use progressive resistance exercise principles. This is a strength training method in which the load is gradually increased to allow muscles to adapt. Muscles adapt to exercise and need to be constantly challenged in order to continue to grow and change. As time progresses, you need to increase the weight, increase the number of repetitions between rests, increase the number of sets, and/or add additional exercises to target complimentary muscles.

Study: Weight Training Improves Parkinson’s Disease Symptoms

Here’s what the CDC says about muscle strengthening activities:

Besides aerobic activity, you need to do things to make your muscles stronger at least 2 days a week. These types of activities will help keep you from losing muscle as you get older.

To gain health benefits, muscle-strengthening activities need to be done to the point where it’s hard for you to do another repetition without help. A repetition is one complete movement of an activity, like lifting a weight or doing one sit-up. Try to do 8—12 repetitions per activity that count as 1 set. Try to do at least 1 set of muscle-strengthening activities, but to gain even more benefits, do 2 or 3 sets.

There are many ways you can strengthen your muscles, whether it’s at home or the gym. The activities you choose should work all the major muscle groups of your body (legs, hips, back, chest, abdomen, shoulders, and arms)

There are a lack of studies to conclusively state what is the best form of exercise, but that is probably because there is no single best form. A lot of experts say the best exercise is the one that you enjoy and commit to doing regularly. To some extent, I agree, let’s face it, any exercise is better than none. But I also think it is important to keep pushing yourself and improving your level of fitness.  It is also critically important to do exercises that directly address PD issues of muscle weakness and balance, so do not neglect strength training.

If you’re just getting started, go find a personal trainer to help guide you.

Check to see if there is a PD boxing program in your area. Start by investigating these programs: Rock Steady BoxingPunching Out Parkinson’s and Power Punch Parkinson’s

Ask your local YMCA if they have any PD exercise programs.

Start by building up to the minimum recommendation:

  • 2-1/2 hours/week moderate intensity or 1-1/4 hours/week vigorous intensity.
  • 2 or more days/week muscle strengthening workout (progressive resistance)

Take it to the next level:

  • Do some form of exercise every day for at least 30 minutes (5 or 6 days is OK).
  • 5 hours/week moderate intensity or 2-1/2 hours/week vigorous intensity.
  • 2 or more days/week muscle strengthening workout (progressive resistance with vigorous intensity)

If your body will let you, push it further.

It is important, of course, to listen to your body. However, remember what one of my friends with PD recently said to me…“If I listened to my body, PD would have told me not to get out of bed this morning. But, here I am for another boxing class.”

 

A 10+ Year Experience with Parkinson’s Disease and Intense Exercise – Neil Sligar

 

Boxing for Parkinson’s Disease is a Life Changer

 

Does vigorous exercise have a neuroprotective effect in Parkinson’s Disease?

 

Kickboxing for Parkinson’s Disease

 

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