The Cure Parkinson’s Trust, in the United Kingdom, hosted a panel webinar discussion on Exercise in Parkinson’s disease (PD) on January 8th, 2020. Panelists discussed why exercise is important in PD, how research suggests it likely affects the brain, and recommendations for those who would like to become more active. We at Stanford Parkinson’s Community Outreach listened to the webinar and are sharing our notes.
This webinar included three panelists:
- Prof. Bas Bloem is a clinical researcher with Radboud University in the Netherlands, co-editor in chief of Parkinson’s journal, and a former elite volleyball player.
- Dr. Michael Jakowec is professor of research at University of Southern California.
- Prof. Karen Raphael, a medical researcher in epidemiology and psychology at New York University, is an avid exerciser and has had PD for 10 years.
The recording of the webinar is available here.
If you wish to contact the speakers or have any questions about the webinar, please contact Cure Parkinson’s (firstname.lastname@example.org).
For additional information about *why* to exercise, see this page on the Stanford Parkinson’s Community Outreach website.
If you would like to find a PD exercise class in the Bay Area and Central Valley, you can access Stanford’s list of classes here.
Plus see Stanford’s list of PD exercise videos here.
Now…on to our notes from the webinar.
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Exercise in Parkinson’s Disease
Webinar presented by The Journal of Parkinson’s Disease, The Cure Parkinson’s Trust, and Parkinson’s Movement
January 8, 2020
It is now widely known that exercise is critical for those with Parkinson’s disease (PD), but there remain a lot of questions among individuals wondering what benefits they can expect to see, how to start, what type of exercise to choose, and how much of it they need.
Exercise is generally classified by the amount of effort we put into it, the “intensity” of our workout. This is often measured with heart rate, to see how hard the heart is working. Everyone who is able should do exercise that gets their heart rate up (“aerobic” exercise), such as running, swimming, walking briskly, or mowing the lawn. While it is good to push oneself, high intensity exercise may not be for everyone, and people should generally avoid exceeding their maximum heart rate (max HR). Max HR is calculated by subtracting your age from the number 220. For a 65-year-old, her max HR would be 155. While exercising, she should aim to stay close to that number but not above it, to avoid possible injury.
To read more about exercise intensity and how to calculate target heart rates depending on your fitness level, please visit the Mayo Clinic’s webpage on this topic.
Exercise can benefit those with PD or those at risk of developing it in many ways: by affecting risk factors for developing PD, by reducing the symptoms of PD, and by modifying the progression of the disease.
Engaging in regular exercise when an individual is younger and healthier is associated with lower risk of developing PD. These effects may not be causal, though – don’t blame yourself if you didn’t exercise as a young person and later developed PD. Environment, genetics, and other factors are involved as well.
A personal experience of exercise and PD
Dr. Raphael shared her personal history with PD and exercise. In her case, she was very active her whole adult life, exercising multiple days a week. She still developed PD, as her father had previously. She started on medication right away because she needed it, but she also decided to increase her already active lifestyle even further. She now exercises seven days a week, primarily through running and strength training. Over the course of several years, she was able to decrease her medications due to the benefits she received from her active lifestyle. If she neglects to exercise for up to 48 hours, she notices a return of her symptoms and needs more medication. Dr. Raphael emphasized that she is a sample size of one person, and that this is just her experience.
While not everyone has as dramatic of a response to exercise, Dr. Bloem cautioned, PD symptoms have been demonstrably improved by exercise, even just three days per week. Motor symptoms such as tremor, slowness, and rigidity can be significantly helped, while mood symptoms, such as depression or anxiety, are also improved.
It is common for people with PD to feel worse immediately after exercise, having more tremor and slowness – this is normal! It is not a sign that you are exercising too much, rather, it is due to the temporary exhaustion of your dopamine, and will return to normal after some time has passed. If it bothers you, you could ask your prescribing physician if you can try taking an extra dose of medication right before exertion.
Besides the intensity of the exercise, another component that may be beneficial is the complexity of the exercise. Are you breaking a sweat? Are you cognitively engaged, and perhaps learning something new? Aim to sometimes exercise in a “learning modality” rather than always doing the same thing. Acquiring new skills – such as taking a tennis lesson, or trying a dance class – targets the connections in the brain, improving brain health.
What mechanisms in the brain might be at play here?
Many studies have evaluated the effects of exercise in the PD brain and the panelists offered some explanations for how this may occur, mostly based on evidence we have gleaned using mice models, which means mice that have been specially bred in the lab to have or develop PD.
Dr. Bloem explained that a challenge in studies of humans with PD is the difficulty in having a control group when the intervention you are studying is exercise. How do you create a blind control group? People know whether they are exercising or not! The placebo effect is powerful and can skew results. A study he was recently involved in, which was published by the Lancet in 2019, used stretching as a control activity and aerobic exercise using a game app to encourage them to work out. The idea is that tying in exercise to a game can help motivate and encourage people who need external motivation to stick with heir exercise. To read more about this study, you can read the full text for free here.
Dr. Jacowec clarified that it’s not the amount of dopamine that changes while exercising, it’s how your brain uses the dopamine that changes when you are active vs sedentary. During a workout, other circuits also become engaged that you weren’t using before. The corticostriatal pathway into the basal ganglia changes dramatically in exercise conditions. Ordinarily in PD, this pathway is functioning abnormally, but it seems to normalize during exercise!
When you are exercising, you are driving the brain to take up dopamine, and driving the motor circuits to function. The brain has to respond to the activity, and sometimes it finds new ways to solve motor learning challenges, creating new pathways and connections in the brain. There are also changes in how the neurons (brain cells) use energy when you are fasting, consuming a ketogenic diet, and exercising. None of this represents a cure for PD, but it can affect the symptoms.
Dr. Jacowec described 5 key points where exercise affects the brain (summarizing above) in rodent models of PD:
- It affects how dopamine is handled by the brain
- Dopamine receptors perform differently
- Other brain circuits are engaged to help with motor efforts
- Glial cells (support cells for neurons, or brain cells) respond to changes in metabolism
- Growth factors in the brain seem be involved in this mix, and may regenerate
- Lactate (which is produced by exercise and causes pain in muscles) crosses the blood-brain-barrier, and seems to feed neurons
As a caveat, Dr. Bloem emphasized that currently the research in humans clearly shows that engaging in regular exercise helps to stabilize the symptoms of PD, but it has not yet been shown how it affects progression of the disease in the brain. These rodent studies are very encouraging but they don’t tell us formally whether the brain progression of PD is modified in people. An upcoming study using dopamine scans in humans will try to show if the rate of cell loss in the brain is slowed down by exercise. This would show true disease-modifying capability and is very exciting!
Question and Answer Session
Q: What is the best time of day to exercise, taking into account medication schedule?
A: Dr. Raphael trains in fasting conditions, so she works out in the early morning; she cannot exercise with any intensity if she has food in her GI tract. This is certainly not for everyone, but it works for her. Most people need to exercise while “on” their medication; she does not advise trying to exercise while off.
She also suggested that one of the best things one can do when traveling internationally is to switch your exercise time in your new time zone as soon as you arrive, which helps reset your physiological clock.
Q: Could we target specific circuits in the brain by engaging in different types of physical exercise?
A: We don’t know yet; we need more studies assessing the cellular effects of exercise in the brain, which have not yet been established. We are a ways away from understanding how exercise affects the cells in the brain. Hopefully in 5-10 years, neurologists will give their PD patients a prescription for specific exercises to target brain circuits!
Q: My meds seem to interfere with my ability to exercise; I can’t get my rhythm down in the mornings. Should I exercise while “Off” meds?
A: Dr. Raphael responded that you probably have to be in an “on” state in order to exercise; you probably can’t do much when “off.” She herself never has “off” periods anymore so it is a little hard for her to address this. A lot of people out there want to exercise but find it extremely difficult to develop (and stick to) a routine. She recommends that you try to anticipate and work around obstacles. For instance, when she’s on and energetic, she makes sure to set up her running clothes in advance for the next day. She has coffee ready-made. She doesn’t give herself time to think about whether she wants to exercise or not, she does it every day so never has a “day off.” Habit formation is an important concept here! Look at it as a problem to be solved, and try to remove barriers for yourself.
Try to enlist other factors to help motivate you, such as social interaction. It can be really helpful to incorporate social interactions with exercise, and can reinforce those habits. She herself prefers to exercise alone because she tends to get competitive with others and pushes herself too far. But for those who can comfortably exercise with a friend, it can be a wonderful motivator.
Q: Do you have safety recommendations? How can I exercise without injuring myself?
A: Safety is a very important consideration! Dr. Bloem gave as an example that they used stationary bicycles in their studies and screened participants to make sure they were in good cardiovascular health before starting the regimen. It is important to think carefully about what exercise will work for you. What are your mobility challenges? What are your goals? What types of movement do you enjoy? It is important to find exercise that is manageable and safe. Stationary cycling is often considered the “ultimate” type of exercise for those with PD, because it can be rigorous but also safe. Make sure you are using appropriate shoes for your activity; stretch and use a foam roller. Speak with an exercise coach or a physical therapist about what you can do to reduce your risk of injury.
Takeaways about exercise and PD:
- There are benefits to exercise no matter when you start it, and no matter what level you’re at! It is never “too late” to start.
- Even those with advanced disease can benefit from movement, such as using a recumbent bike, stretching in bed, or doing exercises in a chair.
- Pick types of exercise that you are likely to stick with. Try to remove barriers for yourself, such as choosing your workout clothes the night before. You are trying to build a new habit.
- Exercise safely, in terms of the environment where you chose to exercise and the specific mode of exertion relative to your own capabilities. Seek advice from a personal trainer or physical therapist if you’re unsure where to start.
- Exercise with others, if you are so inclined! Working out with a group or a friend can be a great way to stay motivated and build some socializing into your routine.