In mid-March, the American Parkinson Disease Association (APDA) hosted a webinar titled “Spring Into Exercise: Put Your Best Foot Forward.”The webinar featured three physical therapists from the APDA’s Center for Neurorehabilitation at Boston University addressing exercise for Parkinson’s disease (PD).
Dr. Tim Nordahl spoke on why walking is important for those with PD. Walking has health benefits such as improving blood pressure, sleep, mood, PD symptoms. Walking is an easy way to work physical activity into a weekly routine. Pacing your walk can help elevate heart rates and ease balance problems. Dr. Nordahl cautioned people to walk on a flat surface and to avoid uneven sidewalks.
Dr. Teresa Baker spoke on exercise intensity, which is the amount of energy expended during any activity and is measured by heart rate and how you feel. The best intensity is at least moderate intensity, 30 minutes at least 3 days a week. It is best to do walking or other aerobic exercise that is safe and enjoyable for you. She advocated that to get started, start with what you can do now and work towards goals.
Dr. Tami DeAngelis spoke on how to stick to your exercise goals by creating habits and routines, and setting a plan and goals. She said that is important to choose goals that are specific, measurable, achievable, relevant, and time-bound.
For information on the benefits of exercise and exercise videos and classes, see these Stanford Parkinson’s Community Outreach webpages:
The webinar recording can be found here.
Please see below for notes on the March 16th webinar.
– Joëlle Kuehn
“Spring Into Exercise: Put Your Best Foot Forward”
Physical therapists/speakers from the Center for Neurorehabilitation, Boston University: Teresa Baker, DPT; Tami DeAngelis, DPT; Timothy Nordahl, DPT
Webinar Host: American Parkinson Disease Association Massachusetts (APDA MA)
Webinar Date: March 16, 2021
Summary by Joëlle Kuehn, Stanford Parkinson’s Community Outreach
Walking – Dr. Tim Nordahl
Why is walking important in the first place:
- Can be important for different reasons for different people
- Health benefits:
- Physical activity has many benefits for your health such as blood pressure, sleep, mood
- PD symptoms
- Easy way to work physical activity into weekly routine
- Walking is very accessible – don’t need expensive equipment or a gym membership
- Have a good pair of shoes
- Can maintain more social distancing while out for a walk than possible in indoor exercise settings
- Can help you with your walking quality
- People get better at walking – stride, balance, helps maintaining walking ability
Important to think about walking pace:
- If walk faster can help maintain lumbar pace and can help improve walking pattern
- It will also make certain you are getting better exercise out of the walk
- If they focus on walking faster, they can keep it going but can lose focus and slow down over time
- Not hard to start walking fast, but hard to keep walking at a faster pace
- Tricks to help walking pace:
- Metronome smart phone app
- There are a lot of free metronome apps that can measure current pace as well as set a desired faster pace
- Start by seeing what current normal pace is and try to go faster
- Physical therapists can help find which faster pace is best for you – it differs per person
- Can also walk to music – pick songs that will help you keep a pace that is a little faster but still doable and safe
Where to walk?
- Walking at brisk pace is best on a flat surface
- Try to avoid uneven sidewalks (pavement cracks and gaps, cobblestone, etc)
- Possibly find a flat trail or a school track
How to get the most out of walking?
- Avoid multitasking or distractions
- Can help you count your steps and focus on posture
- Choose what to focus on – prioritize one or two things, once you get to three you lose focus
- A physical therapist can give you recommendations on priorities
- Avoid crowds and distractions
- Quality walking
- Make it a habit
- Schedule a time in your day
- Medication timing
- Pick a time of day where medication is working well and you can do and move your best
Why exercise intensity matters – Dr. Teresa Baker
What is exercise intensity:
- Amount of energy expended during any activity
- How hard you are working during exercise
- Amount of oxygen consumed
What happens during aerobic exercise?
- If have increased intensity, you are using large muscles and legs
- Body responds by breathing faster and more deeply
- Maximizes amount of oxygen in blood
- Heart increases blood flow back to the muscles and back to the heart and lungs and increases blood flow to the brain
- With increased blood flow to the brain, it increases protein levels of neurotrophic factors which help the nerves communicate better
- Dopamine is more available and dopamine signals are stronger in animal studies
- Can create positive structural changes that can influence behavior such as overall fitness, function, mood, fatigue
- In animal studies where the animals have PD, shown that exercise intensity creates changes in the brain that we can see as a behavior
- Exercise intensity is important for people especially if they have PD
How to measure exercise intensity:
- Heart rate (HR) – how many times your heart is beating per minute
- Find what the maximum heart rate is
- General formula for max HR = 220-age
- Usually a percentage of the maximum is taken to find the target heart rate
- Generally around 65% for moderate intensity
- Sometimes HR is not most accurate measure of intensity
- PD affects how heart rate responds
- Some medications blunt heart rate response
- Find what the maximum heart rate is
- How you feel
- Should base it off of how you feel rather than HR
- Breathing harder / sweating
- Talk test:
- Moderate intensity: you should be able to talk but not sing
- High intensity: you can only get a few words out at a time
- Perceived exertion scale = rating of perceived exertion (RPE scale)
- 1 to 10 from rest/sitting to maximal
- Moderate is 5-6 (challenging to hard)
Research showing this — Study in Parkinson Disease of Exercise (SPARX):
- 128 people aged 40-80
- Early stage PD
- No dopamine replacement meds
- Randomly assigned people into 3 groups:
- Usual care – no changes
- Moderate intensity group (60-65% heart rate) on treadmill
- High intensity (80-85% HR) on treadmill
- Recommended people walk for 30 minutes at intensity zone
- Found slower progression of PD in moderate and high intensity groups
- Both were good, but the question is, is higher better than moderate?
- We don’t know the answer yet
What are some ways to get more intensity with my walking program?
- Start with what is typical for you bc intensity is based on perception
- Assess how you feel
- Consider gradually progression safely
- Progressing with speed: try short intervals
- Progressing with distance: try to walk further
- Connect with a physical therapist for individual assessments
What if walking is not the best way for me to exercise with intensity?
- If concerns for balance or safety – it might not be best
- Prioritize focus on walking quality over intensity
- Other options are: seated cycling, other seated exercise, individual physical therapy assessment
Research: Park-in-Shape trial
- Done in people’s homes
- Randomized into 2 groups
- One was doing stationary cycling
- Other was stretching and relaxation
- Both did 30 minutes, 3x/week
- Both had a coach for their exercise
- Result: only group that did cycling had improvements in physical fitness and motor measures
- It is the intensity that matters more than what activity is going on
How to stick to your exercise routine – Dr. Tami Deangelis
There is a gap between knowing and doing. There is a knowledge of the benefits of exercise, and then it translates to actually using that knowledge in regular participation in an exercise program. Feeling bad doesn’t motivate or encourage exercise behaviors, and feelings can also impact confidence.
- Trouble with motivation is that it’s a finite resource
- Start morning feeling motivated but during the day the motivation wanes
- Or start out the new year motivated and it wanes
- In PD, part of the disease process affects parts of the brain that involve motivation
- Apathy and motivation are part of the disease process
Creating habits and routines:
- In the absence of motivation we can try to create habits and routines
- Know your habits – positive, negative, neutral
- Brushing your teeth, walking the dog
- Can capitalize on them when trying to combine a habit with walking
- Replace habits – instead of checking your phone first thing when you wake up until breakfast, take a walk before breakfast
- Make a plan
- Set goals
- SMART – specific, measurable, achievable, relevant, time bound
- Consider your unhelpful thoughts
- Some automatic thoughts can contribute to you not exercising
- Choosing the snooze button over going to the gym
- Some automatic thoughts can contribute to you not exercising
- Think about the future
- “My future self will thank my current self if I go”
- Remember the big picture reason that exercise is important to you
Also good to get feedback on goals so you can see your progress. Note down what exercise you did, or use a Fitbit or other tracking app. Set rewards for achieving goals.
Remember what you value and what is important to you as a person. Having a goal such as being physically fit enough to travel with family, or get on the floor with grandchildren, or have a job can help motivate you.
Getting support is a big factor in achieving goals and creating habits, and can also help when your motivation is low. Support can be through technology, such as having friends follow on technology to see progress, having a walking buddy, a remote/virtual class, or physical therapists.
Questions & Answers:
Question: What music should I walk to?
Answer: Something with a beat that is a little faster than your natural pace. Try counting steps per minute to find your natural pace. You can google songs with the desired beats/steps per minute. Songs that are motivating or you enjoy exercising to are good as well.
Question: What is the best shoe for PD for walking?
Answer: Generally a shoe that fits and is tied well on the foot. Don’t have anything that you can slide into it. A closed heel is good. Sometimes shoes are marketed for balance and have a rocker shape, but those can challenge balance.
Question: When should I stretch? Before or after exercise?
Answer: For people with PD who have stiffness, doing a bit of activity first to warm up lets them get more out of the stretch. Taking a walk first can be great.
Question: What impact does walking have on balance? Can hiking help people with PD?
Answer: If you have problems with balance, it is good to do balance exercise in addition to a balance routine. There isn’t any research on hiking, but it can help with intensity depending on style of hike. Remember to prioritize safety regarding the terrain. Hiking poles can help. If you enjoy it and are able to do it, it’s a great idea.