“Why Exercise and Finding the Motivation”

In early March, the Parkinson & Movement Disorder (PMD) Alliance hosted movement disorder specialist Dr. James Morley on a webinar on self-care, exercise and motivation. Though the topic was described as “Motivation and Parkinson’s” the focus of Dr. Morley’s talk was about self-care and how to motivate yourself to exercise after receiving a diagnosis of Parkinson’s disease (PD).

Dr. Morley noted that exercise can be good for motor and non-motor PD symptoms. Aerobic exercise can also have a neuroprotective effect, and can slow down disease progression. There is no exercise regimen that fits all PD patients, and it is important to work with your doctors to determine the correct exercise prescription. As your disease progresses, just like medication, your exercise routine will change as well. Dr. Morley stressed the importance that the best exercise is the one you can motivate yourself to do. James Creveling, a PD patient, joined Dr. Morley at the end to give recommendations on ways to stay motivated.

Visit Stanford Parkinson’s Community Outreach webpages for:

More information on the benefits of exercise
Exercise videos
Exercise classes

The webinar recording can be found on the PMD Alliance YouTube channel.

Please see below for notes on the March 5th webinar.

Regards,

– Joëlle Kuehn

Speakers: Jim Morley, MD, PhD, University of Pennsylvania, and James Creveling, PD patient

Host: Parkinson & Movement Disorder Alliance (PMD Alliance)

Webinar Date: March 5, 2021

Summary by Joëlle Kuehn, Stanford Parkinson’s Community Outreach

Motivation and self-care in PD:

Shift in focus – not what your provider can do for you, but what you can do for yourself
Lifestyle interventions require self-agency – exercise, diet, sleep, stress-reduction (mindfulness, etc)
Providing self-care is easier said than done but is worth exploring
Explore through the lens of exercise

Exercise as a medicine:

There is a lot of evidence exercise is good for your brain in particular
Many general health benefits
Can have better cognitive scores in seniors if they exercise
Mid-life exercise can reduce the risk of MCI (mild cognitive impairment) or dementia
If you look at the brains of those people (with a fMRI), there is an increase in functional connectivity
Animal models link exercise with:
- Growth factors (IGF-1, BDNF)
- Markers of synaptic plasticity
- Neurogenesis
Has garnered a lot more interest over the last few years, hundreds of papers every year

What do we mean by “exercise”?

Aerobics/Endurance
- Walking/running. Outdoor. Treadmill
- Elliptical
- Swimming
- Aerobics
- HIIT
- Biking: Stationary or outdoor
- Studies show aerobic exercises help with gait (stride length, velocity, cadence, timed up and go, balance measures) and is very good for motor function
Strength
- Free weights
- Body weight
- Circuit
- Resistance training. Resistance bands
- Kettlebell
- Medicine ball
- Progressive resistance exercise (PRE)
- Studies show there is a benefit of resistance training on leg strength, but only some effect (limited significance) on balance and walking measures
Flexibility
- Yoga: flow/stability/chair
- Static stretching
Balance
- Balanced based physiotherapy
- Tai Chi
- Stability ball/board
- Qi Gong
- Studies show Tai Chi greatly improved balance, and can help improve motor function

Exercise and motor symptoms in PD:

There are many exercise interventions to improve motor symptoms
Different exercise types may target different motor domains. Aerobics will have the broadest effect
Questions remain about translating the results from clinical trials to a “treatment”

Exercise for non-motor symptoms:

Exercise may improve mood, sleep, cognition in PD
- Usually secondary outcomes in studies, not the primary
- Low baseline symptoms make effects more difficult to demonstrate
Good reason to think it is beneficial from general populations and mental health literature
More studies are needed specifically in PD with targeted interventions and outcomes for non-motor symptoms
Overall, in practice it may be a happy side-effect of exercise done to benefit motor symptoms

Study: Does vigorous exercise (particularly aerobic) have a neuroprotective effect in PD?

Neuroprotection is slowing down or halting disease progression
Mid-life (40-60) exercise habits affect the risk of getting PD
People who exercise were half as likely to get PD, and get it later
Exercise in animal studies increases growth factors that may protect against or slow down PD
In a small trial, it is shown that exercise in PD patients increases dopamine receptors

The real problem is how to prescribe it, and will patients take it if we prescribe it.

Will patients take it: only 40% of people with early PD are meeting the goals that the American Heart Association recommends, and more than 50% of patients report that they didn’t ever do moderate or vigorous exercise. This will be even worse in patients with later stages PD.

Factors mentioned when asking what made people who exercise, exercise more, and what kept those who didn’t exercise from exercising:

Health:
- Fear of falling
- Other medical comorbidities
- Lack of motivation
- Desire to maintain independence
Social
- Exercise partners
- PD-specific group programs (ex. Rock Steady Boxing)
- Lack of time due to other commitments
Environment
- Access to gym or exercise classes
- Safe neighborhood for walking
- Weather

Larger conversation: motivation for self-care in PD:

General barriers to exercise or other self care/wellness
- Diet, stress reductions, sleep, meditation, etc
- Barriers can be time, access, etc.
PD-specific physical limitations
- Motor disability, changes in smell/taste
- Non-motor symptoms in PD

Non-motor challenges to motivation:

Apathy
- Loss of interest, enthusiasm, motivation
  - Cognitive domain – not interested in new ideas or things
  - Emotional domain – not as interested in relationships, normal interactions
  - Behavioral domain – not interested in things they normally do in new activities
- Up to 40% of people with PD will experience this
Mood problems
- Depression and anxiety, often together
- Up to 50% of people with PD will experience this
Cognitive impairment
Changes in reward processing
- Differently motivated because of dopamine impact in PD

Dealing with apathy:

Poorly responsive to medications
- Sometimes antidepressants or stimulants are used
Keeping a consistent sleep schedule
Aggressively and intentionally pursuing physical, social, cognitive activities and setting a schedule
Setting personal goals
Getting regular exercise

If we consider exercise as a treatment, how do we prescribe it?

A simple prescription rather to counseling or education
Need to be specific, just like a medication prescription (how often, how much, etc)
- Aerobics:
  - Type (walk, run, swim, bike, etc)
  - Frequency (days/week)
  - Intensity (light, moderate, vigorous)
  - Time (minutes/day)
  - Steps/day
- Strength training
  - Might have muscle exercises
  - Frequency
  - How many repetitions
  - Type
  - Example: body weights, 8-12 repetitions, 2 days a week
A written prescription was associated with >30 minutes increase in exercise/week
See exerciseismedicine.org

Just as medication changes during progression of disease, exercise needs to be tailored as well.

Exercise in COVID era:

Gyms, group classes are closed
Outside exercise is limited by weather
Safety concerns for outdoor exercise
- Exercising in a mask can be difficult
- Uneven roads
- Might have to do it unsupervised/alone
- Online fitness options!

Advice from James Creveling, a PD patient

Speak with your doctor first
Do mental exercise as well – can help with motivation
Talk with someone about exercise – find a buddy
Celebrate your exercise successes – have a journal so you can see your progress
If you feel better, have it motivate you to keep going
Time of day is important – morning is helpful because you might be tired by the end of the day but it depends per person
Change the routine to help exercise different parts of the body so you aren’t getting bored
Try support groups during covid
Define what is successful for you – customize it
Set realistic goals

The audience in the chat said that pets and paying for classes/equipment can be motivating. They also mentioned starting small.

Question & Answer:

Question: How much exercise is recommended for PD?

Answer: We don’t have PD specific recommendations. We generally go with the AMerican Heart Association’s recommendation of 3 times a week of 25 minutes (total of 75 minutes) of vigorous exercise (swimming, running on a treadmill), where the heart rate is high and you can’t hold a conversation, or 150 minute of moderate exercise (dance, brisk walking). If you can’t imagine yourself doing 150 minutes a week, you should start with what you can imagine and can get yourself to do. Getting started is the hardest part. High intensity aerobics is generally considered the best overall. Over a short time (6 months), vigorous aerobics exercise can lead to limited or no measurable progression in early PD.

Question: Can certain exercises stave away the need for PD medication?

Answer: Exercise is medicine, but certain medicines are also medicine and important to take so that we can exercise to the fullest. It is finding the right combination, and not good to avoid medicine at all costs. Exercise can help keep your medication needs at a minimum, but it shouldn’t be completely avoided because that can be unsafe.

Question: Is there a benefit or impact of sunlight (in daytime exercise compared to nighttime exercise)? Is there a best time?

Answer: I’m not aware of anything on sunlight, but you should do it at a time that allows you to do it consistently. Sitting outside in the sunlight is good for your circadian rhythm but it doesn’t mean you have to walk outside or exercise. Don’t exercise too close to your sleep time because it can be hard to wind down if you do.

“Why exercise and finding the motivation”

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