Description #

Meet Pam.

She is 56 years old and lives with her husband and 2 teenage daughters. Pam began to notice tremors in her right arm and hand about a year ago (she is right-handed). Since then she has also had some difficulties with the way she walks (her new gait pattern means she takes small steps when walking) and with her balance, especially in crowds or if the environment is unpredictable. Although her speech is fine, Pam has noticed that it’s become more difficult to sign her name, especially when there is only a small space provided.

Meet Steven.

He is 68 years old and is having increasing difficulty with functional activities, such as moving more slowly and with more effort to stand up after being seated in a chair. Steven has tremors on both sides of the body now and he loses his balance more regularly. When he tries to move his body suddenly, Steven often finds that his neck and shoulders freeze up and it is difficult to move through narrow spaces such as doorways. Steven has noticed that he has to repeat himself several times when ordering food in a restaurant and his partner Chris has started cutting up his food if it requires a knife and fork.

Both Pam and Steven have been diagnosed with Parkinson’s Disease, however, they are experiencing PD differently.

What do I need to know? #

Parkinson’s Disease (PD) is the most common neurodegenerative disease following Alzheimer’s disease (Farley, 2004). It’s a progressive condition involving the nervous system (specifically, the extrapyramidal part) that results in impaired motor function (ACSM, 2016 p.273).  This means that messages from the brain get interupted on their way to the nervous system. See ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities for more detailed description of the pathophysiology related to PD.

Who is typically affected?

• More than 10 million people worldwide (Parkinson’s Disease Foundation, 2017)
• Prevalence increases with age- approximately ½ of the people with PD are diagnosed before age of 65 (Farely, 2004)
• Men are slightly more likely to be affected (1.5 times more than women) (PDF, 2017)
• Exact cause is unknown, although genetics & environment (exposure to toxins) have been identified as risk factors

(Parkinson’s Disease Foundation, 2017, http://www.pdf.org/en/parkinson_statistics)

Why Exercise? Why is it important? #

Exercise is important for everyone! For people with Parkinson’s disease, the benefits of regular exercise include:

• Enhanced mood & mental well-being
• Improved quality of life
• Decreased motor impairments
• Lessen fatigue & improved sleep quality
• Improved speech (Cadet et al., 2003)
• Increased strength & flexibility
• Maintain exercise capacity with regular aerobic activity (even in those with severe symptoms) (Canning, 1997)

The Consultation #

In addition to gathering medical information and details about their fitness/ physical activity experience, you can focus on goal setting and learn about what they want. In addition to talking about exercise, ask the participant about how they will get to the fitness center, and what kind of support (if any) they need to be ready to exercise (for example, accessing the locker room).

You want to support the participant to be as independent as possible. Depending on the individual, this may change over time as they become more familiar with the setting and feel more confident and capable. Some participants may choose to include task-specific training as part of their goal setting (e.g., movements to help with getting out of bed or stopping and changing directions).

When someone with PD comes in for their consultation you may notice the following:

• The may come in on their own or with a family member/ friend
• Their speech may be difficult to understand or they may speak clearly
• They may find it difficult to move from sitting to standing after you have been talking for awhile
• Their body may shake when they are moving (e.g., their arm might shake as they reach to pick up something off of a desk) or when they are sitting still

What are you going to do?

• Direct your questions to the person with PD, not their family member/ friend
• Be patient
• Don’t try to guess what the person is saying before they finish. Wait for them to finish speaking. You can then repeat back what they said as a question to make sure you understood. For example, if you’re talking about goal setting, ‘so you would like to do some exercises to help with your balance?’
• It’s ok to say, ‘I didn’t get that, could you please say that again’.
• It’s important to build a relationship with the person at this stage- don’t worry about saying exactly the right thing. Just be yourself. Be patient. Think about how you would like to be treated.
• It’s ok to ask about the kind of assistance they might need. For example, do they want a hand to get out of the chair? If not, let them do it themselves. Again, be patient. If this is something they are working on then you need to give them the space to do so.

Implications for Exercise #

For someone with PD, they may experience motor difficulties due to a loss of dopamine, which regulates neural activity in the brain that is responsible for starting and stopping movements. This means that you might notice the following related to how someone with Parkinson’s disease moves:

• They sometimes have tremors (you’ll notice the shaking)
  • These can happen at rest or during movements
• Their bodies can be very rigid and stiff
  • It might start with the neck and trunk muscles and the person may notice their bodies are resisting passive movements
• They have difficulty controlling the timing of their muscle movements
  • For example, reduced ability to activate muscles may lead to movements that are slow (bradykinesia), or difficult to stop (festination), start (freezing), or finish (hypokinesia)
• They have trouble with the initial movements that get things going for larger movements
  • For example, the person may have difficulty starting the movements in their trunk and proximal limbs which make voluntary movements (like getting out of a chair) possible.
  • This also means they might have a delayed response to environmental changes (for example, if there is a slippery spot on the gym floor or if there is an unexpected step), which increases the risk of falling or losing balance
• They experience side effects from their medications
  • For example, dyskinesias is a side effect of dompamine replacement medications.
  • It leads to involuntary movements that are excessive and abnormal. This may happen abruptly, be painful and/or interfere with their balance and ability to bear weight (Farely, 2004)

Don’t forget:

Every person is like every other person, like some other person, and like no other person.

Monitoring Exertion & Exercise Intensity #

It’s really important that people who are new to exercise learn how to monitor and describe how they are feeling or how their body responds to exercise. One helpful way to do this is to introduce a Rate of Perceived Exertion (RPE) scale.  The smiley face RPE Scale or the OMNI scale (see below for examples of both) may be more suitable for participants with various disabilities than the age-predicted maximal heart rate (220 – age) (Stanish & Aucoin, 2007).

In the beginning, it is also recommended that participants measure their heart rate (using wearable technology such as a heart rate monitor may make this easier!). This information will help you and the participant work together to learn about how they perceive their exertion during exercise and it may help you with program planning. For example, you may encourage the participant to work towards a specific level of RPE, which can be complemented with information from the HR monitor to measure exercise intensity. Monitoring HR may also be useful in the event that participants are exercising at a level beyond the recommended intensity, which may happen if the person is very engaged in the activity or if they are trying to make a positive impression on you.

OMNI Scale

Smiley Face Relative Perceived Exertion Scale

Medication & Exercise: What do you need to know? #

Individuals with Parkinson’s disease will most likely be taking regular medications. They may have regular cycles that they go through in which they feel on or off, depending on where they are at in their medication cycle. This cycle might include when they take medications, and how long or frequently they feel on or off. Feeling off, may lead to increased fatigue, tremors or dyskinesias (involuntary, excessive, and abnormal movements), which might not be an ideal time to introduce new exercises or increase intensity, duration or frequency. You can raise this question during the consultation or as part of your regular check in to see how the person is feeling each day. It is also important to ensure the individual has the go ahead from their health care provider prior to beginning a new exercise program.

If you would like more information about some of the common medications used by individuals with PD, along with some of the possible side-effects, ASCM has produced a great manual that will provide more details (ACSM, 2016)

Inclusive TIMES: Tips & Strategies for Individuals with Parkinson’s Disease #

The tips and strategies found within the inclusive TIMES section will help you to create an environment that will support your participant’s participation in physical activity as independently as possible. It is important that you involve the participant whenever possible, along the way to ensure the program that you design will meet their needs physically, as well as emotionally and socially. Introducing a few simple strategies such as offering visual images of the participant’s program will help them to be more independent in completing their fitness programme. Ultimately, they will gain confidence and belief in their abilities (increasing self-efficacy) and experience self-determination (sense of control over their own destiny). This is key to establishing healthy habits that will be adopted for the long term.

Time #

• Send a reminder (e.g., text) about appointment or exercise session
• Shorter sessions &/ regular rest periods may be ideal to avoid fatigue- Talk to the participant to find the right time of day (for example, in the morning when they are fresh and ready to go)!
• Schedule exercise sessions that work within the participant’s medication cycles
• Begin with shorter duration and lower intensity activities, progressing gradually to moderate intensity.
• Include a longer cool down (5-10 mins of low intensity aerobic activity & stretch) to ensure blood pressure returns to normal & to prevent blood pooling in the legs

Instruction #

• Be patient.
• Provide clear, simple instructions in more than one format (e.g., verbal and visual).
• Break complex movements into simple discrete movements
• Focus on completing one task or movement at a time- avoid dual tasks
• Introduce mental rehearsal or imagery to help with movement planning
• Use questions to get the participant thinking about and planning their movements. For example, you can ask: How are you going to get across the room? How many steps do you think it’s going to take?
• Clear, simple verbal cues can be used to encourage proper form
• Do not pretend to understand a participant if you do not- give them time to express what they are saying.
• It may help to write down the sequence of an activity or have visual cue cards ready.
• Post coloured targets on the wall at eye level to direct attention and focus on proper posture
• Introduce the RPE Scale and teach participant to learn their body’s response to various intensities. This will help them become aware of what intensity is appropriate for the body on any given day.

Movement #

• Use the motor learning principles of multiple repetitions, lots of effort, and straightforward cues
• Recommend a gentle group exercise class such as seated yoga or tai chi that might focus on both balance and flexibility
• Introduce auditory cues with a regular beat to direct focus during movement (for example, you can play music with a strong beat or ask about the participant’s favorite music, use a metronome, or clap your hands/ tap your fingers)
• Recommend rocking the body from side to side or back to front to initiate movement
• Ask the participant if they have difficulty with performing any activities of daily living (for example, getting out of bed, opening a cupboard). Incorporate task-specific movements into their training programme!

Environment #

• Use visual cues such as strips of tape to direct attention to changes in surface or environment (for example, if there is an unexpected step)
• Work with allied professionals to reassure the participant that their programme is safe. It’s important that the participant feels safe and supported in their fitness programme.
• Seats for resting should be available for participants who need regular rest periods.
• Use non-traditional equipment to assist with balance (for example, the back of a chair may offer the right amount of support- be sure the equipment is stable and can support body weight if necessary)
• Remove clutter and extra equipment where possible to reduce the risk of someone tripping and falling in a messy space

Support #

• Use the consultation to discuss the individual’s desired level of support (this will be unique for each participant). Some may require support staff/ family members or use assistive technology/ mobility aids, others may not.
• If the participant has or is at risk of CHD or other heart conditions, work with their health professionals, especially in the beginning to ensure they exercise at an appropriate & safe intensity
• Social support is vital to promote a healthy lifestyle! Introduce activities with partners to create a positive, fun & enjoyable atmosphere
• Link with local Parkinson’s Disease groups if more specific information is needed or to connect participant to local supports or community opportunities.
• Discuss the participant’s overall lifestyle choices (e.g., nutrition, sleep hygiene), to identify areas where they can enhance their overall health. For example, does the participant smoke? Eat healthy? Are there changes you can suggest?

References #

• Cadet, P., Zhu, W., Mantione, K., Rymer, M., Dardik, I., Reisman, S., … Stefano, G. (2003). Cyclic exercise induces anti-inflammatory signal molecule increases in the plasma of Parkinson’s patients. International Jouranl of Molecular Medicine, 12, 485-492.
• Canning, C. G., Alison, J. A., Allen, N. E., & Groeller, H. (1997). Parkinson’s disease: An investigation of exercise capactiy, respiratory function, and gait. Archives of Physical Medicine and Rehabilitation, 78, 199-207.
• Cheng, S. P., Yang, C. Y., Tang, F. I., & Ju Chen, I. (2013). Training effects of a 12-week walking program on Parkinson disease patients and community-dwelling older adults. NeuroRehabilitation, 32, 967-976.
• Farly, B. (2004). Developing Parkinson’s-specific exercise programs. The Journal on Active Aging. 22-28.
• Moore, G. E., Durstine, J. L., & Painter, P. L. (2016). ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. Champaign, IL: Human Kinetics.
• Stanish, H. I., & Aucoin, M. (2007). Usefulness of a perceived exertion scale for monitoring exercise intensity in adults with intellectual disabilities. Education and Training in Developmental Disabilities, 42, 230-239.
• States, R. A., Sweeny, T. L., Rossi, A., Spierer, D. K., & Yasser, S. (2017). Phyiscal functioning after 1, 3, and 5 years of exercise among people with Parkinson’s disease: A longitudinal oberservational study. Journal of Geriatric Physical Therapy, 40, 127-134.

Further information/ Recommended Resources #

• Canadian Society for Exercise Physiology (CSEP) (2002). Inclusive Fitness and Lifestyle Services for All disAbilities.
• NCHPAD, Parkinson’s Disease, available at: http://www.nchpad.org/162/1237/Parkinson~s~Disease [Accessed July 24, 2017]
• Parkinson’s Disease Foundation, Exercise, available at: http://www.pdf.org/exercise [Accessed July 24, 2017]

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