September/October 2009

Delaying Parkinson’s Disease
By Jackie Russell, RN, BSN, CNOR
Aging Well
Vol. 2 No. 4 P. 24

It appears that regular exercise is beneficial for alleviating some symptoms of Parkinson’s disease (PD). But is symptomatic improvement a placebo effect or proven scientific theory? Exercise has been clearly proven as advantageous for both cardiovascular health and maintenance of strength and flexibility in individuals throughout the aging process. But emerging evidence shows the positive effect a regular fitness agenda can have on the course of PD. When exercise is added to current medication therapies, disease progression may slow or halt from the effect that exercise seems to have on helping the brain produce its own protective chemicals.

PD Basics
Physiologically, a drop in dopamine levels in the brain characterizes PD in older adults. Dopamine, a neurotransmitter, appears to regulate the level of neural activity needed to start or end a movement. Lack of dopamine leads to inadequate muscle activation, resulting in slowness of movement (bradykinesia) or incomplete movement (hypokinesia). It also interferes with the ability to maintain upright posture, resulting in poor balance. However, people with PD retain the ability to increase muscle activation and can learn to perform larger and faster movements using conscious effort.

Research
A growing body of scientific evidence indicates that physical activity has a neuroprotective effect on the brain and nervous system. In the animal model, studies reveal that exercise works at the molecular level to inhibit the death of dopamine-producing cells, concurrently increasing synaptic activity and thereby maintaining the level of dopamine utilized in the brain. The result is the improvement of motor impairments associated with PD.

The details of such studies are exciting. A group of rats injected with a toxin that induced PD experienced a resultant loss of brain cells, mimicking the brain cell loss in a human with the disease. The rats were then divided into two groups. One group was forced to perform motor exercise daily (treadmill running), and the other group was rested. During exercise, the rodents avoided motor impairment associated with PD. When they stopped exercising, symptoms reappeared. These findings suggest regular physical activity is necessary to prevent PD symptoms from developing and progressing. Brain examination showed that in the exercised group of rats, there was only a 6% loss of brain cells containing dopamine compared with an 87% loss of cells in the rested group. Treadmill running enhanced the survival of dopaminergic neurons and their fibers. It is reasonable to hypothesize that these data translate to human PD models and holds promise for individuals diagnosed with PD.

The timing and intensity of exercise intervention also appear to be important. In the animal model, the degree of neuroprotection and neurorecovery depends on how early exercise is started in the course of the disease. This suggests a need for regular activity to commence at the time of diagnosis to provide optimal results. These data are compelling enough to lead researchers to suggest that early physical training interventions may actually halt the progression of the disease. Ongoing clinical trials will help elucidate exercise parameters, intensity, difficulty, and repetition likely to achieve the most robust effects on symptoms.

Currently published human PD studies report outcomes that include improved axial rotation, flexibility, balance, muscle strength, short-step gait, and overall mobility with routine exercise. Improvement was measured using a variety of standardized tests and mobility scales. Results indicate that individuals with PD enhance their activities of daily living and physical performance through exercise. A study by Crizzle and Newhouse that was performed in Ontario, Canada, and published in 2006 in the Clinical Journal of Sport Medicine suggests that future research should include the development of a standardized exercise program specific for problems associated with PD.

Human studies performed to date suggest that exercise is beneficial for individuals with PD, but no study can definitively make this claim. Major study weaknesses include the short duration of exercise intervention and the fact that individuals were not tested while they were off their PD medications. If study participants are evaluated while taking their medications, it is unclear exactly what effect the exercise actually has on the disease. The National Institutes of Health is currently funding a study at the University of Illinois to evaluate the effect of exercise on PD. The Parkinson’s-specific exercise programs are measuring tremor, gait, balance, cognitive, and quality-of-life parameters. The double-blind study is ongoing for a period of two years and tests patients both on and off their medications. Conclusions drawn from this study will be helpful to neurologists with recommending the exact types of activity most beneficial for patients with PD.

Parkinson’s-Specific Fitness Plan
One such exercise program tailored to the needs of individuals with PD has been developed and is being utilized in Columbus, OH. This fitness agenda is detailed in a book and companion DVD, Delay the Disease — Exercise and Parkinson’s Disease. The program is a collaboration among a certified functional fitness trainer, a nurse, and an orthopedic surgeon who retired due to the disease.

The idea for the fitness plan was sparked when Thomas H. Mallory, MD, FACS, an orthopedic surgeon with PD, discovered that a daily exercise routine created by his trainer, David Zid, seemed to dramatically improve his symptoms. His career in total joint replacement had come to an abrupt halt in 2002 with the diagnosis, and he was searching for a way to battle the disease. He asked me, his nurse, to review the medical literature to determine whether research supported his findings of improvement with exercise. My discoveries convinced him that he should share his good fortune with others diagnosed with PD. The result was a book detailing a fitness plan for patients at any stage of the disease. What started as an idea to share good news with others has turned into a program that is being used by the Parkinson’s community in the United States and around the world.

Zid, the book’s author and the leader of a weekly exercise class based on the program, motivates individuals with PD to “just do something every day.” He indicates that users of his program boast about their newfound ability to get up easily from a chair, turn over in bed, get in and out of cars, and maintain balance. They have learned tricks to unfreeze their gaits, get up without help after falls, and enjoy the return of a normal arm swing and a louder voice. Zid focuses on a conscious way to perform previously automatic actions and constantly reminds participants to “think big movements.”

His weekly exercise class yields more than just improvements in mobility and independence; there is a camaraderie that has developed among patients. Caregivers are encouraged to attend and participate, and they also share their concerns and cultivate new friendships. Participants report an increase in self-confidence, improvement in mood, and feelings of well-being with routine exercise. Their sense of accomplishment fuels optimism, and their new exercise friends offer encouragement, support, and the knowledge that they are all part of the same circle.

The idea that something as simple as exercise may be neuroprotective is an exciting breakthrough. With overwhelming scientific evidence and convincing patient testimonials, there seems to be no reason not to start an exercise program when older adults are diagnosed with PD. This treatment doesn’t require FDA approval, is readily available, and can safely be combined with medications. Most importantly, it empowers individuals to take control of the disease with a proactive approach.

— Jackie Russell, RN, BSN, CNOR, is a Columbus, OH-based nurse and freelance writer. She has been published in Today’s Caregiver and the European Parkinson’s Nurses Network. She has been practicing nursing for 30 years, with a dedicated interest in the Parkinson’s community.