10 Exercise Secrets for Professionals Working with Individuals with Parkinson’s Disease
By Patrick LoSasso, CSCS,*D, Personal Trainer
Copyright 2017, Patrick LoSasso
These are some of my experiences and observations for designing a safe and effective exercise program for individuals with Parkinson’s disease. Of all the different sport disciplines I’ve studied and designed exercise programs for, the most challenging and yet rewarding one for me has been preparing my individuals for the “sport” of Parkinson’s. The primary purpose of any exercise program for PWP is to improve or maintain function and a properly designed program will do just that.
Any trainer or physical therapist who works with this community will quickly realize that there is no master list of exercises 1-8 to be introduced on day one. Parkinson’s Disease presents in drastically different ways. Two individuals who appear to have a similar level of symptoms may respond differently to the same exercises. There are responders and non-responders to movement strategies in this neurologically challenged community. What works for one individual may completely fatigue another who presents similarly. Parkinson’s is a complex puzzle and a disease which will challenge your skills as a practitioner of exercise and will require you to fine tune your craft. In this article, I hope to share with you some strategies which I’ve developed which will guide you to becoming a better designer and creator of protocol. Because of the way PD affects each individual differently, you will never be perfect. That’s okay. If you are doing your job correctly, you will make mistakes. Why? Because no single program works for everyone and it takes a creative and courageous practitioner who is willing to apply their knowledge base and experiment with strategies in order to design an effective, individualized program. You have to adjust the program based on how the person you are treating/managing responds.
Inevitably, the following will happen: You will be confident that a certain exercise will be effective at addressing the presenting symptoms, you will employ it, and you will find yourself watching a jumbled mess. That’s okay! If you are a creative, dedicated and skilled practitioner of exercise science willing to apply your knowledge to help those with PD, this will unfortunately be your constant companion. In your attempt to effectively construct an exercise program for PWP, you will need to learn to improvise. Once you acknowledge this and give yourself permission to experiment by applying evidence based principals, you will find that you see things clearer and you will become proficient at quickly adapting a movement or drill so that it becomes meaningful for the individual you are working with. Keep in mind that the exercises you choose must be safe for any postural, spinal, hip, knee or shoulder issues your client/patient has. You will find that many individuals that come to you have health and joint issues that actually have nothing to do with their Parkinson’s.
If you work with elite athletes or well trained individuals, you should be prepared to modify your expectations of the psychological adaptations which typically occur through the implementation of a periodized training season. That’s okay, because meaningful and at times significant improvements can be achieved by shifting the focus, progression and priorities of your program. Sometimes PD can inhibit an individuals ability to maximally innervate the agonist muscles you are attempting to train. Thus, the ability to sufficiently fatigue these muscles to the point where new muscle is formed can be compromised. But the good news is that immediate gains in strength, motor function and coordination can be achieved by introducing “tricks” to encourage motor recruitment. In many cases there is sufficient dormant musculature on the frame of the individual which can be coaxed back into action, almost immediately. I have observed this on many occasion and have seen significant strength improvements occur in a single session. Performing routines on unstable surfaces and providing visual stimuli prompts are great for immediately improving strength, motor activation and speed. More on this in a bit. Here are 10 ideas on how to effectively design a program that is fun, effective and progressive.
Patrick’s 10 secrets for effective exercise for those with PD:
- Assigning Appropriate Challenge: Exercises should be evidence based and achievable. The is nothing more disheartening for an individual who is attempting and to perform a drill beyond their current capacity and failing. Make the exercises challenging yet attainable. If it becomes apparent that the drill is too tough, modify it so that the individual can get a bit closer to accomplishing its objective. They don’t have to be able to perform it 100% correctly on the first day, but they should sense that with work, they will get it done. Also, design every drill you use or develop so that it is based on the principals of exercise adaptation, coordination improvement, motor recruitment, or overall brain health. Explain the reason for the drill, how it will help, and how it will improve function in their daily life.
- Visual Triggers/Targets: Visual cues and sound cues are incredibly effective at improving both amplitude and consistency of movement. I use, well, the BrainBall of course, blinking lights, metronomes, a decibel meter app for measuring vocal levels, colored tape, scarves, kleenex, balls, jingling bells, canoe paddles, ping pong paddles, PVC pipe, rope, colored wires, laser pointers, etc. Find ways of making the exercises new, unusual, fun and game like. Provide the challenge of an achievable skill-set. By prompting with visual cues you will get your clients/patients into start position faster and you will increase amplitude and consistency of movement across their performed sets. This will provide a cumulative effect that will result in a significantly more valuable exercise session.
- Multitasking: Multitasking is okay, but it should be employed cautiously by progressively adding layers or elements. Explaining the specific requirements of each task so that the individual comprehends what is required is also vitally important to address and improve neuroplacisity. Start simple and progress slowly. Layer with breathing and vocalization tasks such as counting, chanting, etc. as well. If everything falls apart, go back to the start, simplify (or modify) and rebuild.
- Hand-eye Coordination: Employ eye tracking challenges and don’t let them rely on their peripheral vision. Focus on events where the body navigates the hand towards an object and make them commit to locking eyes on the task until that moment is completed. Exercise and control of the ocular muscles is incredibly important for those with PD. This will also work on cognition as they attempt to stay with the path of a moving object. I like to use whiffle balls and the small nike agility cones which have a center which will cradle the whiffle ball. The whiffle ball is light and unforgiving so all digits have to be cooperating. An example of how this can be used is to have the individual retrieve, place or gently touch the ball while performing large motor or multi-joint tasks, thus, combining gross muscle function in conjunction with fine motor skill. This is a strategy used by elite athletes when attempting to improve their skill set, accuracy and consistency, and is incredibly valuable at improving the brain-body connection and reestablishing neuro pathways. As with all of the advice here, you will have to use discretion when implementing these strategies as it may not be appropriate for someone presenting severe diskonesia. But I’ve experienced great results with chair bound individuals while attempting to address upper extremity proprioception and hand-eye coordination. I accomplish this by adding open eye/closed eye hand navigation challenges, movement sequencing drills with placement, etc. The options are limitless.
- Task Sequencing: In any multi-movement exercise, task sequencing should be specifically instructed and defined to the individual so that they understand the sequence and structure. The delineation of stages/components of a routine can be incredibly therapeutic for individuals that have a tendency to try to do too much at once. The discipline of starting a movement, stopping, then starting again, has useful applications for those struggling with ADLs (activities of daily living). But the value of this discipline is lost unless the individual is very specifically instructed to delineate the task segments and their associated stop/start moments. That neurological event when control of a movement is stopped, then another one started is a trainable skill. This is a great way to improve neuro plasticity and to create new neuro pathways. Don’t allow the individual to slop through a routine, be specific and instruct.
- Posture Reinforcement: Make the individual take a moment and set their posture before and after every exercise set. It only takes a second and this simple discipline will improve the motor pattern of proper posture. If you perform 30 sets in an exercise session, that’s 60 times you client/patient has had to briefly execute that brain body connection of proper posture. Imagine that entire exercise session absent this maneuver. The session is not near as effective and misses a valuable opportunity. If encouraged, individuals will continue to practice this discipline post exercise session. This has a significant impact on their ability to improve posture. Of course, don’t forget to initiate this practice with a posture lesson so that your client understands explicitly what is proper posture and where theirs is lacking.
- Video Strategies: If one side of the lower or upper extremity weak or slow, video the contralateral side performing a strength training movement (such as a resisted ankle dorsiflection) from the perspective of the exerciser. The iPad or iPhone are great tools for this. Subsequently, the ipad/iphone in the view line of the exercise for the compromised leg, then have the individual attempt to match the pace or amplitude with the weak side while watching playback of the strong side. In most cases, you will notice an immediate improvement in amplitude of movement, range of motion, and speed/strength of execution.
- Agility Drills & Proper Implementation: Agility drills should always incorporate visual and tactile prompts. You can have your clients/patients rehearse and drill footwork patterns over and over, but unless you associate these movements with real-life environmental prompts, the agility will not effectively translate into real world function. For instance, if you’re drilling a footwork pattern that re-establishes balance in a moment of lateral instability, you should practice the drill, then recreate that moment of instability via push or pull and have the individual execute the movement pattern that recovers balance.
- Understand Contraindications for Parkinson’s Disease. For example, with someone with PD, NEVER employ balance drills with their feet close together and touching. Parkinson’s can tend to cause the individual to bring their heels or feet together reducing lateral stability. Practicing in this position just reinforces this foot position. You will experience much better results in fall avoidance by educating the importance of a wide base of support and dropping into an athletic stance during moments of instability. The pull test is a great way to drill this. Have the individual stand in proper posture, then sharply tug on their shoulder from behind. Instruct them to step back and out with each leg as they drop to an athletic stance or “stance of control.”
Utilizing free weights when and individual is experiencing diskenesia is also a possible contraindication. A machine or weighted cable might be more appropriate in this situation and will keep individual’s joints moving through a safe and consistent range of motion. Thus allowing you to provide enough load to safely cause adaptation to the muscle and soft tissue.
High impact activities where movement control is an issue might also be a contraindication. Jump rope, jumping jacks, boxing, are all great activities but not appropriate for certain individuals that lack the ability to control explosive movements that result in uncontrolled impact on the joints. You can very easily injure a shoulder, knee, hip or ankle during any of these forms of exercise. Choose your strategies carefully, and if you choose an explosive sport, emphasize the discipline of the movement rather than the maximal force of impact. I’ve seen trainers and PTs try to get their patients to box when they don’t know the first thing about proper technique. They encourage the individual to hurl their limbs toward a stationary target, all the while, from the wrist to the shoulder to the spine, the individual is executing terrible joint movement mechanics. Although temporarily exciting for the individual, this will cause more harm than good. Don’t teach punching unless you know how to punch, and if you do, choose whom you use it with and how you employ it, carefully.
- Be Unique: Give yourself license to develop your own style. As long as you follow your training and the principals set forth here, your approach will be unique, valuable, and meaningful. In addition it will harness your creative engine and every day you will discover new ways to effect a meaningful change.
Copyright 2017, Patrick LoSasso, Certified Personal Trainer, CDCS,*D