Persistent Exercise and Physical Therapy Improve Motor and Non-Motor Symptoms of Parkinson’s

“Beginners are many; finishers are few.” Stephen Covey

“Nothing comes from doing nothing.” William Shakespeare

Introduction: By now, you know exercise is medicine for many disorders, including Parkinson’s. But how is our health improved for those with Parkinson’s, and what does that mean?

The studies described here are either review articles that summarize the evidence regarding working with a physical therapist (PT) and doing exercise that is suitable for your Parkinson’s, or they are statistical analysis studies done to determine long-term physical therapy benefit(s), specifically in improving symptoms. And please remember, this is a huge field of work; thus, many other very notable papers have not been mentioned here.

I have included review articles to give you additional papers to read and form your own opinions. Below are the graphical depiction of these titles, and the appropriate bibliographic reference citations are at the end of the blog post.

Defining Physical Therapy: As described by Ji et al. (2022), “Physical therapy is an intervention method that enhances muscle strength, aerobic exercise ability, balance ability, posture and gait, and body flexibility through reminders, exercise awareness strategies, and physical exercise.”

I would add that your Physical Therapist (PT) will come to know your Parkinson’s almost better than you understand it, and likely, they may become the most valuable member of your healthcare team. Furthermore, with their guidance and help, a personalized plan will be developed and modified as needed over time. Therefore, please choose carefully, and find the best PT for managing your disorder; it is that important.

Since my diagnosis, I have had the good fortune of working with five different PTs. They include:
•Rebecca Bliss, PT, DPT, FYZICAL Therapy & Balance Centers, Durham, North Carolina. I have spent many hours working with Dr. Bliss for my Parkinson’s and numerous sports-related injuries (lower back muscles, hip region, and spinal discs).

•Jennifer Bazan-Wigle, Pt, DPT, CEEAA, Parkinson Wellness Recovery (PWR) PWR!Gym in Tucson, Arizona. I have been fortunate to be a person (people)-with-Parkinson’s (PwP) volunteer for the PWR! Moves Workshops on several occasions that Dr. Bazan-Wigle teaches. And I have been to Tucson for a Surge exercise program with her working me carefully but pushing me hard.

•Diane Meyer, PT, MSCS. Dr. Meyer was my instructor for LSVT BIG. And she got me interested in PWR! Moves, which is how I met Dr. Bazan-Wigle. And Jennifer taught a PWP! Moves Workshop with Dr. Bliss in attendance. And I was a PwP volunteer for the Workshop that weekend, which is how I met Rebecca.

•Claire McLean, PT, DPT, NCS, Founder, Physical Therapist Rogue Physical Therapy & Wellness, Inc., Fountain Valley, California. Like Dr. Bazan-Wigle, Dr. McLean has been part of my training since I became interested in PWR! Moves as an exercise for my disorder. I have an online membership to her gym and try as often as possible to take one of her classes.

•Becky Farley, PhD, MS, PT, developed the LSVT BIG program as a postdoctoral fellow and founded Parkinson Wellness Recovery (PWR) and the PWR!Gym in Tucson, Arizona. Without Dr. Farley’s guidance and advice over the years, I would not have the understanding and appreciation of the role of the PT and the benefit of exercise that I do regarding Parkinson’s.

“For every obstacle, there is a solution. Persistence is the key. The greatest mistake is giving up!” Dwight D. Eisenhower

Defining Exercise: As described by Hall and Church (2020), “Exercise is a physical activity that requires effort, and it is usually carried out to sustain or improve health and fitness [43,44]. We define low-intensity exercise as an activity that increases your heart rate up to 40–50% of your maximum heart rate (MHR). This would include a casual walk with a pet dog or walking up a few flights of steps instead of taking the elevator. We define moderate-intensity (or simply moderate) exercise as physical activity for ≤60 min that increases your heart rate to 50–70% of your MHR. Moderate-intensity exercise should feel somewhat hard; that is, your breathing quickens, but you are not out of breath. You develop a light sweat after about 10 min of activity, but you can carry on a conversation (from the Mayo Clinic [45] and the American Heart Association [46]). We define high-intensity (also called vigorous) exercise as a physical activity where your heart rate increases to 70–85% of your MHR. The change found in the immune system from exercise depends on the duration and the intensity of exercise [27,29,30].“

The goal of this current post is not focused on any specific exercise regarding treating Parkinson’s; however, it is meant to encompass all types of exercises and reinforce the idea that a PT can be instrumental in helping sustain your treatment program for your disorder.

“Persistent people begin their success where others end in failure.” Edward Eggleston

Synopsis of the Papers on Improving the Symptoms of Parkinson’s: This blog post aims to summarize some key elements/findings from these papers listed above instead of writing five individual detailed overviews; thus, this is the CliffsNotes version (remember CliffsNotes?).

1. “Physical Therapy for at Least 6 Months Improves Motor Symptoms in Parkinson’s Patients: A Meta-Analysis.” Computational and Mathematical Methods in Medicine 2022 (2022) nu Ji, Xiaotian, Danian Lu, Qinglan Yang, Linting Xiao, Jing Wang, and Gaiqing Wang:

• Goal- They evaluated if long-term treatment with a PT would improve motor symptoms.
• Process Utilized– They searched major databases (publications). They had many inclusion/exclusion criteria for their study. For instance, some inclusion factors were mild to moderate Parkinson’s by Hoehn and Yan (HY) staging, receiving PT at least once per week for six months or more, and evidence of appropriate control groups]. Ten studies were chosen from over 69,000 documents based on their search parameters. From here, they performed the statistical analysis of these selected studies, and they extracted data on degrees of disease classification, clinical parameters from the motor (MDS-UPDRS) and daily (ADL) scores, and drug therapy protocols using levodopa equivalent dose (LED).
• Results– They characterized 533 Parkinson’s patients with HY staging of 1-3, including aerobic exercise, resistance training, and PT-focused rehabilitation. Notably, the time of treatment varied from 6-24 months. They showed that long-term work with a PT improved the PwP’s motor symptoms, measured by the MDS-UPDRS; however, changes in ADL scores were not significantly different.
• Discussion– If you like statistical methods, this paper is for you. Their analysis suggests that six months (or more) of PT will help to reduce motor symptoms, which may permit the PwP to reduce their medication burden. The improvement promoted by PT happened in the absence or presence of therapeutic intervention.
• Conclusions– This study shows that long-term physical therapy can help, independent of the patient’s drug treatment. However, the PwP must sustain PT treatment and be persistent in working with a PT to ease motor symptoms from Parkinson’s.

2. “Evidence for early and regular physical therapy and exercise in Parkinson’s disease.” In Seminars in Neurology, vol. 41, no. 02, pp. 189-205. Thieme Medical Publishers, Inc., 2021, by Ellis, Terry D., Cristina Colón-Semenza, Tamara R. DeAngelis, Cathi A. Thomas, Marie-Hélène Saint Hilaire, Gammon M. Earhart, and Leland E. Dibble..

• Goal– The signs of disability in PwP frequently appears in the early stages of onset, even in the prodromal period. The purpose of this review was to summarize that effective methods of physical therapy and exercise exist for the early treatment of Parkinson’s.
•  Progression of Disability in the Early Stages of Parkinson’s– The historical view is that the onset of the disability is linked to moderate disease. This review reports that disability can be linked to a much earlier stage of the disorder. They show statistically that these numbers are significant in PwP by measuring a reduction in daily activity, gait speed decline, loss of postural control, and several non-motor-related signs (sleep disturbances, depression, and anxiety). Interestingly, pain is another common non-motor sign that contributes to functional decline in Parkinson’s.
• Exercise Benefits Both Motor and Non-Motor Symptoms in Parkinson’s- They next summarized the benefits of various forms of exercise for managing the symptoms of Parkinson’s, reviewing aerobic training, resistance training, balance training, and Gait Training.
• Suboptimal Utilization of Physical Therapy Care-  It would seem that only a tiny percentage of Medicare-eligible people use physical therapy care. Unfortunately, the typical scenario is to refer the Parkinson’s patient to a PT several years after symptoms become disabling. Although the PT can improve the outcome, taking the opportunity to introduce the PwP much earlier in the timeframe of progression would be much more beneficial.
• A Model of Secondary Prevention– The authors propose that the ideal setting is that when diagnosed, the patient with Parkinson’s visits the PT. This would accomplish much and establish a relationship between the treatment team and the patient.
• Conclusions-The authors note that while exercise is proving very beneficial in many animal models of Parkinson’s, and there is increasing evidence clinically for the use of exercise to treat Parkinson’s, the mechanism(S) behind this benefit are not fully delineated. Importantly, all of these data are group means, which says that some patients improved somewhat, some more than others, and sadly, some did not show improvement. However, there is still much optimism surrounding routine exercise under the guidance of a PT to manage the motor and non-motor symptoms of Parkinson’s.

3. “Exercise for older adults improves the quality of life in Parkinson’s disease and potentially enhances the immune response to COVID-19.” Brain Sciences 10, no. 9 (2020): 612, by Hall, Mary-Frances E., and Frank C. Church.

• Goal– The purpose of this review was to provide evidence that exercise plays a role in modifying the immune system, which presumably could improve the health outcome of Parkinson’s and potentially protect the PwP against SARS-CoV-2 (COVID-19) infection.
• Older Adults are More Likely to Have Worse Outcomes During Infection by COVID-19- There is evidence to suggest that older adults, older adults with existing medical conditions (e.g., chronic cardiovascular disorders, chronic lung disorders, obesity, immunocompromised states, and diabetes) will have worse outcomes following infection with SARS-CoV-2. And since increased age is a risk factor for Parkinson’s, it has been speculated that PwP are at increased risk of poor outcomes if infected by SARS-CoV-2.
• Exercise and the Immune System- The role of exercise in modulating or enhancing the immune system was discussed. It was presented that moderate exercise could provide the best balance between the anti-inflammatory and Pro-inflammatory response of the immune system. Moderate exercise offers the best balance between the needed surveillance of the immune system and a dampening of the overall local pro-inflammatory response to a pathogen.
• Exercise and Parkinson’s- The role of exercise in helping control the immune system in PwP was summarized. Since neuroinflammation is a part of the cause of Parkinson’s and inflammation is a central feature in the overall immune system, exercise is essential for anyone living with Parkinson’s. 
• Exercise and Protection from COVID-19– Four responses of moderate exercise to the immune system were described, which could serve as possible prophylaxis to SARS-CoV-2. These include reduction in pro-inflammatory response with a prolongation of the anti-inflammatory response, restoration of damaged lung tissue, reduction in cytotoxic reactive oxygen species, and targeted reduction in main health risk factors linked to COVID-19infection.
• Conclusions– Exercise and physical activity improve older adults’ health. Regular exercise can improve the health of those with Parkinson’s, potentially reducing neuroinflammation and even promoting neuroplasticity (over time). Finally, the immune system is bolstered by moderate-intensity exercise and may offer a non-pharmacological strategy against COVID-19 infection and what is ahead of us in the future.

4. “Aerobic-strength exercise improves metabolism and clinical state in Parkinson’s disease patients.” Frontiers in neurology 8 (2017): 698, by Krumpolec, Patrik, Silvia Vallova, Lucia Slobodova, Veronika Tirpakova, Matej Vajda, Martin Schon, Radka Klepochova et al.

• Goal– To study aerobic-strength exercise in 13 sedentary seniors compared to 12 patients with Parkinson’s, with Hoen-Yahr scores of 1-3, and each patient took the appropriate therapeutic intervention daily. 
• Experimental Protocols– The authors designed a clinical exercise program based on 12 patients with Parkinson’s and 13-age-matched controls. The exercise program was a 3-month combined strength and endurance exexercise three times per week. Furthermore, the study groups had one session of aerobic dancing and two sessions of brisk walking/Nordic walking/stationary bicycling. Moreover, metabolic phenotyping, physical fitness, muscle strength, free-living ambulatory Activity, MDS-UPDRS, Berg Balance Scale (BBS), skeletal muscle biopsy, and muscle metabolism measuring phosphocreatine were all performed. 
• Results– The combined strength/endurance training program designed for this study showed that exercise improved the whole-body glucose and energy metabolism profiles in Parkinson’s patients. Furthermore, they induced changes in muscle function, molecular properties, and gene expression in Parkinson’s and control patients. The 3-month exercise program of strength-endurance improved the total MDS-UPDRS scores, motor score, and, more specifically, the bradykinesia subscore. These exercising patients also showed improved static and dynamic balance (BBS).
• Conclusions– A complex and intensive endurance-strength exercise program improved the clinical state of these early/mid-stage patients with Parkinson’s. In addition, the study found an association with improvements in muscle and whole-body metabolism, which suggests that regular exercise’s lifelong maintenance of muscle metabolism is critical to counteract the progression of Parkinson’s. Thus, they conclude that routine exercise should be a part of the management strategy for Parkinson’s.

5. “The Therapeutic Potential of Exercise to Improve Mood, Cognition, and Sleep in Parkinson’s Disease.” Movement Disorders 31, no. 1 (2016): 23-38, by Reynolds, Gretchen O., Michael W. Otto, Terry D. Ellis, and Alice Cronin‐Golomb.

• Goal– This review was focused on exercise programs to improve the non-motor symptoms of mood disturbances (anxiety and depression), sleep disruption, and cognitive dysfunction in Parkinson’s.
• Exercise and Mood Symptoms- Major depression is estimated to occur in 20-40% of those with Parkinson’s, and clinically significant anxiety is found in 30% of the same patients. While there has been some success using some selective serotonin reuptake inhibitors, there are still limited effective therapies available. By contrast, exercise therapy has been beneficial in treating mood symptoms in the general population but not as well tested in the Parkinson’s community. Besides having antidepressant effects, exercise is also anxiolytic. When this review was published, only six trials addressed mood symptoms in Parkinson’s using exercise as therapy. 
• Exercise and Cognitive Impairment- Cognition impairment is another common non-motor feature of Parkinson’s. Up to 57% of patients with Parkinson’s have some cognitive impairment, including executive function, visuospatial function, and attention/working memory. In the general population, there is good evidence for significant benefits on cognition in older adults using exercise. In addition, there is growing evidence that exercise improves memory. Like mood, there is little published evidence relating exercise to cognition deficits in Parkinson’s. Again, at the time of this study, six published reports on exercise, cognition, and Parkinson’s. 
• Exercise and Sleep Disorders- Sleep disruptions are common in the general population, ranging from 25% to 48%. Sleep disruption is a common feature of Parkinson’s and may present with REM sleep behavior disorder, excessive daytime sleepiness, and sleep-onset and sleep-maintenance insomnia. As before, numerous studies show that exercise benefits adults in improving sleep quality benefits. The results benefit young and older adults equally well. In addition, there is evidence that exercising can improve sleeping in Parkinson’s. Again, when this paper was published, only two studies had been published on Parkinson’s and sleeping disorders in Parkinson’s. 
• Potential Mechanism of Action for Exercise in Non-Motor Symptoms of Parkinson’s– The dysfunction of dopamine in the hypothalamus and limbic regions may be linked with mood, cognition, and sleep disturbances in Parkinson’s. Thus, exercise may be partly responsible for modulating this dopaminergic and glutamatergic neurotransmission. Ultimately, exercise may help attenuate basal ganglia hyperexcitability found in Parkinson’s. Besides this dopaminergic effect, exercise alters serotonergic, noradrenergic, and GABA-ergic systems, which are all relevant for depression, anxiety, and sleep.
• Exercise Dose and Adherence in Parkinson’s– The published have demonstrated an excellent adherence to exercise programs for Parkinson’s.
• Treatment Stage Using Exercise– The results of when this paper, as published, show that exercise benefits patients with HY Stages of I-IV. Additionally, the importance of exercise is neuroprotective and even neurorestorative, suggesting that early-stage patients should exercise immediately. 
• Conclusions– Aerobic and resistance training exercise programs are feasible for treating Parkinson’s. In addition, the known benefits of exercise in the older adult population should transfer well into the Parkinson’s community. The ultimate goal should now be treating both motor and non-motor symptoms of Parkinson’s.

“Energy and persistence conquer all things.” Benjamin Franklin

Summarizing These Papers: The findings from these studies are that performing exercise and utilizing a physical therapist over a sustained time can improve both motor and non-motor symptoms. Therefore, exercise should be considered a rest-of-life therapy for treating Parkinson’s.

“Each life is made up of mistakes and learning, waiting and growing, practicing patience and being persistent.” Billy Graham

Exercise and Physical Therapy: We concluded our review on exercise [Hall and Church (2020)] by saying, “Regular physical exercise has numerous beneficial health effects in PD, including the impact on the immune system and the potential to reduce neuroinflammation (which would be neuroprotective) and promote neuroplasticity. Persistent moderate-intensity exercise by PwP is a treatment strategy to improve the QoL (quality of life) and likely reduce neuroinflammation. Using more demanding moderate- to high-intensity exercise programs (examples include PWR!Moves, Rock Steady Boxing, Dance for PD, stationary bike, and power-walking with walking poles) [10,87,88,90–92,101,103–106,109], with sustained use, could eventually promote neuroplasticity in PwP.”

Exercise is a good strategy for treating Parkinson’s, and so many different exercises yield some benefits. Although the precise mechanism of action for the positive effect of exercise is not yet fully understood, it doesn’t mean one should wait for the final answer before trying exercise (especially if you are sedentary). However, please consult your Neurologist before beginning any exercise in your treatment plan. Finally, the physical therapist’s role is complex because they are not free. In the USA, Medicare should handle some of these charges (another topic for future discussion). The importance of a PT is multi-fold, and it relies on their training and experience with Parkinson’s and your favorable decision to work with one. It can be a win-win scenario.

“Don’t let the fear of the time it will take to accomplish something stand in the way of your doing it. The time will pass anyway; we might just as well put that passing time to the best possible use.” Earl Nightingale

References Cited:
Ji, Xiaotian, Danian Lu, Qinglan Yang, Linting Xiao, Jing Wang, and Gaiqing Wang. “Physical Therapy for at Least 6 Months Improves Motor Symptoms in Parkinson’s Patients: A Meta-Analysis.” Computational and Mathematical Methods in Medicine 2022 (2022).

Ellis, Terry D., Cristina Colón-Semenza, Tamara R. DeAngelis, Cathi A. Thomas, Marie-Hélène Saint Hilaire, Gammon M. Earhart, and Leland E. Dibble. “Evidence for early and regular physical therapy and exercise in Parkinson’s disease.” In Seminars in Neurology, vol. 41, no. 02, pp. 189-205. Thieme Medical Publishers, Inc., 2021.

Hall, Mary-Frances E., and Frank C. Church. “Exercise for older adults improves the quality of life in Parkinson’s disease and potentially enhances the immune response to COVID-19.” Brain Sciences 10, no. 9 (2020): 612.

Krumpolec, Patrik, Silvia Vallova, Lucia Slobodova, Veronika Tirpakova, Matej Vajda, Martin Schon, Radka Klepochova et al. “Aerobic-strength exercise improves metabolism and clinical state in Parkinson’s disease patients.” Frontiers in neurology 8 (2017): 698.

Reynolds, Gretchen O., Michael W. Otto, Terry D. Ellis, and Alice Cronin‐Golomb. “The Therapeutic Potential of Exercise to Improve Mood, Cognition, and Sleep in Parkinson’s Disease.” Movement Disorders 31, no. 1 (2016): 23-38.

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