Every 6 minutes someone is diagnosed with Parkinson’s Disease (PD). Most do not expect their physician to prescribe boxing along with dopamine replacement medication. Yet, every day movement disorder physicians, neurologists, and therapists (PT and OT) are doing just that with positive results, and quantifiable findings supported by years of in-depth research.  

Before we answer the question, “why boxing?” Let’s review the epidemiology of Parkinson’s Disease. Parkinson’s Disease is a progressive neurological disease and primarily affects dopamine producing neurons in the substantia nigra. The substantia nigra is a structure located in the midbrain, and plays an important role in how the brain controls movement. Substantia nigra is latin for “black substance,” reflecting the fact that parts of the substantia nigra appear darker than neighboring areas due to higher levels of neuromelanin in dopaminergic neurons.

People living with Parkinson’s Disease experience motor and non-motor symptoms such as, loss of balance, poor gait, postural issues, visual tracking problems, rigidity, tremor, freezing, facial masking, inability to focus on a task or process information clearly, bradykinesia, hypophonia (volume of voice), depression, anxiety, apathy. 

Now, consider the skills a boxer possesses. They train regularly to hone the following skills, skills that align with Parkinson’s symptoms.  

• STRENGTH
• HAND-EYE COORDINATION
• AGILITY
• SPEED
• MENTAL FOCUS
• BALANCE
• GAIT
• CARDIO ENDURANCE
• FLEXIBILITY

Therefore, it makes sense to include boxing in the regular exercise regimen of folks living with Parkinson’s. Additionally, when you integrate boxing with essential strength exercises that aid in bone health, you build a powerful, comprehensive exercise program that results in physical and cognitive growth and HOPE!

Can anyone with Parkinson’s Disease box? It depends on the person and their physical and cognitive imitations, but for the most part, the answer is yes! I work with those recently diagnosed and those fighting PD for over 27 years, ranging in age from 27-94! Some Parkinson’s “fighters” only have a slight finger tremor, while some are wheelchair bound. However, the one thing they have in common – the spirit to fight!

Now, the cherry on top of boxing for those living with Parkinson’s is the research that supports what we see each week in the gym. Rock Steady Boxing, a nationally recognized Parkinson’s fitness program located in Indianapolis, has been the focus of many research projects over the last 10 years to provide concrete supporting data.

1. Exercise is medicine! – Research by Johansson, Hanna et al reports that exercise is shown on a functional MRI (displays which areas of the brain are most active) to improve signal transmission in the PD brain, effectively demonstrating neuroprotection and neuroplastic changes related to exercise. 

• Neuroplasticity is the ability of the brain to form and reorganize synaptic connections, especially in response to learning, or experience, or following injury.
• Neuroprotection mechanisms and strategies employed to defend the central nervous system (CNS) against injury due to both acute (e.g. trauma or stroke) and chronic neurodegenerative disorders (Parkinson’s).

2. Improved Balance and Decrease Falls – In a national study conducted by Moore et al, shows an 87% reduction in falls of people participating in a Rock Steady Boxing program. 

3. Improved Non-Motor Symptoms

• 70% improvement in social life
• 62% improvement in fatigue
• 61% improvement in fear of falling
• 60% improvement in depression
• 58% improvement in anxiety

4. Decreased Risk Of Hospitalization – Kannarkat, T., et al report in their study “Effect of exercise and rehabilitation therapy on risk of hospitalization in Parkinson’s disease,” that participants in Rock Steady Boxing increase exercise duration and intensity which reduces the odds of a hospital visit in the PD population.

The above Information encourages many to join an independent Parkinson’s boxing program or a local Rock Steady Boxing.

It is important to note that while my program, Bridges for Parkinson’s, addresses the symptoms of Parkinson’s Disease with boxing, we also include Parkinson’s specific mobility, strength, fine motor, vocal, and cardio drills in each routine, along with love and support to keep “fighting back”. To quote a Rock Steady Boxing mantra,“ I promise you’ll feel better, but you’ll have to work for it and I’ll help you.”

Parkinson’s Disease is a journey and Bridges For Parkinson’s – Rock Steady Boxing Music City and Franklin want to support you and your Parkinson’s “fighters” on the journey. As a MedFit author and Parkinson’s Fitness Professional, I am here to help. You can contact me at info@bridgesforparkinsons.com for assistance!

Together, we fight back stronger!

Fit Pros: Learn The Skills You Need To Safely and Effectively Meet the Needs of the Clients With Parkinson’s Disease

Enroll in Colleen’s 12-hour online course, Parkinson’s Disease Fitness Specialist. The course brings the research, medical and fitness fields together so that fitness professionals gain a comprehensive understanding of Parkinson’s disease, and learn how to work with those who have it.

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Colleen Bridges has worked for nearly 17 years as an NSCA Certified personal trainer, group exercise instructor and fitness consultant and as an independent contractor for Nashville’s first personal training center, STEPS Fitness. Her passion for understanding the body in sickness and in health, and how it moves, as fed her interest in and enhanced her talent for working with senior adults, especially those living with a neurological disorder such as Parkinson’s Disease.

Determined, consistent and tenacious are just a few words I like to use to describe my Parkinson’s Disease “fighters”. I call them “fighters” because instead of lying down and giving up, they have chosen to take charge of their future. They commit to FIGHT BACK against Parkinson’s Disease, and that is a “fight” I want to join!

It is critical that you observe how the “fighter” moves, processes information and responds to challenges. We utilize that information and create fitness programs to address the motor symptoms those living with Parkinson’s Disease (PD) struggle with each and every day.

And the best place to start is with “Foundational Movements”  that will broaden a fighter’s Activities of Daily Living (ADL). People living with PD require a unique fitness program to address the impact that PD has on their ADLs.

Foundational Movements

Squats
Lunges
Hinge
Push
Pull
Carry
Rotation

I encourage Fitness Professionals to start with the most basic form of each Foundational Movement before progressing to a more challenging version. Neurologically, progressive and regressive movements make an impact on people living with PD. I have learned that repetition and exercise phases are a necessary part of any fitness program, similar to the human development process.

Consider how humans learn how to move from birth to 3 years of age. First, we learn a skill such as rolling over and we repeat it until we succeed. Then, we move on to unsupported sitting, followed by crawling until one day we are up and running!

And just in case you are wondering, the best place to start with foundational movements is in the warm-up. The repetition of the drills enables the fighters to improve their form, prepare for the work phase and create new neural patterns that will improve their functionality.

Let’s briefly discuss the movement patterns and how each movement can improve ADLs.

Squat

This movement pattern is used daily and assists in maintaining the ability to use synergistic muscular tension, stability and mobility through the torso, hips, knees and ankles. However, every fighter is different which means they will need to start at different levels.

EXERCISE	ADL
Seated knee extension	Toileting
Wall Squat	Showering
Squat	Dressing
Squat/stand and lift heels	Cleaning
Squat-jump	Care-giving

Lunge

Falling or the fear of falling is a significant issue for people living with Parkinson’s Disease.  The ability to stand on one leg, shift weight back and forth, maintain an asymmetrical split stance, bend down or get up off the floor is crucial for fall prevention. Lunging, in its various stages, provides Fitness Professionals a way to identify weak links.

NOTE: Some overlap will occur with the lunge and hinge movement.

EXERCISE	ADL
Tap one foot behind	Vacuuming
Reverse Lunge	Stepping in/out of shower
Step one foot forward	Tying shoelaces
Forward lunge	Walking up/down stairs

Hinge

We ALL need to strengthen our posterior chain but it seems to be the one area many Fitness Professionals shy away from including in their program. When you consider how many times a day someone bends over, they must have the strength and basic knowledge of how to hinge so they don’t fall or hurt themselves.

This is even more important for people living with Parkinson’s Disease. If they fall, it could take months for them to recover and by that time, the disease has progressed. Make it a goal to include a hinge movement in every routine.

EXERCISE	ADL
Basic Deadlift with arms crossed	Getting in/out of car
Supported Deadlift with one foot behind	Toileting/Showering
Traditional Deadlift with weights	Dressing
Single Leg Deadlift   Cross-over Deadlift	House and Pet Management

Push

The push-up is one the most popular exercises of all time! Mastering the “push” is a different challenge. The “push” (not always push-ups) requires core stability, upper back and shoulder strength. Once mastered, people living with PD will notice an increase in power and strength.

Word of caution: Parkinson’s Disease typically affects a person’s posture. Please remember that anything overhead will alter the center of gravity which means some fighters need to perform a “push” exercise that keeps the arms closer to the body.

EXERCISE	ADL
Wall Push-up	Rising from the floor
Push-up on Smith Machine Bar	House cleaning
Push-up on knees	Showering
Push-up on hands/toes	Pushing large door open

Pull

With so many postural issues due to weak muscles, developing a stronger “pull” will help people living with PD strengthen their back muscles which will decrease falls, improve posture and relieve back pain.

EXERCISE	ADL
Shoulder retraction only	Opening refrigerator
Shoulder retraction and hold	Vacuuming/sweeping
“Row” arms (no weights)	Showering
“Row” with tubes	Pulling up pants
“Row” with one arm	Picking a child or pet up

Carry

People living with PD want the ability to carry a grocery bag, walk and pull out keys all at the same time. But if they do not know how to use their body correctly, multitasking can be scary. Carry exercises focus on leverage and load. The good thing is we can always make adjustments depending on other variables. For example, bad shoulders mitigate against the overhead version of the carry while weak hands prevent one from carrying heavy loads. Carry exercises don’t necessarily help prevent falling other than the benefits they provide by strengthening the core. However, Fitness Professionals need to remember that carry exercises will serve your fighters in the early pre-kyphosis stage as a posture exercise. Carry exercises also provide a challenging asymmetrical exercise if performed unilaterally.

TIP: The carry movement is a great way to challenge the core without doing crunches!

However, before beginning a gait/carry movement with your fighters, make sure they have been thoroughly assessed.

EXERCISE	ADL
Walking	Carrying groceries
Bird dog walk	Carrying laundry basket
Farmer’s walk with two weights	Child care
Farmer’s walk with one weight	Pet Care
Farmer’s walk with one weight overhead	House Management

Rotation

The core maintains the stability and strength of the torso and acts as a conduit for energy. The movement patterns listed above encourage core strength which means rotational exercises are not so much a movement pattern as a powerful supplement to the above foundational movements.

Rotational exercises for people living with PD help improve gait and posture, reduce falls, improve coordination and mobility,  increase overall strength and, most importantly, enable them to independently perform ADLs.

Rotation Reminders for Fitness Professionals:

• Torso stabilizes the spine and allows movement by coordinating with the pelvic muscles.
• Flex, extend, bend and rotate
• Anti-Rotational Exercises best for beginners. People living with Parkinson’s DIsease often deal with Processing Information issues. Begin with basic exercises in order for fighters to learn proper form and technique.
• Muscles – Rectus Abdominis, obliques, rhomboids, deltoids, glutes, abductors, quads and adductors

Caution! Be sure to include the hips and the lower portion of the spine when rotating.

EXERCISE	ADL
Isometric tube hold	Enter/exit tub or shower
Isometric tube hold and step laterally	Enter/exit vehicle
Circles with tube	Emptying dishwasher
Circles with tube/squat	Laundry related activities
Torso rotation with tube	All ADL categories

In closing, when Fitness Professionals learn the art of organizing movement patterns and creating a program that uses these foundational movements, their fighters living with Parkinson’s Disease experience physical gains such as standing without support, joint mobility, active core stabilization, integrated joint action, cognitive improvement and most importantly the ability to handle a challenging moment with confidence.

Having acquired these foundational skills with the help of you, their Fitness Professional, build trust and credibility for supporting a fighter’s long-term commitment to HOPE. As noted at the beginning of this article, our fighters are determined, consistent and tenacious. They have chosen to take charge of their future and FIGHT BACK against Parkinson’s Disease — a “fight” I hope you, as a Fitness Professional, join!

Become a Parkinson’s Fitness Specialist

You can acquire the tools and resources necessary to integrate foundational movements with ADLs within the Parkinson’s community. Sign up for Colleen’s 12.5-hour online course on MedFit Classroom, Parkinson’s Disease Fitness Specialist.

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Colleen Bridges has worked for nearly 17 years as an NSCA Certified personal trainer, group exercise instructor and fitness consultant and as an independent contractor for Nashville’s first personal training center, STEPS Fitness. Her passion for understanding the body in sickness and in health, and how it moves, as fed her interest in and enhanced her talent for working with senior adults, especially those living with a neurological disorder such as Parkinson’s Disease.

Click to read part 1 of this article, covering background on facial masking, swallowing, vocal issues for people with PD.

As a fitness professional, you can help. The key is is knowing how to appropriately apply facial, swallowing and vocal projections drills to private and group sessions.  Below are some tips to utilize with your “fighters”.

Occupational Therapy Tips

Decreased facial expression

• Practice recognizing emotions in other people and creating appropriate responses. These responses may include facial expressions and verbal communication. Practicing these reactions to others can help support relationships. 
• The word, “affect” refers to the appearance of emotion through facial expressions, voice tone, and body language or gestures. If you have trouble with facial expressions, try to express yourself more through adding gestures or body language when you communicate.
• Communicate your situation! Try explaining your trouble with facial expressions and decreased voice volume to people who may not initially understand.
• Facial exercises: 
  • look in the mirror and practice your facial expressions.
  • hold a smile, raise your eyebrows as high as you can, bring your eyebrows together to frown,  open your mouth as wide to stretch your jaw, close your eyes tightly and open them wide, close your mouth and expand your cheeks, stick your tongue out and stretch it in each direction
  • Try to exaggerate your facial expressions and lip movements when you speak

Drooling

When eating:

• Try to maintain good posture
• Focus on keeping your chin up and lips closed when eating
• Swallow often to limit saliva
• Avoid sugary foods that create more saliva

Lip closure exercises:

• Close lips tightly for 5 seconds and release (5 times)
• Close lips around tongue depressor and hold while trying to pull from mouth for 5 seconds (5x)
• Fill your cheeks with air and move the air from cheek to cheek (5×5 times)

Dysphagia (Swallowing)

Transferring food from a utensil to the mouth, chewing the food then swallowing and most likely socializing all at the same time without any problems is a task most people take for granted.  According to Dr. Jose Vega MD, PhD, three phases must occur in order to swallow properly.

1. The Oral Phase: This phase begins when food is placed in the mouth and moistened with saliva. Moistened food is called a food bolus.
2. The Pharyngeal Phase: As the food bolus reaches the pharynx, special sensory nerves activate the involuntary phase of swallowing.
3. The Esophageal Phase: As food leaves the pharynx, it enters the esophagus, a tube-like muscular structure that leads food into the stomach due to its powerful coordinated muscular contractions. The passage of food through the esophagus during this phase requires the coordinated action of the vagus nerve, the glossopharyngeal nerve, and nerve fibers from the sympathetic nervous system.

Difficulty swallowing as it pertains to PD, reflects a deficiency of dopamine in the brain and often improves with medication and therapy/exercises. Drooling is also a symptom and is caused by reduced reflexive swallowing not from an overproduction of saliva but tends to improve with dopamine replacement therapy.  I have come to learn over the years that tremors and swallowing problems are usually the reason someone living with PD isolates themself.  It is embarrassing to finally get food on your utensil only to get it to your mouth and realize it has scattered all over the place or fear of aspiration which by the way may not always be heard. Aspiration can be quiet and lead to aspiration pneumonia, the leading cause of death in PD.

Care-partners and Fitness Professionals need to recognize the signs of aspiration as noted below. 

Coughing Before/After Swallowing

• Trouble chewing 
• Pocketing food inside the cheek
• Gagging during a meal
• Crying or face turning red while eating
• Drooling especially during meals
• Clearing the throat before/after and throughout the day
• Hoarse during and after the meal

For this reason, Coaches at Bridges For Parkinson’s offers popsicles to our “fighters” at the end of class. And they love it! They can have a fun treat without the fear of dropping food and visit with others so it is a win-win! Plus, it allows us to make sure they are hydrated. Sneaky, sneaky!

If a person living with Parkinson’s Disease or their care-partner is not sure whether their loved one has a swallowing issue, the Parkinson’s Foundation provides some great questions to help determine the answer:

• Have I recently lost weight without trying?
• Do I tend to avoid drinking liquids?
• Do I get the sensation of food being stuck in my throat?
• Do I drool?
• Is food collecting around my gum line?
• Do I cough or choke before, during or after eating or drinking?
• Do I often have heartburn or a sore throat?
• Do I have trouble keeping food or liquid in my mouth? 

ORAL EXERCISES to help with strengthening and coordinating the LIPS

1. Pucker up and blow a “oooo” then transition to an “EEEEEE” (SMILE BIG!)
2. “MMMM” press lips together as much as possible and take a deep breath in and hum..         good for the lungs too.
3. “Blowfish Hold” and hand isometrically pushes into cheek

TONGUE- ROM, Coordination and strength to help with eating and drinking

1. Stick tongue out as far as possible and hold it there (add SPOON FOR RESISTANCE)
2. Stick tongue out and up and hold (ADD SPOON FOR RESISTANCE)
3. Stick tongue into sides of cheek (helps with food deposits)
4. Roll tongue back and press against roof of mouth

In addition to swallowing exercises, meal prep aids in reducing issues brought on by dysphagia and may lower the risk of aspiration. The APDA Organization recommends the following nutritional information:

• Foods that don’t require vigorous chewing. Avoid dry and crumbly foods.
• Moderately textured wheat breads instead of very coarse, nutty breads or very soft, white breads.
• Oatmeal, cream of wheat or moistened dry cereals instead of coarse, dry cereals.
• Well-cooked, tender chicken/turkey, well-cooked fish without bones, chopped and ground meats, instead of stringy, tough meats that require a lot of chewing.
• Soft casseroles and poached or scrambled eggs
• Mashed potatoes or rice, moistened with gravy or margarine, instead of wild rice or French-fried potatoes.
• Soft, cooked pasta elbows, instead of long spaghetti.
• Soft, well-cooked vegetables, cut up or creamed, instead of raw vegetables or those with a hard texture.
• Pureed or mashed fruits, fruit juices and fruit sauces, instead of fruits with seeds or hard outer skins. Avoid nuts, seeds or coconut.
• Custard, yogurt, ice cream or other soft desserts

Speech

The article begins with a story of a grandmother experiencing dysphagia, hypomimia and hypophonia (softness of voice).  But people living with PD are not limited to hypophonia when it comes to speech problems.  Dysarthria and tachyphemia are additional speech issues people living with PD may experience.

Hypophonia or softness of voice is a condition that the Davis Phinney Foundation states 90% of people living with PD will experience. Characteristics of hypophonia include raspy voice, low speech volume, breathy and/or monotone speech.  

Dysarthria is another speech issue related to PD. It is characterized by poor articulation, respiration and/or phonation according to the National Aphasia Association.  Speech will come across as slurred, effortful and can often be mistaken for inebriated.  Doctors encourage people living with PD who are still driving to wear a bracelet to help law enforcement know they are not drunk.

Tachyphemia or acceleration of speech is also related to speech issues. A person struggling with tachyphemia will sound like all their words are jumbled together and often feel like their tongue is twisted.

While these issues are troublesome and frustrating, there are some easy and even fun ways to combat low volume, slurred and accelerated speech.  

1. Music Therapy – therapy defined broadly by the American Music Therapy Association as “a treatment including creating, singing, moving to, and/or listening to music [through which] clients’ abilities are strengthened and transferred to other areas of their lives.” All over the country, Parkinson’s Choirs are using singing to help improve respiration, Swallowing and enhanced volume and clarity of voice.
2. Breathing Drills- Strong lungs reduces risk of pneumonia and allows the person to complete ADL’s with little to no complications.  
3. LSVT LOUD: an effective speech treatment for people with Parkinson’s disease (PD) and other neurological conditions. A study on hypophonia in PD reviewed the effectiveness of LSVT treatment for those with idiopathic PD and found that voice loudness significantly improved. Goals include: increased voice volume, improved articulation, increased confidence with communication, and changes in neural function related to speech (https://n.neurology.org/content/60/3/432)
4. Speak Up For Parkinson’s App: Yes, an app with exercises that also provides visual feedback on volume.  

Exercises

1. Breathe in and exhale on a vowel for 5 seconds.
2. Hum for 3 seconds making sure to press the lips together then have the “fighter” say….
   Their favorite food or movie or color.
3. Hum for 3 seconds then say the vowels, sliding the voice from one vowel to the next.
4. Recite a poem with various emotions.
5. Partner “fighters” and have them share jokes with each other. Whoever laughs the hardest wins!
6. Close class or a session with a short song or team phrase . 

Fitness Professionals have the unique opportunity to incorporate exercises for the face, voice and swallowing while also performing strength and/or cardio exercises. You do not have to separate the two. It is a great way to challenge the cognitive aspects and  the physical, all while having fun! The best part is it creates a community moment which deepens their love and trust for you, the fitness professionals.  You are making a difference!’

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Co-authored by Colleen Bridges, M. Ed, NSCA-CPT; Renee Rouleau-B.S., PhD student, Jacobs School of Biomedical Sciences, University at Buffalo; Kristi Ramsey, OTD, OTR/L.

 

References

• ParkinsonsDisease.net (Emily Downward)
• Mayo Clinic
• https://neurologicalsurgery.in/top-facial-exercise-for-parkinsons-patient/
• https://www.mottchildren.org/health-library/hw81637
• https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=135&contentid=376
• https://n.neurology.org/content/60/3/432
• Ricciardi, L., De Angelis, A., Marsili, L., Faiman, I., Pradhan, P., Pereira, E. A., Edwards, M. J., Morgante, F., & Bologna, M. (2020). Hypomimia in Parkinson’s disease: an axial sign responsive to levodopa. European Journal of Neurology, 27(12), 2422-2429. https://doi.org/https://doi.org/10.1111/ene.14452
• Mäkinen, E., Joutsa, J., Jaakkola, E., Noponen, T., Johansson, J., Pitkonen, M., Levo, R., Mertsalmi, T., Scheperjans, F., & Kaasinen, V. (2019). Individual parkinsonian motor signs and striatal dopamine transporter deficiency: a study with [I-123]FP-CIT SPECT. Journal of neurology, 266(4), 826–834. https://doi.org/10.1007/s00415-019-09202-6
• Adrienne Wootton, Nicola J. Starkey & Carol C. Barber (2019) Unmoving and unmoved: experiences and consequences of impaired non-verbal expressivity in Parkinson’s patients and their spouses, Disability and Rehabilitation, 41:21, 2516-2527, DOI: 10.1080/09638288.2018.1471166
• National Institute of Diabetes and Digestive and Kidney Diseases. Your digestive system & how it works.
• Finsterer J, Grisold W. Disorders of the lower cranial nerves. J Neurosci Rural Pract. 2015;6(3):377-391. doi:10.4103/0976-3147.158768
• National Institute on Deafness and Other Communication Disorders. Dysphagia.

As a fitness professional, you can help. The key is is knowing how to appropriately apply facial, swallowing and vocal projections drills to private and group sessions. Below are some tips to utilize with your “fighters”.

It is important to respect professional boundaries and know when to refer a “fighter” to a neuro-opthamologist or an occupational therapist.  

Here are some simple and safe tips to share with your “fighters”…

In Part 1 of this series, we discussed an overview of bilateral coordination, its importance and how it falters in Parkinson’s Disease (PD).

Now, we’ll discuss strengthening the pathways for those with PD with exercise.

Steps To Incorporating Bilateral Coordination Into Your Exercise Program

Clearly, the brain is a work of art when you consider the “architecture”, the “highway” of nerves required to communicate with the rest of the body, to the final outcome of the original thought or idea. ANY kind of “road block” is going to hinder an individual from completing tasks as simple as writing or buttoning a shirt. And for the person living with PD, this includes walking, bathing, driving, communicating, dressing, well, about every Activity of Daily Living (ADL) that you can conceive.

BUT… never fear, the PD Fitness Specialist is prepared to address these matters of the brain with some challenging YET fun activities to promote improved motor control!

I won’t lie, you may see smoke coming out of the “fighters” ears but the incredible sense of accomplishment at the completion of the drill will be worth it.

Always begin with the fundamental question of program design. What are the needs of my private clients and fighters? What are their common issues?  They definitely need to work on:

Strength (7 foundational movements)

• Lunge
• Squat
• Pull
• Push
• Carry
• Hinge
• Rotate

NOTE: I encourage Fitness Professionals (FP) to start with the most basic form of each Foundational Movement before progressing to a more challenging version. I have learned that repetition and exercise phases are a necessary part of any fitness program, similar to the human development process.

Your program should also include cardiovascular endurance, agility (footwork/hand-eye), cognitive challenges, fine motor drills, balance/gait drills — ALL which incorporate Bilateral Coordination challenges that provoke the brain to enhance:

1. Neuro-protection to preserve at-risk dopamine neurons.
2. Neuro-repair to improve damaged “circuitry”  and rewire the brain.
3. Neuro-Adaptation that trains the brain to move without conscious awareness of each move such as walking .

Yes, this requires the Fitness Professional to sit down and develop a program that is constantly evolving as the abilities and needs of the client change BUT it can be done. For example, to address gait and incorporate an additional Bilateral Coordination drill that will challenge your client(s) mental focus, try the following progressive drill.

NOTE: Step one is a fantastic way to help a person living with Parkinson’s Disease safely transition out of a “freezing of gait” moment.

Criss-Cross Applesauce (Stand in squat stance)-

1. Cross the right hand to the left shoulder.
2. Cross the left hand to the right shoulder.
3. NOW, cross the right hand to the left knee.
4. Cross the left hand to the right knee

Have your client(s) say “Criss-Cross Applesauce” while performing the drill. This will address hypophonia problems and assist in maintaining a strong beat..

Once they have achieved this version, have them progress to the next level….

Criss-Cross Applesauce with Marching Knees

1. Cross the right hand to the left shoulder.
2. Cross the left hand to the right shoulder.
3. NOW, cross the right hand to the left knee BUT lift the knee to meet the hand as if marching.
4. Cross the left hand to the right knee and lift knee to meet hand as if marching.

To add complexity to the drill, have your clients tap the marching knee onto a step or bosu.

Once they have achieved this version, have them progress to the next level….

Criss-Cross Applesauce with A Forward Lunge

1. Cross the right hand to the left shoulder.
2. Cross the left hand to the right shoulder
3. NOW, cross the right hand to the left leg AS you lunge forward.
4. Come back to start position.
5. Cross left hand to the right leg AS you lunge forward
6. Return to start and repeat drill

To add complexity to the drill, have your clients perform a diagonal lunge or a lateral step.

This is just one example of how you can incorporate Bilateral Coordination into a movement we do all day every day! Walking! And if you work with people living with Parkinson’s Disease, then expect their learning time to vary but with repetition and encouragement, they will conquer this drill and be excited to try the next.

Which leads me to share with you the results I have experienced in my Parkinson’s Disease Wellness Center in Nashville and Franklin, Tennessee.

CASE STUDY – RESULTS!

“Susan” is 62 years old and was diagnosed 17 years ago which classifies her as Young Onset Parkinson’s Disease.  Susan had the DBS surgery 10 years ago and although the DBS initially provided relief of tremors and dyskinesia, over time fine motor skills, drooling, hypophonia, balance/poor posture — leading to numerous falls — has become an issue. She is also blind in one eye which limits her spatial awareness, decreases balance and mobility, all of which makes living independently even more challenging. Additionally, the hypophonia had led her to become 80% non-verbal. To answer questions she either nodded yes/no or shrugged her shoulders if she didn’t know the answer.

When we began working 1:1 together, my first priority was to address her posture/gait, as she was stooped forward and shuffling, leading to multiple falls each week. So, in addition to a dynamic warm-up with large ROM drills to properly prepare her body from head to toe, strength training, boxing and cycling, obstacle courses and more, I taught her the “Criss-Cross Applesauce” drill. The first several sessions, Susan had to complete the drill 5x between other warm-up exercises AND march while tapping her hand to the opposite knee when we moved to a new station or machine. She also had to speak the words “Criss-Cross Applesauce” when performing the drill to address her hypophonia.

The first session, Susan could not make the connection that her hand was to tap the opposite shoulder or knee. I had to manually move her hands and say the words with her. By the end of the first session, she was only able to complete the drill at a slow tempo, but that was ok, she did it! She left the gym that day with homework to practice the “Criss-Cross Applesauce” drill three times a day for 5 repetitions. I also assigned marching in place while tapping the hand to the opposite knee 60x twice a day.

The second session, I noticed a significant difference in her timing and coordination. For the first set, I still needed to “mirror” her while she did the “Criss-Cross Applesauce” drill, but overall, Susan was able to complete the drill 3 out of 5x correctly. When Susan would move to a different location, I had her march and tap her hand to the opposite knee. We counted how many steps it took to make it to the next station with the goal of trimming 10-15 steps off the next round. To do so, I had her focus on making precise connections between her hand and opposite knee as well as stomping her foot when stepping. By the end of the session she was able to trim 5-10 steps off between stations.  She completed the session with the same homework as before.

The third session is when I started to notice some fantastic improvements. Susan walked into the gym marching and tapping the hand to the opposite knee. She was able to cover more ground with fewer steps and the best part was that stomping her foot was helping her step with increased assurance. That equates to fewer falls! Additionally, transitioning station to station took less time and she was able to lift her knee higher than the previous sessions.

The “Criss-Cross Applesauce” drill still required me to “mirror” her but she did all 5 reps correctly and her hand/shoulder and/or hand/knee connection was more actively engaged. We continued to perform the drill between each exercise or cardio drill and by the end of the session, she spoke with clarity and increased volume, her stride length had increased, posture was more vertical and her confidence soaring. She even told me a joke!

The exciting results I experienced with Susan have also been experienced in my group exercise classes for Parkinson’s Disease. “Fighters” report that their forward/lateral movements, executive functioning skills, and balance have improved since incorporating Bilateral Coordination drills into our program.

Closing

The brain, in all its complexity, is a beautiful work of architecture. You, the Fitness Professional, have the “blue-prints” at your fingertips and together we can weave together bilateral movements to enhance the lives of those with Parkinson’s strengthening their bodies, mind and spirit and above all giving hope.

To assist you in learning how to create exercises that incorporate Bilateral Coordination into your program, I have included additional videos below demonstrating examples of exercises. (I would like to give credit to Dr. Irv Rubenstein, MedFit author & advisory board for the use of two of his drills in the video.)

This video comes from Dr. Jacob Weiss of handeyebody.com

Become a Parkinson’s Disease Fitness Specialist!

Check out Colleen’s online course on MedFit Classroom….

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Co-Written by Colleen Bridges, M.Ed, NSCA-CPT and Renee Rouleau.

Colleen Bridges is the author of MedFit Classroom’s Parkinson’s Disease Fitness Specialist course. Renee Rouleau is a PhD student at the Jacobs School of Biomedical Sciences, University at Buffalo.

References

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2. Plotnik, M., & Hausdorff, J. M.. (2008). The role of gait rhythmicity and bilateral coordination of stepping in the pathophysiology of freezing of gait in Parkinson’s disease. Movement Disorders, 23(S2), S444–S450. https://doi.org/10.1002/mds.21984
3. Rutz, D. G., & Benninger, D. H.. (2020). Physical Therapy for Freezing of Gait and Gait Impairments in Parkinson Disease: A Systematic Review. PM&R, 12(11), 1140–1156. https://doi.org/10.1002/pmrj.12337
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6. Magalhães, L.C., Koomar, J.A., Cermal, S.A. (1989, July) Bilateral Motor Coordination in 5- to 9-year old children: a pilot study. The American Journal of Occupational Therapy. Volume 43 Number 7.
7. Piek, J.P., Dyck, M.J., Nieman, A., Anderson, M., Hay, D., Smith, L.M., McCoy, M., Hallmayer, J., (2003) The relationship between motor coordination, executive functioning and attention in school-aged children. Archives of clinical neuropsychology. Elsevier’s Ltd. doi:10.1016/j.acn.2003.12.007
8. Roeber, B.J., Gunnar, M.R. and Pollak, S.D. (2014), Early deprivation impairs the development of balance and bilateral coordination. Dev Psychobiol, 56: 1110-1118. https://doi.org/10.1002/dev.21159
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