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The Dark Side of Parkinson’s Disease: The FACE of Parkinson’s Disease, Part 2

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!’


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

aging-hands

The “Dark Side” of Parkinson’s Disease: Why Parkinson’s Changed The Way We See, Part 1

The dark side of the moon is not considered a particularly exciting topic unless you are an astronomer or a Pink Floyd fan.  However, the dark side of the moon exists and is just as important as the front of it.

So, what are the conditions of the dark side of the moon? Does it ever see the light of the sun?  Why is it called the dark side?  These are interesting questions with answers that I will leave to space experts, BUT what I will say is that the moon is similar to Parkinson’s Disease (PD).  Yes, you read that correctly — the moon and Parkinson’s Disease are similar.

Parkinson’s Disease is most often characterized by a tremor and/or gait issues.  Just as the moon has a dark side, unseen but present, Parkinson’s Disease has a dark side”.  As a fitness professional, understanding the “dark side” of Parkinson’s Disease and how it affects your “fighters” will enhance your program design skills, increase your confidence when counseling a “fighter” or care-partner and help build your relationship with other medical and fitness professionals.

The goal of this article series is to shed light on the “dark side” of PD. By incorporating the knowledge of medical professionals on my Bridges For Parkinson’s team, you will learn about research discoveries, resources for program design, useful tools for “fighters” and care-partners and ultimately, hope! 

Vision impairments in those with PD is our first topic in this series. People living with Parkinson’s Disease experience changes in their vision as they age. These changes may include cataracts, macular degeneration, dry eyes, floaters, glaucoma, diabetic retinopathy, detached retina, trichiasis, and blepharitis. NOW, People living with PD may experience one or several of these issues due to normal aging. However, due to the depletion of dopamine neurons in the substantia nigra, those with PD may also experience the following vision issues and/or impairments.

  1. Blepharospasm: uncontrollable eye twitching
  2. Blepharitis: Lack of blinking. On average, we blink 12-14x per minute. A person with PD may only blink 3-5x per minute. The result is inflammation on the edge of the eyelid. Eyelids may become irritated or itchy and appear greasy or crusty.
  3. Apraxia: “oculomotor apraxia” –  the absence of or defect in voluntary eye movement. This may result in trouble initiating movement and moving the eyes in a desired direction
  4. Diplopia (Double Vision): when a single object becomes two objects.
  5. Dry Eyes: eyes may feel sandy or gritty.
  6. Blurry Vision: MAY be related to dopamine depletion in back of the eye and within  the visual connections throughout the eye (Davis Phinney)
  7. Eye movement issues:
  8. Pursuit Movement: eyes are unable to work together to follow an object such as a plane flying across the sky.
  9. Saccadic Movement: unable to move eyes rapidly from one object to another such as completing a line in a book and going to the other side to the beginning of  the next line.
  10. Vergence Movement: as the target or object draws closer to the person with PD, the eyes are unable to converge to maintain focus on the object causing double vision. Approximately 30% of people living with PD suffer from Vergence Eye Movement problems.
  11. Depth/Distance Perception
  12. Photophobia (also known as Light Sensitivity): may wear sunglasses indoors due to bright lights.

Fitness Professionals should inquire about vision impairments before a “fighter” begins an exercise program and obtain specific information about the vision impairment. Each symptom listed above can potentially compromise gait/balance, increase difficulty with Activities of Daily Living (ADL) and cause those with PD to isolate or become depressed due to lack of independence. 

How We See 

When we use our vision, we’re doing a lot of simultaneous tasks. We have to sense and process the stimuli, perceive and make sense of the stimuli in the context of the situation, and translate those signals into a response (i.e. movement, bringing up memories, emotions) to the initial stimuli. 

For example, a stimulus such as a car passing by causes numerous neurological responses to take place in the visual system. First, that stimulus passes through the lens into rod and cone cells that make up light/shadows and colors to put the image together, which then reaches axons in the retina that extend through the optic nerve. Once that signal travels through the optic nerve, it reaches the optic chiasm, where the stimulus passes over to the opposite side of the brain from the visual field and eye. Interestingly, this car is not visually processed right-side up! Instead, it goes into your brain upside-down as the eye lens flips the image. That image then travels through the thalamus (our “sensory relay system”), and to the primary visual cortex, where the image gets processed and relayed to other sensory systems to prepare for a response.The Role of Dopamine in the Eye

You wouldn’t think that dopamine is involved in vision. We think of it relative to its impact on motor control and behavior reinforcement. However, even in ocular movement, lack of dopamine can impact a person with PD significantly, possibly resulting in apraxia. Dopamine also regulates light sensitivity in our retinas that helps to modulate our circadian rhythm, known as our “internal clock”. As dopamine decreases with disease progression, the sensitivity of the visual system decreases as well, hindering the ability to differentiate between light conditions such as day and night, potentially leading to other problems in circadian rhythm (Witkovsky, 2003). Over time, we see a loss of dopamine projections into the eye worsening vision such as blurry vision, light sensitivity, or even color vision deficiency as listed above. Unfortunately, there is not enough research on the involvement of dopamine in PD vision to give a clear-cut role of dopamine, but current research points to dopamine as a larger part of vision problems experienced by those with PD.  

Physicians

It is crucial to understand the connection between the brain and PD vision related issues.  Knowing when to refer a “fighter” to a vision specialist is critical to building your team of advisors and establishing a strong medical-fitness program in your community.

I highly recommend finding a neuro-ophthalmologist or a neuro-rehab optometrist to join your team. A neuro-ophthalmologist specializes in both fields of neurology and ophthalmology.  They complete a residency in either neurology or ophthalmology then continue to complete a fellowship in the complementary field.

Dr. Jamie Ho, OD, FAAO, FCOVD of Nashville, TN is a member of my advisory board and she is a neuro-rehab optometrist. Dr. Ho addresses the functional deficits that result from the neurologic changes.  You can learn more about Dr Ho’s practice at www.hovisiongroup.com.

To find a neuro-optometrist or neuro-ophthalmologist in your area go to www.noravisionrehab.org 

Medication

Medication for PD certainly improves PD symptoms however, visual side-effects can occur.

For example, according to www.healio.com, Anticholinergic meds such as Artane are used to address tremors but can also cause dry or blurry vision. The Journal of Parkinson’s Disease notes that dopamine agonists cause hallucinations, Levodopa may lead to ocular dyskinesia (involuntary eye movements), and MAO inhibitors to blurry vision. 

Fitness Professionals need to record all medications during the initial assessment and update any medication changes quarterly, at minimum

Click to read Part Two of this article, which offers some tips for fitness professionals working with PD clients with vision challenges.


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.

Reviewed By: Dr. Jamie Ho, OD, FAAO, FCOVD

 

References

  1. Berliner JM, Kluger BM, Corcos DM, Pelak VS, Gisbert R, McRae C, Atkinson CC, Schenkman M (2018) Patient perceptions of visual, vestibular, and oculomotor deficits in people with Parkinson’s disease. Physiother Theory Pract. doi: 10.1080/09593985.2018.1492055 [PubMed].
  2. Borm, C., Smilowska, K., de Vries, N. M., Bloem, B. R., & Theelen, T. (2019). How I do it: The Neuro-Ophthalmological Assessment in Parkinson’s Disease. Journal of Parkinson’s disease, 9(2), 427–435. https://doi.org/10.3233/JPD-181523
  3. www.DavidPhinneyFoundation.org.
  4. Mayo Clinic, (2020)“Parkinson’s Disease Symptoms and Causes.” http://wwwmayoclinic.org20376055. 
  5. Nowacka B, Lubinski W, Honczarenko K, Potemkowski A, Safranow K (2014) Ophthalmological features of Parkinson disease. Med Sci Monit 20, 2243–2249.
  6. Witkovsky, P. Dopamine and retinal function. Doc Ophthalmol 108, 17–39 (2004). https://doi.org/10.1023/B:DOOP.0000019487.88486.0a.
PDFS-Exercise

Bilateral Coordination: The Gateway to Successful Movement | Part 2

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….


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

  1. van der Hoorn, A., Bartels, A. L., Leenders, K. L., & de Jong, B. M. (2011). Handedness and dominant side of symptoms in Parkinson’s disease. Parkinsonism & Related Disorders, 17(1), 58-60. https://doi.org/https://doi.org/10.1016/j.parkreldis.2010.10.002
  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
  4. Son, M., Han, S. H., Lyoo, C. H., Lim, J. A., Jeon, J., Hong, K.-B., & Park, H.. (2021). The effect of levodopa on bilateral coordination and gait asymmetry in Parkinson’s disease using inertial sensor. Npj Parkinson’s Disease, 7(1). https://doi.org/10.1038/s41531-021-00186-7
  5. Kramer P., & Hinojosa, J., (2010). Frames of Reference for Pediatric Occupational Therapy: 3rd Edition. Baltimore, Maryland: Lippincott Williams & Wilkins
  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
  9. Rutkowska, I., Lieberman, L. J., Bednarczuk, G., Molik, B., Kaźmierska-Kowalewska, K., Marszałek, J., & Gómez-Ruano, M.-Á. (2016). Bilateral Coordination of Children who are Blind. Perceptual and Motor Skills, 122(2), 595–609. https://doi.org/10.1177/0031512516636527
  10. Schmidt, M., Egger, F., & Conzelmann, A. (2015). Delayed Positive Effects of an Acute Bout of Coordinative Exercise on Children’s Attention. Perceptual and Motor Skills, 121(2), 431–446. https://doi.org/10.2466/22.06.PMS.121c22x1
  11. Tseng, Y., & Scholz, J. P. (2005). Unilateral vs. bilateral coordination of circle-drawing tasks. Acta Psychologica, 120(2), 172-198.

 

parkinsons-graphic

Bilateral Coordination: The Gateway to Successful Movement | Part 1

“You want me to do what?” says Susan when she hears the drill that I want her to complete during our exercise class. 

“You’ve gotta be kidding me! Where do you come up with these drills? You DO remember I have Parkinson’s Disease?” To which I smile and reply, “Yes, and you can do this, I promise!!” 

Susan rolls her eyes and jokingly replies, “Right, I guess we’ll just have to see about that, Colleen!”

“You can do this Susan,” I reply, “but it is going to require work, and I’ll be right here to help you.”

You may be thinking to yourself, what kind of drill is Colleen asking her client to perform? Could it be a 150lb deadlift? Maybe it’s a 5ft plyo-jump on one leg or possibly a 3 minute plank? Not even close! While the deadlift, jump and plank are all fantastic exercises, I’m asking Susan to do a lunge series with lateral arm lift series which incorporates Bilateral Coordination.

Bearfoot OT and Noémie von Kaenel, OTS share that bilateral coordination is the integration and sequencing of movement by using “two parts of the body together for motor activities”.

“To coordinate two-sided or bilateral movements, the brain needs to communicate between both its hemispheres through the corpus callosum which we will discuss later on. But it is important to note that this area of the brain develops at 20 weeks but connections between the two hemispheres strengthen and develop as a child develops . Bilateral coordination is also closely linked to the vestibular system (where your head is in space), posture, and balanced movements.”

For example: We all grew up challenging our friends to pat their head and rub their tummy at the same time. Then switch hand placement and repeat. Take a second and give it a try! Did you find one hand placement easier than the other? Now, imagine that you have Parkinson’s Disease (PD) and you’ve been given this challenge. You would probably tell me that it was tough on both sides. Why is that? 

Let’s take a few moments and discuss Parkinson’s Disease so you understand the challenge of Bilateral Coordination.

By definition, Parkinson’s Disease is a neurodegenerative disorder that affects predominantly dopamine-producing neurons in the Substantia Nigra (SN) (Latin for “Black Substance”, due to its darkened pigment in the brain). The substantia nigra contains the highest concentration of dopamine neurons. It is a part of the Basal Ganglia, an area responsible for motor control, motor learning, and procedural memory, such as learning how to tie your shoes. 

Substantia Nigra in Normal Brain vs. Parkinson’

Without the Substantia Nigra, the brain and body simply do not communicate as well, or at all depending on the stage of PD. To us, fitness professionals, we observe those living with Parkinson’s Disease displaying uncoordinated movements, 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)… and as it pertains to Bilateral Coordination, the challenge to perform a drill with one side of the body such as the left arm while moving the right leg.  Now your wheels are turning and you are probably asking yourself…

Why Is Bilateral Coordination Important?  

Bilateral Coordination requires your small and large motor and visual-motor functioning to work together making it possible to accomplish ALL of your daily tasks! For example, in order to write your grocery list on a piece of paper, you need to hold the paper with one hand while writing the note at the same time. 

Proprioception or body awareness is another great reason to work on Bilateral Coordination. Throughout our entire life, we have the ability to know where our body is in time and space. For the person living with Parkinson’s Disease, this means a lower risk of falling, and believe me, that is crucial!

What Is The Scientific Explanation Of Bilateral Coordination?   

We learned in a previous article, “How a Thought Becomes an Action”, that motion in the brain is complicated and there are numerous steps to ensure that the motion in the brain is coordinated and precise. This all starts in the motor cortex, goes through the spine into motor neurons and muscles, and goes back into the brain to be fine-tuned by the basal ganglia (keep in mind this is where the substantia nigra resides). But now we’re adding onto this process by adding on even more coordinated movement in:

  • The premotor cortex
  • Supplementary motor area
  • The cerebellum
  • And the corpus callosum

Each one of these areas works in tandem with the movement pathways we discussed previously to produce bilateral movement and is the reason that I can type and you can read this paper right now. Let’s go over what each of these areas does, starting with the premotor cortex (Figure 1, below).

Fig. 1 The neural pathway from stimulus sensation to movement response.

  • The premotor cortex is more involved in the planning of movement rather than the execution is important for bilateral coordination in movements even as simple as walking. 
    • When walking, the premotor cortex would be important for planning the gait length required to keep our balance, the speed, and overall how the movement is going to go so we don’t crumple or trip over our own feet (to some extent anyway…)
  • The supplementary motor area (SMA) is also involved in planning movement, but in a different way. 
    • The SMA is planning for movements both ipsilaterally (scientific jargon for same-side), and contralaterally (scientific jargon for different-side).
      • While the premotor cortex is planning for what muscles have to move to do the actual action, the SMA is controlling which sides are going to go first to maintain balance and what makes the most sense given the environment we would be walking in.
  • The cerebellum is less involved in conscious movement but is extremely involved in coordination and balance, which is needed for performing tasks bilaterally. 
    • When walking, we need our brain to fine-tune the balancing and counterbalancing errors (such as arm swing), which happens in the cerebellum. Think of the cerebellum like an editor. The movement keeps happening, and each time it keeps getting better and easier because of the error calculations the cerebellum makes.
  • The corpus callosum, which works in tandem with the rest of the cortex to send signals to the different halves of the brain. 
    • What happens on one side doesn’t always translate to the other side, which is where the corpus callosum comes in. Each side has its own control mechanisms for the opposite side of the body (talk about contralateral). The corpus callosum is the phone line that connects these two hemispheres so they can talk to each other and get the messages for both sides of the body into a beautifully coordinated orchestra of neuronal firing and muscle movements.

So given these four areas of the brain, along with the rest of the movement pathway, there are numerous elements here contributing to sensory integration, planning of movement, checkpoints for these movement executions, and a miscommunication playing out on both sides of the brain. This means that there are a lot of alternate pathways in case anything goes wrong. However, pathways can deteriorate over time, and problems can arise. Which brings us to PD, and the issues that may happen in bilateral coordination as the disease progresses.

How Does Bilateral Coordination falter in the PD brain?

There’s a lot of different attributes to movements like walking –  a complicated movement with a number of variables:

  • First, you have to start walking.
    • Because it requires a lot of input all at once, it’s hard for the brain to do subconsciously, especially for someone who has PD. similar to revving a car for the first time after stopping at a red light.
  • Then you have sensory cues.
    • These can be challenges like incline or decline, which determines how much effort you need to stay upright, stay up to speed, and how much force you need to put into your step to keep up with gravity (like a driver constantly paying attention to the road).
  • Once you start walking, your brain can put less effort into what researchers call “steady-state walking”, where your legs follow the same instructions repeatedly, similar to coasting on a highway (2).
  • Next, we get to turning, where walking requires more input such as:
    • Balancing on one leg while pivoting the other
    • Slowing down, and speeding back up again (all while navigating those sensory cues, mind you), which is where a lot of the times this bilateral coordination seems to freeze up in PD, hence the clinical symptom called freezing of gait (FOG).
    • Thinking again of the car analogy, this is akin to having to slow down and turn the wheel the proper amount so you don’t hit the curb but you make it to the proper lane, speeding back up again.

With all those steps, anything that goes wrong will hurt the body’s ability to keep steady and coordinate larger and smaller movements on both sides. We also need to take into consideration that we all have a dominant side in normal movement that is easier to control. Evidence suggests the dominant side is worse in PD, perhaps due to brain asymmetry, meaning anything involving that side is most likely going to be slower and more uncoordinated, such as balancing on your dominant side or having to pivot on your dominant foot (1,2). Again, comparing it to a car running, if you have a bad steering wheel, your turns are going to be a little rough and you might end up swerving more or less on target. Or you need new adjustments or wheel bearings that make your balance and steadiness just a little bit better (speaking from personal experience). These parts make a car drive smoothly, as the neural circuits involved in the basal ganglia — along with all the new motor regions I mentioned–interact as one unit to make the walking as coordinated as possible.

This type of movement is also affected by our favorite neurotransmitter: dopamine. As we know, dopamine affects the basal ganglia, which has a conversation with all of the different areas we’ve talked about, such as the supplementary motor area, which is important for coordinating movements. We have seen in past research that taking dopaminergic medication has positively affected Phase Coordination Index (PCI), which measures bilateral coordination by looking at footsteps and foot switching (4). What does this mean exactly? Taking dopaminergic medications creates a more balanced movement, most likely by increasing basal ganglia activity, which thus increases the conversation between this and other movement areas needed for bilateral movement.

We also know that exercise is great for PD! Not only has this been seen in PD-specific fitness classes, but in research as well! Taking medications that increase dopamine uptake can mitigate some of these falters in movement and can create a more efficient signaling cascade, but it can only do so much. The other part of strengthening these pathways comes from exercise that can lead to better balance, smoother motion, and greater bilateral coordination! We’ve seen in some research studies on physical therapy techniques that auditory and visual cues, premeditated/thoughtful movements, and most importantly repeated balance drills can decrease FOG episodes, which could be attributed to a lack of bilateral coordination (3).

And what incorporates all of those? Exercise classes! In Part 2, we discuss Steps To Incorporating Bilateral Coordination Into Your Exercise Program.

Become a Parkinson’s Disease Fitness Specialist!

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


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

  1. van der Hoorn, A., Bartels, A. L., Leenders, K. L., & de Jong, B. M. (2011). Handedness and dominant side of symptoms in Parkinson’s disease. Parkinsonism & Related Disorders, 17(1), 58-60. https://doi.org/https://doi.org/10.1016/j.parkreldis.2010.10.002
  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
  4. Son, M., Han, S. H., Lyoo, C. H., Lim, J. A., Jeon, J., Hong, K.-B., & Park, H.. (2021). The effect of levodopa on bilateral coordination and gait asymmetry in Parkinson’s disease using inertial sensor. Npj Parkinson’s Disease, 7(1). https://doi.org/10.1038/s41531-021-00186-7
  5. Kramer P., & Hinojosa, J., (2010). Frames of Reference for Pediatric Occupational Therapy: 3rd Edition. Baltimore, Maryland: Lippincott Williams & Wilkins
  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
  9. Rutkowska, I., Lieberman, L. J., Bednarczuk, G., Molik, B., Kaźmierska-Kowalewska, K., Marszałek, J., & Gómez-Ruano, M.-Á. (2016). Bilateral Coordination of Children who are Blind. Perceptual and Motor Skills, 122(2), 595–609. https://doi.org/10.1177/0031512516636527
  10. Schmidt, M., Egger, F., & Conzelmann, A. (2015). Delayed Positive Effects of an Acute Bout of Coordinative Exercise on Children’s Attention. Perceptual and Motor Skills, 121(2), 431–446. https://doi.org/10.2466/22.06.PMS.121c22x1
  11. Tseng, Y., & Scholz, J. P. (2005). Unilateral vs. bilateral coordination of circle-drawing tasks. Acta Psychologica, 120(2), 172-198.
senior-woman-lunge

How A Thought Becomes An Action: A Guide To Movement And The Disconnect In Parkinson’s Disease | PART 2

In Part 1, we discussed how a thought becomes an action, and the disconnect in Parkinson’s Disease, as well as how a Fitness Professional do to improve brain and body connection.

For those living with Parkinson’s, the three Activities of Daily Living (ADLs) considered to be most difficult to perform are:

  • Rolling over in bed
  • Getting out of a vehicle
  • Working through a freeze episode while crossing over a threshold between rooms.

I have provided a list of exercises to complement these ADLs as well as a “Practice Option” that combines the exercises listed.

Considerations

  1. Remember to begin with the most basic of movements until the client can properly and safely execute the exercise.
  2. Care partners of wheelchair-bound clients need to be instructed on how to safely assist loved ones without causing injury to either person. Please refer the client to an Occupational Therapist if needed.

Activity of Daily Living: Rolling over in bed                                         

Exercises

  • Bridges
  • Push-ups or chest press
  • Tricep extension
  • Rows
  • Glute squeezes (for chair bound)
  • Lateral Step with torso rotation using a tube
  • Side Planks/ Prone Plank
  • Clamshells

Advanced Practice Option: Have the client lay on his or her back. Take the right leg and swing the leg over the left leg and move into the side plank position and hold for 5 counts. From there roll to a prone plane OR bird dog position. Reverse the exercise to practice returning to the supine position.

Assisted Practice Option: If lying down is not an option, have the client sit in a chair.  Have the client hold a tube with both hands in front of them. Trainer provides tension from the side and the client maintains the isometric hold while picking up one leg and moving it out to the side and bringing it back in like a seated jumping jack.

Activity of Daily Living: Getting in/out of vehicle

Exercises

  • Rows (add a diagonal step/lunge)
  • Squats/Lunges
  • Sit to Stand drill (include single leg version)
  • Bridges
  • Clamshells (or any abduction work)
  • ½ Warrior step / ½ Gong arms
  • “Step over the Fence” ( lift left knee and step laterally over the “fence” followed by the right knee and then reverse the movement)
  • “Jazz Hands” (improves ability to reach)
  • Hip circles
  • Bob-n-weave (or lean left/right if needed)
  • Side planks or oblique bend
  • Tricep/Biceps (add lower body exercise)

Advanced Practice Option: (Stand with chair next to left leg). Place a hurdle next to chair to act as the “floorboard” of the car. Client will stand alongside the “car”.  Client will then lift the left knee and hold for 3-5 counts then step “over the fence”/bob-n-weave” to get into the car. Reverse the motion to practice getting out of the car. Repeat on the other side.

Assisted Practice Option: (Begin in a chair and with a short hurdle or object for them to “step” over). Client is in the chair and reaches right arm out as if opening the car door (jazz hands). Client then comes back to center and picks up the right knee and steps over the hurdle and turns foot to the right (½ warrior/ ½ gong) as the entire body turns to the right. Left foot follows the right foot and steps over the hurdle. Once the feet are facing the right, have the client do a full or partial Sit-to Stand drill. Reverse the motion to practice getting into the car.

Activity of Daily Living: Working through a “freeze” episode 

Exercises

  • Obstacle courses
  • Stop and start gait drills
    • Walk and turn head right and left
    • Walk slow then fast then slow etc
    • Walk and at cue, stop and turn
  • Visual drills
  • Lateral steps 5x then walk forward
  • Walk to a song with a strong beat
  • Criss-Cross Applesauce

*If client freezes at room threshold, emphasize that they want to look straight ahead and not down.

These three ADLs are just a few of the frustrating tasks people living with Parkinson’s Disease deal with each and every day.  Fitness Professionals can make a real difference in someone’s life if they will take the time to consider how movement works, where it can go wrong, and what to do to help it go right again. Imagine the success your client will experience during a session and throughout the day as they tackle ADLs with minimal effort! I can tell you this, their level of confidence will soar and the future will be something they look forward to.


Work with Parkinson’s Clients and Change Lives!

Working with Parkinson’s clients is an extremely rewarding experience. Check out Colleen’s course, Parkinson’s Disease Fitness Specialist to get started.


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.

Renee Rouleau is a Clinical Research Coordinator for the Department of Neurology at Vanderbilt Movement Disorder. Her research primarily focuses on the glymphatic system, a proposed waste-clearance system in the central nervous system in different neurodegenerative disorders such as Parkinson’s Disease (PD) and Alzheimer’s Disease (AD).

parkinsons-graphic

How A Thought Becomes An Action: A Guide To Movement And The Disconnect In Parkinson’s Disease | PART 1

It’s 2am and Robert needs to use the restroom but can’t gather enough strength to roll to a seated position to get out of bed without his wife’s help.

Gus decides to go to the kitchen for a snack but “freezes” when he reaches the doorway. His feet feel like they are stuck in mud.

Mary would like to attend her exercise class but the process of getting in and out of the car leaves her exhausted.

What do all of these people have in common? They have a progressive neurological disease called Parkinson’s Disease (PD). Parkinson’s Disease affects the dopamine-producing neurons in the substantia nigra (Latin for “Black Substance”, due to its darkened pigment in the brain).  The substantia nigra contains the highest concentration of dopamine neurons.  It is a part of the Basal Ganglia, an area that is responsible for motor control, motor learning, and procedural memory such as learning how to tie your shoes.

In PD, the onset of dopaminergic neuronal death in the substantia nigra manifests itself in the form of motor and non-motor symptoms that occur over a long period of time and in a progressive fashion.  Most people are not aware they are presenting symptoms of PD until a loved one brings their attention to a tremor, lack of arm swing, or notices a series of falls.

People living with Parkinson’s Disease want to take larger steps, smile more, swallow food without fear of choking, dress and bathe themselves, drive and participate in social activities.

However, for some, when they have a thought such as “I want to walk to the kitchen for a snack”, getting the thought to become an action, is almost impossible due to the lack of dopamine neurons in the Substantia Nigra. But wait a minute! HOW does a thought even become an action and WHAT can a Fitness Professional do to improve brain and body connection?

How a thought becomes an action

The brain is constantly multitasking as it takes in stimuli from your surroundings, interprets what’s going on around you and causes you to take action.  When your mind creates a conscious thought, such as “I want to get a snack”, a chain reaction takes place in the brain involving several areas. This starts in the frontal areas of your brain after processing the stimuli leading to the thought. For example, if you have your eyes set on the kitchen to get a snack, your prefrontal cortex initiates plans to make the movement, sending signals to your premotor cortex to organize those plans, and then sends those signals to the motor cortex to carry out the movement.

Once the movement has been planned and the best course of action has been “decided” by these neurons, the movement can commence. This creates the surge of neuronal firing from the motor cortex through the spinal cord to motor neurons that communicate with muscles and finally manifests the movement.

The above seems straightforward. The tricky part is regulating all of those different areas. Once the gross movement is executed, sensory information ( i.e. touch, temperature, or force) travels back up to the brain through sensory neurons in the spinal cord. The sensory cortex receives and carries the message to other parts of the brain that fine-tune the movement. This is one of the functions of the basal ganglia and other areas in the midbrain.

Because you’ve most likely done these types of movements before, those patterns are all stored in the basal ganglia so it doesn’t take up valuable space in the motor cortex. This area talks back and forth to the frontal areas to figure out what specific pattern should be used to achieve the best result. There are a hundred different ways to get out of a chair and go to the kitchen, but the basal ganglia works together to choose the most efficient option out of all of them and keeps the movements from getting out of control so you’re not high knee-ing to the kitchen when a simple walk will do (unless you want to high-knee to the kitchen). Once everything is adjusted and looks correct, new sensory information goes to the sensory cortex and back to those frontal areas to then signal that the movement has been fully executed.

Now, although that looked like a lot of steps just to complete one movement, this all happens within a fraction of a second, and is constantly going as you move to correct and adjust. The process is fluid, but works as a chain. If one link is broken, the rest of the process is going to fall apart. So how is the link broken in a disease like Parkinson’s?

Because the basal ganglia gets a lot of communication from the substantia nigra, if there is a loss of any sort of dopamine neurons, the relay of information gets discombobulated and, in the case of Parkinson’s, causes the motor system to stop the movement mid-way as there is not enough information from the neurons firing. Instead of creating the controlled movements and fine motor adjustments like you would see in a regular motor response, you have freeze-ups where the frontal areas are telling the midbrain to do one thing, and the basal ganglia just can’t do what it’s being told to do. Thus, the chain of movement is broken and the body cannot execute the action properly. To most, it looks like people with PD can’t seem to execute an action because of cognitive reasons. However, from their perspective, they want to be able to execute it and are consciously telling themselves to do it, but part of their brain isn’t “listening” and it causes the brain and body to be disconnected, resulting in incomplete movements and motor symptoms such as resting tremor, freezing of gait, and rigidity. This is why when PD patients take their medications, which help the brain to produce dopamine, they have “on” periods where these areas are able to have clearer communication with each other, their movements are better and their symptoms are better managed.

This is critical information for Fitness Professionals working with people living with Parkinson’s Disease. Once the information is understood, Fitness Professionals can focus on the second question which is “What can a Fitness Professional do to improve the brain-body connection for those living with Parkinson’s Disease?”

First, remind them that Exercise is Medicine! They need to take a dose each and every day! And the good news is that exercise provides outcomes such as:

  • Improved neuro-protection for at-risk dopamine neurons
  • Neuro-repair for areas of the brain affected by Parkinson’s Disease, and
  • Adaptation by retraining areas of the brain to pick up where the damaged parts can no longer execute commands.

Second, determine the activities of daily living (ADLs) that are most difficult for them. Identifying the ADLs and providing an exercise program that includes the seven functional movement patterns (push, pull, carry, hinge, lunge, squat and rotation) to improve their ability may save their lives. Repetition will be the key to create a spirit of confidence!

In Part 2, I discuss the three ADLs considered by most people living with Parkinson’s Disease to be most difficult, and exercises to complement them.


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.

Renee Rouleau is a Clinical Research Coordinator for the Department of Neurology at Vanderbilt Movement Disorder. Her research primarily focuses on the glymphatic system, a proposed waste-clearance system in the central nervous system in different neurodegenerative disorders such as Parkinson’s Disease (PD) and Alzheimer’s Disease (AD).

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Fight Back Stronger! Working with Clients with 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.


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.