This is a shorter version of the original live webinar. A written summary of Prof Bas Bloem’s talk is available below.
Please note that all session and slide content are the views of the Speakers, not the Parkinson’s Academy. The content of the recording is the speaker’s personal opinion at the time of recording. Due to the everchanging situation, advice given at the time of recording is subject to change.
Chair: Dr Richard Davenport, Consultant Neurologist, Royal Infirmary of Edinburgh
Prof Bas Bloem, Medical Director, Parkinson Center Nijmegen (ParC), Netherlands
Fiona Lindop, Specialist Physiotherapist, Derby Parkinson’s Service
Dr Richard Davenport began by sharing that a number of people living with Parkinson’s have been struggling during this time of lockdown due to inactivity, among other things. He noted that, whilst he intrinsically encourages exercise as a positive thing amongst his patients, he is not personally aware of the evidence base beyond nuances like dance therapy. However, there is a significant evidence base and he welcomed Bas Bloem and Fiona Lindop to share more.
The evidence base for exercise
- Prof Bas Bloem began by highlighting the book, ‘Ending Parkinson’s Disease’ and noted that within it is the evidence base that:
- Parkinson’s is the fastest growing neurological disease on the planet, and we think that it is, to an extent, a man-made disease.
- By regularly engaging in exercise and adhering to particular nutrition, we can reduce the likelihood of developing Parkinson’s.
- All of us tend to be inactive but for someone with Parkinson’s this can be harder due to physical difficulties with balance, gait and freezing, cognitive problems like depression and apathy, and even general physical difficulties like fatigue.
- As Parkinson’s progresses, the level of inactivity increases (vanNimwegen, 2011)
- The adverse effects of inactivity include cardiovascular disease, osteoporosis, insomnia, cognitive decline, depression, constipation, and all lead to early mortality. All of these are risk factors when you have Parkinson’s, so if you are both inactive and have Parkinson’s your risk of early mortality are higher.
- A paper in Nature Neurology (Speelman, 2011) outlines the reasons why people with Parkinson’s ought to exercise. To sum it up, Bas noted:
- Anyone who exercises has better bone and mental health and lower risk of cognitive decline
- Specific benefits for those with Parkinson’s are that exercise suppresses motor symptoms much as a drug does, as well as helping address some non-motor symptoms like sleep, depression, cognitive difficulties and constipation.
- Can we prescribe exercise as we would a drug? We need to consider the risks too; falling and stumbling for example; and how we customise it to personal preferences and needs
- The first study to examine the dosing effects of exercise (Moore, 2013)
- Evaluated the impact of both with moderate and high intensity exercise, and with different time amounts, or ‘time doses’ (fig 1)
- Used the Unified Parkinson’s Rating Scale to measure overall symptoms and progression.
- Found that, over time, the high intensity group stabilised their symptoms, moderate intensity helped stabilise motor symptoms, control worsened over time (fig 2).
Figure 1: Table showing the two groups of people asked to exercise moderately or strenuously
Figure 2: Table showing the outcomes where the y axis is the unified Parkinson’s rating scale and the x axis is the three groups – high intensity (left), moderate intensity (centre) and control group (right)
- V-TIME study looked at multimodal stimulation of the brain using a 3-D environment through virtual reality alongside a treadmill.
- The results found that treadmill running alone reduced the likelihood of falls in people with Parkinson’s or mild cognitive impairment (MCI)
- However, using a treadmill alongside the virtual reality input reduced falls more significantly (fig 3).
- The downside of the study was the need for people to travel to the hospital three times weekly to access the equipment, which was a motivational barrier for many.
- Other barriers included low expectations of outcomes, a lack of personal time, and a fear of falling during exercise.
Figure 3: V-TIME study findings of falls reductions in those using a treadmill versus those using a treadmill and virtual reality input
- The learning from the V-TIME study was used to develop the Park-in-Shape (van der Kolk, 2015)
- Based on learning that someone with Parkinson’s who could not walk due to freezing may still cycle without difficulty (interview with Bloem in Road.cc; Stamelou, 2011), the study put static exercise bicycles into people’s homes, removing the fear of falling, the barrier of physically going to the hospital to exercise.
- There were rewards built into the process supported by family members, as well as gaming elements (termed ‘exergaming’) such as ‘Pacman’ where the individual had to cycle faster to move the icon around the screen and ‘kill the monsters’.
- Another study (van der Kolk, 2019) compared this group of Parkinson’s using ‘exergaming’ for their activity with those with Parkinson’s who were stretching for their form of activity, using the rewards app in both groups (fig 4).
- The study found that, when sufficiently motivated, people with Parkinson’s can exercise regularly at home.
- It also found that the aerobic group had a stabilisation of their motor symptoms.
Figure 4: People with Parkinson’s counteracting sedentarism through aerobic exercise or stretching
- Finally, Bas presented a paper which is currently under submission to the Lancet Neurology looking at brain MRI in the same groups as the previous study – the aerobic versus stretching group. The content is currently embargoed but the brain scans found brain-related benefits for those within the aerobic group which are incredibly positive.
Questions posed to Bas included:
Do we know why exercise seems to have this positive effect on brain health?
- Hypotheses for brain-health benefits are 1) that exercise protects the areas of the brain damaged in Parkinson’s, or
- 2) that it promotes brain health elsewhere in the brain enabling you to compensate for basal ganglia-related damage
- However, Bas said, regardless of the reasons, if aerobic exercise has been found to be beneficial across these various areas, it does not matter why – start moving today!
What about in those who have apathy as part of their Parkinson’s?
Apathy – it’s important to make a distinction between apathy and depression, as depression is treatable and exercise is one of the treatments, whereas true apathy takes a toll on those family members who have a responsibility to really push the individual to move more.
Why is smoking protective against developing Parkinsonism?
We don’t know, but we can see the impact of smoking as a risk factor for so many other diseases and so we cannot say that the possible protection for Parkinson’s outweighs the risks of other health conditions. It is also clearly not beneficial once you have Parkinson’s. Please do not start smoking.
Barriers to exercise
- Fiona discussed some of the barriers to exercise for people with Parkinson’s, some of which Bas had already mentioned.
- She specifically focussed on those which are pertinent to the COVID-19 pandemic, which has created even more barriers to both exercise itself, and the motivation to move.
- She also discussed some of the ways to potentially address these barriers and referred to useful resources which can be accessed.
You can hear from her directly as she discusses some of these elements (video above).
- Book ‘Ending Parkinson’s disease’: endingpd.org
- van Nimwegen et al. Physical inactivity in Parkinson’s disease. J Neurol. 2011
- Speelman et al. How might physical activity benefit patients with Parkinson disease?. Nat Rev Neurol. 2011
- Schenkman M, Moore CG, Kohrt WM, et al. Effect of High-Intensity Treadmill Exercise on Motor Symptoms in Patients With De Novo Parkinson Disease: A Phase 2 Randomized Clinical Trial. JAMA Neurol. 2018
- Mirelman A, Rochester L, Maidan I, et al. Addition of a non-immersive virtual reality component to treadmill training to reduce fall risk in older adults (V-TIME): a randomised controlled trial. Lancet. 2016
- van der Kolk, N.M., Overeem, S., de Vries, N.M. et al. Design of the Park-in-Shape study: a phase II double blind randomized controlled trial evaluating the effects of exercise on motor and non-motor symptoms in Parkinson’s disease. BMC Neurol 15, 56. 2015
- Snijders AH, Bloem BR. Images in clinical medicine. Cycling for freezing of gait. N Engl J Med. 2010
- van der Kolk NM, de Vries NM, Penko AL, et al. A remotely supervised home-based aerobic exercise programme is feasible for patients with Parkinson’s disease: results of a small randomised feasibility trial. J Neurol Neurosurg Psychiatry. 2018
- van der Kolk NM, de Vries NM, et al. Effectiveness of home-based and remotely supervised aerobic exercise in Parkinson’s disease: a double-blind, randomised controlled trial. The Lancet. 2019
- Wallén et al. Levels and Patterns of Physical Activity and Sedentary Behavior in Elderly People With Mild to Moderate Parkinson Disease. Physical Therapy. 2015
- Bouça‐Machado et al. Physical Activity, Exercise, and Physiotherapy in Parkinson’s Disease: Defining the Concepts. Movement Disorders Clinical Practice. 2019
- De Biase et al. The COVID-19 Rehabilitation Pandemic. Age and Ageing. 29 May 2020
- Afshari M, Yang A, Bega D. Motivators & barriers to exercise in Parkinson’s disease. J Parkinson’s Dis. 2017
- Nilsson MH, Iwarsson S et al. Barriers & facilitators for participation in people with Parkinson’s Disease. J Parkinson’s Dis. 2015
- Lee, JH; Choi, M et al. Impacts of an Exercise Program and Motivational Telephone Counseling on Health-Related Quality of Life in People With Parkinson’s Disease. Rehab nursing. 2019
- Hermanns M, Haas B et al. Engaging older adults with Parkinson’s disease in physical activity using technology:a feasibility study. Gerontol Geriatr Med. 2019
- Lai, B; Bond, K et al. Exploring the uptake and implementation of tele-monitored home-exercise programmes in adults with Parkinson’s disease: A mixed-methods pilot study. J Telemedicine and Telecare. 2018
- van Eijkeren FJ, Reijmers RS, Kleinveld MJ, Minten A, Bruggen JP, Bloem BR. Nordic walking improves mobility in Parkinson’s disease. Mov Disord. 2008
- Power for Parkinson’s: 10-minute videos
- Reach Your Peak: 2 weeks free, personalised, daily exercises
- Parkinson’s UK: YouTube exercise classes (live on Facebook)
- Parkinson’s Wellness Recovery (PWR): free exercises
- Dance: Spread Your Wings – Dancing through Parkinson’s
- Parkinson’s Life: 5 Parkinson’s exercise classes for keeping fit in lockdown
- European Parkinson’s Disease Association (EPDA): ExerciseCast programme
- Parkinson’s Foundation: Fitness Fridays
Parkinson’s UK links
- Advice booklet: Parkinson’s and Coronavirus: your questions answered
- Advice for patients on telephone & video appointments
- Resources for professionals relating to COVID-19
- Nordic walking and Parkinson’s
→ Nordic walking for Parkinson’s: warm up exercises (15 mins video)Nordic Walking and Parkinsons Exercise
This meeting is designed and delivered by the Parkinson’s Academy and sponsored by BIAL Pharma. The sponsor has had no input into the educational content or organisation of this meeting.
Posted in: COVID-19