Shake, Rattle and Roll: Parkinson's Disease and Intense Exercise: Neil Sligar's 10-Year Experience

January 2010

No-one should commence strenuous physical activity without first checking with a medically-qualified practitioner that it’s safe to do so.

Parkinson’s Disease and Intense Exercise: My 10-Year Experience

My Parkinson’s disease was diagnosed in mid-1998. I’ve exercised vigorously since January 2000. Kate Kelsall has invited me to set down my experience and to remark, as a person living with Parkinson’s, on recent research findings about benefits of intense exercise for people like me.

“Exercise” is universally recommended for those living with Parkinson’s disease. As to what “exercise” is best, you find it can be anything from tai chi to running depending on the website. Some therapists favor treadmill and stationary bike. Others argue against treadmill and stationary bike on the basis they remove any voluntary element from the activity. There’s no agreement.

There’s been a tendency on Parkinson’s websites to refer to people living with Parkinson’s (PWP) as if we are all invalids. We’ve been advised to avoid strenuous activity, to rest if fatigued, not to exercise within two hours of bedtime. These messages have been challenged by research results during the past few years.

Some recent research findings on exercise and PD

Dr Beth Fisher and Dr Jeanine Yip (both University of Southern California) in 2005 on the National Parkinson’s Disease Foundation website described a “new paradigm.” Drs Fisher and Yip asserted that the benefits of exercise for people living with Parkinson’s (PWP) are positively related to exercise intensity. They outlined the traditional approach of physical therapy, helping people to compensate for symptoms, and contrasted this with an emerging approach of generating neuroplasticity through intense exercise. This approach had been successful with stroke and brain injured patients. Why not Parkinson’s disease? Results had been positive with mice.

The University of Southern California turned to humans in its research into exercise intensity. Would the positive findings with mice be replicated? Dr Giselle Petzinger (USC), addressing a conference convened by the Houston Area Parkinson’s Society in April 2009, announced the result in her opening remarks: “We all know that exercise is helpful to good health. We also know that it is good for the heart and the muscles. But can it change the brain, and might these changes make an impact on Parkinson’s disease (PD) symptoms?

The answer to both of these questions is yes.”

Dr Petzinger concluded “In the meantime, we know the following: intensive exercise can help people with PD move more normally, and research is beginning to reveal how it reconditions the underlying brain circuits.”

http://www.pdf.org/en/edu_events_texas

Dr Jay Alberts (firstly at Georgia Tech and later at the Cleveland Clinic) has noted that, when a PWP applies a bike pedaling speed of 80rpm – 90 rpm for at least 40 minutes, symptoms may be relieved for up to several hours. He’d first observed this by chance in 2003 while riding tandem across Iowa with a woman who had undergone deep brain stimulation. It is Dr Albert’s view that PWP can’t “normally” by themselves pedal beyond 40rpm - 60 rpm. Consequently, a PWP is “forced” to the required speed by a more athletic person riding tandem. An alternative would be a motorized bike, overcoming the need for recruiting a trained cyclist. Dr Alberts concedes that the same effect may be achieved from treadmill running while wearing a harness although he notes that running is more difficult for PWP than cycling.

http://katekelsall.typepad.com/my_weblog/2007/06/pedaling-past-p.html

http://www.wellsphere.com/aging-senior-health-article/forced-exercises/905650

http://www.cleveland.com/medical/index.ssf/2009/10/cleveland_clinic_summit_names.html

I’ve been surprised while preparing this article at how much research evidence was available during the 1990s indicating the capacity of PWP to exercise at higher intensity levels than commonly assumed. Why didn’t this evidence trickle down?

Hirsch (University of North Carolina) and Farley (University of Arizona) in the European Journal of Physical Medicine of June 2009 lamented that “many clinicians and communities remain unaware” of scientific literature underlying exercise-induced brain repair….”

http://www.ncbi.nlm.nih.gov/pubmed/19532109

My experience

I’m a 64 year old Australian. My height is 179cms (5 feet 10 inches), my weight 86kgs (189lbs.) Diagnosed in mid 1998, I have significant off-medication tremor and rigidity, mainly on my right side, some slowness of movement in activities of daily living, and no balance problem. Rigidity caused me in 2001 to change from writing right-handed to writing left-handed. My left hand is now also troubled by rigidity and tremor but not to the degree of my right hand. My posture seems unaffected.

I take 300mg/day Sinemet, 300mg/day Stalevo, 1.5gm/day Sifrol (Mirapax in the U.S.). My total l-dopa intake has remained the same since 2003 although prior to 2008 it had been through Sinemet alone. I take no supplements. I have no other medical conditions. I run a business from a home office.

January 11, 2010 was not only my 64^th birthday. It was the tenth anniversary of embarking on strenuous gym activity, activity which has changed only very slightly across these ten years.

At the start of 2000 my business strategic plan identified health as the greatest threat to my remaining in the workforce. Parkinson’s disease had been beyond my control. Succumbing to other conditions (e.g. heart, stroke, diabetes) was largely within my control through increased physical activity.

Within a year or two either side of my 1998 Parkinson’s diagnosis, my heart, blood pressure, blood chemistry, and lung capacity were checked. The first three were normal; my lung capacity was greater than average.

A detailed description of my gym regime and its emphasis on safety can be found on a 2007 posting on "Lifting the Weight of Parkinson's" in Shake, Rattle and Roll at:

http://katekelsall.typepad.com/my_weblog/2007/09/lifting-the-wei.html

Three overall goals govern my exercise regime:

· Retain good general health, especially in relation to heart, blood pressure, and blood chemistry.

· Develop and maintain a strong musculature to assist in retaining normal posture.

· Continue improving. Measure progress against targets and, when achieved, increase those targets.

Here are examples of levels attained during the past twelve months.

Horizontal bench press 110kgs (242lbs)

Push-ups with 20kgs plate on shoulder blades 25

Push-ups with feet on top of 65cms fitness ball, hands on floor 50

Chin-ups set of 10, followed by sets of 6 then 4

Sit-ups holding a 10kgs plate and lying on a decline bench 20

Distance rowed indoor in 2 minutes 577 metres

Time to ride stationary bike 2 kms 3 mins 29 secs

Highest bike rpm momentarily attained at low resistance 140

My four gym sessions per week last around an hour and remain structured by the same three elements as in 2000: flexibility, aerobic capacity, strength. Each session has its program. About 10 minutes is set down for flexibility, 15 minutes for aerobics, and 30 minutes for strengthening exercises. I follow a cycle of six programs, each having a different set of exercises. I found along the way that rigid muscles on my right side were more prone to soreness from overuse than muscles on my less affected side.

Aerobic exercises are split between treadmill, stationary bike, and indoor rower. Treadmill is my weakest and least enjoyable activity. My right leg tends to drag and rigidity affects the swinging of my right arm. I walk for 10-15 minutes and run for 2-3 minutes. On the bike and rower I feel unimpeded and push myself hard.

Bike and rower follow a soft/hard/soft/hard format. For example, I’ll ride the bike at less than 25km/hr for 5 minutes, followed by 2 minutes above 35km/hr, 2 minutes at less than 25km/hr, 2 minutes above 35km/hr, 2 minutes at less than 25km/hr, 1 minute above 35km/hr, 1 minute at comfortable speed. To reach 36km/hr I set resistance to 14 (max is 20), rpm being 80.

At my first gym session in 2000 I was directed to pedal a stationary bike for 20 minutes at 80rpm on a medium resistance. As I became fitter I increased the resistance, with 80rpm remaining as the default cadence. Unaware of Jay Alberts’ research until several years ago, I’d already noted temporary relief from Parkinson’s symptoms following a hard workout. For me, relief follows any hard physical training session, irrespective of what equipment has been utilized. On reading Dr Alberts’ observation I assessed myself in terms of heart rate and tremor during and following 30 consecutive gym sessions, each concluding with a light or heavy bike ride. How was my writing an hour later? Did my fingers involuntarily tap the desk? My heart rate during hard riding tended to peak in the low 150s beats per minute but on one occasion reached 179 bpm. My resting heart rate settled to 60 bpm within an hour of finishing training. Sure enough, the harder I rode, the more relaxed later. Initially, the tremor could increase after a hard ride but it would soon subside.

By including stretching, aerobics, and strength within each exercise session, and limiting each session to one hour’s duration, I’d never ridden a stationary bike for longer than 20 minutes. While preparing this item, I amended a training session to include riding for 40 minutes as close as possible to a constant 80rpm. My cadence held within a range of 77rpm to 84rpm until lifting to high nineties in the final ninety seconds.

My weightlifting agenda addresses upper and lower body. I lift up to at least 80% - 90% of my maximum in each weights exercise, my first lift in any weights exercise being well short of maximum. Safety is paramount. I call for a spotter (a person who places his open hands beneath the bar to protect me if I lose control) when nearing my maximum and the weight is above my body. The possibility of muscle soreness is reduced by keeping low the total number of lifts and by addressing several body areas at each session rather than concentrating on, say, shoulders.

Targets are listed alongside every aerobic and strength task. As a target is achieved, it’s crossed out and a new figure written. Many small advances translate into big gains. Performance records have been retained except from my earliest years for which period only rough notes are held.

My exercise routine is intense but isn’t treadmill-dominated as described by Dr Petzinger. My routine spreads across flexibility, three types of aerobic activity, and strengthening. My routine isn’t forced as described by Dr Alberts. I’m fit enough to reach the rpm he says is necessary.

Apart from some brief periods with muscle soreness, I’ve not been injured. My blood pressure and chemistry are regularly checked by my general practitioner. Everything has remained within normal bounds

Competition ensures a focus on improving. Around six to eight competitors in the men’s 55yrs – 64yrs age category usually take part in these events where I train at the Aquafit Fitness and Leisure Centre in Campbelltown, a suburb of Sydney.

I’ve not used a personal trainer although I do seek the opinion of my gym’s fitness instructors and have benefitted from occasional commentary from Canadian personal trainer, author, and PhD, Krista Scott-Dixon.

It’s been said that my gym performance is unusual for a person with Parkinson’s. I contend that it flows from:

· clear goals and well-considered, regularly-amended programs;

· training to near maximum capacity;

· setting achievable targets;

· persistence (attending whether rain, hail or shine);

· cheery support of receptionists, fitness instructors and fellow gym users.

What have I learned?

1. Firstly, don’t accept the limitations others may predict, assume, or recommend because of Parkinson’s disease. I don’t, and won’t, accept that my physical capacity is any less than that of anyone else. Parkinson’s disease has been an inconvenience, not an obstacle, for strenuous, physical activity.

2. I respect and am grateful for the opinions of those in the medical and physical therapy professions but the final say in managing my Parkinson’s should be mine.

3. The harder I work, the better I later feel. By 2004, I’d noticed that after a solid aerobic workout, my tremor and rigidity subsided and sleep came more easily. For around an hour following a rigorous bike session, tremor sometimes increased, but then declined and calmness prevailed. I was unaware of the research of Dr Jay Alberts but my experience was consistent with his observations except that I didn’t need someone to force me up to the cadence he’s found necessary.

4. When my stamina falters, the appropriate response is to amend my exercise regime so as to place more emphasis on endurance.

5. Lifting heavy weights has not aggravated my rigidity despite warnings to the contrary on Parkinson’s websites. I keep repetitions down to 5-8 at most per set, and usually perform only one set. It’s more common for PWP and beginners to be advised to perform three sets of 10-15 repetitions with “light” weights. I believe it’s the total volume of lifts more than the heaviness that may increase rigidity.

6. My “explosive” strength, (known as “power”), is significantly diminished by Parkinson’s. An example of power is the action of an Olympic weightlifter when snapping the bar to his shoulders.

7. “Bradykinesia”, slowness of movement, affects me in activities of daily living. Yet when working out hard on the bike or rower I can move as quickly as most. I compete reasonably successfully with my gym peers in bike and indoor rowing challenges. This is an oddity about Parkinson’s. Its hindrances are less apparent at higher levels of effort. Push myself, and Bradykinesia disappears.

8. When I commenced reading Parkinson’s literature on exercise, around early 2004, the prevailing “take it easy” advice didn’t ring true. Working out intensely didn’t exacerbate my symptoms. Training at night didn’t make falling asleep more difficult. I fall asleep more readily. Symptom relief flowed from intensity, not torpor.

9. Intensity is relative to the individual’s capability. Standing and sitting ten times would be intensive for a person with advanced Parkinson’s. Intensity means “giving it almost all you’ve got.”

10. There are many ways to exercise intensely. For several years I’d meet my son daily at the railway station to drive him home. Included as part of my exercise regime was a sprint up the railway stairs. At home there can be push-ups, sit-ups, and so on. Vigorous dancing would add an element of balance, social interaction, and test thinking skills. (All I need is a partner.)

11. Improved physical performance becomes more difficult over time. Drafting exercise programs becomes more challenging.

12. Periods of unexplained performance decline are not unusual. Refresh my programs, and then persist. Performances have, so far, resumed for the better.

In its report to Parkinson’s Australia in 2007, (Parkinson’s: Economic Impacts and Positive Steps), Access Economics identified a 2004 study by the Australian Bureau of Statistics. The bureau analyzed 1,621 people whose death certificates had idiopathic PD listed as an associated cause of death. It found that “…304 died due to stroke (around twice as likely than the general population) and….218 died due to diseases of the respiratory system (around 50% more likely than the general population), of whom 94 died due to influenza or pneumonia (over twice as likely than the general population), and 19 died due to accidental fall (over 78% more likely than the general population),…”

http://www.parkinsons.org.au/media-advocacy/docs/pd-study.pdf

These mortality statistics say to me that it’s important as a PWP to remain as active as possible and to engage in some regular exercise-induced puffing.

The benefits of the exercise regime I embarked upon in January 2000 appear broadly consistent with recent research results as summarized in the introductory comments above. It’s not possible for me to say that my exercise regime has retarded progression of the disease but it does afford temporary symptom relief. What is certain is that speeds and distances achieved on all but the treadmill, along with weights lifted, have increased since 2000 despite living with Parkinson’s. Parkinson’s disease has not been a sentence of physical decline.

The outline above describes my own exercise regime. Anyone’s exercise protocol should be unique, depending on his or her capability and experience. Prior to commencing a rigorous physical program, confirmation should be gained from a medical doctor that there are no impediments to doing so. Exercise is not a substitute for medication. If utilizing a gym, seek initial guidance from an appropriately-qualified fitness instructor. Never lift free weights without another adult being present.

My workouts occur at the Aquafit Fitness and Leisure Centre in Campbelltown, a suburb of Sydney. I’m indebted to staff and fellow members for their encouragement.

Neil Sligar

Sydney, Australia

Comments

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Best exercise can really help prolonging one's life. That is why we need to at least have a one to hour exercise a day. To achieve the best result is to have proper diet which means eat healthy foods only.

Posted by: personal trainer az | February 07, 2010 at 05:34 AM

Regular physical activity is one of the most important things you can do for your health.It has a bounty of benefits and studies have shown a link between exercise and a reduced risk of certain cancers and other health disease.

Posted by: pediatric emr | May 17, 2010 at 12:28 AM

My father has Parkinson disease. God please help him...

Posted by: Parkinsons Disease | June 17, 2010 at 02:01 AM

You will be the role model for many people living with Parkinson’s disease. You are the best example to know the various and true benefits of doing exercises in our daily life. Thank you very much for sharing your workout routine with the world. It will surely bring a smile of hope in many people around the world.

Posted by: Jackson | September 24, 2010 at 05:28 AM