PD Spotlight
May 2021
Colleen Bridges- M. Ed, NSCA-CPT
Renee Rouleau- BS, Vanderbilt Movement Disorder Research Coordinator
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 which 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 your “fighters” 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 your “fighters”. 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!
The three ADLs considered by most people living with Parkinson’s Disease 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 fighter can properly and safely execute the exercise.
2. Carepartners of wheelchair-bound fighters 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 fighter sit in a chair. Have the fighter hold a tube with both hands in front of them. Trainer provides tension from the side and the fighter 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
Exercises Continued
“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. Fighter will stand alongside the “car”. Fighter 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) Fighter is in the chair and reaches right arm out as if opening the car door (jazz hands). Fighter 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 fighter 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 a fighter 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 fighters 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.
If you would like to see a video demonstration of any of the exercises mentioned in this article, please email Colleen Bridges at nashbridges@comcast.net