“…And what do you do for exercise?”

“…And what do you do for exercise?” is not always a popular question with a new patient in clinic. 


But for movement disorder doctors, reviewing patients’ exercise routines is becoming the standard of care, and for good reason. When I see patients with Parkinson’s disease, I especially emphasize the importance of regular physical exercise. Taking on this challenge is no easy feat for the average person – having a regular exercise routine requires a level of accountability that doesn’t come naturally for most of us. Certainly there are tips and tricks that can help with this lifestyle change. Perhaps the most important one is choosing a form of exercise you enjoy, whether this be walking, riding a stationary bike, swimming, yoga, tai chi, dance classes, boxing, physical therapy, etc. Whether you are able to run for long distances, or are limited to exercising in a seated position, it is critical that the exercise be intense and long enough to raise your heart rate and make you breathe more heavily. It is important to be consistent with whichever form of exercise you choose, and to build it into your schedule. For example, those enrolled in formal classes or programs have been shown to demonstrate the most significant gains in motor function. Exercising with a friend or partner often helps people keep a regular routine as well, as workout buddies can keep one another motivated and engaged. And of course, it is important to know your limits, and to exercise in settings that are safe, and that do not introduce the possibility for falls or injuries. 


For many years, we have known that the improved mobility that results from regular physical activity allows for more physical independence, decreases the risk of falls, and allows for an improved overall sense of well-being. In truth, all the new research showing the potential benefits of exercise suggests that it is important for all of us to be exercising. Regular cardiovascular exercise does not only potentially slow the progression of Parkinson’s disease, but may also delay/prevent the onset of dementia, and allow for fewer changes in the brain caused by aging. Personally, I have found this literature so convincing, it has changed how our family structures our own exercise routines. But while the data suggests that we should all be getting regular physical exercise, the stakes may be higher when you have a disease like Parkinson’s disease, in which you are losing a certain type of neuron (dopamine neurons) faster than the average person. 


In my own practice, I prioritize this conversation, “What do you do for exercise?” during clinic visits, and even at the time of a new diagnosis with Parkinson’s disease. This is because physical activity is the only intervention (so far) that has demonstrated, in animal models, that it may potentially slow the course of neurodegenerative diseases, such as Parkinson’s disease.  In other words, we have little to offer that can “modify disease progression.” For example, large studies looking at interventions like creatine, inosine, exenadite, coenzyme Q-10, etc. have failed to support the use of these substances in slowing the progression of disease. But the mounting evidence that exercise may affect the course of the disease is very exciting, both to patients and providers. 


The National Parkinson Foundation is currently performing the largest clinical study of Parkinson’s disease that has ever been conducted, called the Parkinson’s Outcomes Project. Among other questions being investigated, this project is also evaluating the importance of regular exercise. In fact, there are so many basic science studies being produced by research groups from all over the world, that it would be impossible to summarize this growing field in this short entry. However, at this year’s International Parkinson and Movement Disorder Society’s 19th International Congress, researchers emphasized that exercise not only improves the motor symptoms in Parkinson’s disease (stiffness, slowness, rigidity, balance, flexibility, coordination, etc.), but that it also promotes independence, improves quality of life (across all different stages of disease), improves sleep, improves mood (depression, anxiety, apathy), and delays cognitive changes; more specifically, exercise decreases the risk of Parkinson’s disease dementia, as well as Alzheimer’s dementia and vascular dementia (adapted from presentations by Drs. W. Poewe, A. Storch, T. Simuni, T. Mestre, & D.J. Surmeier). 


As the importance of cardiovascular exercise started to receive new recognition during my training, I was always taught that exercise might be protective from a “vascular” standpoint; regular cardiovascular exercise keeps the tiny blood vessels supplying the neurons of the brain healthier for longer (much like regular physical exercise is good for the arteries supplying the blood to your heart). But new research looking at exercise-induced neuroplasticity in animal models is broadening this horizon, and also suggesting that for patients who exercise, brain cells may use dopamine more efficiently. Personally, I’ll be looking forward to learning more from Dr. Giselle Petzinger of University of Southern California, who recently received an Innovative Research Grant from the National Parkinson Foundation for her research studying the biology of exercise at the cellular level. Her group’s exciting work proposes the hopeful message that the neuroplasticity created from exercise in patients with Parkinson’s disease may help combat the neurodegenerative effects inherent to the disease. Dr. Petzinger will be speaking at this year’s annual Parkinson’s Association of Santa Barbara (PASB) symposium on April 16, 2016 (http://www.mypasb.org for further details). See you there! 

- Dr. Sarah Kempe-Mehl