Show Me The Evidence:

Exercise and PDDean P. Sutherland, MD, PhD

Sarasota, Florida

Clinical Assistant Professor, Florida State University College of Medicine

Clinical Assistant Professor, University of Florida College of Medicine

First Physicians Group Neurology

What If I Told You……

….That you could live longer?

…..That you could be stronger?

…..That you could be less afraid of the future?

…..That it was non-toxic?

…..That it made you smarter?

You Have a Choice…

Which Do You Choose?

Outline

’ Basics of PD

’ Symptoms of PD

’ Why should I exercise?

’ What is the Evidence that Exercise helps?

’ Formal Exercise Programs for PD

’ What is the Best Exercise for PD?

’ Rehabilitation programs

’ Coordinating Medicines and Exercise

Soft voice

masked face

freezing of gait

stooped posture

falling

restricted eye movements

Tenting/cramping of hands/feet

(dystonia)

small handwriting

Motor signs and symptoms:

Psychiatric –

depression, apathy, cognitive impairment,

memory loss, hallucinations

Sleep disruption – REM Behavioral Disorder(RBD)

Sensory dysfunction – Anosmia

Non-motor symptoms and signs(may be more debilitating)

Autonomic DysfunctionGI – Constipation, Gastroparesis

Cardiovascular – Orthostatic Hypotension, Loss of variable rate (R-R)

Sialorrhea (severe drooling)

Excessive sweating

Erectile dysfunction

Non-motor symptoms and signs(may be more debilitating)

Staging of Parkinson Disease

’ Hoehn and Yahr (H&Y) Staging (1967)’ 1 - PD on one side of the body only’ 2 – Mild PD on both sides of the body, normal balance’ 2.5 – above, plus mild balance problem’ 3 – Mild or moderate PD with abnormal balance’ 4 – Severe PD, but can walk/stand’ 5 – Severe PD, confined to wheelchair or bed

’ Mild/Moderate/Severe

’ Early/Mid-stage/Late-stage

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Phases of PD

Schapira AH et al. Nat Rev Neurol. 2010;6:309-317.

DiseaseOnset

NonmotorSymptoms

MotorSymptoms

DopaminergicNeurons

Diagnosis

Time (y)Premotor Phase Motor PhasePremotor Phase

Increase

Decrease

How Long Have I Had Parkinson Disease?

Kalia and Lang, 2015, The Lancet, Volume 386, No. 9996, p896–912, 29 August

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Prognosis, rate ofprogression

Parkinson Disease is highly variable between individuals, with many different signs and symptoms. For this reason, it is sometimes referred to as a “Boutique Disease”.

Different people with PD have different rates of progression.

The rate of progression for an individual tends to be stable.People who get worse rapidly tend to continue that rate.People who get worse very slowly tend to continue that rate.

Without treatment, it takes about 1.5 – 2 years to go from one H&Y stage to another stageWith treatment, it takes about 2-4 years to go from one H&Y stage to another stage

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Classic Neuronal Pathology of PD

Nigrostriatal degeneration, primarily in the substantia nigra pars compacta (SNpc) and striatum, and α-synuclein aggregates are pathologic hallmarks

of PD

Significant nigral dopaminergic neuronal loss is marked by a reduction in

neuromelanin pigment in the SNpc

Intraneuronal cytoplasmic inclusions, or “Lewy Bodies”

Normal

Patient with PD

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PD Patients are 1/3 Less Active

’ This leads to:

’Muscle loss - weakness

’ Bone loss – osteopenia/osteoporosis

’Weight loss

’ Depression

’ Decreased socialization

“Dr. Sutherland

Says”

It’s Time To Play…

“Dr. Sutherland Says”

Being Sedentary is Like Poison for PD!

Why Should I exercise?’ Improved Balance

’ Reduced Fall Risk

’ Better Cognition

’ Endurance

’ Strength

’ Bone mass

’ Confidence

’ Slows the physical effects of PD

’ Lowers Risk of GETTING PD!

Studies of Exercise for PD’ Walking

’ Weight Lifting

’ Tai Chi

’ Yoga

’ Qigong

’ Tango, Ballroom, Dance for PD

’ Spinning

’ Water Aerobics

Walking for PD’ 2014 study

’ 48 patients, 3 times per week, 45 minutes, 2 yrs

’ Improvements seen across the board in: ’ maximum oxygen consumption

’ gait speed

’ UPDRS

’ Fatigue,

’ Depression

’ Quality of life

Formalized Exercise Programs

’ LSVT BIG

’ Rock Steady Boxing

’ Peddling for Parkinson’s

’ Whopping Movers

’ Dance for PD

’ Pineapple Yoga

’ Ballet

LSVT BIG’ Lee Silverman Voice Training – created LOUD therapy in

1987 by Dr. Lorraine Ramig

’ BIG therapy created later

’ Incorporates large movements

’ Improves walking, balance, reaching

’ Reduces falls

’ 2018 study with 114 patients – 40-50% improvement in Timed Up and Go, Cognition and Motor scores

’ Isaacson, et al, Journal of Physical Therapy Science, 2018, April 30(4), 636-641.

“Dr. Sutherland

Says”

It’s Time To Play…

“Dr. Sutherland Says”

You Have To Do The Exercises At Home!

Rock Steady Boxing’ Founded in 2006 in Indiana by Scott Newman (PD)

’ 43,500 patients world wide participate

Boxing for PD works’ 2013 study, 36 weeks

’ 31 PD patients, randomly assigned to:’ Boxing Class for 90 min, 2-3 times per week, or

’ Group exercise (mixed exercises) 2-3 times per week

’ Boxing showed significant improvements in:’ Gait speed and endurance (p <0.025)

’ Both groups showed improved balance, mobility and quality of life measures.

Betty says visualizes her mother-in-law

Pedaling for Parkinson’s’ Started based on research done by Dr. Jay Alberts at

Cleveland Clinic in Cleveland

’ National Program

’ Sarasota was one of the first sites

’ Study 2016

’ 14 PD patients, Functional MRI

’ Pedaling faster resulted in more connections in the brain being activated.

’ These effects lasted at least a month.

’ Alberts, et al., Brain Connect Feb 1:6(1), 25-36.

Exercise Reduces Risk of PD

’ 2019 study in Neurology

’ 18,121 people followed for 34 years

’ Reported exercise levels

’ In 2012, asked about RBD and constipation

’ In 2014, asked about sense of smell, excessive sleepiness

’ If you have 3 of these risk factors, risk of PD is around 65%

’ People who exercise in midlife (30s-50s) have significantly lower risk of PD risk factors (p=0.009)

’ This may be important for your children to know!

’ Hughes, et al., Neurology 2019,93:e2157-e2169

When PD Is Properly Treated

’ Time of progression to disability (gait problems) is doubled.

’ 8-10 years without proper treatment

’ 15-20 years with proper treatment

Exercise Quickly Improves Cognition in PD

’ 2018 study

’ 14 patients

’ 3 conditions – sedentary, low intensity continuous exercise for 25 min, and high intensity interval training (HIIT) for 25 min

’ Improvement was seen in memory, attention and sustained attention immediately after HIIT

’ Memory was better immediately after moderate exercise

’ Fiorelli, et al., Journal of Physical Activity and Health, Vol 16, Issue 2, 2018.

Exercise Improves Cognition In PD

’ 2019’ Review of 2000 studies mentioning PD and

cognition’ 11 studies deemed valid’ 508 patients combined, mild to mod/severe PD’ Aerobic exercise significantly helps Memory and

moderately helps Executive Function

’ Weight lifting and balance classes each help global cognition

What Does Exercise Do to the Brain in PD?

’ Produces more of your own dopamine

’ Produces neurotrophic factors – which help with brain cell health and connectivity

’ Produces more Endorphins (pain reduction, feeling good)

’ WE TAKE MEDICINES TO DO THIS!

’ Sooo….

“Dr. Sutherland

Says”

It’s Time To Play…

“Dr. Sutherland Says”

Exercise Is Medicine!

Exercise Has Sustained Benefits in Dopamine Production

’ 2019 study

’ 35 subjects with PD, age 45-80, mild to moderate

’ Functional MRI (fMRI), UPDRS, VO2 max at baseline and again 3 months later

’ Exercise (spinning) versus stretching, 3 days per week for 3 months

’ VO2 max improved 25% with spinning 3 days per week for 3 months (p < 0.001); stretching did not

’ Dopamine production increased 80% in the caudate (p < 0.05) with aerobic exercise but not with stretching

’ These are sustained benefits, not just instantaneous

’ Sacheli, et al., Movement Disorders 2019, 34:12 1891-1900.

Hou, et al., Front. Aging Neurosci. 2017; 9: 358.

Hou, et al., Front Aging Neurosci. 2017; 9: 358.

What is the Best Exercise for PD

’ Very few head-to-head trials

’ Tango versus Exercise Class

’ Tai Chi versus Weight Lifting versus sedentary

’ The Best Exercise is Anything You Can Do!

Tai Chi v. weight lifting v. stretching

Li, Fuzhong et al., NEJM: 366,6 (2012): 511-9. doi:10.1056/NEJMoa1107911

’ 2012 study at Oregon Health Sciences University

’ 195 patients with PD, 40-85, mild to mod/sev PD

’ 24 week study, twice per week Tai Chi, Weight Lifting or Stretching

’ Tai Chi significantly improved’ Balance, Gait Speed, Reach, Stride length, UPDRS

’ Weight lifting also improved these same things, though not at much as Tai Chi

’ Stretching did not not significantly help

“Dr. Sutherland

Says”

It’s Time To Play…

“Dr. Sutherland Says”

Exercise Is As Important As Any Medication You Can

Take For PD!

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Wearing off and dyskinesia both increase over time

Adapted by permission from Macmillan Publishers Ltd: Nat Clin Pract Neurol., Olanow CW, Obeso JA, Stocchi F. Drug insight: Continuous dopaminergic stimulation in the treatment of Parkinson's disease. Nat Clin Pract Neurol. 2006;2:382-392. copyright 2006.

Plas

ma

LD C

once

ntra

tions

Dyskinesiathreshold

Efficacythreshold

Time (y)

Early disease Moderate disease Advanced disease

Therapeutic window

“on” “on” “off”“off” “on” “off”

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Goals of Add-on Therapy to LD Are to Reduce “Off” Time and Improve Symptoms and

Functionality Throughout the Patient’s Day

Pahwa R et al. Curr Med Res Opin. 2009;25:841-849.

Improved

Worsened

Sym

ptom

Con

trol

LD + Add-on LD + placebo“Off” time

“On”

“Off”

Improve severityduring “on”

Less“off” time

LD + Add-on dose

LD doses

Improve severityduring “off”

Coordinating Medicines and Exercise

’ On-time – best time to exercise

’ Off-time

’ Exercise burns up PD medications faster

’ You may benefit from taking extra medication just before exercise

’ Hydration and Electrolytes before and during exercise

’ If possible, exercise at your best time of day

’ If you have a trainer or physical therapist, educate them about the meds

Which Do You Choose?

Thank You!