One on One

The One-On-One Column provides scientifically

supported, practical information for personal trainers
who work with apparently healthy individuals or
medically-cleared special populations.

COLUMN EDITOR: Paul Sorace, MS, RCEP,

CSCS*D

Exercise Programming for

Parkinsons Disease
Lance M. Bollinger, MA,1 Celsi E. Cowan, BS,2 and Thomas P. LaFontaine, PhD3
1
Kinesiology Department, East Carolina University, Greenville, North Carolina; 2Department of Nutrition and Exercise
Physiology, University of Missouri, Columbia, Missouri; and 3University of Missouri, Columbia, Missouri

SUMMARY
PARKINSONS DISEASE (PD)
PRESENTS NUMEROUS MOTOR
AND NONMOTOR LIMITATIONS
TO EXERCISE PROGRAMMING.
EXERCISE PROFESSIONALS MUST
UNDERSTAND THESE LIMITATIONS
AND CURRENT EXERCISE RECOM-
MENDATIONS TO DEVELOP EFFEC-
TIVE EXERCISE STRATEGIES FOR
CLIENTS WITH PD.
arkinsons disease (PD) is one of
age (12), it is also advised that the
exercise professional (EP) thoroughly
examine any potential comorbidities
and obtain medical clearance before
working with persons with PD.
Although exercise intervention is
unable to positively modify the under-
lying pathology of PD, many associated
functional limitations can be improved
with regular exercise. An effective
exercise program should consist of
aerobic, resistance, flexibility, and func-
tional training. The EP should be aware
of the limitations of PD and appropriate
because PD is a progressive disease
process, functional status needs to be
reevaluated at regular intervals. Zhao
et al (21) demonstrated that the
median rates of progression through
stages 1, 2.5, 3, and 4 of the Hoehn and
Yahr scale are 20, 25, 24, and 26
months respectively. Therefore, it is
recommended that functional status be
reevaluated every 2 years.
All 4 cardinal symptoms need to be
evaluated before beginning an exercise
program. Tremors can be classified as

P the most common neurodegen-

erative diseases and presents
numerous functional limitations (12).
exercise interventions (17).

The accompanying Special Populations
column includes a discussion of the
epidemiology, symptoms, functional
limitations, and benefits of exercise
associated with PD. The cardinal symp-
toms of PD include resting tremor,
rigidity, bradykinesis, and decreased
postural reflexes (10), which can present
many functional limitations such as
abnormal gait patterns, decreased bal-
ance, and difficulty performing activities
of daily living (ADLs). Exercise inter-
vention has been shown to be an
effective means to improve functional
status (6,7,11). However, the limitations
presented by PD can severely limit
exercise performance and adherence.
Because the major risk factor for PD is
FUNCTIONAL EVALUATION
Evaluation of PD severity is crucial
before beginning an exercise program.
Medical history information should
include a physician evaluation includ-
ing the Hoehn and Yahr stage rating
(9) (see Special Populations column,
Table 1) or Unified Parkinsons Disease
Rating Scale score (13). The former
system relies primarily on the evalua-
tion of motor symptoms, whereas the
latter evaluates the severity of both
motor and nonmotor symptoms.
These rating systems provide valuable
information regarding functional limi-
tations; however, additional functional
evaluations by the EP can provide
information regarding other areas
to improve (Table 1). Additionally,
resting, postural, or intention tremors.
Resting tremor is perhaps the most
common and easily identifiable symp-
tom of PD and usually presents as
a pronation/supination of the wrist or
pill rolling between the thumb and
index finger. To elicit resting tremor,
the EP should instruct the client to sit
in a relaxed position with hands
resting in the lap. The EP should then
give the client a mentally challenging
task (17) such as counting backward
by 2s from 100 or reciting the alphabet
backward. To assess postural tremor,
the client should be instructed to
suspend a limb against gravity (such
as fully extending arms parallel to the
floor). Because PD may present uni-
laterally, it is important to assess both
sides. Intention tremors may be eval-
uated by having the client carefully

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One on One

Table 1
Physical function examination for persons with Parkinsons disease

Symptom Test description Criteria

Tremor
Resting Give a mentally challenging task while hands Pronation/supination of wrist or pill rolling with thumb
are at rest and index finger
Postural Suspend limb against gravity Excessive shaking of limb, especially in distal regions
(note amplitude)
Intention Index finger to nose Note accuracy of movement
Rigidity Moving each joint through ROM while relaxed Lack of full ROM
Increased muscular resistance
Bradykinesis Instruct to pronate and supinate forearm rapidly Slow speed and lack of coordination through movement
Postural reflex Pull test Two or more steps backward
Failure to respond
ROM = range of motion.

touch the index finger to the nose.
Noting the degree and amplitude of
tremors during these tests gives an
idea of the severity of PD. A more
detailed discussion of tremor varia-
tions can be found in the review by
Jankovic (10).
To assess rigidity, the EP should note
muscular resistance and range of
motion (ROM) while manually mov-
ing each major joint through its full
ROM with the client in a relaxed
position (17). This can be scored
subjectively on a 15 scale according
to the judgment of the EP because no
scale has been established to objec-
tively measure rigidity. Specifically, this
test should be performed for the
shoulders, elbow, hip, knee, and ankle.
Caution should be used when perform-
ing these tests for the neck and trunk.
Bradykinesis can be evaluated by
instructing the patient to rapidly pronate
and supinate the forearm (17). If brady-
kinesis is present, the speed and
coordination of the movement will be
compromised as the duration of the
activity increases. Finally, postural
reflexes can be evaluated by the pull
test (17). With the patient facing away,
the EP reaches around to the front of
the shoulders and pulls firmly. Two or
more steps backward or failure to (20). Other authors have shown that in
respond to the pull test are both indi- a non-PD population, persons requiring
cative of compromised postural reflexes. .10 seconds to complete this task have
Additionally, it may be beneficial to use an 80% chance of falling (18). This test
a walking test, such as the Timed Up allows the EP to evaluate several ADLs:
and Go test (15). In this test, the client standing, turning, sitting, and balance as
must stand from a seated position, walk well as gait abnormalities, such as
3 m (;10ft), turn around, walk back to decreased stride length, festination
the start, and return to a seated position. (small shuffling steps), and/or freezing.
Completing this task in less than 9
seconds indicates very low risk of fall, AEROBIC EXERCISE
whereas a time of 20 seconds or more Currently, there are no established
may indicate an increased risk of falls exercise guidelines specific to PD.
Table 2
Aerobic training guidelines according to Parkinsons disease stage*
Disease stage Intensity (%V_ O2 max) Duration (min) Frequency (d/wk)
1 6080 4060 46
2 6080 4060 46
3 5070 3050 intermittent 35
4 5070 3050 intermittent 35
5 5065 2545 intermittent 35
Intermittent exercise should be no shorter than 5 minutes per bout. It is also advised to use
various modes of exercise (see Table 3) to train different recruitment patterns and limit
physical distress associated with symptoms of Parkinsons disease.
*Disease stage based on modified Hoehn and Yahr staging scale (Special Populations, Table 1).

56 VOLUME 34 | NUMBER 2 | APRIL 2012

 Table 3 It is important to note that PD may be
Recommended exercise modes for Individuals with Parkinsons disease accompanied by other age-associated
comorbidities, such as hypertension,
Disease stage cardiovascular disease, arthritis, and
cognitive decline/dementia, which
Mode 1 2 3 4 5
may require modifications to the AT
Aerobic prescription (10,12,17). Typical AT
guidelines for disease stage can be found
Treadmill R R S N N
in Table 2. Additionally, recommended
Elliptical/ski machine R R S N N modes of AT can be found in Table 3.
Rower R R R Arms only Arms only
RESISTANCE EXERCISE
Bicycle (upright/recumbent) R R R R R As with AT, there are minimal estab-
Arm ergometer R R R R R lished exercise guidelines for resis-
tance training (RT) for persons with
Resistance PD. Tremor and rigidity offer sub-
Free weights R R/S S N N stantial limitations with respect to
coordination and ROM, respectively.
Resistance machines R R R R R Intention tremor usually decreases
Resistance bands R R S S S with cognitive movement strategies.
This strategy may provide a safer
Manual resistance R R R R R atmosphere for RT by reducing trem-
Isometric exercise R R R R R or severity. Depending on the severity
of tremor, free weight exercises may
N = not recommended; R = recommended; S = supervision advised. be an appropriate intervention. This
is especially true of exercises that
However, aerobic training (AT) guide- persons with PD. Depending on do not involve overhead lifting. How-
lines for PD may mirror those for the severity of bradykinesis, it may be ever, free weights may become unsafe
healthy persons (15). Although treadmill difficult to achieve sufficient workloads with increasing disease stage. Selec-
exercise has been demonstrated to be to induce aerobic adaptations. Addi- torized or plate loaded machines offer
effective in improving functional status tionally, it is important to note that a safe alternative to free weights and
(3,5,16), safety, disease stage, and func- muscular strength is often compro- have been shown to provide similar
tional limitations may dictate other AT mised with increasing velocity of move- strength gains in healthy persons (20).
modalities. Bicycle and arm ergometers ment in PD (14). Considering these Many selectorized and/or plate
have been shown to be safe and effective two limitations, persons with PD may loaded machines allow unilateral use,
AT modalities (17). Bradykinesis pres- respond better to AT using relatively which can be a good RT strategy
ents a specific challenge to AT for lower velocity and higher resistance. because PD often presents with uni-
lateral symptoms. Additionally, exer-
cise modifications may be necessary to
Table 4 accompany decreased ROM associ-
Resistance training guidelines according to Parkinsons disease stage* ated with PD. Likewise, additional
ROM training may improve exercise
Disease Intensity (%1RM) Volume (sets 3 repetitions) Frequency (d/wk) tolerance and improve ADLs. It is
stage
possible that RT with lower velocity
1 6080 3 3 812 24 may provide greater muscular recruit-
ment and therefore greater strength
2 6080 3 3 812 24
gains and/or hypertrophy. However,
3 5070 2 3 1015 23 training at greater velocities may
improve speed-specific strength and
4 5070 2 3 1015 23
therefore improve ADLs. Although
5 4565 12 3 1020 23 this type of training has not been
investigated in PD, it has been shown
*Inclusion of high velocity resistance training has been shown to increase strength and
improve functional training in elderly individuals. This type of training has not been tested in to improve functional performance
persons with PD. and muscle power in elderly men
without PD (4). A combination of
RM = repetition maximum.
both strategies may be necessary to

Strength and Conditioning Journal | www.nsca-lift.org 57

One on One

Table 5
Cueing strategies for Parkinsons disease

Type of cue Internal External

Auditory Repetitive mantra reminding self to maintain Metronone (;80% basal frequency), music (march), verbal
frequency or amplitude of step cues from exercise specialist
Visual Visualization-imaging step performance before Floor markings, such as tape to increase stride length
engaging in step cycle and amplitude
Tactile Coordinate step and breathing frequency Exercise specialist provides tap on shoulder to maintain
stride frequency
Cognitive Actively think through each motion of step cycle Remind client which muscle to activate and movement to
produce at each phase of step cycle

elicit optimal benefits of RT. Recom-
mended types of RT can be found in
Table 3, and a typical RT program
depending on disease stage can be
found in Table 4.
FLEXIBILITY AND ROM
Flexibility training should consist of slow
static stretches and passive ROM exer-
cises for all major muscle groups and
joints. Because PD symptoms are typi-
cally initially noted in the trunk and
arms (17), flexibility and ROM exercises
should emphasize these areas first to
minimize the risk for complications,
such as frozen shoulder and loss of spinal
mobility. As with AT and RT, there are
no established guidelines for flexibility
exercise for persons with PD. One study
showed that in persons with PD, flexi-
bility is increased after 10 weeks of
training 3 times per week (19).
FUNCTIONAL TRAINING
Despite some skepticism of the func-
tional benefits of exercise in PD,
a recent meta-analysis by Keus et al.
(11) demonstrated the efficacy of exer-
cise in PD. These authors suggest using
cueing and cognitive movement strat-
egies as a means to improve daily
functioning. Cues can effectively im-
prove stride length and frequency and
decrease instances or duration of
freezing. Cueing strategies are thought
to improve gait by providing external
rhythmic or visual stimuli to compen-
sate for the improper stimuli supplied
by the basal ganglia (11). Cues can be
external (from the surrounding envi-
ronment) or internal (supplied by the
person with PD) and can be divided
into auditory, visual, tactile, and cog-
nitive cues. Table 5 provides an outline
for cueing strategies. These strategies
can be implemented in exercise and
normal living situations.
Cognitive movement strategies involve
deconstructing complex movements
into a series of smaller movements
executed in a fixed order (11). For
example, standing from a chair could be
composed of placing hands on hand-
rails (or table), leaning forward at the
waist, extending the knees, and finally,
extending the hips. This pattern should
be practiced mentally (visualization of
the proper movement pattern) before
physically executing the task. Once the
pattern is developed, it should remain
under conscious control rather than
becoming an automated movement. It
is thought that in PD, the basal ganglia
loses the ability to perform sequential
movements. By consciously perform-
ing each task individually, sequential
movements can be improved (11).
Functional training should also include
balance exercises. Although balance
exercise has been shown to be effec-
tive, some evidence suggests that it is
more effective when combined with
lower limb RT (8). It has previously
been reported that improved balance is
not necessarily associated with reduced
incidence of falls (2). It should be noted,
however, that the fear of falling, not just
decreased balance, is a risk factor for falls
(1). Successful functional training should
not only improve ADL performance but
also instill confidence. By improving
confidence through exercise, it may be
possible to reduce the fear of falls.
SUMMARY
PD is a complex disease that can
compromise physical performance.
Additionally, depending on the symp-
tom severity, PD can present many
obstacles to traditional exercise pro-
gramming. By understanding the dis-
ease process and appropriate exercise
interventions, the EP is able to design
safe, effective exercise programs and
play an important role in improving
exercise performance and physical
functioning of the client.
Lance M. Bollinger is pursuing a doc-
torial fellowship in Bioenergetics and
Exercise Science at East Carolina
University.
Celsi E. Cowan is a graduate student in
the Department of Exercise Physiology at
the University of Missouri and the
graduate assistant at Optimus: The Center
for Health.
Thomas P. LaFontaine is a personal
health fitness mentor at Optimus: The
Center for Health in Columbia, Missouri.
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