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The Effects of Exercise

Research studies indicate a general consensus about improvements in both kinematics and quality of life in patients with Parkinson's disease as the result of physical exercise [10].
Senior caucasian man doing lateral flexion movement


Why exercise?

People with PD are challenged with a decrease in their motor learning ability [4].  Therefore, exercise programming that amplifies sensory input while maintaining simplified functional training is best, as well as a comfortable and familiar environment.  People who develop Parkinson’s disease are automatically predisposed to lack of balance, flexibility and coordination which can lead to other disorders and increase their risk of injury[4].  


Bakhshayesh et al. (2017) recommend that exercise programming include muscle strengthening exercises, aerobic exercise and stretching.  The Pilates Method as a primary exercise training modality encompasses both isotonic and isometric exercises as well as stretching of muscles, decoaptation of joints, and depending on intensity, some cardiovascular intensity.  Pilates exercises consistently stimulate physiological adaptations by offering variations of external stimuli within a structured exercise format. In this way, there is continual skill learning which develops cortical plasticity (a continuous ability of the brain to reorganize neural connections based on external stimuli).   



One of the most debilitating aspects of PD is postural decline and instability, which can lead to an increased risk of falls and impaired physical function and mobility. Multiple studies demonstrate that Pilates exercises improve both static and dynamic balance.  Improved balance can greatly reduce the risk of falls correlated to disease progression. Pilates exercise helps avoid or deter the emergence of postural issues such as forward flexion, forward drop of shoulders, anterior head carriage (neck dropped forward), flexed knees, and bending of hands, among many other musculoskeletal postural deviations.  Most research indicates that an improvement in balance disorders is best approached using balance exercises and resistance training [4]. The nature of Pilates exercises is to engage deep core muscle stabilizers to elicit erect posture and alignment which supports balance, while the use of one’s own body weight provides safe and appropriate resistance. 


Pilates exercise is associated with improvements in functional movements, increased strength, better recruitment of lower extremity muscles, and core stability [4].  According to Bakhshayesh et al. (2017), Pilates exercises retrain postural control and enhance neuro-plasticity and are therefore an ideal method to develop mind-body awareness, and control postural movements, and Pilates exercises have been proven to be more effective in improving balance than regular walking [10]; [2].

What about Aerobic Exercise? 

Pilates as a primary exercise training modality does not negate the importance of aerobic exercise which has been shown in multiple studies to be beneficial in improving gait, balance, physical function, muscle strength, motor function, and QOL [20]; [4].  In fact, numerous scientific investigations conclude that aerobic exercise in the form of dance, Tai Chi, boxing, treadmill walking, and many other cardiovascular activities directly attenuate disease progression by influencing cerebral mechanisms [3].  Success with aerobic exercise applied in animal studies indicated enhanced brain neuroplasticity, improved cognitive task performance, increased brain neurotrophic factors, (which is relative as a therapeutic approach to neurodegenerative diseases), and was observed to even reverse striatal neuron hyperexcitability [3].  As technical as this sounds, PD is a complex chemical imbalance in the brain and noteworthy improvements in animal brain chemistry due to consistent exercise have opened a wide path for human studies.  The bottom line in recent research is that exercise increases brain derived neurotrophic factors (BDNF), and improves cognitive and physical health in people in general, and this is especially important for people with PD. Thus, consistent aerobic exercise should automatically be included in a program to slow PD progression [3].


Unfortunately, randomized controlled studies with long term follow ups which could attest to the efficacy of regular aerobic exercise to slow disease progression are lacking.  This is due to distinct complicating methodological factors which create impediments to clinical study assessments on the influences of exercise on PD.  PD progression varies by individual but tends to be very slow.  It is difficult to assess outcome measures, especially those not tainted by medication effects.  Currently, there does not exist a valid and reliable system of biomarkers outside of development of dementia or dopaminergic medication refractory symptoms.  Since these problems generally develop late in the disease, and are conditions not subject to medication influences, they evade the confluence of randomized controlled trials (RCT).  Another aspect which precludes RCT is a long term adherence to exercise programs by patients of PD who are generally in their senior years, although that’s not to say that PD is exclusive to people over age 50.  PD is now reaching younger populations of up to 20% of all cases in the United States.  Finally, it is quite difficult to validate that control group participants (in the non-exercise groups) are complying with RCT parameters since it is a well known tenet that exercise may delay disease progression.  


Nevertheless, there are other factors as to why aerobic exercise should remain a consistent auxiliary training mode for people with PD, while the Pilates Method remains the primary template for exercise programming.  Among these reasons is that aerobic exercise may not be accessible to all stages of Parkinson’s disease, especially when comorbidities exist, while Pilates is safe and effective for all stages of PD and offers support for complex health conditions.  Pilates also has rehabilitative and therapeutic aspects helpful in correcting muscle imbalances, movement deviations, and poor musculoskeletal alignment.  With this view, Pilates is an excellent precursor to aerobic activity or resistance training.

What about Resistance Training?

Some research studies exist in which patients with PD were trained using progressive resistance exercise (PRE), or different types of strength training.  Positive affects were noted in static posturography, speed of fast rhythm walking, and QoL (as perceived by the person with PD).  However, data is lacking which demonstrates changes in freezing of gait, area and speed of walking (Center of Pressure parameters), motor symptom changes, and no significant improvements were noted in balance control especially under perturbation [21].  Further, it is difficult to compare study results since some trials did not report Parkinson's disease sub-type while others focused on AR-subtype-PD (Akinetic-Rigid Parkinson's) [21].  


It is difficult to underline progressive resistance exercise or strength training as a primary exercise mode for people with PD since it is not accessible in all stages of disease progression, it requires a trained professional present to ensure safety, a specialized location (gym) and equipment, it is not suitable for people with PD and co-morbidities such as Scoliosis or Osteoporosis, and finally it has not been demonstrated to improve balance which is of the utmost importance in people with PD [22].



Delaying Disease Progression

An effective exercise program can delay or even possibly reverse motor dysfunction in people with PD [4], while improving balance, gait pattern, physical function and overall quality of life in people with PD.  Cancela et al. (2017), note that physical exercise as a complementary treatment to confront PD is effective at forestalling disease progression.   A combination of exercises which combine training balance, flexibility and strength, show the most optimal improvements in motor function [4].  Secondary benefits of exercise include improvements in non-motor symptoms like depression and anxiety.  Further, exercise has been proven to decelerate the emergence of other motor and non-motor symptoms of the disease in its early stages [4].


Which Exercise is Right for Me?

Most exercise training modalities for PD involve supervised intervention with specialized tools and/or specialized facilities [5].  In addition, the burden to commute to receive exercise therapy, and the potential cost of fitness specialists to deliver specialized programming, may contribute to a lack of consistent adherence to a regular exercise program.  For this reason, a home-based exercise program which involves no special apparatus or machine and/or minimal inexpensive props is ideal, and would greatly enhance the possibilities of people with PD maintaining a consistent exercise regimen. Both Pilates and some forms of aerobic exercise can be done at home, without special equipment by people with PD in an effort to diminish or delay the onset of motor symptoms.


Although there have been many studies citing the benefits and improvements in people with PD after incorporating a Mat Pilates (MP) program in conjunction with other exercise modalities, there is a lack of specific Pilates exercise programming for people with PD [5].  Cancela et al. (2017) undertook an exploratory study to determine the feasibility of a supervised MP program for people with PD with a detailed description of the program’s components, and provide insight into the efficacy and ease of implementing a MP program by an individual at home. The findings of the Cancela et al. (2017) study show MP to be a feasible rehabilitative exercise strategy for people with PD, and that following this program will improve fitness level and ultimately quality of life.  Also observed was a willingness by participants to maintain a MP exercise schedule indicating a confidence in the programming and a lack of fear of falling since most exercises are conducted on the floor [5].  

Why Pilates?

Pilates is a goal-oriented movement practice which helps to strengthen neural networks to boost the mirror neuron system, and facilitate an increase in motor learning.  By utilizing techniques such as cueing with emotional priming, visual enhancement, and touch, Pilates instructors are able to enhance sensory input into areas of the brain which process motor activity.  In a study by Masterson (2015), research concluded that when motor and emotional learning centers of the brain were stimulated through positive emotional and technical cueing, participants in the control Pilates group improved in physical skill, obtained a higher level of physical self-efficacy, and were more goal self-motivated.

We recommend Pilates as a primary exercise training modality, and some form of aerobic exercise whether that is boxing, dance, Tai Chi, treadmill walking, swimming, or any other cardiovascular activity, as an auxiliary exercise training mode. The most crucial decision is to undertake a consistent physical fitness regimen which adheres to a daily practice of Pilates.   

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Which exercise is best for me?

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Parkinson’s Disease is unique in the manner in which it manifests in each individual.  Further to consider is that pharmacological treatments may vary and fluctuate regularly, thereby affecting the possibility to physically exercise, and may make exercising in one way or another, more challenging.  The factor of preference also exists, while physical ability and cost must be considered as well. 


Exercise can help to improve motor symptoms, neuro-plasticity, and  may even restore some degree of cognitive circuitry [17].   Another benefit could be improved motor learning and behavioral performance.  Dance improved mood, and due to its fun and social aspects, researchers reported smaller attrition rates, especially in older adults who find it difficult to exercise regularly [27].  This may encourage people to incorporate dance exercise into their home life.  


Boxing clearly demonstrated improvements in gait function and endurance, and improved forward reach ability, while instilling a sense of control and a higher perception of quality of life [26].


Tai Chi was effective showing improvement in motor symptoms, neuroplasticity, and overall well-being.  It is a low cost, low tech, low impact, moderate intensity exercise appealing to all ages and physical conditions [6].


The Pilates Method was designed to retrain postural control and motor learning, and thus helps most to control postural movements and in particular maintain balance [4].   Regardless, which exercise mode is most appealing to the patient of PD, the most crucial decision is to undertake a consistent exercise regimen, and best would be exercises from the Pilates Method as a primary training modality, and any or as many other exercise modes possible, as auxiliary fitness training modes.

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