Recently, our country was shocked when actor Michael J. Fox revealed he was coping with Parkinson's disease. Other prominent individuals such as Muhammad Ali and Attorney General Janet Reno have been living day-to-day with this progressive disease for years. According to the American Parkinson's Disease Association, Inc., 1.5 million Americans were diagnosed with Parkinson's disease in 1993 and the number continues to grow.

Definition and Cause

In 1817, the major symptoms of the disease were discovered and named "Shaking Palsy" by Dr. James Parkinson. It was not until the 1960s that pathological and biochemical changes in the brains of affected individuals were discovered.

Parkinson's disease is a progressive neurological disorder associated with a reduction of the brain's neurotransmitter dopamine. This reduction of dopamine results in the destruction of dopaminergic cells within the basal ganglia of the brain's substantia nigra, leading to a decrease in voluntary muscle movement, coordination, posture and muscle tone. The rate of progression and severity differ from person to person. There is no known cause of Parkinson's disease. However, environmental factors (e.g., toxins, pollutants) and genetics may play a role. Other contributing factors may include aging bodily mechanisms, autoimmune responses and mitochondrial dysfunction (Protas et al., 1997). An individual can be living with the disease for seven to 10 years without symptoms.

What are the risk factors for family members? According to Enrico Fazzini, D.O., Ph.D., (member of the American Parkinson's Disease Association, Inc.), a sibling has only a 5% chance of getting Parkinson's disease when one parent is affected. In families where Parkinson's disease is prevalent, the gene has been localized. However, when tested in sporadic cases, the genetic defect is not detected. Experts are still seeking answers to what causes Parkinson's disease.

Incidence and Symptoms

Parkinson's disease is usually found in individuals over 50 years of age, but it can afflict younger populations, as noted in the case of Michael J. Fox. Some symptoms include tremors while at rest or active, muscle rigidity starting at the neck, shoulders and upper back, migrating to trunk and extremities, freezing (sudden involuntary cessation of a movement or the incapacity to initiate a desired movement) and gait and postural abnormalities along with slowing of movement (bradykinesia). These symptoms can make it difficult for individuals with Parkinson's to perform daily activities. For example, muscle rigidity can effect the arms, making them fixated at the sides and eliminating the natural swing action performed in a natural walking pattern. This can lead to balance and gait complications. The ability to move fingers, hands, arms and legs quickly is greatly reduced, causing the performance of daily tasks to take longer than usual. The ability to rise from a chair becomes more difficult due to bradykinesia and the reduction in motor control. Gait may be impaired due to festination (the acceleration and abbreviation of movements), which accounts for a tendency to take quick running steps when a natural walk is desired. When this is accompanied by slow shuffling steps, a "stooped posture" with rounded shoulders (kyphosis) and flexed knees, the difficulty in turning the body and controlling other postural reflexes produces a potentially dangerous risk of falling. Eating, bathing, dressing, handwriting, shifting from one position to another, preparing meals and just trying to get from one spot to another can be extremely challenging.

This disease affects the muscles that control facial expression, breathing, swallowing and speaking. It can also effect the muscles responsible for eye movement, making reading difficult, decreasing the ability to clear irritants from the eyes through blinking and potentially leading to blurred vision.

Drug Management

Drug management has been the most successful way to treat many of the symptoms associated with Parkinson's disease, helping correct or prevent neurochemical imbalances related to dopamine, epinephrine, norepinephrine and acetylcholine. Some common drugs used are levodopa, carbidopa/levodopa (better known as Sinemet), pergolide, benztropine and deprenyl. As with many drug therapies, side affects do occur. Some of the most common side effects include confusion, insomnia, changes in mental state and gastrointestinal upset. Long-term use can lead to dyskinesia (uncontrolled involuntary movement of the face, torso, arms and legs), a reduced response to drug therapy and a clinical fluctuation of motor disabilities.

Effects of Exercise

The effects of exercise on the disease and medication are still under investigation. Various research studies have found exercise to affect both direct (tremors) and indirect (loss of muscle strength, range of motion and cardiorespiratory function) symptoms of Parkinson's disease (Lewis & Bottomley, 1994; Schenkman, 1992). Dealing with this crippling disease can result in low self-esteem and lack of desire or motivation to live. Exercises performed in a group setting may help boost self-esteem, improve emotional state and enhance exercise adherence.

Physical activity programs should include aerobic fitness, resistance training for muscular strength and endurance, balance, gait and coordination activities, as well as flexibility and relaxation exercises (Rimmer, 1998). It is important to realize that the role of exercise should not be considered a cure for the disorder but rather a strategy for maintaining as much normal function as possible. Research indicates muscle weakness is inherent to Parkinson's disease (Kakinuma et al., 1998). However, even though movement can be difficult, training programs can help improve muscular strength, postural stability, balance and gait (Turnbull, 1992). According to Dr. Tetrud, M.D., member of the Board of Directors at the Parkinson's Institute in Sunnyvale, California, "Exercise for individuals with Parkinson's disease is much more than a pursuit of physical fitness. It is a lifelong necessity and as much a part of the treatment program as the medication."

Gait

Exercise programming for individuals with Parkinson's disease has been traditionally focused on aiding secondary musculoskeletal changes and related deconditioning, as well as the deterioration of functional mobility that eventually develops (Rogers, 1996). Research supports that exercise provides important benefits for Parkinson's patients similar to non-afflicted individuals (Butler et al., 1998). The Schenkman et al. (1998) study demonstrated that improvements in spinal flexibility and physical performance could be achieved in a 10-week exercise program for people in early and midstages of Parkinson's disease. Recently, more strategies targeting motor control have emerged. Gait training is a suitable exercise protocol whether utilizing walking patterns with added challenges or manipulating speed and elevation on a treadmill.

As previously mentioned, problems related to Parkinson's disease are associated with disorders of the basal ganglia. The basal ganglia are thought to play an important role in regulating motor activities involving gait and the fluidity and sequencing of movement (Hausdorff et al., 1998). The components of gait, however, are multifactorial and specific links to the basal ganglia are difficult to pinpoint. For example, with regard to gait initiation, Rosin et al. (1997) state that deficits from Parkinson's disease most frequently originate from the basal ganglia's internal cueing function for movement sequences, which delays the onset of the gait function and slows the continuing gait pattern. Morris et al. (1996) believe the stride length component of gait could also be explained by a deficient internal cue production. He also suggested that an inadequate contribution to cortical motor funtion set by the basal ganglia was an additional possibility.

Functional Assessment

When working with clients afflicted with Parkinson's disease, it is important not only to acquire written permission from their physician to participate in a physical activity program, but also documentation determining their physical limitations.

Assessing gait, balance, coordination, flexibility, agility, aerobic fitness, strength and muscular endurance has become a challenge for fitness professionals working with older adults and those with chronic disease. Presently, there are no national norms to appropriately evaluate these factors. However, in 1997, Roberta Rikli, Ph.D., and Jesse Jones, Ph.D., took on the challenge of developing normative physical performance standards for seniors focused on functions needed to maintain physical dependence in daily activities. These parameters include lower and upper body strength, physical endurance, lower and upper body flexibility, agility and dynamic balance. The assessment protocol and norms will be available in April, 1999, in the Journal of Aging and Physical Activity, published by Human Kinetics. These assessment protocols should help professionals working with older adults design appropriate physical activity programs. However, these two may need to be modified when working with clients affected with chronic diseases.

In summary, Parkinson's disease is a progressive neurological disease that affects the regulation of voluntary movement at a subconscious level. It affects individuals at varying rates of progression and levels of intensity. Drug therapy seems to be the most effective treatment, yet exercise may help lessen its effects.

Fitness professionals interested in taking on clients with chronic diseases such as Parkinson's should be well informed about the disorder. Be familiar with what it is, its causes, symptoms, preferred method of treatment and drug therapy complications. Also, refer to research studies that address the relationship of exercise to chronic disease management. Signage of an informed consent, contract agreement and liability forms is also very important. Proper pre-screening and functional assessments should be administered. This may help assure proper program design and implementation. Focus on designing programs that meet your client's specific needs based on their physicians' recommendations. Maintain open communication between yourself, your client and his/her physician. Design a program that is progressive in nature, achievable, improves or maintains functionality and promotes lifelong commitment.

On a personal note, I would like to thank Greg Welch, M.S., of SpeciFit, who works with older adults challenged by chronic disease and/or medical conditions and Morton J. Smith, AFAA certified personal trainer from 24-Hour Fitness, who has worked closely with a client affected with Parkinson's disease, for their contributions. Their dedication and input can help guide other fitness professionals towards successful physical fitness programming for seniors and chronic disease clients.

For further information, contact the American Parkinson's Disease Association, Inc. at (800) 223-2732.

The following guidelines are for fitness professionals working with clients suffering from Parkinson's:

1. Acquire written consent for participation in physical activity from patient's physician. Complete other applicable forms such as contract agreements and liability waivers.
2. Discuss an appropriate exercise program design with your patient's physician.
3. Perform appropriate assessments, both written and functional.
4. Establish client's personal goals.
5. Establish realistic goals, starting with small steps. Provide caring and positive feedback.
6. Make sure the training environment is free of hazards which may lead to injury. The fitness trainer should continually spot the client. If the client is participating in a group exercise environment, make sure a ballet barre, chair and/or railing is available for support. If a physical support is not available, conduct the program in a seated position for those who are at high risk of falling.
7. Schedule exercises when rigidity is less pronounced. This will depend upon the time of day that medication is taken and when peak drug effects occur.
8. Focus on exercises enhancing posture, balance, coordination, range of motion, muscular strength and endurance, flexibility, breathing and relaxation.
9. When utilizing machines for cardiorespiratory and muscle conditioning, make sure the machines are safe for individuals at high risk of injury.
10. When performed in 86 degree (Fahrenheit) water, aqua fitness classes can be beneficial for your client since water helps prevent falls and provides a natural medium for cardiorespiratory, resistance, flexibility, range of motion and balance training.
11. Duration, frequency and intensity of exercise will vary depending on the client's ability to perform, which is based on physical deterioration, disease progression and exercise selection.
12. Begin your exercise program by gradually building up to five repetitions whether performing range of motion activities or strength training exercises.
13. Keep the number of repetitions from 10 to 15 maximum to prevent injury.
14. It's important for the fitness professional to regularly document any changes in performance, attitude and general health. First, regular program evaluations help determine if the client's needs are being met. Secondly, certain unusual or concern-causing changes in physical and/or mental characteristics should be reported to the client's physician. Maintain an open line of communication between all parties involved.
15. Most importantly, be patient and supportive. There will be times when the disease takes control and limits client participation.

Exercise Suggestions (Each exercise will depend upon the level or degree of Parkinson's progression within each individual.)

Breathing

Begin by having clients sit in a chair while maintaining good posture. Slowly inhale for four counts, utilizing the diaphragm and exhale for four counts through pursed lips. Focus on lifting the diaphragm and expiring the air as if blowing out a candle. Repeat two times, working up to five repetitions. This exercise helps strengthen respiratory muscles and indirectly encourages proper posture. Be careful not to perform the exercise routine too quickly or with too many repetitions. Clients may become lightheaded and dizzy.

Range of Motion

Have the client slowly rotate his/her head from side-to-side, staying within his or her comfort zone. Incorporate breathing by inhaling as you rotate to the right, exhaling as you come to the center, inhaling as you rotate to the left and exhaling as you come back to the center. Start out with two repetitions and build up to five. Perform exercises reaching all joints. Perform each repetition slowly, incorporate breathing and stay within the client's comfort zone. These exercises improve range of motion and relaxation.

Chin Retraction

Standing or seated in a chair with proper posture, gently pull chin toward neck using neck muscles and keeping the chin parallel with the floor. Gentle manual assistance may be appropriate. This helps improve cervical posture of the spine.

Scapula Adduction

Standing or seated in a chair and maintaining proper posture, slowly contract the shoulder blades together, hold for four counts and relax. Repeat five times. This exercise helps improve posture.

Balance and Posture

If the client is able, have him/her place feet shoulder width apart (broad stance) with available support (e.g., chair, ballet barre or wall). Stand in this position for approximately 30 seconds. Focus on proper posture (maintaining neutral spine) and stand with knees relaxed. Encourage a natural rhythmic breathing pattern as your client stands in place. Repeat. To increase difficulty, have the client move from this position, placing one foot behind and one in front (a tandem stance). Again, make sure support is available and check posture and breathing technique. Maintain stance for 20-30 seconds. You can also incorporate a one-foot stand. These exercises help enhance balance.

Walking in a Straight Path

Practice a normal walking pattern. Focus on breathing, proper posture and foot placement. When this task becomes easier, vary the task by adding objects to step over. Spot the client to prevent falls. If freezing should occur, have your client stop and provide them with support. Gradually, encourage a more normal posture and try to establish a stable stance before re-attempting the walking exercise. This exercise can help enhance balance and coordination.
Bio:

Laura A. Gladwin M.S., is a member of California State University, Fullerton Advisory Board for the LifeSpan Wellness Clinic and Senior Fitness Certificate program, a Special Advisor to the California Governor's Council on Physical Fitness and Sports and serves on the Older Adult Committee. Gladwin is an AFAA Master Specialist and President of LGA Consultant Services.