In any exercise program it is important to perform preliminary tests in order to obtain a baseline fitness level so the program can be specified to the client's particular needs. There are three main components to an exercise program: cardiovascular, flexibility, and strength training. When assessing baseline CV fitness, maximal oxygen consumption (VO2max) is the traditional tool of choice. VO2max is the amount of O2 one utilizes during exhausting work and is an objective measure of the circulatory system's maximal capacity to deliver O2. The more aerobically conditioned the individual, the greater the VO2max and the greater the capacity for aerobic energy transfer. However, sub-maximal testing may be more appropriate for clients whom are of below average health. The modality of choice for individuals with PD to be tested is the recumbent stationary bicycle, due to the allowance to lean against a seat back and to use your legs to pedal, which alleviates any pressure on the lower back and requires very little balance (Lieberman et al., 1993).
The next assessment for an exercise program is for muscular strength. All the major muscle groups should be tested either with a 1RM (repetition maximum) or 10RM to acquire a baseline strength level. It may be necessary to use very low weight or even to substitute a weight with a household item (i.e., can of soup, etc.).
The final assessment for the program deals with flexibility. Assessing flexibility is critical to determine active range of motion of the client. The American College of Sports Medicine (ACSM) recommends screening the range of motion of the following:
- Cervical flexion/extension
- Vertebral flexion/extension
- Hip: internal/external rotation, flexion/extension, straight leg raises
- Shoulder: flexion/extension, combined rotation and elbow flexion
- Postural: assessment to look for any vertebral deviation (i.e., kyphosis, lordosis, scoliosis)
- Gait: objective notes on general gait patterns and timing
As mentioned earlier, a recumbent stationary bike is an excellent tool for CV fitness. However, for individuals with PD, there are other good options, such as swimming and walking. Walking is the most practical of all aerobic activities because persons with PD are not only exercising, but they are also working on the most debilitating aspect of PD - the poor gait associated with hypokinesia.
Aerobic exercise should occur a minimum of 3 times per week for 30 minutes or more at an intensity of 60% to 75% of HRmax, which is recommended by the ACSM using one of the previously mentioned methods. Walking is recommended primarily because it works on two aspects of the disease. While walking, the client will receive verbal instructional cues from the exercise specialist in order to correct their gait abnormalities, while performing aerobic exercise. The use of instructional sets is a rehabilitation strategy, which may assist patients with PD to immediately improve their movement (Behrman et al., 1998). Furthermore, patients with PD may also benefit from a practical self-instructional strategy to enhance the retention of training (Behrman et al., 1998) once there is improvement in regards to the exercise specialist's instructional cues. When walking is not used for the aerobic portion of the exercise program, the client should still have an instructional cue walking session at least twice per week.
The ACSM and other organizations recommend one set of 8 to 12 reps for 8 to 10 major muscle groups two to three times per week (American Council on Exercise, 1999). It may be safer for individuals with PD to utilize machines for strength training. Machines will provide the back support necessary for the client with PD to maintain balance in case of fatigue or any other occurrence that might cause a fall.
It is also recommended to perform static stretches for all major muscle groups with each stretch being held for 20 to 30 seconds in order to maintain full range of motion. It is important to have clients perform stretching exercises after a 5-minute warm-up and after a 5-minute cool-down. It would also be beneficial for the client with PD to perform the stretching exercises at home, on off days from the exercise program. Some specific recommendations from Lieberman et al. (1993) for flexibility exercises are:
- Chin tuck
- Head tilts
- Head turns
- Trunk bends - forward/backward, side-to-side
- Trunk twists
- Hip stretch
- Hamstring stretch
- Shoulder stretch
- Shoulder raises
- Facial mobility
- Arm stretches
Along with the exercise guidelines, the exercise specialist must be aware of some safety precautions that may arise with a client with PD. Pharmacotherapeutic management may have side effects on the client with PD. Therefore, it is recommended that the exercise specialist obtain a complete list of medications and accompanying side effects in order to identify problems associated with the medicine in use (Barker et al., 1994). Another precaution to be aware of is the risk of falling for clients with PD. Sometimes while sitting unsupported or rising from a chair, a client with PD may lose his or her balance and fall. Also, orthostatic hypotension often occurs when a client with PD rises from a lying or sitting position, causing a sharp decrease in blood pressure resulting in a fall. And finally, the gait abnormalities associated with PD may contribute to falls as a result of shuffling gait or freezing.
The importance of exercise in PD is indisputable. It has been shown many times that exercise both increases and maintains functionality. Exercise guidelines for a particular disease can never be etched in stone. Individuals within a disease group may have as many differences among one another as two entirely different diseased groups have to each other. But the key to success with an exercise program is adherence. Comella et al. (1994) found that even with documented gains in functionality, and instruction to continue the exercises at home, at the completion of the rehabilitation program, every patient resumed a sedentary lifestyle. This observation suggests that exercise programs for individuals with PD are not easily incorporated into one's lifestyle at home. Thus, this demonstrates the importance of community-based programs for older adults with PD. Community-based exercise programs can help prevent the individual with PD from returning back to baseline immediately after a cessation of physical therapy. Any prolonging of functionality in this group will be a welcome addition to their quality of life.