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Parkinson's Disease - Fitness Counts


									          Parkinson Disease:


                  3rd Edition

            Heather Cianci, PT, MS, GCS
      The Dan Aaron Parkinson’s Rehab Center
Parkinson's Disease and Movement Disorders Center at
                Pennsylvania Hospital
                   Philadelphia, PA
                           PARKINSON D ISEASE : F ITNESS C OUNTS

The information contained in this publication is provided for informational and educational purposes only
and should not be construed to be a diagnosis, treatment, regimen, or any other health-care advice or
instruction. The reader should seek his or her own medical or other professional advice, which this publi-
cation is not intended to replace or supplement. NPF disclaims any responsibility and liability of any kind
in connection with the reader’s use of the information contained herein.


Chapter 1            Foundation for Fitness .................................................... 1

Chapter 2            Putting It All Together .................................................... 9

Chapter 3            Balance, Falls and Posture .............................................. 19

Chapter 4            Helpful Therapies ............................................................ 26

Chapter 5            Carepartner Assisted Exercise ........................................ 28

Appendix A           Resources........................................................................... 30

Appendix B           A Note for Therapists...................................................... 32

About the Author ...................................................................................... 33

Acknowledgements .................................................................................... 35

                      About this booklet

     This manual is intended to be a resource for increasing your fitness level, and for
improving your ability to do everyday activities. Read Chapter 1 for an overview of
stretching, strengthening and conditioning—the foundation for fitness. For the
“how to” of exercises, see Chapter 2. Chapter 3 explains how fitness counts for good
balance, posture, and preventing falls. Other therapies that are complementary to an
exercise program are explained in Chapter 4. The appendices provides resources for

    This booklet is part of a literature series addressing topics including nutrition,
medications, speech and swallowing. The booklet Activities of Daily Living: Practical
Pointers for Parkinson Disease is particularly complementary to Fitness Counts. This
free booklet provides more information about activities of daily
living and adaptive aids for PD. Contact the National Parkinson Foundation at
(800) 327-4545, or to request a copy.


   Some people turn away from exercise because they think that it will be too difficult,
or that they can’t fit it into their busy schedules. Others simply do not understand
how exercise can help them. Exercise is important for everyone. It is the foundation
for fitness, and it also helps us fight the effects of aging.

   If you have Parkinson disease (PD), exercise is even more important. Recent
research shows that regular exercise can help people with PD stay more flexible,
improve posture, and make overall movement easier.

   While medication has long been the most promising treatment available, a regular
exercise program should always be part of managing PD. Exercise is one of the few
treatments available that is free, has no bad side effects, and can actually be enjoyable!
Though exercise is not a cure, it can help you to stay ahead of the changes that take
place in your body and can help you feel more in control of your condition.

   This manual is designed to provide general information and suggestions regarding
exercise to all people living with PD. Specific questions or problems should be dealt
with by a licensed physical therapist (PT) or occupational therapist (OT).
   Physical or occupational therapists can:

■ Design or modify an exercise program to meet your particular needs.
■ Evaluate and treat mobility and walking problems.
■ Evaluate and treat joint or muscle pain which interferes with the activities
  of daily living.
■ Help with poor balance or frequent falling.
■ Teach carepartners proper body mechanics and techniques for
  assisting someone with PD.
■ Refer to movement and exercise programs in the community.
■ Treat difficulties performing activities of daily living (ADL) such as eating,
  dressing, bathing and handwriting.
■ Recommend and teach the use of appropriate adaptive equipment.

   Your doctor or other health care professional should be able to refer you to a thera-
pist in your area. When possible, it is best to see a therapist that has special training
and/or experience with PD. Visits to a physical or occupational therapist are usually
covered by medical insurance with referral by a physician.

                             Chapter 1:
                   Foundation for Fitness

     To build a foundation for fitness you will need three main components:
stretching, strengthening, and aerobic conditioning. Each component on its own
is important, but together they can help you remain as active as possible and bet-
ter equipped to deal with the changes that PD can bring. After learning more
about each of these components, you may follow along with examples of each in
Section 2.

   Regular s-t-r-e-t-c-h-i-n-g is the first step in your exercise program, and it can
be one of the most enjoyable. Stretching helps you combat the muscle rigidity
which comes with PD. It also helps your muscles and joints stay flexible.
People who are more flexible tend to have an easier time with everyday move-

Why should I stretch?

    You should stretch because it:

■   Increases range of motion of joints.
■   Helps with good posture.
■   Protects against muscle strains or sprains.
■   Improves circulation .
■   Releases muscle tension.

Do’s and Don’ts of Stretching

■ DO stretch until you feel a gentle pull.
■ DON’T stretch to the point of pain.
■ DON’T bounce while you stretch. Bouncing can cause small tears in muscle
  fibers. This can actually lead to less flexibility.
■ DON’T hold your breath while you stretch. Breathe evenly in-and-out
  during each stretch.
■ DON’T compare yourself to others. Everybody varies in how far they
  can stretch.


When Should I Stretch?

   A good thing about stretching is that you can do it at any time. Get your
day off to a good start by stretching before getting out of bed. Try to stretch
throughout the day. For example, you can stretch while you watch television or
ride in a car.

Choose a time for exercise when you are well-rested and your
PD medications are working.

How often should I stretch? Everyday!

How many times should I do each stretch?

Each stretch should be done 3 times. If you can’t do the entire series of stretches
at one time, select a few stretches to do at different times throughout the day.

How long should I hold each stretch?

For at least 3-5 breath counts. 1 breath count = 1 full breath in and out.

A note about deep breathing
    Learning how to breathe deeply will not only help you get more oxygen, but
will help you relax. Often times, people with PD take shallow breaths. Taking a
shallow breath means we are not fully using our lungs or diaphragm. Shallow
breaths only use the upper part of the lungs and overwork the upper chest mus-
cles. This can lead to tension and fatigue. It can also affect the quality of your
speech. Full, deep breaths allow the diaphragm to lower and the lungs to expand
more deeply, ensuring more oxygen is taken in with each breath.

This simple exercise can help you practice breathing deeply:
1. In a lying or sitting position, gently place your palms over your lower
2. Take in a full breath through your nose, allowing the diaphragm to expand.
   You will feel your abdomen lift out if you are doing this correctly.
3. Slowly breathe out through the mouth. Your out breath should last longer
   than your in breath.
4. Perform this exercise for 5 minutes a day, or at any time you need help to
   feel relaxed.


Breathing exercise

1. Stand tall with feet hip width apart.

2. Cross arms over one another.

3. Take in a deep breath and begin lifting arms up and open.

4. Breathe out and lower hands to starting pose.

5. Perform for 5 deep breaths.

    Strengthening is another important part of a PD exercise program.
Strengthening certain muscles can help you stand up straighter and can make
tasks like getting up from a chair easier. Strengthening exercises also helps to
make bones stronger, so if you fall, you are less likely to get a fracture.
    Strength training is more than just lifting weights. If you have access to hand
held weights or a gym with weight machines, by all means, use them. However,
you can build strength by using your own body weight as resistance. Like
stretching, you can do strengthening exercises in the privacy of your home.
The trick is to find out what kind of strengthening exercises work best for you.


What tools do I need to do strengthening exercises at home?

  There are many tools available that you can use to build strong muscles and
bones. Choose the one that best suits your situation and surroundings.
Here are some examples:

■ Small hand weights (commonly available in sporting goods departments).
■ Wrist and ankle weights with Velcro® closures.
■ Elastic resistance bands, such as TheraBands®.
■ Common household items:
   • Soup cans
   • Plastic shampoo or milk bottles filled with water or sand
   • Laundry detergent bottles
■ Some exercises use your body weight as resistance. A few examples are
  squats and prone on elbows.

Do’s and Don’ts for strengthening

■ DO work one muscle group at a time.
■ DO stop any exercise that causes pain.
■ DO perform the movements slowly.
■ DO concentrate on standing up straight while doing the exercises.
■ DO breathe in while performing the movement, breathe out while relaxing
  the movement.
■ DON’T grip hand weights too tightly.
■ DON’T do rapid or "jerky" movements.
■ DON’T hold your breath. Breathe evenly throughout each exercise.

How much weight should I use?

   Use a technique known as the 10 Rep Max. This means that you use the
maximum amount of weight you can lift for 10 repetitions. For example, if you
can lift 3 pounds 10 times with no difficulty, the weight is too light for you. You
could try 5 pounds. If you can only do 10 repetitions with 5 pound weights
before getting too tired to continue, 5 pounds is a good weight for you to use.

How often should I perform strengthening exercises?

    You shouldn’t perform strengthening exercises on the same muscles two days
in a row. So, you could strengthen your arms one day, and your legs the next,
but you shouldn’t strengthen your arms on both days.


How many repetitions should I perform?

■ Begin by performing 1 set of 10 repetitions of the exercise. Slowly increase
  to 3 sets of 10 repetitions.
■ Increase the amount of weight once you can perform 2-3 sets
  with no difficulty.
■ If you are unable to perform the entire series of strengthening exercises at
  one time, select a few to perform at different times throughout the day.

Aerobic Conditioning Exercise
   Aerobic, or conditioning exercise includes any nonstop activity that uses the
entire body, working the heart and lungs as well as muscles. Examples of aero-
bic activities include:

     ■ Walking
     ■ Swimming
     ■ Water aerobics
     ■ Biking
     ■ Dancing

Even some regular daily activities have an aerobic, or conditioning benefit,

■ Household chores such as mopping or vacuuming.
■ Walking the dog.
■ Gardening and yard work.

A program of regular aerobic exercise performed 3 or more times per week can:

■   Strengthen the heart and lungs.
■   Improve stamina and endurance.
■   Reduce stress.
■   Improve mood and combat depression.
■   Help control high blood pressure, high cholesterol, and diabetes.

Aerobic, or conditioning may also be done from a seated position. "Armchair
aerobics” exercise videos can be found at many sporting goods stores or video
areas of department stores.


How often should I perform aerobic exercise?

   Your goal should be at least 20 minutes of aerobic exercise 3 times per week.
Start slowly and gradually increase the time until you reach 20 minutes or more.

■ Begin by performing a 3-5 minute warm-up. This does not necessarily have
  to be the same as the activity you are going to perform.
  Example: Walk around the block or march in place for 3-5 minutes before
  swimming or biking.
■ Finish your routine with a 3-5 minute cool-down. This can be done by
  continuing your activity for an additional 3-5 minutes at a lesser intensity, or
  switching to a different activity.
  Example: If you were biking, either take a gentle walk or sit and perform leg

You should get approval from your doctor before beginning an aerobic, or condi-
tioning program. This is especially important if you are over 50 years of age, or
have a history of cardiovascular disease.

How hard should I work when performing aerobic exercise?

   There are two methods to rate how hard you are working.

   The first is the Target Heart Rate method. This method helps you keep track
of your heart rate while exercising. For the best benefit, you should keep your
heart rate between 60-and-80% of your maximum heart rate. For beginners, it is
good to start out at 60%.

To calculate your Target Heart Rate, subtract your age from 220. This is the
maximum number of times your heart can beat in a minute. This number is then
multiplied by the percentage of your maximum heart rate that you want to
exercise. If you are just starting you aerobic program, your target heart rate
should be between 60 to 75% of your maximum heart rate. Generally, after 6
months at this rate, you may increase to 85%.

For example, if you are 65 years old:
220-65=155: This is your maximum heart rate.
If you want to exercise at 60% of your maximum heart rate:
155 x .60= 93: This is your target heart rate.
If you want to exercise at 80% of your maximum heart rate:
155 x .80=124: This is your target heart rate if you want to exercise at 80% of
your maximum heart rate.


You can periodically check your heart rate by counting your pulse for 6 seconds
and multiplying by 10. If the total is lower than your target heart rate, you can
increase how hard you are working. If the total is higher, you should work less

CAUTION - Do not use the target heart rate method if you:
■ Take any medications that change your heart rate.
■ Have a pacemaker.
■ Have atrial fibrillation.

The following chart can give you a quick gauge of your target heart rate at 60%
and 85% of your maximum heart rate.

       Age                Target Heart Rate

                   60%           85%

       30           114           161
       40           108           153
       50           102           144
       60            96           136
       70            90           127
       80            84           119


   The second method is the Borg Rating Scale. This scale assigns a number to
describe how hard you feel you are working. For your aerboic program, you
should gradually work up to level 13.

Least Effort

 7   Very, Very Light
 9   Very Light
11   Fairly Light
13   Somewhat Hard
15   Hard
17   Very Hard
19   Very, Very Hard
20   Maximum Effort

                             Chapter 2:
                   Putting it all together


1. Stand facing a corner,
   placing forearms and palms on each wall.

2. Lean forward into the corner.

3. Keep head up and feet flat on floor.

1. Sit tall in a chair with hands clasped
   behind back of chair.

2. Allow neck to gently fall back.


1. Sit tall in a chair with one arm behind
   back of chair.

2. Reach around in front of you with
   other arm to grab the back of chair.

3. Turn your neck and look back over
   your shoulder.

                            OVERHEAD STRETCH
                            1. Sit tall in a chair and interlock fingers together.

                            2. Turn palms facing out and slowly lift arms

                            3. Gently allow neck to fall back and
                               look up at hands.

1. Stand with feet hip width apart.

2. Place palms on low back.

3. Gently lean trunk and neck back.


1. Sit tall in chair and place one leg
   straight out on another chair.

2. Keep toes pointed up, knees
   flat, and back straight.

3. Gently reach for toes.

4. Only reach as far forward as
   you can without your knee

                                          LYING SHOULDER
                                          1. Lie flat on your back.

                                          2. If you are using a pillow, do not
                                             place it under your shoulders.

                                          3. Slowly lift arms straight up and allow
                                             them to fall back overhead.

1. Sit to one side of a chair with arm rests.

2. Reach one arm down toward floor.

3. Reach other arm up and over to side.

4. Keep feet flat on floor.


1. Stand tall with feet hip width apart.

2. Clasp hands behind back.

3. Gently lift arms up and away
   from the back, keeping head up.

1. Lie on your back, with knees bent and feet flat. Arms should be
   outstretched at your side.

2. Rotate both knees to one side, keeping arms and upper torso flat.
   Turn head in opposite direction.

3. Repeat, rotating knees in the opposite direction.


1. Support upper body on wall. Stand at
   arms length from wall.

2. Step one foot back.

3. Lean weight forward onto front foot.

4. Press back foot down, keeping heels flat
   on floor and toes pointed forward

                                        ANKLE CIRCLES
                                        1. Kick foot in front of you.

                                        2. Move foot in slow, complete circles.

                                        3. Repeat in both directions.



                       ■ Begin by performing 1 set of 10 repetitions of the
                         exercise. Slowly increase to 3 sets of 10 repetitions.

                       ■ If you are unable to perform the entire series of
                         strengthening exercises at one time, select a few to
                         perform at different times throughout the day.

1. Stand with feet about 6-8 inches from
   the wall.

2. Rest your back and hands on the wall.

3. Slowly bend your knees and slide down
   the wall.

4. Do not let your knees move past your feet.

5. Hold this pose for a count of 5.


1. Lie on back with
   knees bent and feet

2. Raise hips up and
   squeeze buttocks.

3. Hold this pose for
   a count of 5.

NOTE: A physical or occupational
therapist can supply you with a
Theraband®‚ or you can buy them at
most sporting goods stores.

1. Hook middle of Theraband® around
   doorknob of closed door.

2. Hold ends of Theraband‚ in each hand.

3. Slowly pull on TheraBand® by pulling
   elbows back and squeezing shoulder
   blades together.

4. Hold this pose for a count of 5.

NOTE: You can also perform the
shoulder blade squeeze without a


1. Place hands in front of chest.

2. Pull elbows back.

3. Avoid shrugging shoulders.

                                     QUAD STRENGTHENING
                                     1. Sit tall in chair.

                                     2. Kick leg straight out, toes pointing up.

                                     3. Hold leg for a count of 10.

1. Begin on hands and knees,
   keep back level.

2. Reach one arm straight

3. Extend opposite leg
   straight back.

4. Hold for a count of 3-5.

                     PARKINSON D ISEASE : F ITNESS C OUNTS

1. Lie on stomach.

2. Lift upper body off surface, supporting body weight on forearms.

3. Hold position for 5 to 10 counts.

NOTE: Remember, this is not a push up. Your back muscles should be doing
the work, not your arms.

                     Aerobic exercise
                     See the section on aerobic exercise on page 5.
                     Perform aerobic exercise at least 3 times per week.

                      PARKINSON D ISEASE : F ITNESS C OUNTS

Daily Exercise Record
Week of ____________

Use this form to help keep track of your progress.

Day          Aerobic/Conditioning       Stretching     Strengthening   Other

Example      Walked 15 minutes          Performed 5    Performed all   Performed
                                        exercises in   leg exercises   breathing
                                        AM & 3 in PM                   exercises
                                                                       and planted
                                                                       in garden









                            Chapter 3:
              Balance, Falls, and Posture

    Balance problems are one of the main symptoms of PD. Another name for
balance problems is postural instability. Balance problems increase the risk of
falling, especially when combined with other symptoms and complications of
PD, including:

■ Slowness of movement, also called bradykinesia, which causes delayed
   reaction time.
■ Stooped posture, which can cause your center of gravity to shift forward.
   This adds to the feeling of the feet always having to “catch up” to the body.
■ Shuffling walk.
■ Freezing.
■ Falling backwards, also called retropulsion.
   This is common in PD and tends to happen when you are:
   ■ Opening doors that pull toward you.
   ■ Backing up to sit down in a chair.
   ■ Stepping backward to move away from a counter or the refrigerator.
■ Quick, short steps forward where you feel you cannot stop, which is also
   called festination. This is more likely to happen when you:
   ■ Shuffle.
   ■ Reach to far ahead of yourself.
   ■ Try to fight your way through a “freeze.”
■ Involuntary writhing movements called dyskinesias.


How Can I Improve Balance?
    Balance exercises can help improve balance and decrease the chance of falling.
If you are having trouble with balance, or are falling, you should see a physical
therapist. Your doctor of or other health care professional can refer you to one.
A physical therapist can recommend specific exercises, equipment and tech-
niques to improve balance and reduce falls.

1.   Stand with feet hip width apart and one
     foot ahead of the other.

2.   Slowly shift weight forward onto front
     leg and reach hands out in front of you.

3.   Slowly shift weight backward onto the
     back leg and pull elbows back.

4. Move back and forth between the two
   moves 10-20 times.
NOTE: Have someone near you for safety.

                                   For safety, stand in front of a bed with a
                                   chair in front of you, or have someone stand
                                   nearby to guard you.

                                   1. Stand tall with feet apart.

                                   2. Slowly lift one leg and try to balance on
                                      the other leg.

                                   3. Try to balance for 5-10 seconds.


What Can I Do To Prevent Falls?
    There are some important tips and techniques you can use to help prevent
falls. When you have PD, you must now think about many things your body used
to perform automatically. By thinking about what you are doing, you are using a
different part of your brain than the part affected by PD.

■ Try not to move too quickly, think about what you are doing.

■ When walking, tell yourself to land with the heel striking down first.

■ DO NOT pivot your body over your feet when
  turning. Instead try:
  ■ Making a “U-turn” while walking.
  ■ If you are standing in place and must turn, make
     sure the feet and the body move together, OR
     move the foot on the side you are turning
     toward with a march step. Now step around               “U-turn” - Useful for more open
     with the other foot and body together.                  areas. Move your feet & body togeth-
                                                             er in an arc...

■ Never lean your center of gravity, which is near the
  belly-button area, too far forward over your feet.
  If you must reach forward:
  ■ Widen your stance and place one foot ahead
      of the other.
  ■ Stand directly in front of what you are
      reaching for.
  ■ Place one hand on the counter, wall or other
                                                            “Clock-turn” Technique - Useful
      stable object while you reach with your               in small areas & for when you
      other hand.                                           are stopped & must turn. Start
                                                            at 12PM & take 2 slow steps to
                                                            3PM, and so on...
■ The moment you begin to shuffle or freeze, try to
  come to a complete stop. Take a breath and start
  again, focusing on that first step or your heel strike.

■ Do not carry many things while you are walking. It has been shown that
  people with PD have difficulty performing more than one task at a time.
                                                      “Side-step Arc” Technique - Useful in
■ Avoid walking backwards,                             small spaces & as a way to avoid stepping
  instead try:                                              backwards. Take slow side-steps in an
  ■ Stepping sideways.
  ■ Take large marching steps to
      turn and then walk forward.
■ When returning to sit, turn all of
  the way around and make sure that both

   legs are touching the chair. Reach back with both arms to slowly lower
   yourself. NEVER reach forward for the chair first and then turn to sit. This
   can lead to landing sideways on the end of the chair, landing too hard in the
   chair, or missing the chair and falling to the floor.

              INCORRECT                                     CORRECT

What Should I Do if I Fall?
■ First, remain calm. Determine any pain or possible injuries before you try to
  get up.
■ Plan your strategy carefully. Use a heavy piece of furniture to assist in
  getting up. If you doubt your ability to safely get up alone, crawl or scoot to
  a phone and call for help.
■ Persons who fall frequently should enroll in some emergency signaling
  system, and may need to use protective equipment such as knee and elbow
  pads to avoid repeated injuries.

Getting Up from the Floor
    1. Crawl to a sturdy piece of furniture, such as chair, bed, or sofa.
    2. Hold on to the furniture as you raise one knee up so the foot is flat on
       the floor.
    3. Slowly push up on the bent knee so you straighten to stand.
    4. Keep holding for balance as long as needed.

A physical or occupational therapist can teach you the best techniques for getting
up from the floor.


   PD can cause many changes in the body. One easily recognizable change is
posture. The characteristic changes in posture can include:

■ A forward head position.
■ Rounding of the shoulders and upper back.
■ A forward trunk position with increased bending of the hips and knees.

Exercise and proper body positioning can help to limit or correct these changes.

   Even without PD, it is very easy for anyone to fall into the habit of bad pos-
ture. Some typical positions we place ourselves into contribute to bad posture.
These include:

■   Sitting on the couch watching TV.
■   Leaning over to work on the computer.
■   Driving/riding in the car.
■   Looking downward while reading, or propping your head against the
    headboard while reading.

Fortunately, there are some easy ways we can break bad habits.

The following tips are helpful for maintaining good posture in all positions:

■ Avoid sitting in chairs without back support or arm rests.
■ Avoid recliners. They promote rounding of the neck, shoulders and
  head, and also tightness in the hips.
■ Avoid low, soft couches and chairs.
■ The height of the chair should allow for your hips and knees to be level
  with one another.
■ Keep your chin parallel to the floor.
■ Avoid crossing your legs.
■ Keep your head, shoulders and hips in line with one another. Sit so that
  your back is fully in contact with the chair back and seat.
■ Use a lumbar roll along your low back, especially for long car rides,
  plane rides and in the theater – it will help you to sit tall.
■ Your computer screen and TV should be at eye level to minimize
  neck and eye strain.


■ While reading, use a book stand or rest your elbows on a pillow or a table.
  This allows you to look directly ahead at the pages. When reading in bed, sit
  with your entire back resting on the head board, not just your head and

DO NOT sit for long periods at a time. After about 20-30 minutes, get up and
move around.

Example of poor sitting posture.           Example of good sitting posture using
                                           cushion and lumbar roll.

Standing and Walking
■ Keep your chin parallel to the floor.
■ DO NOT look straight down while walking. Instead, look out in front
  you and down.
■ Keep a broad base of support by keeping feet at shoulder width.
■ Keep your tummy in, your shoulders rolled back and your head and
  chest up.


■ Keep your thumbs facing forward with your palms facing in at your sides.
■ Keep your hands free – carry light loads in fanny packs or small back packs.
■ Have walkers and canes adjusted to proper heights. A physical or
  occupational therapist can help you with this.

Lying Down
■ Avoid using too many pillows, or too thin of a pillow under the head.
■ The best postures for sleeping include lying on your back with a soft
  pillow under the knees or lying on your side with a soft pillow
  between the knees.

Other Posture Hints
■ Perform frequent neck and shoulder stretches to relieve muscle tension.
■ Maintain eye contact during conversation. This holds the head erect.
■ Avoid sleeping in a chair - lie down to nap with the head and neck
■ Practice these techniques every day.
■ Place written reminders on commonly used items like the bathroom mirror,
  computer screen, dashboard, television. “Stand tall...Shoulders back...Sit
  straight...Chin up”
■ See a physical or occupational therapist for specific posture exercises.

                             Chapter 4:
               Complementary Therapies

Massage Therapy
   Massage therapy has been shown to increase circulation, stimulate lymphatic
drainage, reduce muscle tension, and promote relaxation. It can be particularly
helpful to the person with PD who experiences problems with rigidity.
   Massage is not a substitute for regular movement and exercise, but may be a
useful part in your overall exercise program. Select a massage therapist who is
certified by the American Massage Therapy Association, and interview the
potential therapist regarding the techniques they prefer to use. It is also impor-
tant to provide feedback to the therapist throughout the massage regarding the
level of pressure being used and any discomfort you experience.
     Self-massage and care partner-assisted massage is possible. Using items
such as wooden rollers or hand-held electric massagers will allow you or your
care partner to apply gentle pressure to tight areas of the body. These items can
be purchased at most drug or department stores. It is important to note that
massage services are often not covered by health insurance.

Tai Chi
    Tai chi, an ancient form of Chinese exercise, is a slow, flowing form of move-
ment which has been shown to aid in flexibility, balance, and relaxation. Many
people with Parkinson's disease have reported benefits from learning and prac-
ticing tai chi principles.
    There are several forms of tai chi that can be done by anyone regardless of
age or physical condition. Classes are often offered at fitness centers, senior cen-
ters, and community recreation centers. It is important to first speak with the tai
chi instructor to learn if the type of tai chi they teach is best for you. Videotapes
teaching basic principles and moves of tai chi can also be purchased or rented at
a variety of retail stores.


    Yoga is a form of exercise which can be very helpful for persons with PD.
Yoga has been shown to increase flexibility, increase breathing and posture
awareness, and help with relaxation and stress reduction. Yoga is a self-paced
activity, which means that not everyone has to perform a pose in the same way
or hold it for the same amount of time. Most poses can be modified depending
on your needs. Yoga can even be performed in a chair.
    Since there are many types of yoga, it is important to contact the instructor
prior to beginning a class. Generally, a beginner class or a class for those with
special needs is a good place to start for those with PD.

Pet Therapy
    "Lap" pets, such as dogs and cats, can provide great satisfaction in the lives of
their human companions. Numerous studies have shown that having animals in
the home improves both mental and emotional health of their owners, not to
mention ample opportunities for movement and exercise. Research has demon-
strated that pets can:

■ Lower blood pressure and heart rate.
■ Improve mobility and flexibility (through stroking, grooming, and
  walking the pet).
■ Satisfy the human need for touch and nurturing.

Creative Expression
    Creative expression, unique to each person, may also stimulate movement
and physical activity. Painting on an easel with large, forceful strokes stretches
the arms and shoulders. "Conducting" the music of a favorite symphony or
opera has shown to have a strengthening and aerobic benefit.
    Ceramics, woodworking (using extreme caution with power tools), and other
creative endeavors stimulate fine motor skills and improves manual dexterity and
strength. Singing alone or in a choral group promotes deep breathing needed for
louder speech and increased endurance.
    Persons with PD are encouraged to research and identify the creative outlets
that best fit their talents and abilities.

                            Chapter 5:
           Carepartner Assisted Exercise

   Persons with advanced Parkinson symptoms may not be able to follow com-
mon exercise programs due to changes in physical or thinking abilities. It may
be better to work exercises and stretching into the daily routine. Here are some
suggestions for doing this:

■ Sitting and reaching in different directions can stretch the arms and trunk.

■ Household chores such as folding laundry, dusting, wiping dishes or assisting
  in food preparation take on added value as gentle exercise.

■ Simple games such as balloon volleyball, playing catch with a large, soft ball
  or blowing soap bubbles are fun alternatives to structured exercise.

■ Music stimulates movement such as marching or dancing. If balance is a
  problem, try chair dancing. "Conducting" to the beat of up tempo music
  provides both upper body exercise and good emotional therapy!

■ Perform a few extra arm and leg motions during dressing tasks.


An example of partner-assisted hamstring stretching is demonstrated below:

1.   Have the person with PD lie flat on their back.

2.   Kneel beside one leg.

3.   Gently lift the leg by supporting it
     under the ankle and above the knee
     on the thigh.

4.   Place the ankle on your shoulder (you
     can place a folded towel here for

5.   Place both hands on the thigh, just
     above the knee.

6.   Slowly lean forward to lift the leg
     straight up.

7.   Push the leg until you meet with

8.   Hold for 30 seconds, then lower the
     leg and relax.

9.   Repeat on the other leg.

                          Appendix A:

National Parkinson Foundation, Inc. (NPF)
Telephone: (800) 327-4545

American Physical Therapy Association (APTA)
Telephone: (800) 999-2782

American Occupational Therapy Association (AOTA)
Telephone: (301) 652-2682

American Massage Therapy Association (AMTA)
Telephone: (847) 864-0123

Yoga Journal's Teacher Directory
Telephone: (800) 359-9642

Exercise: A Guide from the National Institute on Aging
A 48-minute video shows you how to start and stick with a safe, effective pro-
gram of stretching, balance, and strength-training exercises. You can order the
video and 80-page companion booklet by mailing a check or money order for
$7.00 to:
NIAIC, Dept. W
P.O. Box 8057
Gaithersburg, MD 20898-8057
Or visit the the website


Gentle Fitness
A videotape of gentle stretches and exercise, guided by recreational therapist
Catherine MacRae.
Telephone: (800) 566-7780

Sit and Be Fit
The Parkinson's disease special edition patterned after the popular public televi-
sion series hosted by Mary Ann Wilson, RN.
Telephone: (509) 448-9438

Parkinson’s Disease & the Art of Moving
Written by John Argue, a movement & voice teacher, this book teaches exercises
and movement methods for coping with everything from balance to freezing.
Available at most local or on-line book sellers. The video companion to the
book can be ordered by phone: (510) 985.2645 or on-line at www.parkinsonsex-

                           Appendix B:
    A Word to Rehabilitation Therapists

   It is important that the therapist have a clear understanding of the purpose,
side effects, and dosage of antiparkinson medications. Many patients are
on multiple medications; therapy is most effective when the dopaminergic
medications are working at "peak dose" and the patient's motor function is
good. This may vary from day to day and even hour to hour. Detailed
educational publications about Parkinson's disease and drug therapy are
available at no charge from the National Parkinson Foundation.

Recommended Readings
Here is an abbreviated reference list to help in your treatment of
people with PD:

■ Morris, ME. Movement Disorders in People with Parkinson Disease: A
  Model for Physical Therapy. Physical Therapy, 2000; 80(6): 578-595.

■ Schenkman, M, et al. (1998). Exercise to Improve Spinal Flexibility and
  Function for People with Parkinson’ Disease: A Randomized, Controlled
  Trial. J Am Geriatr Soc., 46: 1207-1216.

■ Turnbull, GI., editor. (1992). Physical Therapy Management of Parkinson’s
  Disease. New York: Churchill Livingston.

■ Argue, J. (2000). Parkinson’s Disease and the Art of Moving. California:
  New Harbinger Publications.

■ “Guidelines for Physiotherapy Practice in Parkinson’s Disease” link from the
  University of Northumbria in England, website:

                    About the Author

Author, 2nd Edition
Heather Cianci, PT, MS, GCS
Heather Cianci has been a physical therapist for over 10 years at Pennsylvania
Hospital in Philadelphia, Pennsylvania. For 6 years she has specialized in treat-
ing people with Parkinson’s disease. Since 2000, Heather has been the senior
therapist at the Dan Aaron Parkinson’s Rehabilitation Center at Pennsylvania
Hospital. Heather received her degree in physical therapy from the University
of Scranton in Scranton, Pennsylvania, and her Master’s degree in gerontology
from Saint Joseph’s University in Philadelphia, Pennsylvania. She became a
Board Certified Geriatric Clinical Specialist in 1999. Heather frequently lectures
on Parkinson’s disease to local college physical therapy programs, support
groups, and patient and caregiver symposiums. She is a consultant to the NPF’s
Allied Team Training for Parkinson (ATTP) Program and is actively involved in
research on Parkinson’s disease.


Numerous people have contributed to this manual. Special thanks to:

■ Rose Wichmann, PT, and Maria Walde-Douglas, PT, of Struthers Parkinson’s
  Center, Minneapolis, MN, who authored the first edition of Fitness Counts,
  as well as Carey Harris, PT, who edited the first edition. Much of that
  material appears in the 2nd edition.

■ Marsha Melnick, PT, PhD, of Port Angeles, WA and Charlotte Chatto, PT
  of Medical College of Georgia, Augusta, GA, for their thoughtful reviews of
  the first edition of Fitness Counts.

■ Gale Kittle, RN, MPH, Barrow Neurological Institute, Phoenix, AZ who
  edited and facilitated publication of this manual.

■ NPF staff for their guidance, assistance and support: Ruth Hagestuen, Field
  Services Director, and Julian Pearson, Administrator.

■ Members of the NPF Publications Task Force and the Task Force for
  Caregiver Initiatives for their thoughtful reviews and assistance in
  development of NPF publications:
  Jill Burkholder, RN, Markham-Stouffville Health Centre, Markham,
  Ontario, Canada; Joan Carpenter, RN, NP, Bear, DE; Carol Eickhorn,
  ARNP NPF Florida Care Center, North Ridge Medical Center, Fort
  Lauderdale, FL; Joan Gardner, RN, BSN, Struthers Parkinson’s Center,
  Minneapolis, MN; Gladys Gonzalez-Ramos, PhD, Ehrenkranz School of
  Social Work, New York, NY; Ruth Hagestuen, RN, MA, NPF Director of
  Field Services, Miami, FL; Susan Hamburger, MA, MS, Chevy Chase, MD;
  Gale Kittle, RN, MPH, Barrow Neurological Institute, Phoenix, AZ; Sharon
  Metz, RN, MPH, NPF Florida Care Centers, Miami, FL; Deborah Orloff-
  Davidson, RN, MPH, Michigan Parkinson Foundation, Detroit, MI; Patricia
  Simpson, RN, MHA, Scott & White Clinic, Temple, TX; Marge Thurin,
  MEd, MSW, Minneapolis, MN; Mignone Trenary, MA, Orange County
  Chapter, NPF and Hoag Hospital, Newport Beach, CA; Jane Wright, MSW,
  The Parkinson Council Chapter NPF, Philadelphia, PA.

■ The clients of the Dan Aaron Parkinson's Rehabilitation Center who
  modeled for the photos in this booklet.

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Please return this form to:           National Parkinson Foundation
                                      Attn: Publications
                                      1501 NW 9th Ave.
                                      Miami, FL 33136
National Parkinson Foundation Centers of Excellence
 Alexian Neurosciences Institute            Kings County Hospital / SUNY              Scott & White Clinic
 Hoffman Estates, Illinois                  Downstate Medical Center                  Texas A & M University Health Science
                                            Brooklyn, New York                        Center Temple, Texas
 Aurora Sinai Medical Center
 Milwaukee, Wisconsin                       Madden/ NPF Center of Excellence          Segawa Neurological Clinic for Children
                                            for Parkinson's Disease and Related       Chiyoda-Ku, Tokyo Japan
 Beijing Institute of Pharmacology and      Movement Disorders,
 Toxicology, Academy of Military            The Ohio State University                 Southern Illinois University School of
 Medical Sciences                           Columbus, Ohio                            Medicine
 Beijing, China                                                                       Springfield, Illinois
                                            Massachusetts General Hospital
 Betty and Morton Yarmon Center for         NPF Center of Excellence, Harvard         Struthers Parkinson's Center
 Parkinson's Disease at Beth Israel         Medical School                            Golden Valley, Minnesota
 Medical Center, The                        Boston, Massachusetts
 New York, New York                                                                   Technion - Israel Institute of Technology
                                            Medical College of Georgia, Movement      Haifa, Israel
 California Neuroscience Institute at St.   Disorders Program
 John's Regional Medical Center,The         Augusta, Georgia                          Toronto Western Hospital Movement
 Oxnard, California                                                                   Disorders Center
                                            Muhammad Ali Parkinson                    Toronto Western Hospital Movement
 Center for Neurological Restoration,       Research Center                           Disorders Centre University of Toronto
 Cleveland Clinic Foundation                Barrow Neurological Institute             Toronto, Ontario
 Cleveland, Ohio                            Phoenix, Arizona
                                                                                      Université Pierre et Marie Curie,
 Centre for Movement Disorders              Northwestern University Parkinson's       Hopital de la Salpêtrière
 Markham, Ontario Canada                    Disease & Movement Disorders Center       Paris, France
                                            Chicago, Illinois
 Centro Neurólogico Hospital Francés                                                  University of California
 Buenos Aires, Argentina                    Oregon Health & Science University        San Francisco Parkinson's Disease
                                            Parkinson Center of Oregon                Clinic & Research Center
 Chang Gung Medical College                 Portland, Oregon                          San Francisco, California
 Tapei, Taiwan
                                            Pacific Parkinson's Research Centre,      University of Florida Parkinson's Disease
 Clinica Universitaria, University of       University of British Columbia            & Movement Disorders Center
 Navarra                                    Vancouver, British Columbia Canada        Gainesville, Florida
 Pamplona, Spain
                                            The Parkinson's Disease & Other           University of Kansas Medical Center
 Clinical Neuroscience Center               Movement Disorders Center                 Parkinson's Disease Center
 William Beaumont Hospital Research         University of Southern California         Kansas City, Kansas
 Institute Southfield, Michigan             Los Angeles, California
                                                                                      University of North Carolina at Chapel
 Colorado Neurological Institute            Parkinson's Disease and Movement          Hill School of Medicine
 Movement Disorders Center                  Disorders Center of the University of     Chapel Hill, North Carolina
 Englewood, Colorado                        Pennsylvania
                                            Philadelphia, Pennsylvania                University of Pittsburgh School of
 Johns Hopkins Hospital Department                                                    Medicine
 of Neurology                               Parkinson's Disease Center & Movement     Pittsburgh, Pennsylvania
 Johns Hopkins Hospital                     Disorders Clinic at Baylor College of
 Baltimore, Maryland                        Medicine                                  University of Rochester Medical Center
                                            Houston, Texas                            Rochester, New York
 Juntendo University School of
 Medicine - Dept. of Neurology              Rabin Medical Center, Sackler School of   Klinik und Poliklinik für Psychiatrie und
 Tokyo, Japan                               Medicine, Tela Aviv University            Psychotherapie University of Würzburg
                                            Beilinson Campus                          Würzburg, Germany
 Kings College London                       Petah-Tikva, Israel
 Franklin Wilkins Building,                                                           Vanderbilt University Medical Center
 Waterloo Campus London, England                                                      Nashville, Tennessee
                                   National Headquarters
                             Bob Hope Parkinson Research Center
              1501 N.W. 9th Avenue, Bob Hope Road • Miami, Florida 33136-1494
        Telephone: (305) 243-6666 • Toll Free Nat’l: 1-800-327-4545 • Fax: (305) 243-5595
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