Monday, July 6, 2015

PD: Bob's Comeback

In this post, we share Bob's success with an individualized training program.  Every person has a unique exercise history and is affected by Parkinson's disease (PD) differently, with a different set of risk factors and exercise preferences.  This is why individual exercise prescription is so important.

In a recent post, I stated that the typical recommendation 'You should exercise.' is not enough. It lacks the guidance that enables new exercise behaviors.  In this post we use Bob's program as an example of an individualized training program and provide the rationale for its design.  In an upcoming post, we will explain the basic principles of designing a training program: specificity, overload, and individual differences. They are applied here.

We hope that you can use information like this to design an exercise program for yourself, your client or your patient.  You might want to talk with your doctor before beginning a new exercise program and you can see this ACSM Comment on the relevant considerations. You should also know that we did not 'fix Bob' all by ourselves.  Bob has a team that he really values including a movement disorders specialist at UPENN and a Physical Therapist who specializes in PD.  

Who is Bob?  Bob is a 75 year old man.  He was diagnosed with PD about 5 years ago.  Around Thanksgiving (it is now June) he was falling all the time and experiencing a downward spiral.  We know Bob from the PD support groups in our community and my colleagues at the Parkinson's Clinic told us that he didn't look so good.  So we invited him to the lab to see if we could help.

Q. Bob, why did you come to our lab?

Q. PD has several symptoms which affect people differently.  What symptom affects you the most?

Lab Notes: When Bob arrived at the lab, we walked in from the parking lot together.  His difficulty was obvious.  He was freezing in place, especially at doorways and if you stood too close to him. He looked like he might tip backwards and fall at any moment.  He had bruises and cuts on his arms and head from recent falls and his speech and/or cognition were not as fluid compared to what I remembered. After discussing his health history, we identified a set of priorities to address.
  1. Falling that seemed mostly related to his symptom of freezing in place
  2. Poor balance - not even good enough to begin balance exercises
  3. Poor upper body strength would not allow him to get up after a fall
  4. Low confidence in his abilities and behavioral withdrawal from activities of daily living.  He would carry his phone into the basement so that he could call someone upstairs if he fell. 
  5. We also noted that he had received treatment for an orthopedic issue with his shoulder and we would be very careful with this in any related exercises.


First Speedwork: Use high speed bicycling to speed up his nervous system and see if the SpeedGeezer program could disrupt his pattern of freezing in place.  See our companion post on SpeedGeezer Training including downloadable training sheets at the bottom.

Then Functional Conditioning: Using a suspension training system, medicine balls, a homemade T-bar weight, table pushups and creativity, we sought to design a program based on twice-weekly 45-minute workouts that would improve his strength, balance and muscular endurance.


SpeedGeezer:  Bob began with this high-speed interval cycling program because he wasn't in good enough condition to begin the functional strength and conditioning exercises. His fall risk was high. Bob did about 6 weeks of twice-weekly SpeedGeezer sessions (30 minutes each).

Right: Bob and the lab team multitasking: Graduate and undergraduate students supervised Bob's workout while we all watched a podcast about exercise from the Michael J. Fox Foundation (Link Here).  The students are gaining first hand experience working with people who have Parkinson's disease.  Many of our students are aspiring health care professionals and researchers so they value these opportunities very highly.  Thanks for teaching our students, Bob!

After six weeks of high speed cycling, Bob's freezing was almost entirely gone and he was considered ready for the next phase of training.  The really fun part. 

"Around Thanksgiving, I was falling all the time and on Saint Patrick's Day I walked a 5K." Bob Klopfenstein

Functional Conditioning Exercises:  Bob worked directly with an experienced personal trainer during two 45-minute sessions each week for six weeks.  His adherence to the program was perfect and the only challenging day he had was one on which he did not have a good breakfast. Each session began with a few minutes of warm-up on the bicycle followed by two sets of about 6 different exercises.  The training space is free of tripping hazards and all extraneous equipment is stored in cabinets to prevent a cluttered environment from stimulating episodes of freezing.  Bob listens to his favorite station on Pandora while exercising. 

Q. Can you tell us about some of the equipment you used and the exercises?


Return to this blog again for a list of specific exercises and equipment used .

Q.  Applying overload principle, we tried to improve your balance by increasing the complexity of the exercises.  Did this seem effective to you?  

Lab Notes: In Bob's program, the early weeks required him to learn several new and relatively complex exercises. All exercises required Bob to activate the core muscles in his trunk and also involved postural control.  Simply lifting a weighted yellow ball to eye level requires several postural muscles to be activated first, or he would fall forward.  This is coordination. Not only were the exercises complex but we also began to complicate their sequence.  At first he would do 2 sets of an exercise and then move on to another exercise, with plenty of rest in between.  By the end of the program, these 'straight sets' became 'super sets' in which he would quickly alternate between two different exercises and the rest periods were minimal. Bob had to remember how to do the exercises and switch between them frequently, not only overloading the physical and cognitive complexity, but also overloading the muscles to increase endurance.

Assessment and Self-Efficacy Best practices in training include periodic assessment of a person's function.  This is an effective tool for motivation and program revisions.  A person's belief in their own abilities is just as important as the abilities themselves.  We can improve Bob's balance, but he won't try to cut his lawn again unless he also has confidence in his balance.

All of Bob's measures improved, especially balance and muscle endurance.  This video is part of a meeting in which Bob and I had discussed some results.  We enable our participants by teaching them the purpose of the exercises and the meaning of the measures.  In addition to discussing functional tests, we also summarize their attendance record and show how much work they have done.  For a 75 year old person with Parkinson's disease, preventing further decline is meaningful.  Achieving improvements is fantastic!

Q.  Bob, our ability to try this new equipment and test new training strategies was possible due to generous support from Shake It Off, Inc. and their friends.  Do you have anything you would like to say to them?