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High Intensity Interval Training for Parkinson’s Disease

Justin Wilson

2^nd Year DPT Student

UNC Chapel Hill

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Learning Objectives

Understand why HIIT is beneficial for patients with Parkinson's Disease, including improvements in functional mobility, mood, and overall quality of life.
Learn about the principles of HIIT, including the use of frequent bursts of high-intensity exercise followed by short periods of rest.
Gain knowledge of specific HIIT activities that may be suitable for people with Parkinson's Disease, such as cycling, treadmill walking, and boxing, tai chi etc.
Learn how to adjust the frequency, intensity and duration of HIIT exercises to match the patient’s ability level.

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Learning Objectives

Gain knowledge of the current research on HIIT for people with Parkinson's Disease, including the effectiveness of this type of exercise in improving functional mobility, ambulation and quality of life.
Understand how HIIT fits into a broader treatment plan for people with Parkinson's Disease, including medication management, physical therapy, and other interventions.

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What is Parkinson’s Disease?

Parkinson's disease (PD) is a neurodegenerative disorder characterized by loss of the dopaminergic neurons, accompanied by chronic inflammation and neuroinflammation.

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What is Parkinson’s Disease?

Parkinson’s Disease

Basal ganglia Pathways (Cars going down a hill):

Direct (Allows for travel down hill)

Reduces the tonic inhibition of the Globus Pallidus internal on thalamus
Thus allows for more excitation of the motor cortex which produces movement.

Indirect Pathway (Puts the breaks on)

When active increases inhibitory influence of Globus Pallidus internal segment
Thus creating net loss of movement

When Dopamine Releases

D1 = Excitatory Dopamine Receptors Stimulates the Direct = Movement
D2 = Inhibitory Dopamine Receptors inhibits the Indirect = Less movement Suppress competing motor programs

What happens with Parkinson’s Disease

LESS Dopamine

Input from SNpc D1 (excitatory) is diminished
Less D1 excitation = Less movement
More D2 inhibition = Less movement
Equals Net Less Movement overall OR imbalance of excitatory and inhibitory functions of basal ganglia

Transient inhibition from the striatum is more difficult
Leads to more tonic inhibition which leads to less thalamic excitation and hypokinetic movement.

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What is Parkinson’s Disease

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Exercise for Parkinson’s Disease

Primary Results of Exercise:

Prolongs Independent Mobility
Improves gait, strength and endurance
Improves sleep, mood and memory
Slows disease progression

Secondary Results of Exercise:

Decreases complications of immobility

Cardiovascular
Osteoporosis

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What is HIIT?

H : High
I : Intensity
I : Interval
T : Training

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HIIT vs Steady State

HIIT

Performance enhancements
Improved insulin sensitivity
EPOC
Improved cardiovascular health
Shorter duration

Steady State

Less Stress on cardiovascular system
Increased endurance
Faster Recovery
Uses fat stores for fuel
Targets slow twitch muscle fibers

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HIIT on Parkinson’s Disease Physiology

Two Major Takeaways

Exercise Increases D2 Receptor expression in the Brain
Brain cells use Dopamine more efficiently
Brain Derived Neurotrohphic Factor Viability

Increase in D2 Receptor expression in the brain – only tested in mice in a study in 2010. Not a lot of research evidence to back this claim (Marta G. Vučković)

Remember D2 receptors = Inhibits the Indirect Pathway

More D2 receptor expression = Less inhibition = more movement allowed More balance in pathways

More receptors = a greater chance for dopamine binding.

Main Points of the Study Included:

Unsure if there was really an increase in D2 receptor expression or number or if the brain just became more efficient in using the receptors it had remaining OR

The enhanced effect of exercise in MPTP mice may reflect an attempt of the injured brain to optimize dopaminergic neurotransmission through increased receptor number while dopamine levels remain depleted.

The primary conclusion of our study is that exercise in the form of intensive treadmill running facilitates neuroplasticity through increased expression of striatal DA-D2Rs, a process most evident in the injured brain.

BDNF (protein) plays an important role in neuronal survival and growth, serves as a neurotransmitter modulator, and participates in neuronal plasticity

BDNF is reduced in Parkinson’s patients. Research indicated that exercise could increase BDNF’s neuroprotective effects

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Benefits of HIIT for Parkinson’s Disease

Decrease in fat tissue
Lower blood sugar levels
Improved cognition
Lower risk of cardiac disease
Reduction of rigidity and stiffness
Improvement in overall fitness

https://davisphinneyfoundation.org/neuroplasticity-exercise-and-parkinsons/

Mike Studer TED talk on Neuroplasticity

Parkinson’s slows movement or could make someone apprehensive to movement which could lead to other comorbidities down the line such as cardiovascular disease, diabetes, bone health etc

HIIT is another form of exercise which we all know is good for all of our body systems
HIIT can help the body improve on the way it utilizes and oxygen and insulin
With skeletal muscle growth comes better movement, balance, mobility, bone health etc.

Davis Phinney Foundation for Parkinson’s
PD patients are still capable of neuroplasticity which is essential for preserving cognition (Mike Studer) – Highly regarded in the field of Parkinson’s and Geriatrics

“Preserve what you have, and make connections that you haven’t previously made”
Brain Derived neurotrophic factor (BDNF) is important for neuronal survival and growth
In neurodegenerative diseases you see a reduction in BDNF
High intensity exercise increases the BDNF viability
Talk about guy freezing 50 x a day and during sessions they would imitate the shuffling pattern w/ marks on the treadmill and then allow longer steps

Graphic Explanation - I like this graphic because it is a good biopyschopsocial model

Arrows are bidirectional
When outside factors controlled, Parkinson’s expression is reduced
The reverse is also true
Parkinson’s controlled so are all outside factors

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Tailoring HIIT to a Patient

IT DEPENDS!
Core Components

Aerobic/Endurance Training
Strength Training
Balance
Flexibility
Progressive Overload

There is no One Size fits All approach to prescribing HIIT to a patient (Ellis)

Key is to slowly ramp up patient

Education is important
Address lifestyle behaviors and then build into HIIT if you have a patient that has been sedentary recently

It depends on the patient

- What do they enjoy?

- Comorbidities or other factors that may impact their ability to exercise

- Functional vs Other forms of exercise

- Functional include specific tasks that aim to improve functional mobility that transfer to a specific tasks (ie Gait Training)

- Other forms of exercise can be specific and when combined with functional tasks can result in functional gains like gait, STS, etc

Dosing has not been widely studied

However, Higher dosing in some studies have led to better outcomes
Optimal dose must have a volume and intensity that overloads the body initiating a response …. Hence the use of progressive overload

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HIIT Activities

Cycling
Treadmill Walking
Tai Chi (faster paced version)
Boxing’
Circuit Training
Dancing
MANY MORE!

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HIIT Activities

Cycling workout Example

5 minute warmup
Pedal at 90% for 1 minute
Pedal to a slower ~40% pace for 1 minute
Repeat intervals for 20 minutes
5 minute cooldown

Treadmill workout Example

5 minute warmup
20 minutes of treadmill ambulation with periods at target HR (80-85%)
Adjusting incline and speed as needed

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HIIT Activities

Strength Training Example (Used in a study)

5 minute warmup on ergometer
Core Exercises included: Leg Presses, Knee extension, Chest press, Overhead press, Lat Pulldowns
3 sets with 8-12 repetitions in each set
BW exercises such as (bodyweight squats, push ups, step ups, lunge) were done for ~ 60 seconds in between sets to maintain HR >50%

Kelly NA, Ford MP, Standaert DG, et al. Novel, high-intensity exercise prescription improves muscle mass, mitochondrial function, and physical capacity in individuals with Parkinson’s disease. J Appl Physiol. 2014;116(5):582-592. doi:10.1152/japplphysiol.01277.201

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HIIT Activities

Rock Steady Boxing

Non-contact boxing
Punching a heavy bag
Footwork drills
Resistance training

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Who Shouldn’t do HIIT

Fixed rate pacemaker or ICD device with HR limits
Major cardiovascular event (< 3 months)
Chronic atrial fibrillation CHF secondary to significant uncorrected primary valvular disease
Obstructive cardiomyopathy
History of CHF
Uncontrolled hypertension
Uncontrolled Diabetes
Severe COPD
Severe Neuropathy

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Developing a HIIT Program for PD

What is the patient interested in?
What are their functional deficits?

Hoehn Yahr Scale (1-5)

Frequency: ~ 3 times a week
Intensity: more reps, add resistance, shorter rest etc.
Time: HIIT lasts normally 20-30 minutes
Type: Various types of exercises
Volume: Number of reps
Progression: Progressive overload

Things to Consider when making a Program specific to PD

Ambulatory Status
Tolerance for exercise (some may currently be sedentary)
What are their current deficits?

Strength
Gait are they shuffling, experiencing freezing etc.
Cognition

Making sure we touch each of these areas when planning treatment or HEP

Frequency – recommended guidelines for exercise

Intensity – Several ways t =o increase the intensity based off the exercise. Common ones uses are less rest breaks, or more reps

Time – What makes HIIT different is it’s relatively short duration

Type – Refer back to slide about the different popular exercises for HIIT with Parkinsons

Volume -- Number of reps – also modifiable. For ex if strength training using the RIR or RPE principle to either add weight or increase the number of reps

Progression – must overload tissue to promote change

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What’s trending in Research?

Treadmill Exercise

Hoehn and Yahr Stage 1 and 2
128 participants
HIIT Treadmill Training 4 days a week vs moderate intensity exercise group
Change in UPDRS score was minimal in HIIT group compared to moderate intensity group

Ergometer

Hoehn and Yahr Stage 1 – 3
4 participants
4 weeks of HIIT vs 4 weeks of aerobic exercise
physical exercise induced improved serum BDNF protein levels in PD

Strength Training

Hoehn and Yahr Stage 2 -3
15 participants
Five exercises (leg press, knee extension, chest press, overhead press, lat pull down), each for three sets × 8–12 repetitions to volitional fatigue.
led to a reduction in body fat percentage and gains in muscle mass

Just shows some of the variability in research

Treadmill exercise

did not elicit a lot of change in regards to PD function and mobility

Ergometer study was looking at BDNF and neuroplasticity ( relatively recent 2020) they want to do further studies

We can’t change the loss of dopamine but can we maintain the connections we have and form new connections in previously unused areas
Used biomarkers to look at BDNF

Strength training

Looked more at the changes in skeletal muscle at the cellular level, increase in type 1 and 2 muscle fibers along with increased mitochondrial activity
Changes could be due to any strength training regimen not just HIIT

Several outcome measures used throughout the articles including: PDQ-30, TUG, 6 MWT, STS, UPDRS,

Is HIIT really effective for Parkinson’s????
Further research NEEDS to be done

Found a great article on Exercise and how it relates to Parkinson’s Disease and it highlights areas that we may want to take a look at Such as:

Dosing
Is HIIT good for Early onset only or people that are still in the de novo (not taking medication) stage

Given the side effects of levodopa such as dyskinesia

More research done on the pathophysiology and the mechanisms

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Treatment Plan for Parkinson’s

Exercise early and often!
Many patients will be on medication
Plan for HIIT around medication “on” time
Resources for Parkinson’s Patients

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Some Resources for Parkinson’s Patients

Rocksteady Boxing

http://nctriangle.rsbaffiliate.com/

Parkinson’s Association of the Carolinas

https://www.parkinsonassociation.org/exercises-for-parkinsons-disease/

ParkNC Exercises and resources of PD patients

http://www.parknc.org/exercise-for-parkinsons.html

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Conclusion

HIIT relies on short bursts of exercise with increased intensity at 80-85% maximal HR.

Research is showing that HIIT can be effective for increasing strength, mobility, balance and cognition for Parkinson’s patients

There is NO One Size Fits All approach and there are multiple ways to facilitate HIIT for Parkinson’s Patients

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Questions??

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Thank you!

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Resources

1.
Alberts JL, Rosenfeldt AB. The universal prescription for parkinson’s disease: exercise. J Parkinsons Dis. 2020;10(s1):S21-S27. doi:10.3233/JPD-202100
Bathina S, Das UN. Brain-derived neurotrophic factor and its clinical implications. Arch Med Sci. 2015;11(6):1164-1178. doi:10.5114/aoms.2015.56342
Ellis T, Rochester L. Mobilizing parkinson’s disease: the future of exercise. J Parkinsons Dis. 2018;8(s1):S95-S100. doi:10.3233/JPD-181489
Fayyaz M, Jaffery SS, Anwer F, Zil-E-Ali A, Anjum I. The Effect of Physical Activity in Parkinson’s Disease: A Mini-Review. Cureus. 2018;10(7):e2995. doi:10.7759/cureus.2995
Hisahara S, Shimohama S. Dopamine receptors and Parkinson’s disease. Int J Med Chem. 2011;2011:403039. doi:10.1155/2011/403039
Jansen AE, Koop MM, Rosenfeldt AB, Alberts JL. High intensity aerobic exercise improves bimanual coordination of grasping forces in Parkinson’s disease. Parkinsonism Relat Disord. 2021;87:13-19. doi:10.1016/j.parkreldis.2021.04.005
Kelly NA, Ford MP, Standaert DG, et al. Novel, high-intensity exercise prescription improves muscle mass, mitochondrial function, and physical capacity in individuals with Parkinson’s disease. J Appl Physiol. 2014;116(5):582-592. doi:10.1152/japplphysiol.01277.2013
Malczynska-Sims P, Chalimoniuk M, Wronski Z, Marusiak J, Sulek A. High-intensity interval training modulates inflammatory response in Parkinson’s disease. Aging Clin Exp Res. 2022;34(9):2165-2176. doi:10.1007/s40520-022-02153-5

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Resources

Miller Koop M, Rosenfeldt AB, Alberts JL. Mobility improves after high intensity aerobic exercise in individuals with Parkinson’s disease. J Neurol Sci. 2019;399:187-193. doi:10.1016/j.jns.2019.02.031
Neuroplasticity, Exercise, and Parkinson’s - Davis Phinney Foundation. Accessed April 18, 2023. https://davisphinneyfoundation.org/neuroplasticity-exercise-and-parkinsons/
Palasz E, Wysocka A, Gasiorowska A, Chalimoniuk M, Niewiadomski W, Niewiadomska G. BDNF as a promising therapeutic agent in parkinson’s disease. Int J Mol Sci. 2020;21(3). doi:10.3390/ijms21031170
Parkinson’s Disease and Strength Training: Benefits | Parkinson’s Foundation. Accessed March 29, 2023. https://www.parkinson.org/blog/tips/strength-training
Rosenfeldt AB, Koop MM, Fernandez HH, Alberts JL. High intensity aerobic exercise improves information processing and motor performance in individuals with Parkinson’s disease. Exp Brain Res. 2021;239(3):777-786. doi:10.1007/s00221-020-06009-0
Schenkman M, Moore CG, Kohrt WM, et al. Effect of High-Intensity Treadmill Exercise on Motor Symptoms in Patients With De Novo Parkinson Disease: A Phase 2 Randomized Clinical Trial. JAMA Neurol. 2018;75(2):219-226. doi:10.1001/jamaneurol.2017.3517
Vučković MG, Li Q, Fisher B, et al. Exercise elevates dopamine D2 receptor in a mouse model of Parkinson’s disease: in vivo imaging with [¹⁸F]fallypride. Mov Disord. 2010;25(16):2777-2784. doi:10.1002/mds.23407
van Wegen EEH, Hirsch MA, van de Berg WDJ, et al. High-Intensity Interval Cycle Ergometer Training in Parkinson’s Disease: Protocol for Identifying Individual Response Patterns Using a Single-Subject Research Design. Front Neurol. 2020;11:569880. doi:10.3389/fneur.2020.569880