In June, The Michael J. Fox Foundation hosted a Hot Topics call “Living with PD: Going Beyond Medications” with featured speaker Dr. Monique Giroux, MD, co-founder and medical director of the Colorado Movement Disorders and NeuroPerformance Center.

Following the call, some participants shared additional questions they had that Dr. Giroux didn’t have an opportunity to answer.

Dr. Giroux was happy to provide follow-up responses to some of these, including insights into how exercise, nutrition, and “the mind-body connection” can affect a person’s experience with Parkinson’s.

Q. What is the Big and Loud Program?

Dr. Giroux: Big and Loud is a rehabilitation and home exercise program designed by a physical therapist and speech therapist to improve movement and speech.

 The program includes a series of exercises designed to enhance and normalize everyday movement for people with Parkinson’s who experience small, tight and restricted movement and soft and slurred speech. Big dynamic and exaggerated movements and loud and pronounced speech exercises are used to train the brain and body with the goal of normalizing ‘movement patterns’. Similar to many exercise programs, the principles of practice, repetition, and task specific training are used.

Q. I have a problem with getting a good night’s sleep no matter what I do or what medications I take. Can exercise help improve sleep?

Dr. Giroux: Exercise can improve sleep but it is important to pay attention to what you do and when you do it. Active aerobic (cardio) exercise during the morning and afternoon is energizing and can ultimately improve energy levels during the day as well as improve sleep quality at night. This form of exercise at night before bed can energize you to the point that you cannot sleep. Conversely, gentle exercise such as stretching or low impact yoga coupled with relaxation prepares the body and mind for sleep.

Q. I run every day. Does my exercise reduce or “eat up” the efficacy of my levodopa and Mirapex? It seems that my off time between med cycles when I run is increasing.

Dr. Giroux: Dr. Giselle Petzinger from the University of Southern California is researching the effect of vigorous exercise on brain chemistry. Her research shows that vigorous exercise actually modulates brain activity in the basal ganglia (the movement region of the brain affected by Parkinson’s) to utilize dopamine more efficiently for exercise. Total dopamine levels do not appear changed but how efficient your brain is at using available dopamine does change. There are many factors that can affect an individual’s response to the medicine. Diet, fatigue, blood pressure, endurance, medication side effects (sedation or low blood pressure for example), efficiency of movement and the added work or energy consumption’ required to move with Parkinson’s symptoms can all play a role. Be sure to talk with your healthcare provider to be sure your medication regimen is optimized for your daily routine. A physical therapist can also review your exercise routine to explore whether additional strengthening, balance or flexibility exercises can help balance out an exercise program and improve running efficiency or identify movement patterns or habits that can affect performance.

Q. On the call you mentioned yoga and tai chi as good forms of exercise. How do you feel about Pilates?

Dr. Giroux: There are many forms of exercise that are helpful and what works may depend on the needs and preferences of the individual. Pilates’ focus on core strength (strengthening truncal muscles around the back and abdomen) can be very helpful for power. Tai chi’s gentle, slow and precise movements enhance balance and coordination. Yoga styles vary and can range from the physical focusing only on poses, strength and posture to styles that blend the mind-body connection to focus on the body’ healing response. Follow these principles when selecting an exercise program:

1. 1. Fortunately, there are many exercises that are beneficial – ‘not one size fits all’
   2. Listen to your body and respect how it feels. Be careful not to push your body too hard with new exercises or through pain to avoid injury.
   3. Start with a physical therapist or specialized trainer with experience in Parkinson’s to avoid injury.
   4. Remember you will be more successful with exercises you enjoy or have access to.
   5. A balanced exercise program including a variety of exercises optimizes endurance, health, strength, balance and motor control.

Q. Is there evidence that strength training exercise benefits PD patients? Can you suggest any specific exercises?

Dr. Giroux: Yes, researchers from the University of Maryland showed that resistance training improved flexibility, balance, and strength and results lasted up to 2 years. Exercises should always be tailored to the needs and ability of the individual. In general, exercises targeting leg strength and core strength will combat the strength loss that can come with disuse. A physical therapist can review a person’s weak areas and couple this with Parkinson’s specific strengthening exercises to keep you strong and moving.

Q. Please comment on the role of protein in the PD diet. What amounts are recommended? Should high protein foods be eaten at certain times of the day/night?

1. 1. Protein competes with the absorption of levodopa through the intestines and the entry of levodopa into the brain. Protein does not interfere with other Parkinson’s medicines. Slower and more erratic absorption of levodopa due to protein in your diet is most noticeable for people with advanced Parkinson’s that experience motor fluctuations and dyskinesia and as a result are sensitive to the timing of their medicine.
   2. Protein is needed for energy, muscle and cell health, immune function, tissue healing and many other body functions so it is important to include protein in your diet. How much a person needs is individualized. A nutritionist is a specialist that can help determine the right amount.
   3. Paying attention to when you eat protein can help reduce the protein-levodopa interaction and can be especially helpful for people with on-off periods, dyskinesia or doses that fail to ‘take effect’. The following tips can be helpful, however, because timing of medicine is so important, these tips are meant for information only and must be reviewed with your healthcare provider before implementing
      1. Taking levodopa 1 h before or after meals ensures greater absorption of medicine before protein is digested.
      2. Eat more of your daily protein at times when you are less active, for example with your dinner (a high protein breakfast can interfere with medicines ‘kicking in’ first thing in the morning just when you are starting your day)
      3. Eat vegetable protein instead of animal protein (meat) Be which may be more efficiently used by cells in the body, and which may, in turn, reduce the protein effect (This has not yet been definitely proven by researchers but vegetable protein is a good choice since it is better for your overall health).

Q. What has been learned about the effects of acupuncture on PD symptoms, energy level or overall outlook on life?

Little is known about the effect of acupuncture on Parkinson’s symptoms, mood, fatigue and wellbeing. Our understanding of the potential benefits is from anecdotal reports such as simple observations from people about how they feel after this therapy. Because these reports do not test the possible effect of placebo or the benefits of other therapies that are sometimes combined with acupuncture (such as relaxation techniques, physician or acupuncturist counselling or other lifestyle changes or attitudes) it is unclear how acupuncture truly affects Parkinson’s wellbeing. Research does support the use of acupuncture for pain and headache suggesting this is a valid therapy for health and disease. Future studies designed to compare acupuncture to the placebo effect with a careful measure of symptoms and outcomes are needed. MJFF is currently funding Benzi Kluger, MD, for work on acupuncture and fatigue in people with PD.

• I was interested in the study that showed an intensive work-out to be most beneficial. This contradicts another study that showed a low rate on a treadmill was more beneficial than an intensive work-out on the treadmill. How do you reconcile these two results? Unfortunately, exercise studies cannot be compared as they use different protocols, different measures, goals and outcomes. Bottom line, many research studies have documented improvement with exercise high-intensity, low intensity, resistance training, task specific training, and neuro-reeducation. Research designs vary, what was measured, quality of the instruction, duration and goals of the study differ and this likely explains the differing results. All forms of exercise if done consistently, safely and with proper form seems to improve symptoms of PD.

Q. Can you share the latest on the effects of dance and rhythmic music on movement disorders and any upcoming studies?

Dr. Giroux: Music, dance and rhythmic beat change how we move, think and feel. Many people with Parkinson’s find their movement becomes easier, has a natural flow, and is easier to initiate when accompanied by music. Music not only helps entrain movement to a beat, but energizes us, engages us, and changes our mood. Dance encourages new patterns of movement, increases motor learning, creativity, fun, personal connection and even intimacy. Movement, emotion, creativity, sensation, vision, hearing, intimacy are part of the experience reflecting the complex activation of almost every part of the brain. Researchers analyzing the effect of music therapy note a specific improvement in bradykinesia or slowness of movement. Additional research studying just how music, dance and creative expression impact brain activity and general well-being are underway.

Q. Has the benefit of sound therapy been tried for people with PD?

Dr. Giroux: Music and its effect on mood, well-being, creative expression and movement is just one example of how sound affects body, mind, brain and Parkinson’s disease. Sound therapy, on the other hand, is designed to use the effect of specific sound frequencies on mood, energy and well-being. Currently, there are no studies analyzing its effect on individuals with Parkinson’s.

Q. How do you find a holistic practitioner who is skilled, reliable and knowledgeable about PD?

Dr. Giroux: Not all holistic providers will have the skill and knowledge of Parkinson’s. Start by asking your doctor or another healthcare provider for recommendations. Remember that some holistic providers can be very helpful even if he/she does not have a background in Parkinson’s disease. Interview any holistic provider to be sure they are the best fit. Here are some questions you may find helpful:

1. 1. What is the practitioner’s certification?
   2. How many years’ experience?
   3. Experience with other brain conditions, if not Parkinson’s?
   4. Are they open to your suggestions ideas or needs or simply trying to promote a specific therapy or service?
   5. Do they listen to you? Are they open and willing to learn more about Parkinson’s?
   6. What evidence do they have to support the use of a therapy or service? Is it based only on individual stories or is there good data to suggest a true benefit?
   7. How expensive is the treatment and is this financial cost driving therapy treatments?
   8. What is expected and how many treatments will be tried before stopping?
   9. Are their claims too good to be true?

Q. Which types of physical exercise or therapies are most effective in controlling the symptoms of PD?

Dr. Giroux: This is a very common question and one that simply cannot be answered. The reason is that there is no specific exercise for Parkinson’s. In fact, recommending just one exercise or way of exercising may even be harmful as there are many personal, health and behavioural factors, goals of exercise, and effects that are important to take into consideration.